Neurogenic Bowel Dysfunction Research Articles

BJNN conference focuses on neurogenic bladder and bowel

On 13 September the Neurogenic Bladder and Bowel Dysfunction Conference, organised by the British Journal of Neuroscience Nursing, took place in London. To give readers an insight into the procedings, each presentation has been summarised below, with slides available online at: http://tinyurl.com/j7qotzx

Assessment of severity of neurogenic bowel dysfunction in chronic patients with a simple 1-item questionnaire (PGI-S)

Bowel symptoms (constipation and incontinence) are frequent in patients with a neurologic disease. The prevalence of neurogenic bowel dysfunction (NBD) in rehabilitation centers is still largely unknown, their assessment difficult and the use of transanal irrigation non systematic even in presence of severe NBD. Prospective study by detailed questionnaire, with use of the Neurogenic Bowel Dysfunction Score (0–47) and the Patient Global Impression of Severity (PGI-S), a 1-item questionnaire (absent, mild, moderate, severe) for the severity of the bowel symptoms, and Bristol Stool Chart for stool consistency. All patients presenting a chronic (> 2 months) neurological disease were included during a 3-month period in 2 rehabilitation centers. Inclusion of 169 patients, 97 with spinal cord injury, 42 with multiple sclerosis and 30 with hemiplegia. Moderate to severe bowel symptoms were seen in 61% of spinal cord injury, 43% of multiple sclerosis and 23% of hemiplegic patients, with NBD scores of 11.9 ± 6.5, 5.7 ± 4.9 et 3.7 ± 4.2, respectively ( p < 0.01). There was a significant relation between PGI-S and NBD score ( p < 0.01). Significant lower NBD scores were associated with normal stool consistency (Bristol type 3 or 4) ( p < 0.01). In case of severe bowel symptoms, the use of transanal irrigation was hampered by patients’ motivation and acceptation, and their autonomy. This study confirms the high prevalence of bowel symptoms in patients with a chronic neurological disease. PGI-S and Bristol Stool Chart are reliable tools to assess the presence of bowel symptoms in clinical practice.

Neurogenic bowel dysfunction translation and linguistic validation to classical Arabic

To translate and linguistically validate in classical Arabic the French version of the neurogenic bowel dysfunction (NBD). The Arabic translation was obtained using the “forward translation/backward translation” method. Multiple sclerosis patients and spinal cord injury patients were included. Clinical measures involved the evaluation of the intestinal and anorectal dysfunction. Patients were asked to respond to a questionnaire twice within a 15-day interval. An item-by-item analysis was conducted. Construct validity was investigated using the spearman rank correlation coefficient. The internal consistency of each factor was assessed by the Cronbach alpha coefficient. Twenty-three patients with colorectal disorders secondary to neurological disease were included, the average age was 40.79 ± 9.16 years and the sex ratio was 1.85. The questionnaire was feasible and acceptable, no items were excluded. The Spearman correlation was of 0.842. Internal consistency was judged as good through the Cronbach's alpha which was of 0.896. The Arabic version of NBD was reproducible and construct validity was satisfactory. The study of sensitivity to change with a larger number of patients will be the subject be further work.

Long-Term Cost-Effectiveness of Transanal Irrigation in Patients with Neurogenic Bowel Dysfunction.

BackgroundPeople suffering from neurogenic bowel dysfunction (NBD) and an ineffective bowel regimen often suffer from fecal incontinence (FI) and related symptoms, which have a huge impact on their quality of life. In these situations, transanal irrigation (TAI) has been shown to reduce these symptoms and improve quality of life.AimTo investigate the long-term cost-effectiveness of initiating TAI in patients with NBD who have failed standard bowel care (SBC).MethodsA deterministic Markov decision model was developed to project the lifetime health economic outcomes, including quality-adjusted life years (QALYs), episodes of FI, urinary tract infections (UTIs), and stoma surgery when initiating TAI relative to continuing SBC. A data set consisting of 227 patients with NBD due to spinal cord injury (SCI), multiple sclerosis, spina bifida and cauda equina syndrome was used in the analysis. In the model a 30-year old individual with SCI was used as a base-case. A probabilistic sensitivity analysis was applied to evaluate the robustness of the model.ResultsThe model predicts that a 30-year old SCI patient with a life expectancy of 37 years initiating TAI will experience a 36% reduction in FI episodes, a 29% reduction in UTIs, a 35% reduction in likelihood of stoma surgery and a 0.4 improvement in QALYs, compared with patients continuing SBC. A lifetime cost-saving of £21,768 per patient was estimated for TAI versus continuing SBC alone.ConclusionTAI is a cost-saving treatment strategy reducing risk of stoma surgery, UTIs, episodes of FI and improving QALYs for NBD patients who have failed SBC.

Long-Term Outcomes and Longitudinal Changes of Neurogenic Bowel Management in Adults With Pediatric-Onset Spinal Cord Injury

ObjectivesTo describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI). DesignLongitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews. SettingCommunity. ParticipantsAdults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y). InterventionsNot applicable. Main Outcome MeasuresType and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time. ResultsAt first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023–1.134; P=.005), oral laxatives (OR=1.052; 95% CI, 1.001–1.107; P=.047), and colostomy (OR=1.071; 95% CI, 1.001–1.147; P=.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896–.973; P=.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256–.974; P=.042) and digital rectal stimulation (OR=.490; 95% CI, .274–.881; P=.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264–2.771; P=.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores (P<.05). ConclusionsChanges in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.

Neurogenic bowel dysfunction (NBD) translation and linguistic validation to classical Arabic

To translate and linguistically validate in classical Arabic; the French version of the neurogenic bowel dysfunction (NBD). Arabic translation of the NBD score was obtained by the "forward translation/backword translation" method. Patients with multiple sclerosis (MS) and spinal cord injury were included. Evaluation of intestinal and anorectal disorders was conducted by the self-administered questionnaire NBD, which was filled twice two weeks apart. An item-by-item analysis was made. The feasibility, acceptability, internal consistency using Cronbach's alpha, and test-retest repeatability by non-parametric Spearman correlation were studied. Twenty-three patients with colorectal disorders secondary to neurological disease were included, the average age was 40.79±9.16years and the sex-ratio was 1.85. The questionnaire was feasible and acceptable, no items were excluded. The spearman correlation was of 0.842. Internal consistency was judged good through the Cronbach's alpha was of 0.896. The Arabic version of NBD was reproducible and construct validity was satisfactory. The study of its responsiveness to change with a larger number of patients will be the subject of further work. 4.

Sévérité des troubles colorectaux associés aux maladies neurologiques et évaluation pratique par questionnaire à un item (PGI-S)

Bowel symptoms (constipation and incontinence) are frequent in patients with a neurologic disease, but rarely assessed in rehabilitation centres. To study the prevalence of neurogenic bowel dysfunction (NBD) in those patients, and to assess its severity with the Patient Global Impression of Severity (PGI-S). Prospective study by questionnaires, with the Neurogenic Bowel Dysfunction Score (0-47) and the PGI-S, a 1-item questionnaire (absent, mild, moderate, severe) for the severity of the bowel symptoms, and the Bristol Stool Chart for stool consistency. All patients presenting a chronic (>2months) neurological disease were included. Inclusion of 169patients, 97with spinal cord injury, 42with multiple sclerosis and 30with hemiplegia. In each population, prevalence of constipation was 67%, 45% and 17%, of pelvic floor dyssynergia 82%, 45% and 27%, and leakages (gas or stools) de 74%, 48% and 43%, respectively. Moderate to severe bowel symptoms were seen in 61% of spinal cord injury, 43% of multiple sclerosis and 23% of hemiplegic patients, with NBD scores of 11.9±6.5, 5.7±4.9and 3.7±4.2, respectively (P<0.01). There was a significant relation between PGI-S and NBD score (P<0.01). Significant lower NBD scores were associated with normal stool consistency (Bristol type 3or 4) (P<0.01). In case of severe bowel symptoms, the use of transanal irrigation was hampered by patients' motivation and acceptation, and their autonomy. PGI-S and Bristol Stool Chart are reliable tools to assess the presence of bowel symptoms in clinical practice.

Electroacupuncture at Zusanli (ST36) ameliorates colonic neuronal nitric oxide synthase upregulation in rats with neurogenic bowel dysfunction following spinal cord injury

Study designExperimental study.ObjectiveTo determine the effects of electroacupuncture (EA) at Zusanli (ST36) on colonic motility and neuronal nitric oxide synthase (nNOS) expression in rats with neurogenic bowel dysfunction (NBD) after spinal cord injury (SCI).SettingSecond School of Clinical Medical, Nanjing University of Chinese Medicine, Jiangsu, China.MethodsWe divided 30 adult Sprague-Dawley rats into a sham group (10 rats), a model group (SCI alone, 10 rats) and a EA group (SCI+EA at ST36, 10 rats). Defecation time was recorded as the time from activated carbon administration (on day 15) to evacuation of the first black stool. Immunohistochemical, real-time PCR and western blot analyses were performed to assess changes in nNOS-immunoreactive cells, and nNOS messenger RNA (mRNA) and protein, respectively, after 14 experimental days.ResultsDefecation time was lower in the EA group than in the model group (P<0.01). On immunohistochemical analysis, nNOS was localized in the myenteric plexus of the colon. The number of nNOS-immunoreactive cells and the intensity of nNOS staining were greater in the model group than in the sham group and lesser in the EA group than in the model group. Consistent with the immunohistochemical findings, nNOS mRNA and protein expression was higher in the model group than in the sham group and lower in the EA group than in the model group (P<0.05 for both).ConclusionIncreased colonic nNOS expression can induce/aggravate NBD in SCI rats. EA at ST36 ameliorated NBD, possibly by downregulating colonic nNOS expression.

Medical and surgical management of neurogenic bowel

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence. Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases. Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Bladder and bowel continence in bilateral cerebral palsy: A population study

The attainment of continence is an important milestone in all children, including those with disability. To describe the age of bladder and bowel continence in children with bilateral cerebral palsy (BCP), and the association with intellectual impairment (II) and severity of motor disability. The parents of 346 children with BCP were interviewed as part of a population-based prospective study of the children at 3, 7, and 17 years of age. The age of bladder and bowel continence by day and night was ascertained and compared with controls from the Avon Longitudinal Study of Parents and Children (ALSPAC). The median age for daytime bladder and bowel continence in BCP children was 5.4 years compared with 2.4 years in the controls. At 13.8 years of age, 59.4% of BCP children and 99% of controls were continent by day. In BCP children, there was no difference between the attainment of daytime bladder and bowel control. Night-time bladder and bowel control was slower and less completely attained, with 50% of BCP children continent by the age of 11.8 years compared with 3 years in control children. At 13.8 years of age, 51.9% of BCP children compared with 99.4% of controls were continent for bowel and bladder at night. Gross Motor Functional Classification Score (GMFCS) and intellectual ability (IA) (II) were strongly associated with continence attainment (P<0.0001), but gender was not. Delayed and less complete continence attainment was noted in other clinic series of children with cerebral palsy (including hemiplegics) and children with II. Severity of motor disability (GMFCS), and II impacted on other aspects of toilet training, such as: motivation, understanding, communication, and independence skills. The presence of neurogenic bladder and bowel dysfunction can occur in all levels of GMFCS. Thus, there are many reasons that can prevent continence attainment. Children with BCP achieved day and night-time bladder and bowel continence more slowly and less completely than controls, with 60.8% being continent by day and 54.6% by night at the age of 17 years. The majority of BCP children who were continent by day had achieved this by the age of 5.5 years (86%). At least 88% of BCP children with GMFCS I/II and normal, specific or mild learning impairment were continent for bladder and bowel by day and night. Expectations should be shared with parents, and failure to attain expected continence should be actively investigated.

Anorectal biofeedback for neurogenic bowel dysfunction in incomplete spinal cord injury.

A case-control study of prospectively collected data was performed. To compare anorectal biofeedback (BF) outcomes in patients with incomplete motor spinal cord injury (SCI) and neurogenic bowel dysfunction (NBD) with a group of functional anorectal disorder-matched control patients. Neurogastroenterology Unit affiliated with a Spinal Injury Unit in a tertiary referral centre in Sydney, Australia. All consecutive patients with SCI and NBD referred for anorectal manometry and BF were matched in a 1:2 ratio with age, gender, parity and functional anorectal disorder-matched control patients. Instrumented BF was performed in six nurse-guided weekly visits. Outcomes included changes in anorectal physiology measures, symptom scores and quality-of-life measures. Twenty-one patients were included. These were matched with 42 patient controls. Following BF, symptom scores improved significantly in both groups, as did effect of bowel disorder on quality of life. Improvement in these measures did not differ between the groups. Patients with SCI and NBD showed improvement in their sensory and motor anorectal function, including lowering of first sensation threshold and more effective balloon expulsion. Patients with incomplete motor SCI responded as well to anorectal BF as functional anorectal disorder-matched controls. Spinal cord-injured patients also showed improvement in anorectal sensorimotor dysfunction and balloon expulsion. These novel findings indicate that clinicians should not be dissuaded from considering behaviour-based therapeutic interventions such as anorectal BF in selected spinal cord-injured patients.

Long-term efficacy and safety of transanal irrigation in multiple sclerosis.

Multiple sclerosis (MS) is the commonest disabling neurological disease in young adults. A majority of patients experience bowel dysfunction, reporting a wide spectrum of bowel symptoms that significantly negatively impact social activities and emotional state. Transanal irrigation (TAI) is a method of managing such bowel symptoms. We aimed to investigate long-term efficacy of TAI, to measure health status-related quality of life and identify factors predictive of TAI outcome. Forty-nine consecutive MS patients (37 female; mean age 51, range 26-80) were studied. We investigated predominant symptoms, reason for beginning TAI and medical comorbidity. All patients underwent anorectal physiology testing. They completed Neurogenic Bowel Dysfunction and EQ-5D questionnaires at baseline and annual follow-up. Mean follow-up was 40 months, at which there was 55% rate of continuation of TAI. Severe bowel dysfunction was present in 47% at baseline, falling to 18%. The EQ-5D scores at latest follow-up were not statistically significant, but 42% had improved visual analog scores. The only predictive factor for successful therapy was impaired anal electrosensitivity (p = 0.008). Long-term continuation of TAI, with improved bowel symptomatology, is seen in the majority of patients. The EQ-5D is insufficiently sensitive to show change in MS patients that using TAI.

Risk Factors Associated With Neurogenic Bowel Complications and Dysfunction in Spinal Cord Injury

ObjectivesTo (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling. DesignCross-sectional observational study. SettingA Spinal Cord Injury Model System, with additional participants recruited from other sites. ParticipantsSubjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview. InterventionsNot applicable. Main Outcome MeasuresConstipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling. ResultsRisk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake. ConclusionsThese results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

Altered Colorectal Compliance and Anorectal Physiology in Upper and Lower Motor Neurone Spinal Injury May Explain Bowel Symptom Pattern.

Supraconal spinal cord injury (SCI) and lower motor neurone spinal cord injury (LMN-SCI) cause bowel dysfunction; colorectal compliance may further define its pathophysiology. The aim of this study was to investigate rectal (RC) and sigmoid (SC) compliance and anorectal physiology parameters, in these subjects. Twenty-four SCI subjects with gut symptoms (14 RC, 10 SC) and 13 LMN-SCI subjects (9 RC, 4 SC) were compared with 20 spinal intact controls (10 RC, 10 SC). Staircase distensions were performed using a barostat. Anorectal manometry, including rectoanal inhibitory reflex (RAIR) measurement, was performed in all. Data presented as mean±standard error (SCI/LMN-SCI vs. controls). SCI subjects had a higher RC (17.0±1.9 vs. 10.7±0.5 ml/mm Hg, P<0.05) and SC (8.5±0.6 vs. 5.2±0.5 ml/mm Hg, P=0.002). LMN-SCI subjects had a lower RC (7.3±0.7 ml/mm Hg, P=0.0021) while SC was unchanged (8.3±2.2 ml/mm Hg, P>0.05). Anal resting pressure was decreased in SCI (55±5 vs. 79±7 cmH2O, P=0.0102). Anal squeeze pressure was decreased in LMN-SCI (76±13 vs. 154±21 cmH2O, P=0.0158). In SCI and LMN-SCI, the amplitude reduction of the RAIR was greater (62±4% and 70±6% vs. 44±3%, P=0.0007). Colorectal compliance abnormalities may explain gut symptoms: increased RC and SC contributing to constipation in SCI, reduced rectal compliance contributing to fecal incontinence (FI) in LMN-SCI. Reduced resting anal pressure in SCI and reduced anal squeeze pressure in LMN-SCI along with a greater RAIR amplitude reduction may be factors in FI. These co-existing abnormalities may explain symptom overlap, and represent future therapeutic targets to ameliorate neurogenic bowel dysfunction.

Managing neurogenic bowel dysfunction: what do patients prefer? A discrete choice experiment of patient preferences for transanal irrigation and standard bowel management.

BackgroundMost patients with bowel dysfunction secondary to neurological illness are managed by a range of nonsurgical methods, including dietary changes, laxatives, and suppository use to transanal irrigation (TAI). The aim of the present study was to explore individuals’ preferences regarding TAI devices and furthermore investigate willingness to pay (WTP) for attributes in devices in the UK.MethodsA discrete choice experiment survey was conducted to evaluate the patients’ perceived value of TAI devices. Attributes were selected based upon a literature review and input from clinicians. Interviews were conducted with three clinicians and the survey was developed and finalized with the input from both patients and professionals. The final attributes were “risk of urinary tract infections” (UTIs), “risk of fecal incontinence” (FI), “frequency of use”, “time spent on toilet”, “ease of use”, “level of control/independence”, and “cost”. Participants were recruited by a patient panel of TAI device users in the UK. Data were analyzed using the conditional logit model whereby the coefficients obtained from the model provided an estimate of the (log) odds ratios (ORs) of preference for attributes. WTP was also estimated for each attribute.ResultsA total of 129 participants were included in the final analyses. Sixty two percent of the participants had suffered from three UTIs in the preceding year and 58% of patients reported currently experiencing FI using their current device. All attributes were significant predictors of choice. The most important attributes for participants were the “risk of FI”, “frequency of use”, and “risk of UTIs”.ConclusionParticipants with bowel dysfunction regarded “risk of FI”, “frequency of use”, and “avoiding UTIs” as the most important features of a TAI device. These preferences are valuable in informing decision makers and clinicians regarding different bowel management solutions as well as for development of future devices.

Intestinal Microbiota in Patients with Spinal Cord Injury.

Human intestinal flora comprises thousands of bacterial species. Growth and composition of intestinal microbiota is dependent on various parameters, including immune mechanisms, dietary factors and intestinal motility. Patients with spinal cord injury (SCI) frequently display neurogenic bowel dysfunction due to the absence of central nervous system control over the gastrointestinal system. Considering the bowel dysfunction and altered colonic transit time in patients with SCI, we hypothesized the presence of a significant change in the composition of their gut microbiome. The objective of this study was to characterize the gut microbiota in adult SCI patients with different types of bowel dysfunction. We tested our hypothesis on 30 SCI patients (15 upper motor neuron [UMN] bowel syndrome, 15 lower motor neuron [LMN] bowel syndrome) and 10 healthy controls using the 16S rRNA sequencing. Gut microbial patterns were sampled from feces. Independent of study groups, gut microbiota of the participants were dominated by Blautia, Bifidobacterium, Faecalibacterium and Ruminococcus. When we compared all study groups, Roseburia, Pseudobutyrivibrio, Dialister, Marvinbryantia and Megamonas appeared as the genera that were statistically different between groups. In comparison to the healthy group, total bacterial counts of Pseudobutyrivibrio, Dialister and Megamonas genera were significantly lower in UMN bowel dysfunction group. The total bacterial count of Marvinbryantia genus was significantly lower in UMN bowel dysfunction group when compared to the LMN group. Total bacterial counts of Roseburia, Pseudobutyrivibrio and Megamonas genera were significantly lower in LMN bowel dysfunction group when compared to healthy groups. Our results demonstrate for the first time that butyrate-producing members are specifically reduced in SCI patients when compared to healthy subjects. The results of this study would be of interest since to our knowledge, microbiome-associated studies targeting SCI patients are non-existent and the results might help explain possible implications of gut microbiome in SCI.

Evaluation and Treatment of Neurogenic Bowel Dysfunction – A Review

Neurogenic bowel dysfunction is a severely troubling entity for patients with neurological disease or injury. The complex symptom cluster presents a challenge, not only for the patients but also for the treating clinician. Without intervention, patients are bound to have a reduced quality of life, and experience social impacts and secondary complications that come along with it. A careful initial assessment provides an idea of symptom severity and is crucial for successful rehabilitation. The mainstay of treatment remains a conservative approach of managing faecal incontinence or optimising the mechanics of defecation to improve patient’s quality of life. This article attempts to provide a comprehensive review of existing literature on pathophysiology, assessment and management of neurogenic bowel dysfunction.

Manual Therapies Promote Continence and Mobility in a Patient with Cerebellar Agenesis

Objective: Present single case study of a 26 year old female with congenital agenesis of cerebellum and other congenital malformations who achieved fecal continence and measurable mobility improvements following a prolonged series of craniosacral therapy. Design: Retrospective review of data based on several interviews with the patient’s mother, her primary caregiver and review of the medical record. Setting: Community based private therapy clinic in the upper Midwest. Interventions: Craniosacral Therapy and minimal use of other therapies. Results: Craniosacral Therapy over the course of 4 years contributed to unexpected attainment of fecal continence as well as other areas of functional improvements. The patient was 22 years of age at the time this therapy series began and had life-long neurogenic bowel and bladder dysfunction. Gains were indirectly achieved. Treatment had been initiated to address chronic pain from an older spinal surgery and sessions continued long term for health and wellness. Mobility improvements beyond pre-surgery status and fecal continence were a surprise to all parties involved. Conclusion: Clinical significance of these outcomes stimulates curiosity as to the actual type of stimulation CST actually provides to the central nervous system and its effect upon neuroplasticity.

Global audit on bowel perforations related to transanal irrigation.

Transanal irrigation is increasingly used against chronic constipation and fecal incontinence in selected patients. The aims were to estimate the incidence of irrigation-related bowel perforation in patients using the Peristeen Anal Irrigation(®) system, and to explore patient- and procedure-related factors associated with perforation. External independent expert audit on the complete set of global vigilance data related to Peristeen Anal Irrigation from 2005 to 2013. In total, 49 reports of bowel perforation had been recorded. Based on sales figures, this corresponds to an average risk of bowel perforation of 6 per million procedures. The latest two-year data indicate a risk of 2 per million procedures. In 29 out of 43 evaluable cases (67%), perforation happened within the first 8weeks since start of treatment. After 8weeks, long-term use has an estimated risk of less than 2 per million procedures. Among patients with non-neurogenic bowel dysfunction, 11 out of 15 (73%) had a history of pelvic organ surgery compared to 5 out of 26 (19%) in neurogenic bowel dysfunction. In 11 of 46 (24%) evaluable cases, burst of the rectal balloon was reported. Enema-induced perforation is a rare complication to transanal irrigation with Peristeen Anal Irrigation, which increases the benefit risk ratio in support of the further use of transanal irrigation. Increased risk is present during treatment initiation and in patients with prior pelvic organ surgery. Careful patient selection, patient evaluation and proper training of patients are critical to safe practice of this technique.

The Severity of Bowel Dysfunction in Patients with Neurogenic Bladder

Patients with neurological conditions often experience severe debilitating lower urinary and bowel dysfunction in addition to the physical disabilities. However, only the bladder has received the attention of medical providers with neurogenic bowel being poorly understood and characterized. This is a cross-sectional analysis of a prospective institutional neurogenic bladder database from 2010 to 2013. Of the 175 patients 60.6% had traumatic spinal cord injury and 18.3% had multiple sclerosis. Median ± SD FISI (Fecal Incontinence Severity Index) scores were 18.0 ± 1.39 (moderate). The median neurogenic bowel dysfunction score was 11.0 ± 0.63 (moderate). Those scores were worse in those patients with spinal cord injury and spina bifida compared to those with other diseases and in younger patients (each p = 0.020), and those in the spinal cord injury group with higher levels of injury (p = 0.0046). Based on the Bristol stool scale 65% of patients had abnormal stool consistency, mostly constipation. None of the FISI, Bristol or neurogenic bowel dysfunction scores correlated significantly with SF-12® quality of life measures. However, bladder symptom scores on M-ISI (Michigan Incontinence Symptom Index) (p = 0.05) and AUA-SI (American Urological Association symptom index) (p = 0.03) correlated with FISI severity while the neurogenic bowel dysfunction score correlated with M-ISI (ρ = 0.29, p= 0.02). Patients with abnormal stool consistency on the Bristol scale reported more urgency and stress incontinence on M-ISI. Bowel dysfunction is common among patients with neurogenic bladder. Those with worse bladder symptoms also experience worse bowel dysfunction. This highlights the importance of addressing both bowel and bladder dysfunction in this often poorly understood population.