Bowel Management

Andrei Krassioukov, MD, PhD

Janice Eng PT, PhD
Bonnie Venables, RN

www.scireproject.com Version 4.0

 Key Points

There is limited evidence that supports a multifaceted program for managing a

neurogenic bowel.

There is a need for further research to examine the optimal level of dietary intake in
spinal cord injured patients.

Digital rectal stimulation increases motility in the left colon in individuals with SCI.

Electrical stimulation of the abdominal wall muscles can improve bowel management
for individuals with tetraplegia.

Functional magnetic stimulation may reduce colonic transit time in individuals with
SCI.

Sacral anterior root stimulation reduces severe constipation in individuals with SCI.

More research is needed to warrant the use of the Praxis FES system for bowel
management in individuals with SCI.

Posterior tibial nerve stimulation is a relatively new treatment for fecal incontinence
and while preliminary results show promise, the sample size is limited and more
research is needed to warrant this new modality.

Pulsed water irrigation may remove stool in individuals with SCI and transanal
irrigation alleviates constipation and fecal incontinence. Often, more than one
procedure is necessary for individuals that are unable to develop an effective bowel
routine.

Cisapride, prucalopride, metoclopramide, neostigmine, and fampridine may be used

for the treatment of chronic constipation in persons with SCI.

Cisapride and Prucalopride are not currently available in Canada or the United
States due to adverse side effects. More research is required on these prokinetic
agents prior to their regular use.

Polyethylene glycol-based suppositories (10 mg. bisacodyl) are effective in

maintaining or enhancing a successful bowel management program, especially for
persons with an upper motor neuron SCI.

Colostomy is a safe and effective treatment for severe, chronic gastrointestinal

problems and perianal pressure ulcers in persons with SCI, and greatly improves
their quality of life.
The Malone Antegrade Continence Enema is a safe and effective treatment for
severe, chronic gastrointestinal problems in persons with SCI when conservative
bowel management options are unsuccessful.

There is limited evidence that the use of a standing table and a washing toilet seat
improves bowel function in individuals with SCI.

There is limited evidence that a washing toilet seat with visual feedback may assist
bowel care.

The abdominal massage appears to be ineffective for treatment of the neurogenic

bowel.
 Table of Contents

1. Introduction ...........................................................................................................................1

2. Spinal Cord Injury and its Impact on Bowel and Ano-rectal Function ..............................2
2.1 General bowel management systematic reviews ...................................................................4

3. Management ..........................................................................................................................5
3.1 Multifaceted Programs ..........................................................................................................5
3.2 Dietary Fibre .........................................................................................................................8
3.3 Reflex Stimulation of the GI Tract..........................................................................................9
3.4 Electrical and Magnetic Stimulation .......................................................................................9
3.5 Irrigation Techniques...........................................................................................................16
3.6 Use of Pharmacological Agents ..........................................................................................19
3.7 Use of Suppositories ...........................................................................................................23
3.8 Colostomy ...........................................................................................................................25
3.8.1 Systematic review ............................................................................................................25
3.9 The Malone Antegrade Continence Enema and the Enema Continence Catheter ..............28
3.10 Assistive Devices ..............................................................................................................30
3.11 Abdominal Massage..........................................................................................................31

4. Summary .............................................................................................................................32

5. References ..........................................................................................................................35

This review has been prepared based on the scientific and professional information available in 2011. The SCIRE
information (print, CD or web site www.scireproject.com) is provided for informational and educational purposes only. If
you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors,
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from the use or misuse of this material.

Krassioukov A, Eng JJ, Venables B (2012). Neurogenic Bowel Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller
WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan V, Boily K, Mehta S, Sakakibara BM, editors. Spinal Cord
Injury Rehabilitation Evidence. Version 4.0. Vancouver, p 1-39.

www.scireproject.com
 Bowel Management
Following Spinal Cord Injury

1. Introduction
Neurogenic bowel is a syndrome commonly observed in individuals with SCI and defined as colonic
dysfunctions due to lack of central nervous control. Bowel dysfunction following spinal cord injury
(SCI) is a major source of morbidity (Han et al. 1998; Stone et al. 1990a). Not surprisingly, bowel
dysfunctions alone or bladder/bowel dysfunctions were rated among the highest priorities among
individuals with SCI in numerous studies (Anderson 2004; Glickman and Kamm 1996). Depending on
the level of injury, a variety of GI problems could arise in these individuals and it has the potential to
disrupt almost every aspect of their life. Correa and colleagues found that 27 – 41 % of patients with
neurogenic bowel report chronic gastrointestinal GI problems that alter their lifestyle and may require
treatment (Correa and Rotter 2000). Fear of bowel accidents is common among individuals with SCI
and deters them from participating in social and other outside activities (Correa and Rotter 2000).
Severe constipation often follows SCI and chronic constipation has a significant impact on quality of
life (Longo et al. 1995). The prevalence of chronic GI symptoms increases with time after injury,
suggesting that these problems are acquired and potentially preventable (Rajendran et al. 1992).

Decreased mobility (where constipation is more prevalent) and lack of sensation may partially
contribute to GI dysfunction. However, disrupted autonomic control of the GI tract is probably the
dominating cause for major bowel dysfunctions observed in this population, leading to delayed gastric
emptying (Leduc et al. 2002; Gondim et al. 2001; Menter 1997; Rajendran et al. 1992; Fealey et al.
1984), poor colonic motility (Lynch & Frizelle 2006; Fajardo et al. 2003) resulting in prolonged bowel
transit time (Brading & Ramalingam 2006; Lynch et al. 2001), constipation (Faaborg et al. 2008;
Finnerup et al. 2008; Lynch et al. 2000;), and postprandial (after eating a meal) abdominal distension
(Stone et al. 1990a). Furthermore, a significant number of bowel dysfunctions following SCI are
associated with episodes of autonomic dysreflexia (Furusawa et al. 2007; Cosman and Vu 2005).

The level and severity of SCI are important factors to consider when deciding on bowel management
strategies with the goal of re-establishing some level of evacuation control.
Clinical experience indicates that a successful bowel program results in predictable, regular and
thorough evacuation of the bowels without the occurrence of incontinence and additional
complications (i.e. autonomic dysreflexia). An effective bowel program takes into consideration diet
and nutritional factors, use of medications when necessary and is consistent with the neurologic
condition and needs of the individual with SCI. It is important to emphasize that each person with SCI
is unique and that individual bowel programs need to be client-specific. Clinical experience indicates
that the procedures used and the need for medications will depend greatly on the level of neurologic
injury, the extent of impairment and subsequent effect of the injury on bowel function. The
effectiveness of a bowel program should be reevaluated and modified as needed.

1
Figure 1: 1 Innervation of the gastrointestinal system. Schematic diagram of the autonomic
and somatic innervations of the lower GI tract and pelvic floor. The brainstem, spinal cord and
sympathetic chain are shown on the left, and the colon, rectum and pelvic floor on the right.
Sympathetic innervation (dashed lines) originates from the thoracic and upper lumbar regions;
parasympathetic innervation (solid lines) orginates from the vagus nerve (to the upper GI and
colon up to the colonic flexture) and from the sacral region of the spinal cord (to areas below
the splenic flexture). Dotted lines represent the mixed nerves supplying the somatic
innervation to the musculature of the external anal sphincter and the pelvic floor.

2. Spinal Cord Injury and its Impact on Bowel and Ano-rectal Function
Bowel function is a major physical and psychological problem for persons with spinal cord injury.
Following a spinal cord injury, changes in bowel motility, sphincter control and gross motor dexterity
interact to make bowel management a major life-limiting problem. In 2000, Lynch et al. surveyed 1200
persons with SCI and 1200 age and gender-matched controls to describe bowel function. For persons
with SCI, their mean Fecal Incontinence Score (FIS) was significantly higher than controls. It was also
noted that for persons with complete SCI, their mean FIS was significantly higher than those persons
with incomplete SCI. Quality of life was affected by incontinence in 62% of SCI respondents compared
with 8% of controls. Fecal urgency and time spent on bowel management were also significantly
higher for persons with SCI. A significantly higher percentage (39%) of SCI respondents use laxatives
compared to 4% of controls. The decreased ability to discriminate between gas and liquid for complete
SCI patients also makes the chance for fecal incontinence more likely.

Depending on the level of injury, there are two distinct patterns in the clinical presentation of bowel
dysfunction: injury above the conus medullaris results in upper motor neuron (UMN) bowel syndrome

1
Reprinted from Archives of Physical Medicine and Rehabilitation, 78(3), Steins SA, Biener Bergman S, Goetz LL,
Neurogenic bowel dysfunction after spinal cord injury: clinical evaluation and rehabilitative management, S86-S102,
Copyright (1997), with permission from Elsevier.

2
and injury at the conus medullaris and cauda equine results in lower motor neuron (LMN) bowel
syndrome (Singal et al. 2006; Steins et al. 1997).

The UMN bowel syndrome, or hyperreflexic bowel, is characterized by increased colonic wall and anal
tones. Voluntary (cortical) control of the external anal sphincter is disrupted and the sphincter remains
tight, thereby promoting retention of stool. The nerve connections between the spinal cord and the
colon, however, remain intact; therefore, there is preserved reflex coordination and stool propulsion.
The UMN bowel syndrome is typically associated with constipation and fecal retention at least in part
due to external anal sphincter activity (Steins et al. 1997). Stool evacuation in these individuals
occurs by means of reflex activity caused by a stimulus introduced into the rectum, such as an irritant
suppository or digital stimulation.

LMN bowel syndrome, or areflexic bowel, is characterized by the loss of centrally-mediated (spinal
cord) peristalsis and slow stool propulsion. A segmental colonic peristalsis occurs only due to the
activity of the intrinsic myenteric plexus, resulting in the production of drier and round- shaped stool.
LMN bowel syndrome is commonly associated with constipation and a significant risk of incontinence
due to the atonic external anal sphincter and lack of control over the levator ani muscle that causes
the lumen of the rectum to open.

Completeness of injury also has a significant impact on bowel function in individuals with SCI. Those
with an incomplete injury may retain the sensation of rectal fullness and ability to evacuate bowels so
no specific bowel program may be required.

Table 1: Clinical Presentations in Bowel Functions Following SCI (Singal et al. 2006)

Upper Motor Neuron lesion Lower Motor Neuron lesion

>T10 vertebral or T12 spinal

Level <T10 vertebral or T12 spinal segment
segment

Time from cecum to anus ↑ ↑

Motility of left colon ↓ ↓

External anal sphincter Spastic paralysis Flaccid paralysis

Absent with lesions > T6 spinal

Sympathetic output Retained
segment

Constipation Constipation
Symptoms Difficulty with evacuation Difficulty with evacuation
Incontinence Incontinence

Fecal impaction Proximal colon Rectal

Autonomic dysreflexia Common Rare

Reflex defecation Present Not known

Difficulties with bowel emptying are of concern to most persons with SCI. For the tetraplegic patient,
loss of control over visceral function may be seen as more important than the ability to walk (Frost et
al. 1993). Urinary problems in patients with SCI have been extensively studied, and with the advent of
intermittent self-catheterization, electrical stimulation of the bladder and advances in diagnostic
techniques, considerable improvements have been made in managing lower urinary tract and renal
function. In contrast, the management of bowel disorders, and in particular, the intractable constipation
that is so common in these patients, has remained essentially unchanged over the past two decades
(MacDonagh et al. 1990).

3
Various researchers have shown that electrical stimulation of the somatic nervous system can bring
about an alteration in visceral function in humans. Riedy et al. (2000) showed that short periods of
electrical stimulation with perianal electrodes resulted in an increase in anal pressures. Bowel reflex
centres within the sacral spinal cord may be released from descending inhibition after SCI and may be
altered with somatic input (Frost et al. 1993). Electrical sacral root stimulation induces defecation in
SCI patients and is currently under examination as a new therapy for fecal incontinence. In contrast to
electrical stimulation, magnetic stimulation may produce similar results and is noninvasive (Morren et
al. 2001). Morren et al. (2001) studied the effects of magnetic sacral root stimulation on anorectal
pressure and volume in both fecal incontinence and SCI patients. Sun et al. (1995) investigated the
role of spinal reflexes in anorectal function. Their subjects underwent anorectal manometry and
electromyography, before and after having a sacral posterior rhizotomy performed by the same
neurosurgeon. They found that all subjects lost conscious control of the external anal sphincter as well
as responses to intra-abdominal pressure and rectal distention. While the use of sacral root
stimulation, either electrical or magnetic, seems to be producing positive results, further research is
required.

2.1 General bowel management systematic reviews

As the body of knowledge is growing in the field of bowel management for spinal cord injury (SCI), it is
becoming increasingly important to review the literature and ensure that the information used both in
research and in practice is current and evidence based. The aim of this section of the bowel chapter is
to provide an overview of the current systematic reviews available in areas related to bowel
management in SCI population.

Table 2: General bowel management systematic review

Authors; Country
Date included in the Methods
review Databases Conclusions
Total Sample Size Level of Evidence
Score

Methods: Literature search for 1. Multifaceted bowel management programs are

Randomized-controlled trials
(RCTs), prospective cohort, case–
control, pre–post studies, and case
reports that assessed
pharmacological and non-
Krassioukov et al. 2010; pharmacological intervention for the
Canada management of the neurogenic
bowel after spinal cord injury
Reviewed Published
articles from 1950 to July Databases: PubMed/MEDLINE,
2009 CINAHL, EMBASE, PsycINFO
N= 57 Level of Evidence:
PEDRo Scale-was used to grade
AMSTAR: 5 RCTs
Modified Downs and Black scale –
was used to grade non RCTs (0 to
28)
the first approach to neurogenic bowel
programs and are supported by lower-level
evidence (pre–post studies, level 4)
2. More than one procedure is often necessary for
individuals that are unable to develop an
effective bowel routine (e.g. Digital rectal
stimulation and diet and fluid intake).
3. Evidence is low for non-pharmacological
approaches and high for pharmacological
interventions.
4. Diet and fluid intake are important components
of multifaceted bowel management programs.
5. Transanal irrigation is a promising technique to
reduce constipation and fecal incontinence
6. The need for colostomies and the MACE are
often viewed as a failure of rehabilitation
services. However, it is of importance to note
that colostomy is a safe, effective method of
managing severe and chronic GI problems,
and perianal pressure ulcers in persons with
SCI

4
Discussion

We found one systematic review examining bowel management for patients with SCI. Krassioukov et
al. (2010) found that although multifaceted bowel management programs are commonly used, only
lower levels of evidence support these programs. Overall, there is a need for higher quality trials and
systematic reviews in the field of bowel management for SCI patients.

3. Management
Few SCI patients feel normal desire to defecate and most use a variety of methods to initiate
defecation, including laxatives, enemas, suppositories or digital stimulation of the rectum and anal
canal. SCI results in severely prolonged colonic transit times both in the acute and chronic phase.
However, the type of colorectal dysfunction depends on the level of SCI (Krogh et al. 2000; Stiens et
al. 1997). Colorectal problems often restrict their participation in social activities and influence their
quality of life. Krogh et al. (2000) and Nino-Murcia et al. (1990) measured colonic transit time in
individuals using ingested radiopaque markers and abdominal radiographs taken at 24 hour intervals.
They found that the mean transit time through the entire colon in SCI patients was significantly longer
than normal adults. Future studies on colonic transit times and anorectal dynamics could aid in the
approach used to manage bowel dysfunction in SCI patients. Difficulty with evacuation has been
attributed to prolongation of the colonic transit time in individuals with SCI.

The Consortium for Spinal Cord Medicine developed guidelines for neurogenic bowel management
(Consortium for Spinal Cord Medicine 1998). A comprehensive evaluation of bowel function,
impairment, and possible problems is recommended at the onset of SCI and at least once annually.
The evaluation may include a patient history, physical exam, an assessment of the ability of the
individual or his caregiver to perform procedures safely and effectively, as well as of the bowel
program design, assistive techniques/devices used, and the patient’s diet. More recently, the
Multidisciplinary Association of the Spinal Cord Injury Professionals (MASCIP 2009) in affiliation with
the Spinal Cord Injury Centres of the United Kingdom and Ireland released guidelines for the
management of neurogenic bowel. These guidelines provide standards for care for both those being
admitted for rehabilitation and those living in the community.

Management of neurogenic bowel complications is reliant on the clinician to recognize common

complications and their clinical presentation (Consortium for Spinal Cord Medicine, 1998, MASCIP
2009). Common complications include constipation, fecal impaction and hemorrhoids. Recommended
management protocols for constipation include the establishment of a balanced diet with adequate
fluid and fibre intake, increased daily activity, and if possible, reduction or elimination of medication
contributing to constipation. If these recommendations fail, prokinetic medication may be used to
promote transit through the gastrointestinal tract. The step-wise management recommended for
fecal impaction is first manual evacuation, then if not successful, oral stimulants, and finally oil
retention enemas. To minimize the development of hemorrhoids, oral agents (to maintain soft-formed
stool), minimize straining during bowel efforts, and minimal physical trauma during anal stimulation are
recommended. Once hemorrhoids have developed, topical anti-inflammatory creams or suppositories
are suggested as early treatment. Overall, the Consortium for Spinal Cord Medicine recommends
further research in all bowel management areas (Consortium for Spinal Cord Medicine, 1998).

3.1 Multifaceted Programs

There are several factors that may influence bowel function including diet, fluid consumption, and
routine bowel evacuations. Multifaceted programs target more than one factor in an attempt to reduce
colonic transit time as well as decrease the incidences of difficult evacuations.

5
Table 3: Multifaceted Bowel Management Programs
Author Year; Country
Score
Methods
Research Design
Total Sample Size
Population: Experimental group: 24 male,
11 female; Median age = 49.5; 17 subjects
with diagnosis of AIS-A, 5 AIS-B, 4 with
diagnosis of AIS-C, with diagnosis of AIS-D.
Control group: 21 male, 12 female; Median
age = 47; 19 subjects with diagnosis of AIS-
A, 3 with diagnosis of AIS-B, 2 with
diagnosis of AIS-C, 9 with diagnosis of AIS-
Coggrave & Norton 2009a; D.
United Kingdom Treatment: 6-week, 8-stepwise protocol
PEDro = 7 designed by Badiali et al. (2007) (steps: 0)
RCT simulation of gastro-colic reflex 20 min
N = 68 before starting bowel care: 1) abdominal
massage; 2) perianal digitation; 3) anorectal
digitation; 4) glycerin suppositories; 5)
rectal stimulants; 6) manual evacuation; 7)
stimulant oral laxative. The control group
undertook their usual type, number and
order of interventions to achieve
evacuation.
Outcome Measures: duration of bowel
movement and level of the 8-stepwise
protocol to complete evacuation.
Population: 14 males and 3 females; Age:
mean 41.24 years, range 19-59; 8 subjects
with cervical injuries; 8 with thoracic
injuries, and 1 with conus medularis; all
subjects had motor compete SCI.
Treatment: Pre and post study; baseline
bowel management (2 weeks observation)
was compared with bowel management
Coggrave et al. 2006; following introduction of the modified
United Kingdom progressive protocol (4 weeks of
Downs & Black = 17 observation) designed by Badiali et al.
Pre-post (1997) – the manual evacuation step (step
N=17 6) was added to the protocol.
Outcome Measures: Comparison of the
number of episodes requiring laxative use
at baseline and under the progressive
protocol; duration of bowel management
episodes
Population: age range=19-71yrs; 21
subjects with complete injuries, 10 with
incomplete injuries, and 7 with conus
Correa & Rotter 2000; medullaris and cauda equine injuries; 2
Chile subjects with tetraplegia and 19 with
Downs & Black = 13 paraplegia (complete lesions); length of
Pre-post injury range=5 months-16yrs
N=38 Treatment: Intestinal program
administration and 6-month follow-up.
Outcome Measures: Difficult Intestinal
Evacuation (DIE) scale; colonic transit time;
anorectal manometry; recto-colonoscopy;
gastrointestinal (GI) symptoms
6
Outcome
1. Bowel care was consistently longer in
the experimental group throughout the
study. Significantly longer at week 6
(p=0.05)
2. Less invasive interventions (ie. steps 0-
4) did not reduce the need for more
invasive interventions (ie. steps 5-7).
3. Time to first stool was consistently
longer in the experimental group
(p=0.2-0.5)
1. For 12 subjects, use of the progressive
protocol resulted in an increase in the
number of successful bowel
management episodes without the use
of laxatives.
2. The total number of successful bowel
management episodes requiring
laxative decreased from 62.8%
(baseline observation) to 23.1% (in
protocol phase) (p<0.0001)
3. In 3 subjects, there were fewer
successful bowel management
episodes with use of the protocol
4. Mean duration of bowel management
episodes was less with use of the
protocol than in baseline (51.81 vs.
73.54 minutes)
5. There was a significant decrease in
proportion of the bowel management
episodes requiring manual evacuation
in the protocol phase than in the
baseline phase (87.6% versus 27%)
1. Subjects felt their DIE scores after their
SCI worsened (from 2.6% to 26.3%)
compared to before their SCI (based on
recall from memory).
2. The most frequent GI symptom was
abdominal distention.
3. With the intestinal program, the
incidence of DIE was reduced to 8.8%
and manual extraction was reduced
from 53% to 37%.
 Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Gender: 5 male and 5 1. Bowel frequency was reported to have
female; Age range= 20 to 60 years, mean increased at the end of training.
Badiali et al. 1997; 33yrs; Level of injury: C3 to L4 2. By the end of the study period of the
Italy Treatment: Multifaceted intervention gastrointestinal transit time was
Downs & Black = 13 including diet, water intake, and evacuation reduced.
Pre-post schedule
N=10 Outcome Measures: 3 variables were
assessed: bowel movement frequency,
bowel habit, total and segmental large-
bowel transit time.

Discussion
Improving the movement of stool through the GI tract is the most important part of any bowel
management protocol following SCI. An array of interventions, as components of a bowel routine, is
recommended for the management of neurogenic bowel following SCI. These include dietary
recommendations, anorectal/perianal stimulation, timing the performance of the bowel routine with
food intake (thus taking advantage of gastro-colonic and recto-colonic reflexes), and a variety of
pharmacological agents. Unfortunately, only a limited number of studies evaluated the effects of
different protocols on bowel function following SCI. From the results of three pre-post studies, it is
apparent that response to the protocols is highly individualized. However, Badiali et al.’s (1997)
multifaceted bowel management program effectively reduced gastrointestinal transit time while Correa
and Rotter’s (2000) program reduced the incidence of difficult intestinal evacuation. Coggrave et al.
(2006) modified the bowel management program originally proposed by Badiali et al. (1997) by
including an additional step of manual evacuation and found a significant decrease in the number of
bowel movement episodes requiring laxatives (from 62.8% to 23.1%). These authors also reported a
significant decrease in the mean duration of bowel management episodes with the introduction of this
protocol (Coggrave et al. 2006). As these three studies incorporated several factors into the bowel
management programs including diet, fluid consumption, and routine bowel practice, it is not possible
to determine the key factor. In using the same management program in their 2006 pre-post study
(Coggrave et al. 2006), Coggrave et al. (2009a) more recently conducted a 6-week randomized
controlled trial in which the management program was compared to the control group’s usual bowel
care consisting of each subject’s usual type, number and order of interventions to achieve evacuation.
The authors wanted to examine whether systematic use of less invasive interventions (ie the first few
steps in the management program: simulation of gastro-colic reflex 20 min before starting bowel care;
abdominal massage; perianal digitation; anorectal digitation; and glycerin suppositories), could reduce
the need for oral laxatives or more invasive interventions such as rectal stimulants and manual
evacuations. Findings revealed that bowel care took longer in the intervention group, fecal
incontinence was more frequent (p=0.04), and the need for oral laxatives and invasive interventions
was not reduced (p=0.4). The findings in this RCT (Coggrave et al. 2009a) are in contrast with other
published findings in which the use of a multifaceted program reduced the level of intervention needed
for evacuation and duration of bowel management. (Coggrave et al. 2006, Badiali et al. 1997). The
samples in the earlier studies, however, were younger and injured for a shorter period of time, which
both are associated with less frequent use of medicated rectal stimulants, manual evacuation, and oral
laxatives (Coggrave et al. 2009b).
Conclusion
There is level 1b evidence (from one RCT; N=68) (Coggrave et al. 2009) that systematic use of
less invasive interventions do not reduce the need for oral laxatives and invasive
interventions. There is also level 1b evidence (Coggrave et al. 2009 that use of multifaceted
bowel management programs increase the duration of time required for bowel management.

7
This is in contrast with level 4 evidence (from three pre-post studies; aggregate N=65)
(Coggrave et al. 2006; Correa and Rotter 2000; Badiali et al. 1997;) that multifaceted bowel
management programs reduce gastrointestinal transit time, incidences of difficult evacuations,
and duration of time required for bowel management.

There is limited evidence in support of multifaceted programs for managing a neurogenic bowel.

3.2 Dietary Fibre

It is well-known that fibre is an important part of any diet. There are different types of fibre, each
benefiting the body in a different way. Soluble fibres mix with water in the intestine to form a gel-like
substance, which acts as a trap to collect certain body wastes and then move them out of the body.
Insoluble fibres absorb and hold water, producing uniform stool and helping to push content of the gut
through the digestive system quickly. Insoluble fibres promote regularity and treat constipation.

The Consortium for Spinal Cord Medicine (1998) recommends an initial diet with no less than 15
grams of fibre daily, and the MASCIP (2009) group identify an average intake of 18 grams, however,
acknowledge that adjustments should be made if problems arise with stool consistency. The most
common source of dietary fibre is bran. It is not recommended to place individuals with SCI on high
fibre diets (Consortium for Spinal Cord Medicine, 1998).
Table 4: Dietary fibre for managing neurogenic bowel after a spinal cord injury
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Age range: 19-53yrs, Injury level: 1. Following the addition of bran, dietary
C4-T12; 1 subject with incomplete injuries and fibre intake significantly increased from
10 with complete injuries; 7 subjects with 25g/d to 31g/d.
Cameron et al. 1996; tetraplegia and 4 with paraplegia. 2. Mean colonic transit time lengthened
Australia Treatment: In phase 1, subjects ate a normal from 28.2 hours to 42.2 hours (p<0.05)
Downs & Black = 10 hospital diet and maintained their bowel
Case Series routine. In phase 2, fibre intake was increased
N=11 with the addition of 40g Kellogg’s All Bran.
Outcome Measures: stool weight, total and
segmental transit time, bowel evacuation time
and dietary intake.

Discussion
Results of this study suggest that increasing dietary fibre in SCI patients does not have the same
effect on bowel function as has been previously demonstrated in individuals with normal-functioning
bowels. The effect may actually be the opposite of the desired result (Cameron et al. 1996). Therefore,
adding more fibre alone does not improve bowel function, however, more evidence is required to
assess the effectiveness of adding fibre to diets.

Conclusion
There is level 4 evidence (from 1 case series; N=11) (Cameron et al. 1996) that indicates high
fibre diets may lengthen colonic transit time.

There is a need for further research to examine the optimal level of dietary intake in spinal cord
injured patients.

8
3.3 Reflex Stimulation of the GI Tract
Utilization of the preserved GI reflexes could be useful in bowel management following SCI. For
example, the gastro-colonic and ano-rectal reflexes could be successfully incorporated into a bowel
routine for individuals with SCI. It is well-known that following breakfast, a gastric distention could
activate bowel motility and morning defecation (Sloots et al. 2003; Ford et al. 1995). Furthermore,
digital ano-rectal stimulation has been shown to be useful in bowel evacuation following spinal cord
injury (Shafik et al. 2000).
Table 5: Reflex Stimulation of the GI Tract
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Six male subjects with SCI 1. Compared with the baseline (0 waves/min),
(4 with paraplegia [complete SCI; 3] and the mean number of peristaltic waves/min
2 with tetraplegia [complete SCI; 1]); increased during DRS (1.9±0.5/min) and
Age: mean 50.2 years, range 44-50 immediate after DRS (1.5±0.3/min) (mean ±
Korsten et al. 2007; years; Level of injury: C5-T10; AIS A-C; SEM)
USA Duration of injury: 10-29 years. 2. The average amplitude of all the peristaltic
Downs & Black = 12 Treatment: Digital rectal stimulation contractions was 43.4±2.2 mmHg (range 0.7-
Pre-post (DRS) to facilitate bowel evacuation 250)
N=6 Outcome Measures: Colorectal 3. The peristaltic contractions in the left colon
monometry: mean number of peristaltic were accompanied by increased motility of the
waves per minute; amplitude of left colon, and improvement in evacuation of
contractions; colonic motility barium as documented by fluoroscopy.

Digital rectal stimulation increases peristaltic waves in the left colon, thus increasing motility in this
segment (Korsten et al. 2007).

Conclusion
There is level 4 evidence (from 1 pre-post study; N=6) (Korsten et al. 2007) that digital rectal
stimulation increases motility in the left colon.

Digital rectal stimulation increases motility in the left colon in individuals with SCI.

3.4 Electrical and Magnetic Stimulation

A significant number of electrical or magnetic stimulation methods have been proposed and tested for
their ability to improve bowel function in SCI individuals. These techniques are varied, from less
expensive and non-invasive ones such as abdominal belt stimulation (Korsten et al. 2004) and
superficial peripheral nerve stimulation (Mentes et al 2007), to more complex and invasive techniques
including the Praxis FES system (implantation of epineural electrodes for skeletal muscle activation)
(Davis et al. 2001) and the implantation of epidural or anterior sacral root electrodes (Kochourbos et
al. 2000; Chia et al. 1996; Binnie et al. 1991; MacDonagh et al. 1990) More recently, magnetic
stimulation techniques have also been also used. This method, based on Faraday's Law, uses
devices to generate a magnetic field in order to induce an electric field, which then generates sufficient
current to stimulate the peripheral nerves (Lin et al. 2002).

9
Table 6a: Functional Electrical or Magnetic Stimulation for of Skeletal Muscles
Author Year; Country
Score
Research Design Methods Outcome
Total Sample Size

Population: Age range=23-67 years ( 1. Activation of the abdominal belt resulted

part A subjects), mean=48 years (part B in a significant reduction in time to first
subjects); 9 subject with tetraplegia, 7 stool and time for total bowel care
subjects with paraplegia; mean length of independent of the level of injury.
injury=13 yrs 2. The time to first stool and time for total
Korsten et al. 2004; Treatment: An abdominal belt with bowel care were significantly shortened
USA embedded electrodes was wrapped in the 6 subjects with tetraplegia, but
PEDro=6 around at the umbilicus level. Device not in the 2 subjects with paraplegia.
RCT activation was random, subjects did not
N=16 know whether the device was activated.
Subjects used the belt for six bowel care
sessions over 2 weeks (the belt was
activated for three sessions and
deactivated for three sessions).
Outcome Measures: time to first stool,
time for total bowel care.
Population: 7 subjects with injury level 1. Accelerated colonic transit times in the
T10 or higher and complete paralysis of ascending, transverse, and descending
abdominal muscles (6 male, 1 female, colon in all subjects who received
age 42 + 19 yrs) were divided into treatment.
treatment (4 subjects) and control (3 2. No changes in the colonic transit times
Hascakova-Bartova et al. subjects) groups. The 3 subjects in in the control group.
2008; control groups subsequently decided to
Belgium receive the treatment, at which point 3
Downs & Black=20 new subjects (all male, ages 25, 43, and
Prospective Controlled Trial 63) were recruited as control.
N = 10 Treatment: Surface abdominal
neuromuscular electrical stimulation
(NMES), administered for 25 minutes
per day, 5 days a week, for 8 weeks
Outcome Measures: colonic transit
times
Population: 22 chronic SCI subjects 1. Mean colonic transit times decreased
with intractable neurogenic bowel from 62.6 h to 50.4 h
dysfunction (19 male, 3 female, mean 2. Frequency of laxative use, unsuccessful
age 46.7 yrs, range 22 – 65); divided evacuation attempts, feeling of
into group 1 (supraconal lesion) and incomplete defecation, difficulty with
Tsai et al. 2009; group 2 (conal/caudal lesion) evacuation, and time taken significantly
Taiwan Treatment: Functional magnetic decreased (p<0.02)
Downs & Black=20 stimulation, in 20-minute sessions twice 3. Mean scores on the KESS significantly
Pre-Post daily for 3 weeks decreased from 24.5 to 19.2 points
N = 22 Outcome Measures: Colonic transit (p<0.001), indicating a significant
times; Knowles-Eccersley-Scott overall improvement in bowel
Symptom Questionnaire (KESS, symptoms.
evaluates frequency of bowel movement
using existing therapy, difficulty of
evacuation, laxative use, and time taken
for bowel evacuation)

10
Author Year; Country
Score
Research Design Methods Outcome
Total Sample Size

Population: A 51-year-old woman who 1. Patients showed improvements in

had undergone discectomy for lumbar Wexner FI score, FIQL score, clinical
disc herniation 3 years ago and a 31- parameters and physiological
year-old man with a 10-year history of measurements. Significance of
lumbar cavernous haemangioma. improvements not reported in this
Mentes et al. 2007 Treatment: Posterior tibial nerve study.
Turkey stimulation was performed for 30 min,
Downs & Black=13 every other day for 4 weeks, and was
Pre-post then repeated every 2 months for 3
N=2 months.
Outcome Measures: Rectal sensory
threshold, Wexner faecal incontinence
score, faecal incontinence severity
index, faecal incontinence quality of life
scales, resting pressure, and maximum
squeeze pressure measurements.
Population: 13 SCI, 2 controls, level of 1. Rectal pressures increased with
injury range=C3-L1; length of injury sacrolumbar stimulation, and with
range=11-35 years (protocol 2 only); transabdominal stimulation.
AIS classes=7 A, 3 B, 1 C. 2. With stimulation, the mean colonic
Treatment: Protocol 1: measured the transit times decreased from 105.2 to
Lin et al. 2001; effects of functional magnetic 89.4 hours.
USA stimulation (FMS) on rectal pressure by
Downs & Black=12 placing the magnetic coil on the
Pre-post transabdominal and lumbosacral
N=15 regions. Protocol 2: consisted of a 5-
week stimulation period to investigate
the effects of functional magnetic
stimulation on total and segmental
colonic transit times.
Outcome Measures: rectal pressure
and total and segmental transit times
Population: 4 subjects with a SCI, 5 1. The gastric emptying time of post-
controls, mean age: 42+/-5.8 years; stimulation was significantly shorter
level of injury: C3-C7; AIS classes: 3 B, than the baseline.
1D 2. There was significantly more gastric
Treatment: Each subject participated in emptying after FMS than at baseline.
Lin et al. 2002; a 3-day protocol. On the first day 3. Gastric emptying with FMS was
USA subjects received a baseline gastric accelerated by 25 minutes when
Downs & Black=11 emptying study. On day 2 there was compared to baseline values.
Pre-post no change in the eating pattern and the
N=9 subject did not undergo any
intervention. On day 3, subjects
received functional magnetic stimulation
(FMS) while undergoing a second
gastric emptying study.
Outcome Measures: Rate of gastric
emptying

11
Table 6b: Implanted Electrical Stimulation Systems
Author Year; Country
Score
Methods
Research Design
Total Sample Size
Population: 36 subjects, 22 female, 14
male; 17 subjects with spinal cord
surgery, 11 with spinal cord trauma,
and 4 with meningomyelocele; median
Holzer et al. 2007 age 49 (range 10-79) years.
Austria Treatment: Sacral nerve stimulation
Downs & Black = 17 (SNS), follow up after 12 and 24 months
Pre-Post Outcome Measures: Number of
N = 36 incontinence episodes, maximum resting
and squeeze anal canal pressure,
American Society of Colorectal Surgeons
(ASCRS) Quality of Life questionnaire
Population: Total of 11 patients suffering
from flaccid paresis of the anal sphincter
muscle and faecal incontinence caused
by cauda equina syndrome underwent
percutaneous nerve evaluation;
eventually 5 proceeded to permanent
Gstaltner et al. 2008; implantation of sacral nerve stimulation
Austria (SNS) system
Treatment: Patients underwent
Downs & Black=16
Pre-Post percutaneous nerve evaluation (PNE);
N = 11 following this analysis, a period of
external temporary SNS was performed,
and if the patient showed improvements,
a permanent SNS system was implanted
Outcome Measures: Wexner score
(severity of fecal incontinence); subject’s
subjective perceptions of quality of life,
determined through interview
Population: 18 subjects with SCIs, 9
men 9 women, mean age 39 (range 18-
63) years, 4 subjects with cervical
injuries, 13 with thoracic, and 1 with
lumbar lesions; 14 subjects with AIS-A, 1
Valles et al. 2009; with AIS-B, and 3 with AIS-C
Treatment: Sacral anterior root
Spain
Downs & Black=15 stimulator, follow up from 12 to 21
Pre-Post months post implantation
Outcome Measures: Use of laxatives;
N = 18
number of bowel evacuation methods
used; frequency of and time dedicated to
bowel movements; constipation; the
Wexner score (severity of fecal
incontinence)
Population: Mean age = 36±9 years; 15
Lombardi et al. 2009; male; 2 subjects with cervical injuries, 9
Italy with thoracic injuries; 13 with lumbar
Downs & Black=15 injuries; 12 subjects had constipation, 11
Case-series had fecal incontinence.
N = 23 Treatment: sacral neuromodulation
Outcome Measures: Wexner
questionnaire, SF-36, number of
evacuations per week, time per
defecation.
12
Outcome
1. 29 subjects demonstrated positive
results during acute testing and
underwent permanent implantation
2. The median number of incontinence
episodes decreased from 7 (range 4-
15) to 2 (range 0-5) in 21 days
3. There were statistically significant
improvements in maximum resting
pressure and maximum squeeze
pressure after 12 and 24 months.
4. There was significant improvement in
QoL for subjects who underwent
permanent implantation
1. Improved faecal continence in all 5
subjects
2. Reported perianal sensitivity and
improved deliberate retention of faeces
in all 5 subjects
3. Reported improved quality of life in all 5
subjects
1. After implantation, fewer patients took
laxatives (10 vs. 13) and patients used
significantly less methods to evacuate
bowel (1.5 vs. 2.1) (p<0.05)
2. The frequency of bowel movements
significantly increased (10 vs. 6
subjects had bowel movements every
day) (p<0.05), and time dedicated to
bowel movement decreased (11 vs. 9
subjects dedicated <30min) but was not
significant.
3. Constipation significantly decreased (7
vs. 11) (p<0.05); incidence of fecal
incontinence increased (18 vs. 16) but
the mean Wexner score decreased (4.6
vs. 5.2) but were not significant.
1. Both the constipation and fecal
incontinence groups experienced
significant improvements in the Wexner
score, more evacuations per week, and
reduced time per defecation.
2. Both groups had a significant
improvement in the mental and general
health subscales of the SF-36
 Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 75 males with incomplete 1. Patients presenting NBSs improved all
SCI; age 18-75; YPI >6 months; suffering parameters by 50% compared with
from neurogenic bowel symptoms (NBSs), baseline for mean number of occurrence
neurogenic lower urinary tract symptoms of fecal incontinence (4.33 vs 1.25); days
(NLUTSs), and/or neurogenic erectile with pads (4.5 vs 1.33) and Wexner
dysfunction (NED) refractory to scores (13.66 vs 5.83) at baseline vs final
conservative therapies visit
Treatment: Sacral Neuromodulation 2. 20% improvement in SF-36 scores for all
Lombardi et al. 2011; (SNM) implantation (Medtronic, Inc) patients compared with baseline (p<0.05)
Italy Stage 1- electrode inserted percutaneously
Downs & Black=14 in third sacral foramina.
Retrospective Stage 2- Permanent implantable pulse
N= 75 generator implanted in patient’s buttock
only if main symptoms improved by at
least 50% during phase 1.
Follow-ups scheduled at 1, 3, 6 months,
and subsequent every 6 months
Outcome Measures: SF-36 health
survey questionnaire; number of fecal
incontinence episodes per week; number
of evacuations per week and Wexner
score (severity of fecal incontinence)
Population: 3 subjects; ages from 17 to 1. Low-frequency electrical stimulation (20
21; all sustained motor-complete thoracic Hz, 350 μs, 8mA) at S3 increased anal
SCI (T3-T8) of 1-1.5 years duration. sphincter and rectal pressure
Treatment: All subjects received 2. Over a 2-month period, daily use of
implantation of pineural electrodes for electrical stimulation appeared to
Johnston et al. 2005; skeletal muscle stimulation for upright provide a significant improvement in
USA mobility. 2 subjects also received bowel management, causing an
Downs & Black = 14 additional extradural electrodes (S2,3,4) increased frequency of defecation, a
Pre-post for bowel and bladder management. decrease in time required for bowel
N=3; however, only 2 had Stimulation was conduced via 22 channel evacuation (from 52 min to 23 min), and
neurogenic bowel outcome implanted Praxis FES system. improved satisfaction over non-
measures and results Outcome Measures: Rectum and anal stimulation evacuation methods.
presented only for 1 sphincter local pressures, patient diary
wherein he described the quantity of stool
passed during each daily session, the
time spent, and a numerical ‘satisfaction’
rating from 1 (least satisfied) to 10 (most
satisfied)
Population: 6 males and 2 females; 1. 6 of 8 patients had improvement in
mean age 40 (range 20-53) years; level bowel function: 4/6 were able to
of injury: 4 with cervical (C4-C6) injuries evacuate spontaneously after
and 4 with thoracic (T3-T11) injuries. All stimulation, 1 described digital
patients suffered from severe evacuation as “easier,” 1 used an
Chia et al. 1996; constipation (≤2 bowel movements/week occasional suppository without the need
Singapore and/or straining at stool for more than to digitally evacuate.
Downs & Black = 14 25% of the time) 2. Six individuals with improved bowel
Pre-post Treatment: All patients had anterior routine also showed a positive rectoanal
N=8 sacral roots electrodes (S2,3,4) pressure difference after immediately
implanted for electrical stimulation. after stimulation.
Outcome Measures: Bowel frequency,
laxative use, suppository use, need for
digital evacuation, anorectal monometry

13
 Author Year; Country
Score
Methods
Research Design
Total Sample Size
Population: 16 males with complete
traumatic SCI (above T12, AIS A); 10 in
treatment group, 6 SCI controls; mean age
Sievert et al. 2010; 31 (range 19-47)
Germany Treatment: Treatment group implanted
Downs & Black=13 with tined lead electrode/sacral nerve
Case-Control modulator (SNM) at S3-foramen. Controls
N SCI treated with SNM= 10 prescribed oral antimuscarinics.
Outcome Measures: Participants
provided a bladder, bowel and erectile
function diaries and answered a specific
questionnaire including laxative use
Population: 6 subjects with disc
prolapse, 4 with trauma, and 1sibject
with spinal stenosis ; 9 women, 4 men;
median age 58 (range 39-73)
Jarrett et al. 2005; Treatment: Temporary sacral nerve
USA stimulation, permanent implant if subject
Downs & Black = 13 demonstrated positive results, median
Pre-Post follow up is 12 months (range 6-24)
N = 12 Outcome Measures: Frequency of
incontinence; resting and squeeze anal
canal pressure ASCRS QoL
questionnaire; SF-36 quality of life
questionnaire
Population: 16 adult patients with SCI
and a history of bowel complications
Treatment: Implantation of sacral roots
electrodes (S1-S3) with rhizotomy at the
Kachourbos & Creasey 2000; conus medularis. Stimulation was
USA delivered via use of VOCARE Bladder
Downs & Black = 12 and Bowel Control System (Finetech-
Pre-post Brindley stimulator).
N= 16 Outcome Measures: Bowel program
times; Occurrence of autonomic
dysreflexia due to bowel; Quality of life
regarding dependence, socialization,
sense of control, and overall QOL
Population: 12 Patients with complete
MacDonagh et al. 1990; supraconal spinal cord lesions, > 2 years
UK post-injury
Downs & Black =10 Treatment: Implanted Brindley-Finetech
Pre-post
intradural sacral anterior root stimulator
N=12 Outcome Measures: full defecation
Population: 2 groups: 7 subjects with
implanted stimulator; 10 subjects without
implant, Age range=20-50 years; C3-T10;
Binnie et al. 1991; time since injury range=1-21 years.
UK Treatment: comparing individuals with
Downs & Black = 8 SCI with a Brindley anterior sacral root
Prospective Controlled Trial stimulator implant to individuals with SCI
N=27 without the implant
Outcome Measures: Oro-caecal and
oro-anal transit time, fecal water content,
and frequency of defecation
14
Outcome
1. SNM group had sufficient movement
without oral laxatives
2. SNM group has improved bowel
movement control
3. All SNM patients reported significantly
better QoL than controls
1. 12 subjects demonstrated positive
results and underwent permanent
implantation
2. Mean frequency of incontinence
decreased from 9.33+7.64 episodes per
week at baseline to 2.39+3.69 at last
follow up
3. ASCRS QoL coping score significantly
improved; the SF-36 QoL scores did not
change
4. Neither resting nor squeeze anal canal
pressure changed significantly
compared to baseline
1. Bowel program times were reduced
from a mean of 5.4 hours per week pre-
operatively to 2.0 hours per week post-
operatively
2. Autonomic dysreflexia due to bowel was
eliminated
3. Users reported a greater sense of
independence, increased socialization,
greater control over their lives,
improved self-image, decreased
feelings of depression, improved
interpersonal relationships and an
overall improvement in QOL
1. 6 patients achieved full defecation with
implant and manual help no longer
required.
2. time taken to complete defecation was
reduced
3. All were free from constipation
1. There was no significant difference
between the oro-caecal times for the
controls and the SCI group or between
the controls and the Brindley stimulator
group (p>0.05).
2. Paraplegics in stimulator group had a
significant increase in defecation
frequency compared to the SCI group.
3. There was a non-significant trend
towards a more rapid CTT in the
stimulator group compared to the SCI
group.
Discussion
A variety of methods using electrical or magnetic stimulation devices have been tested to determine
whether or not it improves colonic transit time in individuals with SCI. The use of functional magnetic
stimulation decreased the mean colonic transit time (Tsai et al. 2009; Lin et al. 2002; Lin et al. 2001),
as did stimulation of the abdominal muscles (Hascakova-Bartova et al. 2009; Korsten et al. 2004,).
While preliminary results for posterior tibial nerve stimulation appear promising, it is important to note
that the statistical significance of the improvements in clinical and physiological parameters were not
reported and the study involved only two subjects (Mentes et al. 2007).

In terms of implanted electrical stimulation systems, Binnie et al. (1991) found that an implanted
Brindley stimulator did not reduce oro-caecal time for individuals with SCI, however, subjects in the
stimulator group did experience a significant increase in defecation compared to the SCI group (Binnie
et al. 1991).

Subsequent studies using sacral nerve root stimulation yielded improvements in bowel function,
including better spontaneous evacuation (Lombardie et al. 2011; Sievert et al. 2010; Chia et al. 1996),
reduced bowel program times (Kachourbos and Creasey 2000, Valles et al. 2009, Lombardi et al.
2009), elimination of autonomic dysreflexia related to bowel management (Kachourbos and Creasey
2000), and increased quality of life (Sievert et al. 2010; Lombardi et al. 2011; Lombardi et al. 2009;
Holzer et al. 2007; Kachourbos and Creasey 2000) and elimination of manual help for defecation
(Macdonagh et al. 1990). Both Holzer et al. (2007) and Jarrett et al. (2005) found reduced number of
incontinence episodes through the use of sacral nerve stimulation, but conflicting evidence on the
effects of resting and squeeze canal pressures (Lombardi et al, 2011; Holzer et al. 2007, Jarrett et al.
2005). Gstaltner et al. (2008) found an improved fecal continence, quality of life, and deliberate
retention of feces in their study among individuals with cauda equine syndrome. Finally, the Praxis
FES system increased the frequency of defecation and decreased the time required for bowel
evacuation in one subject (Johnston et al. 2005).
Conclusions
There is level 1b evidence (from 1 RCT) (Korsten et al. 2004) that electrical stimulation of the
abdominal wall muscles can improve bowel management for individuals with tetraplegia.

There is level 2 evidence (from 1 prospective controlled trial) (Binnie et al. 1991) that support
the use of sacral anterior root stimulation to reduce severe constipation in complete injuries.

There is level 4 evidence (from 3 pre-post studies) (Tsai et al. 2009, Lin et al. 2001; 2002) that
functional magnetic stimulation may reduce colonic transit time in individuals with SCI.

There is level 4 evidence (from 1 pre-post study with two subjects) (Mentes et al. 2007) that
posterior tibial nerve stimulation improves bowel management for those with incomplete SCI.

There is level 4 evidence (from 1 pre-post study with two subjects) (Johnston et al. 2005) that
the Praxis FES system increases the frequency of defecation and decreases time required for
bowel care in individuals with SCI.

15
 Electrical stimulation of the abdominal wall muscles can improve bowel management for
individuals with tetraplegia.
Functional magnetic stimulation may reduce colonic transit time in individuals with SCI.
Sacral anterior root stimulation reduces severe constipation in individuals with SCI.
More research is needed to warrant the use of the Praxis FES system for bowel management
in individuals with SCI.
Posterior tibial nerve stimulation is a relatively new treatment for fecal incontinence and while
preliminary results show promise, the sample size is limited and more research is needed to
warrant the use of this new modality.

3.5 Irrigation Techniques

Persons with SCI require assistance with emptying their bowels regularly. Forms of assistance include
the use of medications, suppositories, digital stimulation and/or mini-enemas. Clinical experience
shows that despite their best efforts, some persons with SCI are unable to achieve an effective,
regular bowel routine and thus, other methods may be explored. Pulse water irrigation is one such
technique and consists of supplying intermittent, rapid pulses of warm water into the rectum to break
up stool impactions and to stimulate peristalsis (Puet et al. 1997). Christensen et al. (2006) assessed
the use of the newly developed Peristeen Anal Irrigation system (Coloplast A/S, Kokkedal, Denmark)
for transanal irrigation. The system consists of a rectal balloon catheter, a manual pump, and a water
container. The catheter is inserted into the rectum and the balloon inflated to hold the catheter in place
while a tap water enema is administered with the manual pump (Christensen et al. 2006).
Table 7: Irrigation Techniques for Neurogenic Bowel After Spinal Cord Injury
Author Year; Country
Score
Research Design Methods Outcome
Total Sample Size
Population: 1. The constipation score, fecal
1) Transanal irrigation group – mean age = 47.5 incontinence score, and
years; 13 females and 29 males; 21 with neurogenic bowel dysfunction
complete SCIs and 10 with incomplete injuries. scores were lower in the transanal
For subjects with injuries T9 and above, 3 were irrigation group
complete and 5 were incomplete; subjects with 2. Transanal irrigation group scored
injuries T10-L2, 1 was complete and 1 was better on symptom-related quality-
incomplete; for subjects with injuries L3-S1 1 of-life tool
was incomplete. 3. Improvement found in the
2) Conservative bowel management group – transanal irrigation group as a
Christensen et al. 2006; Age: mean 50.6 years; 12 females and 33 whole was not confined to the
Denmark males; For subjects with injuries T9 and above, more physically able patients
PEDro =7 22 were complete and 11 were incomplete; for 4. Data from study weeks 7-10
Randomized control trial subjects with injuries T10-L2, 1 was complete showed reduced time spent on
N=87 and 3 were incomplete, For subjects with bowel management each day;
injuries L3-S1, all 8 were incomplete. patients reported being less
Treatment: Transanal irrigation (Peristeen Anal dependent on help
Irrigation system) or conservative bowel 5. The frequency of urinary tract
management (Paralyzed Veterans of America infection was lower in the
clinical practical guidelines) for a trial period of transanal irrigation group
10 weeks.
Outcome Measures: Cleveland Clinic
constipation scoring system (CCCSS), St
Mark’s fecal incontinence grading system
(FIGS), American Society of Colon and Rectal
Surgeons fecal incontinence score.

16
Author Year; Country
Score
Research Design Methods Outcome
Total Sample Size
Population: 45 men, 17 women; mean age 1. Subjects’ CCCSS scores
47.5 + 15.5 yrs were enrolled; 55 actually significantly improved from mean
completed the study 13.5 to 10.2.
Christensen et al. 2008; Treatment: Peristeen Anal Irrigation for a 10- 2. Subjects’ FIGS scores significantly
USA week period improved from mean 8.5 to 4.5.
Downs & Black = 20 Outcome Measures: CCCSS, FIGS, 3. Subjects’ NBD scores significantly
Pre-Post Neurogenic Bowel Dysfunction score (NBD). improved from mean 15.3 to 10.8.
N = 62 4. Peristeen anal irrigation is shown
to significantly improved
constipation, anal continence, and
symptom-related quality of life in
SCI subjects
Population: 1. Overall success with the ECC was
Group 1) Enema continence catheter: 21 found in 12 of 21 patients (57%).
patients, including 15 with a SCI; 11 women In patients with fecal incontinence,
and 10 men; Age: mean 39.9, range 7-72 the ECC was successful in 8/11
years; Level and type of injury: 3 subjects with (73%), while 4/10 (40%) with
supraconal SCIs (T2 incomplete, T4 complete, constipation were successfully
T11 complete), 12 with conal or cauda equina treated.
Christensen et al. 2000; injuries (all incomplete) ; mean follow-up 16 2. Overall success with the MACE
Denmark months, range 1-51 was found in 7/8 (87%) patients.
Downs & Black = 17 Group 2) Malone antegrade continence enema: 3. Successful treatment with the
Retrospective interviews 8 patients, including 4 with a SCI; 5 females ECC or the MACE was followed by
and case series and 3 males; Age: mean 32.8 years, range 15- significant improvement in quality
N=29; 19 SCI patients 66; 2 subjects with supraconal SCIs (C5-6 and of life.
T2, incomplete); mean follow-up 38 months,
range 4-77
Treatment: Enema continence catheter (ECC)
vs. Malone antegrade continence enema
(MACE)
Outcome Measures: colorectal function,
practical procedure, impact on daily living and
QOL, general satisfaction

Population: 36 SCI patients with severe 1. Significant increase in the scores

neurogenic bowel dysfunction and on the QoL questionnaire, and on
unsatisfactory bowel management were intestinal functionality opinion
enrolled in study; 32 actually completed the scores.
study 2. Significant decrease in abdominal
Del Popolo et al. 2008; Treatment: Peristeen Anal Irrigation for 3 pain or discomfort
Italy weeks 3. Significant decrease in incidence
Downs & Black = 14 Outcome Measures: Quality of life (QoL) of fecal or gas incontinence
Pre-Post questionnaire; subjects’ opinions on their 4. Significant improvement of
N = 36 intestinal functionality; use of pharmaceuticals; constipation (63% of patients
dependence on caregivers; incidence of experiencing constipation reported
incontinence and constipation; abdominal pain improvements)
or discomfort 5. 28.6% of patients reduced or
eliminated their use of
pharmaceuticals
Population: 211 SCI patients with neurogenic 1. Successful outcomes in 98 (46%)
bowel dysfunction (96 male, 115 female, age 7- of patients after a mean follow-up
81 yrs, median 49), who were introduced to of 19 months (range 1-114
Faaborg et al. 2008; transanal irrigation between 1994 and 2007. months)
Denmark Treatment: Enema continence catheter (same 2. Dropout rate of 20% in the first 3
Downs & Black = 13 as that used in Christensen et al. 2000) months of using transanal
Post-test Outcome Measures: Rate of success irrigation
N = 211 (treatment was considered successful if the 3. Success rate 3 years after
patient is currently using transanal irrigation, if introduction of transanal irrigation
the patient used transanal irrigation until he/she was 35%
died, or if the patient’s symptoms resolved while 4. The male gender, mixed

17
 Author Year; Country
Score
Research Design Methods Outcome
Total Sample Size
using TAI), evaluated by a questionnaire, as symptoms, and prolonged
well as the patient’s medical records; incidence colorectal transit times were
of bowel perforation and other side effects significantly correlated with
successful outcomes
5. Chance of bowel perforation was
approximately 1 in 50000
6. Other minor side effects (such as
abdominal pain, minor rectal
bleeding, and general discomfort)
were observed in 48% of subjects
Population: 31 individuals with SCIs. 1. Successful in removing stool in all
Treatment: Pulsed irrigation evaluation was but three patients.
Puet et al. 1997; used in SCI patients. It consists of 2. 11 patients had multiple
USA intermittent, rapid pulses of warm water to procedures.
Downs & Black = 12 break up stool impactions and stimulate 3. 162 procedures were performed
Case Series peristalsis. on 4 outpatients on a regular basis
N=31 Outcome Measures: Efficacy of technique, because they could not develop an
outpatient use effective bowel routine with the
standard digital stimulation,
suppositories, or mini enemas.

Discussion
Pulsed irrigation evacuation is a safe and effective method for individuals with SCI who develop
impactions or do not have an effective bowel routine (Puet et al. 1997). Compared to conservative
bowel management practices outlined by the Paralyzed Veterans of America, transanal irrigation,
through the use of the Peristeen Anal Irrigation System, reduces time spent on bowel management,
dependency on others for help, and the frequency of defecation-related symptoms (i.e. abdominal
pain, anorectal pain, chills, nausea, dizziness, pounding headache, sweating, facial flushing, general
discomfort) (Christensen et al. 2006). In addition, transanal irrigation appears to alleviate fecal
incontinence and constipation more so than conservative bowel management (Christensen et al.
2006). Christensen et al. (2008) and Del Popolo et al. (2008) found similar results. Del Popolo et al.
(2008) also found that 9 out of their 32 subjects either reduced or eliminated their use of
pharmaceuticals. Finally, Christensen et al. (2000), found that the Enema Continence Catheter can be
used to treat the neurogenic bowel with improved fecal incontinence and quality of life.
Conclusion
There is level 4 evidence (from 1 case series study) (Puet et al. 1997) that supports using
pulsed water irrigation (intermittent rapid pulses) to remove stool in individuals with SCI.

There is level 1b evidence (from 1 RCT) (Christensen et al. 2006) that supports the use of
transanal irrigation (Peristeen Anal Irrigation system) over conservative bowel treatment (as
outlined by the Paralyzed Veterans of America clinical practical guidelines).

There is level 4 evidence (from 1 case series study, and one post-test) (Faaborg et al. 2008;
Christensen et al. 2000) that supports the use of an Enema Continence Catheter to treat the
neurogenic bowel.

Pulsed water irrigation may remove stool in individuals with SCI and transanal irrigation alleviates
constipation and fecal incontinence. Often, more than one procedure is necessary for individuals
that are unable to develop an effective bowel routine.

18
3.6 Use of Pharmacological Agents
Chronic constipation is a common problem after SCI, affecting up to 80% of such patients (Krogh et al.
2002). Prokinetic agents are presumed to promote transit through the GI tract, thereby decreasing the
length of time needed for stool to pass through the intestines and increasing the amount of stool
available for evacuation. Cisapride (the most commonly used), prucalopride, metoclopramide,
neostigmine (administered both with and without glycopyrrolate), and fampridine are five examples
presented in the following research. The presence of constipation in patients with SCI with slow transit
times has been well-documented (Geders et al. 1995). Often, medication is considered the last resort,
with its use reserved for persons with severe constipation and where modification of the bowel
program has failed.
Table 8: Treatment studies using pharmacology for neurogenic bowel after SCI
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 7 SCI subjects with 1. Compared with placebo,
defecatory problems (age 46.9 + 3.4 yrs, neostigmine/glycopyrrolate significantly
range 30 – 56 yrs). reduced the total bowel evacuation time
Treatment: injections of neostigmine/ from 98.1 + 7.2 min to 74.8 + 5.8 min
Rosman et al. 2008; glycopyrrolate for 1 week, wash-out 2. Neostigmine/glycopyrrolate significantly
USA period for 1 week, and placebo for 1 reduced the time to first flatus from 56.9 +
PEDro = 8 week, in random order 5.4 min to 21.8 + 4.5 min
RCT with crossover Outcome Measures: Total bowel 3. Neostigmine/glycopyrrolate also
N=7 evacuation time; time to first flatus; time significantly reduced the time to beginning
to beginning of stool flow; time to end of of stool flow from 69.8 ± 2.8 to 42.3 ± 6.4
stool flow. min, and time to end of stool flow from
80.3 ± 4.0 to 53.3 ± 8.3 min.

Population: mean age range: treatment
group - 58.8 years, controls - 63.4 years,
2 subjects with paraplegia, 7 subjects
with tetraplegia
Treatment: Cisapride or placebo
Geders et al. 1995; administered in oral doses. Subjects
USA received cisapride or placebo 3 days
PEDro = 8 before ingestion of the radiopque
RCT markers.
N=9 Outcome Measures: total and
segmental colonic transit time (CTT),
questionnaire on type, frequency, and
severity of clinical symptoms before and
after cisapride or placebo administration
1. Mean total colonic transit time (CTT) was
significantly longer in SCI patients than
controls.
2. Subjects with a normal CTT demonstrated
no benefit to the administration of
cisapride.
3. 5 subjects with tetraplegia with initial
abnormal total CTT improved their left
CTT following treatment
4. No adverse side effects of cisapride
administration were noted.

Population: Age range: 19-71yrs, Level 1. No delay or improvement in gastric

of injury: C4-L2; 7 subjects with emptying was observed after the
tetraplegia and 7 subjects with administration of cisapride.
paraplegia; length of injury range=7 2. Mean MCTT in subjects with tetraplegia
months-33yrs. was significantly longer than normal
Rajendran et al. 1992; Treatment: Subjects were administered subjects; cisapride resulted in
USA cisapride orally (10mg four times a day) normalization of the MCTT among the
PEDro = 8 for 4d. Gastric emptying or mouth-to- subjects with tetraplegia.
RCT cecum transit time (MCTT) was
N=14 measured either on the 4th or 5th day
after the administration of cisapride or
placebo. The control subjects were
tested without medication or placebo.
Outcome Measures: MCTT; gastric
emptying

19
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: mean age: 34.7±2.49 yrs 1. Compared with baseline, mean changes
(placebo), 36.5±3.91 yrs (1mg group), in constipation severity increased with
44.3±3.05 yrs (2mg group) placebo, but decreased with prucalopride.
Treatment: Subjects randomized to 2. Diary data showed an improvement in
Krogh et al. 2002; double-blind treatment with prucalopride average weekly frequency of all bowel
Denmark 1mg or placebo, taken 1/day for 4 wks. A movements over 4 wks within the 2 mg
PEDro = 7 nd
2 group of subjects was randomized to group.
RCT double-blind treatment with prucalopride 3. 4 subjects (2 mg group) reported
N=22 2mg or placebo for 4wks. moderate/severe abdominal pain.
Outcome measures: constipation;
urinary habit; constipation severity and
symptoms; colonic transit times

Population: 5 subjects with tetraplegia 1. Neostigmine and the combination of

and 8 with paraplegia; Age: mean 46
years, range 25-69; TSI: mean 14 years,
range 1-31; Type of injury: All motor
complete except 1, 8 sensory
Korsten et al. 2005; incomplete, 5 sensory complete; Level of
USA injury: C4-T12
PEDro = 6 Treatment: On separate days, subjects
RCT received, in a randomized, blinded
N=13 design, one of three intravenous
infusates (normal saline, 2 mg
neostigmine, or 2 mg neostigmine + 0.4
mg glycopyrrolate).
Outcome Measures: The effect of these
infusates on bowel evacuation of barium
paste.
neostigmine and glycopyrrolate both
caused a similar expulsion of the stool,
which was greater than with normal saline
(median score 3 vs. 4 vs. 0, respectively)
2. Mean time to expulsion was 11.5 min
(range 5-20 min) after neostigmine and
13.5 min (range 4-23 min) after the
combination
3. There was no correlation between the
level of SCI and likelihood of bowel
evacuation with any of the infusates.

Population: A total of 91 subjects with 1. A significantly larger number of subjects

motor-incomplete SCI randomized to in the 25 mg bid (6/30 subjects) and 40
three groups: mg bid (7/30 subjects) groups had an
(1) Fampridine, sustained release, 25 mg increase in the number of days with bowel
bid – Sex: 22 males, 8 females; Age: movements compared to subjects in the
mean 44, range 23-66; Duration of injury: placebo group. Number of days increase
mean 8.3 years, range 1-30; Level of not reported.
injury: 23 cervical, 7 thoracic; AIS grade:
14 C, 16 D
Cardenas et al. 2007; (2) 40 mg bid – Sex: 26 males, 4
USA females; Age: mean 42 years, range 21-
PEDro = 6 67; Duration of injury: 10.8 years, range
RCT 1-35; Level of injury: 24 cervical, 6
N=78 thoracic; AIS grade: 12 C, 18 D
(3) Placebo – Sex: 24 males, 7 females;
Age: mean 38, range 19-61; Duration of
injury: mean 8.3 yrs, range 1-37; Level of
injury: 26 cervical, 5 thoracic; AIS grade:
18 C, 13 D
Treatment: Drug treatment or placebo
for 8 weeks
Outcome Measures: Number of days
with bowel movement

20
Author Year; Country
Score
Methods
Research Design
Total Sample Size
Population: 10 patients suffering from
constipation due to complete supraconal
spinal cord lesion; Age: mean 35.8,
range 19-63; Level of injury: C6-L1; Time
since injury: 1-12 months
Treatment: Cisapride 10 mg four times
De Both et al. 1992; daily vs. placebo
Netherlands Outcome Measures: Defecation
PEDro = 5 frequency and ease, consistency of
RCT stools, percentage of defecations
N=10 preceded by digital stimulation or
suppository, time between suppository
and successive defecation, oro-caecal
and oro-anal transit time
Outcome
1. No statistical difference between the
number of defecations per week under
the influence of cisapride and placebo
2. With respect to the ease of evacuation, a
significant improvement in both the
cisapride and placebo phase was
observed
3. The mean degree of consistency of stools
changed significantly with cisapride.
4. Percentage of defecations preceded by
digital reflex stimulation or suppository
use were unaffected by cisapride or
placebo
5. There appeared to be a significant
reduction of oro-caecal transit time with
cisapride

Population: mean age: 34.1yrs, 9 1. The colonic transit time (CTT) was
males, 1 female, age range 20-45yrs; reduced from 185 to 123 hours.
level of injury: C4-T10, all subjects had
Binnie et al. 1988;
complete injuries; length of injury: mean
UK
8.1yrs, range 1-20 yrs
Downs & Black =12 Treatment: Intravenous injection of 10
Pre-post
mg cisapride. After an interval of at
N=10
least 48 hours the subject was
commenced on oral cisapride.
Outcome measures: Oro-caecal transit
time

Population: All male; 12 subjects with
tetraplegia, 3 subjects with paraplegia,
length of injury=3-356 months.
Treatment: After establishing baseline
studies, patients with constipation
Longo et al. 1995; received one oral cisapride 20mg tablet
USA three times each day for one month.
Downs & Black = 9 Subjects offered drug for two additional
Pre-post months, all measurements were
N=15 repeated.
Outcome Measures: colonic transit
study; anorectal manometry; bowel
movement per day or week; intestinal
transit and pelvic floor studies
1. All subjects had three months or more of
treatment with cisapride.
2. 6/12 reported that symptoms of
constipation improved.
3. 9/12 subjects reported that the amount of
time needed to accomplish a bowel
movement decreased.
4. No subject reported a worsening of
constipation.

Population: Age range was from 20 to 1. The mean gastric emptying (GE) half
55 years, all subjects with complete SCI, time for a liquid meal decreased in the
11 subjects with tetraplegia, 9 subjects subjects with tetraplegia from 104.8 min
Segal et al. 1987; with paraplegia, 8 controls to 18.8 min after treatment with
USA Treatment: subjects ingested a liquid metoclopramide.
nd
Downs & Black = 9 meal, then within 2 weeks, ingested 2 2. The pretreatment mean GE of 111.5 min
Prospective Controlled liquid meal while metoclopramide was decreased to 29.1min among the
Trial administered intravenously; gastric subjects with paraplegia.
N=20, Control N=8 emptying (GE) was evaluated after each
liquid meal
Outcome Measures: half time of gastric
emptying, gastric emptying patterns in
the early and later phases

21
Discussion
The efficacy of cisapride (a “prokinetic" agent with serotoninergic receptor agonist action) for treatment
of the neurogenic bowel remains inconclusive. Longo et al. (1995) found subjective improvements in
colonic and anorectal function, alleviation of symptoms, an increase in stool frequency, a decrease in
the use of laxatives, and an increase in the ease of defecation. These findings are contradicted by an
earlier study by De Both et al. (1992) in which the authors found no difference in the number of
defecations per week between subjects in the cisapride and placebo groups, similar improvements in
both groups in terms of ease of evacuation, and the use of digital stimulation or suppositories
unaffected by both treatments. However, cisapride use does seem to improve transit times in persons
with SCI. A significant reduction in colonic transit time, from 7.7 days to 5.1 days, was reported by
Binnie et al. (1988) and a significant reduction in oro-caecal transit time was reported by De Both et al.
(1992). Geders et al. (1995) and Rajendran et al. (1992) found that cisapride improves transit times
in subjects with tetraplegia with initial abnormal transit times. In conjunction with newer and more
sophisticated techniques of colonic transit times measurement, further investigations of cisapride in
those with SCI and symptomatic bowel dysfunction is warranted (Geders et al. 1995).

Segal et al. (1987) investigated the use of metoclopramide (a potent dopamine receptor antagonist
with prokinetic properties) for enhancing gastric emptying in persons with SCI. They found that
impaired gastric emptying is correlated with decreased drug absorption. Since constipation in patients
with both acute and chronic SCI is considered primarily a consequence of prolonged colonic transit
time, stimulating intestinal motility would appear to be a reasonable therapeutic approach.
Improvement in constipation and increased frequency of bowel movement were also seen with the use
of prucalopride - a novel, highly selective serotonin receptor agonist with enterokinetic properties that
facilitate cholinergic and excitatory non-adrenergic, non-cholinergic neurotransmission (Krogh et al.
2002). Korsten et al. (2005) found that neostigmine (a reversible cholinesterase inhibitor) or the
combination of neostigmine and glycopyrrolate administered intravenously improved stool expulsion
over normal saline. Rosman et al. (2008) reported similar findings for the use of neostigmine and
glycopyrrolate in combination over placebo. Finally, a study by Cardenas et al. (2007) reported an
increase in the number of days with bowel movements in approximately one-fifth of the subjects given
sustained-release fampridine (selective potassium channel blocker).
Conclusion
Cisapride: There is level 1a evidence (from 3 RCTs) (De Both et al. 1992; Rajendran et al. 1992;
Geders et al. 1995) that cisapride significantly reduces colonic transit time for chronic
constipation.

Prucalopride: There is level 1b evidence (from 1 RCT) (Krogh et al. 2002) that prucalopride
increases stool frequency, improves stool consistency and decreases gastrointestinal transit
time.

Metoclopramide: There is level 2 evidence (from 1 prospective controlled trial; N=20) (Segal et
al. 1987) that intravenous administration of metoclopramide corrects impairments in gastric
emptying.

Neostigmine: There is level 1b evidence (from 1 RCT) (Korsten et al. 2005) that neostigmine,
administered with or without glycopyrrolate, leads to a greater expulsion of stool. There is level 1
evidence that neostigmine with glycopyrrolate decreases total bowel evacuation times and
improves bowel evacuation.

Fampridine: There is level 1b evidence (from 1 RCT) (Cardenas et al. 2007) that fampridine can
increase the number of days with bowel movements.

22
 Cisapride, prucalopride, metoclopramide, neostigmine, and fampridine may be used for the
treatment of chronic constipation in persons with SCI.
Cisapride and Prucalopride are not currently available in Canada or the United States due to
adverse side effects. More research is required on these prokinetic agents prior to their regular
use.

3.7 Use of Suppositories

More than 20% of persons with SCI report difficulty with evacuation of their bowels (House et al.
1997). The use of chemical rectal agents (suppositories) is a common and often necessary
component of a successful bowel management program. Bisacodyl (dulcolax) and glycerin are the
most common active ingredients in these suppositories. The glycerin suppository is a mild local
stimulus and lubricating agent. Bisacodyl (dulcolax) is an irritant that acts directly on the colonic
mucosa producing peristalsis throughout the colon. The most commonly used laxative suppositories
contain 10 mg of bisacodyl powder distributed within a hydrogenated vegetable-oil base (HVB) (House
et al. 1997).
Table 9: Treatment studies using suppositories for neurogenic bowel after SCI
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Age range=26-61, 9 subjects with 1. Time to Flatus: PGB sig. less time
cervical injuries, 6 with thoracic injuries, 11 with than HVB
complete injuries, 4 with incomplete injuries, 2. Flatus to stool flow: No sig.
length of injury: 3 months to 45 years differences
House & Stiens 1997; Treatment: At each regularly scheduled bowel 3. Defecation Period: PGB sig. less
USA care session, either a 10 mg hydrogenated time than HVB
PEDro = 7 vegetable-oil base (HVB) or 10 mg polyethylene 4. Overall: PGB suppositories
RCT glycol base (PBG) suppository was inserted. significantly decreased bowel care
N=15 Outcome Measures: time to flatus, flatus to stool time
flow, defecation period, wait until transfer
cystometrogram, intracolonic pressure, colonic
motor and myoelectrical activity

Population: All males; 4 with incomplete and 10 1. Time to flatus: HVB=31 min,
with complete injuries; Age: mean 53.4 years, PGB=12 min (p<0.002); Defecation
mean time since injury 18.3 years; Level of injury: period: HVB=58 min, PGB=32 min
C3-L1 (p<0.0005); Total bowel care time:
Stiens et al. 1998; Treatment: Polyethylene glycol vs. vegetable oil HVB=102 min, PBG=51.2 min
USA based bisacodyl suppositories to initiate side- (p<0.0005)
Downs & Black = 18 lying bowel care 2. The numbers of digital stimulations
Prospective controlled Outcome Measures: Time to flatus; flatus to required for the bowel care
trial stool flow; defecation period; clean up; total bowel sessions: HVB=5.0, PGB=3.2 (no
N=14 care time significant difference, p=0.3505)
3. Use of PGB statistically improved
bowel outcomes compared to HVB.

23
 Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Age: mean 64 years, range 41-81; 1. All patients experienced a
115 subject had motor complete injuries; mean shortening of bowel care time with
Frisbie 1997;
time since injury: 19 years (range 3-51); 15 PEGBS. Average time for bowel
USA
cervical and 4 thoracic (T1-7). evacuation was 2.4 hours (range
Downs & Black = 16
Treatment: A bisacodyl suppository based in 1.0-4.5 hours) with HVOBS and 1.1
Prospective controlled
polyethylene glycol (PEGBS) was compared with hours (range 0.3 to 1.8 hours) with
trial
a conventional bisacodyl suppository based in PEGBS
N=19
hydrogenated vegetable oil (HVOBS)
Outcome Measures: Average time for complete
bowel evacuation

Population: Age range=27-67yrs, level of injury: 1. 10 subjects complete all

C5-L1, 5 subjects with tetraplegia, 9 subjects with treatments.
paraplegia, length of injury range=2-38yrs 2. Of these 10 subjects, the mean
Treatment: First, subjects used bisacodyl evacuation time was significantly
suppositories for five bowel programs for baseline reduced with Theravac SB
Dunn & Galka 1994; data. Second, they used a docusate sodium mini compared to the mean times with
USA enema (Theravac SB) for the next five bowel both the bisacodyl interventions.
Downs & Black = 12 programs. Finally, they used bisacodyl for five 3. No significant difference in
Case Series more bowel programs all while recording similar evacuation time between the first
N=14 information in a diary log. and second bisacodyl
Outcome Measures: time of insertion of the interventions.
rectal medication; time of first evacuation; time
required to complete the first evacuation; other
interventions used; bowel problems between
bowel programs

Population: Age range=21-76yrs, injury level;
C4-T12, 6 subjects with tetraplegia, 1 subject with
paraplegia, length of injury range=2-25yrs
Treatment: Each subject was studied after
receiving one week of therapy with one of the
following four modalities: 1) two bisacodyl
suppositories, 2) two glycerin suppositories, 3)
Amir et al. 1998; one mineral oil enema and 4) one docusate
USA sodium mini enema (Theravac SB) daily.
Downs & Black = 9 Outcome Measures: total colonic and segmental
Cohort colonic transit times
N=7
1. The total colonic transit time was
significantly reduced with
docusate sodium mini-enemas.
2. There was no significant
difference in total colonic between
docusate sodium and mineral oil
enema, and both produced
significantly shorter transit times
compared to bisacodyl or glycerin
suppositories.
3. Bowel evacuation time was least
for docusate sodium mini-enemas.
4. In terms of difficulty with
evacuation, docusate sodium
scored best in symptom reduction
followed by, in descending order
of efficacy, mineral oil enema,
bisacodyl suppositories and
glycerin suppositories.

Discussion
The effectiveness of the hydrogenated vegetable oil-based bisacodyl suppositories compared to the
polyethylene glycol-based suppositories has been thoroughly examined. The total bowel care time
with the polyethylene glycol-based suppository is significantly less (Stiens et al. 1998; Frisbie 1997;
Dunn & Galka 1994). House and Stiens (1997) compared the effectiveness of hydrogenated
vegetable-based, polyethylene glycol-based and docusate glycerin (mini-enema) in subjects with
upper motor neuron (UMN) lesions. Results showed a significant decrease in bowel care time using
the polyethylene glycol-based suppository and the mini-enema as compared with the hydrogenated
vegetable oil-based suppositories. Chemical rectal agents (suppositories) are used commonly by
persons with SCI to maintain or enhance a successful bowel management program.

24
Conclusion
There is level 1b evidence (from 1 RCT) (House and Stiens 1997) to support polyethylene
glycol-based suppositories for bowel management. There is a clinically significant decrease in
the amount of nursing time for persons requiring assistance and less time performing bowel
care for the independent individual.

Polyethylene glycol-based suppositories (10 mg. bisacodyl) are effective in maintaining or

enhancing a successful bowel management program, especially for persons with an upper motor
neuron SCI.

3.8 Colostomy
Bowel dysfunction is perceived as one of the most disabling aspects of SCI, causing great anxiety and
being a source of emotional upset. Of all the medical problems experienced by persons with SCI,
many rate the loss or change in bowel habit as one of the most significant factors affecting their quality
of life. A colostomy is the surgical formation of an artificial anus by connecting the colon to an opening
in the abdominal wall. SCI patients who receive elective colostomy usually have exhausted all other
medical treatments available to them for bowel management. Colostomy is an option when the
extent of bowel dysfunction becomes severe and other non-surgical methods have failed to produce
the desired result. Colostomy is also frequently advocated as an adjunct to the treatment of perineal
pressure ulcers in SCI patients. However, colostomy following SCI is not routinely used and is seen by
many as the failure of rehabilitation services. There is no general consensus as to when colostomy
should be performed in patients with SCI because there has been no way to capture the GI problems
that often necessitate colostomy.

3.8.1 Systematic review

One systematic review examined studies that directly compared clinical, functional, QOL out- comes
or satisfaction among patients with intestinal diversions to patients managed by conservative means.

Table 10: Systematic review on Colostomy

Authors; Country
Date included in the
Methods
review
Databases Conclusions
Total Sample Size
Level of Evidence
Types of Articles
Score

Hocevar and Gray, 2008 Methods: literature search for
USA prospective and retrospective
studies that directly compared
Reviewed Published clinical, functional, QOL outcomes
articles from January 1960 or satisfaction among patients with
to November 2007 intestinal diversions to patients
managed by conservative means.
N= 6
n=203 Databases: MEDLINE, CINAHL,
Cochrane Database for Systematic
Types of Articles: Reviews, Google Scholar
2 case-control
3 interviews Level of Evidence:
1 cross-sectional survey No formal validity assessment was
described
AMSTAR: 3
1. Creation of an ostomy in selected patients
provides equivocal or superior QOL outcomes
when compared to conservative bowel
management
2. Both colostomy and ileostomy surgery
significantly reduce the amount of time required
for bowel management (Level of Evidence: 3).
3. Patients who undergo ostomy surgery tend to be
satisfied with their surgery, and a significant
portion report a desire to be counseled about this
option earlier.
4. There are no clear advantages when functional,
clinical, or QOL outcomes associated with
colostomy are compared to those seen in SCI
patients undergoing ileostomy (Level of evidence:
4).

25
Table 11: Colostomy after a spinal cord injury
Author Year; Country
Score
Methods
Research Design
Total Sample Size
Population: 26 subjects with colostomy:
age: 22-87 yr, 10 subjects with cervical
Randell et al. 2001; injuries, 16 with lumbar/lower thoracic
New Zealand injuries matched with 26 subjects
Downs & Black = 17 without colostomy.
Case-control Treatment: Colostomy
N=52 Outcome Measures: Burwood Quality
of Life Questionnaire: 5 areas: systemic
symptoms, and emotional, social, work
and bowel function
Population: 12 males and 2 females;
Age at time of operation: mean 54.8,
range 20-65; time from injury to stoma
formation: 15 years, 2-37; Level of
injury: C4-T11; 3 subjects with cervical
Kelly et al. 1999; injuries, 10 with thoracic, and 1 with
UK lumbar injuries.
Downs & Black = 15 Treatment: 12 patients underwent left
Post-test iliac fossa end colostomy and 2 patients
N=14 right iliac fossa end ileostomy
Outcome Measures: Time spent on
bowel care per week; independence in
bowel care; quality of life
Population: 23 SCI subjects who had a
colostomy in the digestive surgery
department of Brugmann Hospital
between Jan 1996 and Dec 2005 (age
Munck et al. 2008; range 22-72).
Belgium Treatment: Intestinal stoma formation
Downs & Black = 13 Outcome Measures: Demographic
Case-series information and medical information on
N = 23 the stoma formation and complications,
collected from patients’ medical records;
quality of life questionnaire
Population: 21 subjects with
tetraplegia, 24 subjects with paraplegia
Safadi et al. 2003; (44 male, mean age 55.9), 20 right side
USA colostomy, 21 left side, 7 underwent an
Downs & Black = 13 ileostomy
Post test Treatment: Colostomy
N = 45 Outcome Measures: quality of life,
colonic transit time, bowel care time
Population: Patients in 6 centers that
were selected to be representative of
Luther et al. 2005; the 23 Veteran Affairs SCI centers.
USA Survey respondents with colostomies
Downs & Black = 12 were matched to controls based on age,
Post-test year of injury, classification of paralysis
N=370 and marital status by calculating
propensity scores. Comparison of 74
patients with a sample of 296 matched
controls without colostomies.
26
Outcome
1. No significant difference (p>0.05) in the
group with a colostomy compared to the
group without a colostomy in regard to
their general well being, emotional, social
or work functioning.
1. Colostomy patients (n=12): mean time
spent on bowel care per week before
stoma formation was 8.8 h (0.6-12.2)
compared with 1.4 h (0.3-3.5) after; 50%
of these patients were independent in
bowel care before, 92% independent after;
10 patients claimed that the colostomy had
a beneficial effect on their quality of life
2. Illeostomy patients (n=2): mean time spent
on bowel care per week before ileostomy
was 17.5 h and this was unchanged after
ileostomy formation. 1 subject decreased
the time he spent on bowel care from 28 h
to 14 h; the other developed complications
and his time increased from 7 h to 21 h.
1. 10 subjects had a stoma for perineal
wounds
2. Average time spent on bowel care per
week decreased from 5.95 hr prior to
stoma formation to 1.5 hr after
3. Of the 10 patients, 3 reported cutaneous
irritations and 1 reported detachment of
the pocket
4. Of the 10 patients, 9 reported having much
easier bowel care since the stoma
formation, and 6 felt that the stoma had
given them greater independence.
1. Colonic transit time was significantly
longer in the right side colostomy
compared to the left side colostomy and
the ileostomy.
2. In all groups, quality of life increased and
bowel care time decreased
1. No statistically significance differences
were found in the demographic
distributions for cases and controls.
2. No statistically significant differences were
reported between the cases and the
matched controls for any of the bowel care
outcomes or bowel-related quality of life
both groups reported low incidence of
accidental/unplanned bowel movements
and falls related to bowel care.
Author Year; Country
Score
Methods
Research Design
Total Sample Size
Treatment: Colostomy
Outcome Measures: Bowel care-
related items; quality of life
Population: Age at injury: average 28.9
yrs; 10 subjects with cervical injuries, 18
Branagan et al. 2003;
with thoracic, and 3 with lumbar injuries;
UK
length of injury: mean 17.1 years
Downs & Black = 11 Treatment: Medical records were
Case Series
reviewed for patients who had a
N=32
colostomy.
Outcome Measures: Results of surgery
Population: Mean age 51.6 years, level
of injury C4-T10; length of injury mean
Stone et al. 1990; 15.7 years
USA Treatment: Medical records were
Downs & Black = 11 reviewed for patients who had
Case Series undergone a colostomy
N=7 Outcome Measures: Efficacy of
colostomy.
Population: 19 males and 1 female;
Age: median 55, range 27-75; Level of
injury: 9 cervical, 11 thoracic; Duration
of the enterostomies at time of interview
was 3 months to 14 years, median 11
months
Frisbie et al. 1986; Treatment: A total of 24 enterostomies
USA were carried out in 20 subjects: 17
Downs & Black = 9 sigmoid colostomies, 5 transverse
Post-test colostomies, and 2 ileostomies.
N=20 Outcome Measures: Bowel care time,
bowel care frequency, bowel care
related complaints, quality of life
Population: mean age=62.9 years; 26
males, 1 female, level of injury
range=C4-L3; 17 subjects with complete
and 10 with incomplete injuries; mean
length of injury=25.8 years
Rosito et al. 2002; Intervention: Colostomy
USA Outcome Measures: Quality of Life
Downs & Black = 8 questionnaire with 5 domains: physical
Case Series health, psychosocial adjustment, body
N=27 image, self-efficacy, and
recreation/leisure
27
Outcome
3. Mean responses to the quality of life items
were generally very high; however, a large
number of respondents continue to
express dissatisfaction with bowel care.
1. The average time spent on bowel care per
week decreased from 10.3 hours to 1.9
hours (p<.0001).
2. 18/31 patients felt the colostomy gave
them greater independence.
3. 25 patients wished they had been offered
a stoma earlier.
4. No patients wanted a stoma reversal.
1. All seven patients who had colostomy
performed as an adjunct to the treatment
of perianal pressure ulcers successfully
healed their ulcers.
2. The amount of time spent on bowel care
decreased dramatically in the patients with
prolonged bowel care.
1. Bowel care frequency increased from a
median 3 times/week (range 2-7) before
enterostomy to a median 7 times/week
(range 4-14) after enterostomy
2. Bowel care duration diminished from a
median 6 hours/week (range 0.7-14 hours)
before enterostomy to a median 1
hour/week (range 1.3-7 hours) after
enterostomy
3. The number of patients affected by bowel
care related complaints pre- vs. post-
operatively, respectively, were as follows:
abdominal pain in 10 vs. 2, fecal leakage
in 8 vs. 0, anorexia in 7 vs. 2, flatus in 9
vs. 4, sweating in 4 vs. 2 and foul odor in
4 vs. 5
4. Bowel care programs were simplified
1. Quality of life improved significantly
(p<0.0001) after colostomy.
2. All 27 patients were satisfied, 16 very
satisfied
3. Colostomy reduced the number of
hospitalizations caused by chronic bowel
dysfunction by 70.4%.
4. After colostomy, the average amount of
time spent on bowel care was reduced
from 117.0 min/day to 12.8 min/day
(p<0.0001).
5. Significant improvements were recorded in
the areas of physical health, psychosocial
adjustment, and self-efficacy.
Discussion
Colostomy is a safe, effective and well-accepted method of managing severe and chronic GI problems
in persons with SCI. As research shows, colostomy reliably reduces the number of hours spent on
bowel care (Munck et al. 2008; Branagan et al. 2003; Rosito et al. 2002; Kelly et al. 1999; Stone et al.
1990; Frisbie et al. 1986), reduces the number of hospitalizations caused by GI problems (Rosito et al.
2002) and bowel care-related complaints (Frisbie et al. 1986), simplifies bowel care routine (Frisbie et
al. 1986), and improves quality of life (Munck et al. 2008; Safadi et al. 2003; Rosito et al. 2002;Kelly
et al. 1999). Colostomy increases independence, facilitates travel, elevates feelings of self-efficacy,
and does not negatively affect body image (Branagan et al. 2003; Rosito et al. 2002). Colostomy was
well-received by patients and either met or exceeded their expectations (Rosito et al. 2002). Most
wished to have the colostomy done earlier (Branagan et al. 2003). The evolution of health care will
require physicians to evaluate more critically the impact of surgical interventions, including colostomy,
on the patient’s well-being.
Conclusions
There is level 4 evidence (from six studies) (Frisbie et al. 1986; Stone et al. 1990; Kelly et al.
1999; Rosito et al. 2002; Branagan et al. 2003, Munck et al. 2008) that colostomy reduces the
number of hours spent on bowel care.

There is level 4 evidence (from 1 retrospective pre-post study) (Frisbie et al. 1986) that
colostomy greatly simplifies bowel care routines.

There is level 4 evidence (from 1 case study) (Rosito et al. 2002) that colostomy reduces the
number of hospitalizations caused by gastrointestinal problems and improves physical health,
psychosocial adjustment and self-efficacy areas within quality of life.

Colostomy is a safe and effective treatment for severe, chronic gastrointestinal problems and
perianal pressure ulcers in persons with SCI, and greatly improves their quality of life.

3.9 The Malone Antegrade Continence Enema and the Enema Continence Catheter
The Malone Antegrade Continence Enema (MACE) is an approach using a surgically-created entry
into the large intestine to irrigate the intestine. The procedure consists of re-implanting the appendix
into the cecum and bringing the other end to the abdominal wall, thus forming an appendicostomy
(Malone et al. 1990). Consequently, a catheter can be introduced to the patient through the stoma and
an enema administered (Christensen et al. 2000). Due to the wash-out effect and perhaps the
stimulated colonic peristaltic, the colon and rectum will empty, thus preventing fecal incontinence and
constipation (Christensen et al. 2000).
Table 12: The MACE and Enema Continence Catheter
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 1. Overall success with the ECC was found in
1) Enema continence catheter: 21 12 of 21 patients (57%). In patients with
Christensen et al. 2000; patients, including 15 who are SCI; 11 fecal incontinence, the ECC was successful
Denmark women and 10 men; Age: mean 39.9, in 8/11 (73%), while 4/10 (40%) with
Downs & Black = 17 range 7-72 years; Level and type of constipation were successfully treated.
Retrospective interviews injury: 3 supraconal SCIs (T2 incomplete, 2. Overall success with the MACE was found
and case series T4 complete, T11 complete), 12 conal or in 7/8 (87%) patients.
N=29; 19 SCI patients cauda equina injuries (all incomplete) ; 3. Successful treatment with the ECC or the
mean follow-up 16 months, range 1-51 MACE was followed by significant
2) Malone antegrade continence enema: improvement in quality of life
8 patients, including 4 who had a SCI; 5 4. Authors view the ECC as a simple

28
 Author Year; Country
Score
Methods
Research Design
Total Sample Size
females and 3 males; Age: mean 32.8
years, range 15-66; 2 supraconal SCIs
(C5-6 and T2, incomplete); mean follow-
up 38 months, range 4-77
Treatment: Enema continence catheter
(ECC) vs. Malone antegrade continence
enema (MACE)
Outcome Measures: colorectal
function, practical procedure, impact on
daily living and QOL, general satisfaction
Population: 3 males; Age: mean 36,
range 29-47; Level of injury: T5
complete, C6 complete, C7 incomplete;
Mean follow-up 4.5 years
Teichman et al. 2003; Treatment: Malone antegrade
USA continence enema (MACE)
Downs & Black = 15 Outcome Measures: Bowel
Retrospective review incontinence; subjective patient
N=6; 3 SCI patients satisfaction
Population: 80 subjects, 64 female, 16
male, mean age 51 (range 17-84)
Treatment: Antegrade colonic enema
(ACE), or ACE combined with colostomy
Worsoe et al. 2008 Outcome Measures: A 44-item
Denmark questionnaire, including whether the
Downs & Black =14 patient is still using ACE and if not, why;
Case Series functional results and side effects of
N = 80 ACE; overall satisfaction with bowel
function and quality of life; success of
treatment, defined as subjects still using
ACE or symptoms resolved because of
ACE
Population: 4 males; Age: mean 32.5,
range 22-47; Level of injury: C6
complete, C7 incomplete, T5 complete,
Teichman et al. 1998; C6; Mean follow-up 11 months
USA Treatment: Malone antegrade
Downs & Black = 8 continence enema
Retrospective review Outcome Measures: Number of fecal
N=7; 4 SCI patients incontinence episodes per week; Time
for evacuation; bowel management
attempted
Discussion
In persons with SCI for whom conservative bowel management measures prove ineffective, the MACE
eliminates fecal incontinence (Worsoe et al. 2008; Teichman et al. 2003; Christensen et al. 2000;
Teichman et al. 1998), reduces time spent on bowel care (Worsoe et al. 2008; Teichman et al. 2003;
Teichman et al. 1998), improves quality of life (Teichman et al. 2003; Christensen et al. 2000),
resolves autonomic dysreflexia secondary to the neurogenic bowel (Teichman et al. 1998), and
successfully treats constipation (Christensen et al. 2000; Teichman et al. 2000).
29
Outcome
therapeutic method in severe neurogenic
colorectal dysfunction. If the ECC fails, the
MACE, as a minor and reversible operation,
is a suitable alternative to more extensive
procedures.
1. 2 out of 3 SCI subjects experienced fecal
incontinence prior to the operation. Post-
operatively, both these subjects became
continent
2. All 3 SCI subjects were satisfied with their
outcomes and rated their quality of life
higher after their MACE procedure
compared with beforehand.
3. All 3 SCI subjects experienced prolonged
toileting pre-operatively as a result of bowel
status. Post-operatively, all subjects had a
reduction in their toileting times such that it
was no longer an issue.
1. 69 subjects were available for follow up, of
whom 43 were still using ACE and 8 had
their symptoms resolved; ACE success rate
was 74%
2. Complications occurred in 30 patients,
including wound infection, urinary tract
infection, stenosis of the appendicostomy,
and problems with catheterization
3. 34 of the 43 patients still using ACE were
satisfied or very satisfied with the results; on
a 0-100 scale, mean values for subjective
bowel function was 12 before and improved
to 81 after ACE
1. 3 out of 4 SCI subjects experienced fecal
incontinence prior to the operation. All
became continent as a result of the
operation.
2. Pre-operatively, SCI subjects’ toileting
times ranged from 1-4 hours as a result of
their bowel status. Post-operatively, these
subjects were able to evacuate within 30
minutes or less.
3. Autonomic dysreflexia secondary to
neurogenic bowel was resolved post-
operatively.
Christensen et al. (2000) compared the efficacy of MACE with the Enema Continence Catheter (ECE).
The ECE, a specially designed catheter with an inflatable balloon, was originally developed by
Shandling & Gilmour (1987) for bowel management in individuals with spina bifida. The catheter is
inserted into the rectum and the balloon inflated to hold the catheter in place. When the enema is
administered in the bowel, the balloon is deflated, the catheter removed and the bowel contents
emptied (Christensen et al. 2000). Christensen et al. (2000) reported successful treatment of fecal
incontinence, slow transit or constipation, and obstructed defecation in persons with SCI. The authors
recommend that if the ECC fails, the MACE is a suitable alternative to more extensive procedures.

Conclusion

There is level 4 evidence (from 4 retrospective reviews) (Teichman et al. 1998; Christensen et
al. 2000; Teichman et al. 2003, Worsoe et al. 2008) that the Malone Antegrade Continence
Enema successfully treats the neurogenic bowel.

There is level 4 evidence (from 1 retrospective review) (Christensen et al. 2000) that the Enema
Continence Catheter can be used to treat the neurogenic bowel.

The Malone Antegrade Continence Enema is a safe and effective treatment for severe, chronic
gastrointestinal problems in persons with SCI when conservative bowel management options
are unsuccessful.

3.10 Assistive Devices

In addition to standard bowel protocols and pharmacological modalities, numerous devices were
evaluated as means to improve bowel evacuation in individuals with SCI. These include a standing
table and a modified toilet seat.

Table 13: Assistive Devices

Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 62-year-old male with T12-L1 1. The frequency of bowel movements nearly
Hoenig et al. 2001; AIS B paraplegia; time since injury = 36 doubled (from 10 to 18) with the use of the
USA years standing table
Downs & Black = 15 Treatment: Standing table for the 2. The time spent on bowel care was reduced
Case Report treatment of constipation from 21 to 13 minutes
N=1 Outcome Measures: Frequency of bowel
movements and length of bowel care
episodes.
Population: 20 male subjects; Age: range 1. Time needed for bowel management was
18-73, mean 46.3 years; 11 subjects with shorter than that with patients’ usual
cervical injuries, 7 with thoracic, and 2 manner of bowel care
with lumbar injuries; AIS level: 8 A, 4 B, 4 2. 35% (n=7) of patients originally spent less
C, and 4 D; all were at least 5 months than 30 minutes for usual defecation
Uchikawa et al. 2007; post injury compared to 75% (n=15) with modified
Japan Treatment: Newly developed procedure device
Downs & Black = 13 to induce bowel movement involving a 3. Residual stools found in 8 of the 15
Post-test toilet seat equipped with an electronic patients who successfully defecated within
N=20 bidet (provides water flow), a CCD camera 30 minutes with device.
monitor and a light (facilitates location of 4. Success of defecation not related
anorectal area). significantly with injury level of AIS
Outcome Measures: Time required for impairment scale.
successful bowel movement, amount of
residual stool in rectum

30
Discussion
Hoenig et al. (2001) reported the case of an individual with SCI who, through the use of a standing
table, doubled the frequency of his bowel movements and reduced time spent on bowel care.
Uchikawa et al. (2007) developed a new procedure to induce bowel movements using a toilet set
equipped with an electronic bidet that provides water flow to the anorectal area. A CCD camera and
light are included to facilitate location of the anorectal area. The authors report that a reduction in the
time needed for bowel management, with an increase of 40% (n=8) of subjects who can complete
defecation in less than 30 minutes.
Conclusion
There is level 5 evidence (from 1 case report with one subject) (Hoenig et al. 2001) that a
standing table alleviates constipation in individuals with SCI.

There is level 4 evidence (from 1 post-test study) (Uchikawa et al. 2007) that a newly developed
washing toilet seat with a CCD camera monitor for visual feedback reduces time spent on
bowel care.

There is limited evidence that a standing table may reduce constipation.

There is limited evidence that a washing toilet seat with visual feedback may assist bowel care.

3.11 Abdominal Massage

Table 14: Abdominal Massage
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size

Population: Age: mean 39.8 years, range 1. Mean frequencies of defecation

33.1-46.6; Level of injury: C4 to L3, 10 increased from 3.79±2.15 (range 2.75-
subjects with supraconal lesions, 14 with 4.55) to 4.61±2.17 (range 3.67-5.54) per
caudal/conal lesions; 15 with complete SCI week
Ayas et al. 2006;
and 9 with incomplete SCI; FIM score: 2. Mean total colonic transit time decreased
Turkey
mean 76.3, range 68.9-83.7; TSI: mean from 90.60±32.67 (range 75.87-110.47)
Downs & Black = 18
136.54 days, range 70.12-202.95. hours to 72±34.10 (range 58.49-94.40)
Pre-post
Treatment: Abdominal massage beginning hours with abdominal massage
N=24
at the cecum and extending along the
length of the colon to the rectum
Outcome Measures: Colonic transit times,
frequency of defecation

Discussion
Patients received at least 15 minutes of abdominal massage which began at the cecum and extended
along to the length of the colon to the rectum (Ayas et al. 2006). Differences were found in the
frequency of defecation and mean CTT between phase I, when subjects partook in a standard bowel
program in which they received a standard diet containing 15-20 g of fiber/day and underwent daily
digital stimulation, and phase II, when the subjects continued to receive this standard care and
abdominal massages. However, these differences were statistically insignificant (Ayas et al. 2006).

31
Conclusion
There is level 4 evidence (from 1 pre-post study; N=24) (Ayas et al. 2006) that the abdominal
massage is ineffective for treating the neurogenic bowel.

Abdominal massage appears to be ineffective for treating neurogenic bowel.

4. Summary
Gastrointestinal (GI) complications are frequent following a SCI and their daily challenges can
severely affect the quality of life of an individual. In addition, GI complications can lead to visits to
physicians, re-hospitalizations, and even death. The evidence suggests that a multi-faceted
approach to bowel management is effective and includes consideration of diet, medications, fluid
intake, and evacuation schedules. When severe constipation persists and a bowel program cannot
be attained, surgical options such as a colostomy or implanted stimulator may be considered.

There is level 1 evidence (from one RCT; N=68) (Coggrave et al. 2009) that systematic use of
less invasive interventions do not reduce the need for oral laxatives and invasive
interventions. There is also level 1 evidence (Coggrave et al. 2009 that use of multifaceted
bowel management programs increase the duration of time required for bowel management.
This is in contrast with level 4 evidence (from three pre-post studies; aggregate N=65)
(Coggrave et al. 2006; Correa and Rotter 2000; Badiali et al. 1997;) that multifaceted bowel
management programs reduce gastrointestinal transit time, incidences of difficult evacuations,
and duration of time required for bowel management.

There is level 4 evidence (from 1 case series; N=11) (Cameron et al. 1996) that indicates high
fibre diets may lengthen colonic transit time.

There is level 4 evidence (from 1 pre-post study; N=6) (Korsten et al. 2007) that digital rectal
stimulation increases motility in the left colon.

There is level 1b evidence (from 1 RCT) (Korsten et al. 2004) that electrical stimulation of the
abdominal wall muscles can improve bowel management for individuals with tetraplegia.

There is level 2 evidence (from 1 prospective controlled trial) (Binnie et al. 1991) that support
the use of sacral anterior root stimulation to reduce severe constipation in complete injuries.

There is level 4 evidence (from 3 pre-post studies) (Tsai et al. 2009, Lin et al. 2001; 2002) that
functional magnetic stimulation may reduce colonic transit time in individuals with SCI.

There is level 4 evidence (from 1 pre-post study with two subjects) (Mentes et al. 2007) that
posterior tibial nerve stimulation improves bowel management for those with incomplete SCI.

There is level 4 evidence (from 1 pre-post study with two subjects) (Johnston et al. 2005) that
the Praxis FES system increases the frequency of defecation and decreases time required for
bowel care in individuals with SCI.

There is level 4 evidence (from 1 case series study) (Puet et al. 1997) that supports using
pulsed water irrigation (intermittent rapid pulses) to remove stool in individuals with SCI.

32
There is level 1b evidence (from 1 RCT) (Christensen et al. 2006) that supports the use of
transanal irrigation (Peristeen Anal Irrigation system) over conservative bowel treatment (as
outlined by the Paralyzed Veterans of America clinical practical guidelines).

There is level 4 evidence (from 1 case series study, and one post-test) (Faaborg et al. 2008;
Christensen et al. 2000) that supports the use of an Enema Continence Catheter to treat the
neurogenic bowel.

Cisapride: There is level 1a evidence (from 3 RCTs) (De Both et al. 1992; Rajendran et al. 1992;
Geders et al. 1995) that cisapride significantly reduces colonic transit time for chronic
constipation.

Prucalopride: There is level 1b evidence (from 1 RCT) (Krogh et al. 2002) that prucalopride
increases stool frequency, improves stool consistency and decreases gastrointestinal transit
time.

Metoclopramide: There is level 2 evidence (from 1 prospective controlled trial; N=20) (Segal et
al. 1987) that intravenous administration of metoclopramide corrects impairments in gastric
emptying.

Neostigmine: There is level 1b evidence (from 1 RCT) (Korsten et al. 2005) that neostigmine,
administered with or without glycopyrrolate, leads to a greater expulsion of stool. There is level 1
evidence that neostigmine with glycopyrrolate decreases total bowel evacuation times and
improves bowel evacuation.

Fampridine: There is level 1b evidence (from 1 RCT) (Cardenas et al. 2007) that fampridine can
increase the number of days with bowel movements.

There is level 1b evidence (from 1 RCT) (House and Stiens 1997) to support polyethylene
glycol-based suppositories for bowel management. There is a clinically significant decrease in
the amount of nursing time for persons requiring assistance and less time performing bowel
care for the independent individual.

There is level 4 evidence (from six studies) (Frisbie et al. 1986; Stone et al. 1990; Kelly et al.
1999; Rosito et al. 2002; Branagan et al. 2003, Munck et al. 2008) that colostomy reduces the
number of hours spent on bowel care.

There is level 4 evidence (from 1 retrospective pre-post study) (Frisbie et al. 1986) that
colostomy greatly simplifies bowel care routines.

There is level 4 evidence (from 1 case study) (Rosito et al. 2002) that colostomy reduces the
number of hospitalizations caused by gastrointestinal problems and improves physical health,
psychosocial adjustment and self-efficacy areas within quality of life.

There is level 4 evidence (from 4 retrospective reviews) (Teichman et al. 1998; Christensen et
al. 2000; Teichman et al. 2003, Worsoe et al. 2008) that the Malone Antegrade Continence
Enema successfully treats the neurogenic bowel.

There is level 4 evidence (from 1 retrospective review) (Christensen et al. 2000) that the Enema
Continence Catheter can be used to treat the neurogenic bowel.

There is level 5 evidence (from 1 case report with one subject) (Hoenig et al. 2001) that a
standing table alleviates constipation in individuals with SCI.

33
There is level 4 evidence (from 1 post-test study) (Uchikawa et al. 2007) that a newly developed
washing toilet seat with a CCD camera monitor for visual feedback reduces time spent on
bowel care.

There is level 4 evidence (from 1 pre-post study; N=24) (Ayas et al. 2006) that the abdominal
massage is ineffective for treating the neurogenic bowel.

34
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