Bowel Management in Spinal Cord Injury

Original Editor - Naomi O'Reilly

Top Contributors - Redisha Jakibanjar, Naomi O'Reilly, Kim Jackson, Anas Mohamed, Arnold Fredrick D'Souza, Admin and Lucinda hampton  

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Introduction

Neurogenic bowel dysfunction with changes to bowel motility, sphincter control, coupled with impaired mobility and hand dexterity, is a major physical and psychological problem for many individuals with a spinal cord injury, as well as major source of morbidity. Neurogenic bowel occurs secondary to a lack of central nervous control of the bowel resulting in dysfunction of the colon, with two distinct clinical presentations. 

Upper Motor Neuron (UMN) Bowel Syndrome, occurring in a spinal cord injury above the conus medullaris results in a hyperreflexic bowel, characterised by increased colonic wall and anal tones, with disrupted voluntary external anal sphincter control. Typically associated with constipation and fecal retention at least in part due to external anal sphincter activity.

Lower Motor Neuron (LMN) Bowel Syndrome, occurring in a spinal cord injury at the injury at the conus medullaris or cauda equina results in an areflexic bowel, characterised by loss of spinal cord-mediated peristalsis and slow stool propulsion with an atonic external anal sphincter. Typically associated with constipation and a significant risk of incontinence due to flaccid paralysis of the external anal sphincter and reduced motor control of levator ani. 

The three main implications of disruption to motor, sensory and autonomic pathways post spinal cord injury on bowel function are an inability to:

1. feel when the bowel is full
2. voluntarily control muscles to defecate
3. voluntarily contract muscles to prevent defecating

Successful bowel management is multi-dimensional and needs to be specific to each individual requiring careful assessment for accurate diagnoses and prescription of treatments for bowel management following spinal cord injury, recognising that completeness of injury also has a significant impact on bowel function.Key strategies for bowel management include a high-fibre diet although further research to examine the optimal level, adequate fluid intake and a regular routine for bowel evacuation, which may incorporate digital stimulation or manual evacuation. Transanal irrigation is also now seen as a promising technique to reduce constipation and fecal incontinence. Prokinetic agents such as cisapride, prucalopride, metoclopramide, neostigmine, and fampridine are supported by strong evidence for the treatment of chronic constipation in individuals with a spinal cord injury in those where conservative management is not effective. 

Bowel Management Options	Considerations for Appropriate Bowel Management Options
High Fibre Diet	Presence or Absence of Bowel Reflexes Complete Lesions below the conus medullaris have loss of bowel reflexes, Complete Lesions above the conus medullaris do not have loss of bowel reflexes Hand Function Patients’ Preference Other Complex Factors
Adequate Fluid Intake
Regular Bowel Emptying Routine
Digital Stimulation Bowel Reflexes
Medication Oral e.g. Bowel Softeners Rectal e.g. Enemas