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PubMed Central CANADA
Author Manuscript / Manuscrit d'auteur
Spinal Cord. Author manuscript; available in PMC 2011 June 18.
Published in final edited form as:
Spinal Cord. 2010 October ; 48(10): 718–733. doi:10.1038/sc.2010.14.

Neurogenic bowel management after spinal cord injury: A
systematic review of the evidence
Andrei Krassioukov, MD, PhD, FRCPC1,2,3,4,5, Janice J. Eng, PhD, BSc (PT/OT)1,3,4,5,6, Geri
Claxton, RN5, Brodie M. Sakakibara, BSc5,6, Serena Shum, BHK5, and the SCIRE Research
Team
1 International Collaboration on Repair Discoveries (ICORD)
2 Division of Physical Medicine and Rehabilitation, University of BC
3 Department of Physical Therapy, University of BC
4 ICORD, University of British Columbia

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5 GF Strong Rehabilitation Centre, Vancouver, BC
6 Graduate Program in Rehabilitation Sciences, University of BC

Abstract
OBJECTIVE—To systematically review evidence for the management of neurogenic bowel in
individuals with spinal cord injuries (SCI).
DATA SOURCES—Literature searches were conducted for relevant articles, as well as practiceguidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950
to July 2009 were also conducted to identify literature.
STUDY SELECTION—Randomized controlled trials, prospective cohort, case-control, and prepost studies, and case reports that assessed pharmacological and non-pharmacological intervention
for the management of the neurogenic bowel in SCI were included.
DATA EXTRACTION—Two independent reviewers evaluated each study’s quality, using thePEDro scale for RCTs and the Downs & Black scale for all other studies. Results were tabulated
and levels of evidence assigned.

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DATA SYNTHESIS—2956 studies were found as a result of the literature search. Upon reviewof the titles and abstracts, 52 studies met the inclusion criteria. Multi-faceted programs are the first
approach to neurogenic bowel and are supported by lower levels of evidence. Of the nonpharmacological (conservative and non-surgical) interventions, transanal irrigation is a promisingtreatment to reduce constipation and fecal incontinence. When conservative management is noteffective, pharmacological interventions (e.g., prokinetic agents) are supported by strong evidence
for the treatment of chronic constipation. When conservative and pharmacological treatments are
not effective, surgical interventions may be considered and are supported by lower levels ofevidence in reducing complications.
CONCLUSIONS—Often, more than one procedure is necessary to develop an effective bowel
routine. Evidence is low for non-pharmacological approaches and high for pharmacologicalinterventions.

Corresponding author: Andrei Krassioukov, MD, PhD, FRCPC, ICORD, 818 West 10th Avenue, Vancouver, BC, Canada, V5Z 1M9,
TEL: 604 675 8819, FAX: 604 675 8820, krassioukov@icord.org.

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INTRODUCTION
Neurogenic bowel is a colonic dysfunction resulting from a lack of central nervous control(see figure 1 for a schematic diagram of the GI tract). It is a syndrome commonly observedin individuals with spinal cord injury (SCI). Lynch et al.1 assessed surveys from 467 persons
with SCI and 668 age and gender-matched controls. They reported quality of life wasaffected by fecal incontinence in 62% of SCI respondents compared with 8% of controls.
People with SCI suffered from greater extents of fecal urgency and required more time forbowel management. Coggrave et al.2 assessed surveys from over a thousand individuals
over a year post-SCI and reported the presence of constipation (39% of sample),hemorrhoids (36%) and abdominal distension (31%).
Neurogenic bowel dysfunction is a major physical and psychological problem for persons
with SCI, as changes in bowel motility, sphincter control, coupled with impaired mobility
and hand dexterity, result to make bowel management a major life-limiting problem. As
bowel dysfunction following SCI is a major source of morbidity3,4 it is not surprising that
improving bowel function alone or bladder/bowel functions are rated among the highest
priorities among individuals with SCI.5,6

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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 andinjury at the conus medullaris and cauda equine results in lower motor neuron (LMN) bowel
syndrome.7,8 The UMN bowel syndrome, or hyperreflexic bowel, is characterized byincreased 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 remain intact, and therefore,
there is preserved reflex coordination and stool propulsion. The UMN bowel syndrome istypically associated with constipation and fecal retention at least in part due to external anal
sphincter activity.7 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 ofcentrally-mediated (spinal cord) peristalsis and slow stool propulsion. 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 thatcauses 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 thesensation of rectal fullness and ability to evacuate bowels so no specific bowel program may
be required, however, the pathophysiologic mechanisms of fecal incontinence andconstipation in subjects with incomplete SCI are similar to subjects with complete SCI andpreserved spinal sacral reflexes.9 Further, individual variations in bowel routing prior to SCI
and preexisting conditions may also influence the pattern of bowel evacuation post injury.
Careful evaluation and individual approaches are therefore important for accurate diagnoses
and prescription of treatments for bowel management following SCI.
Successful bowel management is multi-dimensional, and as such, treatments may be multifaceted, while others have focused on isolated strategies such as dietary, pharmacological,
electrical stimulation and surgery. A systematic review of the evidence underlying bowel
management has not been presented previously. The Consortium for Spinal Cord
Medicine10 provided guidelines for neurogenic bowel based on evidence and best practice,although they are now over a decade old. The following systematic review was therefore
undertaken to evaluate the evidence that supports the efficacy and effectiveness of thevarious strategies used to manage neurogenic bowel complications. These findings are part

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PMC Canada Author Manuscriptof the Spinal Cord Injury Rehabilitation Evidence (SCIRE) project,11 available atwww.scireproject.com.

METHODS
A keyword literature search of articles, practice guidelines, and review articles was
conducted to identify literature, published between 1950 and July 2009, evaluating
treatments and therapies for neurogenic bowel in SCI populations. The key words of spinal
cord injury, paraplegia and tetraplegia, were combined with neurogenic bowel, bowel
management, incontinence, constipation, irregular, hemorrhoids, as well as treatment
specific terms such as cisapride, colonic, colostomy, dietary fibre, laxative, andsuppositories. Studies with SCI subjects as part of a mixed population sample were excluded
if the results did not provide information specific to SCI.

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Study quality was assessed by two independent reviewers. Randomized controlled trials(RCT) were evaluated with the Physiotherapy Evidence Database (PEDro).12 PEDro is a 10
point score which assesses internal validity of a study, with higher scores indicating bettermethodological quality (9–10: excellent; 6–8: good; 4–5: fair; <4: poor).13 A modified
version of the Downs and Black evaluation tool was used to assess non-randomized studies.
Scores on the modified Downs and Black tool range from 0 to 28, with higher scores also
indicating a higher quality study. 14
Levels of evidence developed by Sackett et al.15 were modified and collapsed into 5
categories, where: Level 1 = RCT with a PEDro score ≥ 6; Level 2 = either a RCT with a
PEDro score ≤ 5, non-randomized prospective controlled study, or cohort study; Level 3 =case-control study; Level 4 = either pre- and post-test or case-series; and Level 5 = either anobservational report or case report involving a single subject or from clinical consensus.14

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As a result of the literature searches through the electronic databases, 2956 articles were
found that met the search criteria. After eliminating duplicates and then reviewing the titles
and abstracts, a total of 52 studies evaluating neurogenic bowel management strategies met
the inclusion criteria. Management strategies evaluated in this review are either of nonpharmacological (conservative and non-surgical), pharmacological, or surgical in nature.
Twenty-five studies assessed non-pharmacological conservative management strategies,
including multifaceted programs (three studies), suppositories (five studies), dietary fibre(one study), reflex stimulation (one study), abdominal massage (one study), assistive devices(two studies), irrigation techniques (six studies), and functional electrical stimulation ofskeletal muscles (seven studies). Ten studies evaluated pharmacological treatment strategies,
and seventeen studies on surgical interventions, including implantation of electricalstimulation systems (five studies), colostomy (nine studies), and the Malone procedure(three studies).
The following are the results for each type of management strategy.
Non-Pharmacological (Conservative and Non-surgical)
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. Improving the movement of stool through the GI
tract is the most important part of any bowel management protocol following SCI. An arrayof interventions, as components of a bowel routine, are recommended for the management

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PMC Canada Author Manuscriptof neurogenic bowel following SCI. These include dietary recommendations, anorectal/
perianal stimulation, timing the performance of the bowel routine with food intake (thustaking advantage of gastro-colonic and recto-colonic reflexes), and a variety ofpharmacological agents. Unfortunately, only a limited number of studies evaluated theeffects of different protocols on bowel function following SCI.
There is level 4 evidence (from three pre-post studies; aggregate N=65)16,17,18 thatmultifaceted bowel management programs reduce gastrointestinal transit time, incidences ofdifficult evaluations and duration of time required for bowel management (Table 1). Badiali
et al.’s16 multifaceted bowel management program effectively reduced gastrointestinal
transit time while Correa and Rotter’s17 program reduced the incidence of difficult intestinal
evacuation. Coggrave et al.18 recently modified the bowel management program originallyproposed by Badiali et al.16 by including an additional step of manual evacuation and founda significant decrease in the number of bowel movement episodes requiring laxatives (from62.8% to 23.1%). These authors also reported a significant decrease in the mean duration of
bowel management episodes with the introduction of this protocol. As all 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.

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Use of Suppositories—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. Fivestudies (aggregate N =69)19–23 examined the effect of suppositories on bowel managementin SCI including one RCT and two controlled trials which were not randomized (Table 2).
There is level 1 evidence (from 1 good quality RCT),19 in addition to lower levels ofevidence,20–22 to support polyethylene glycol-based suppositories for bowel management.
These suppositories resulted in a clinically significant decrease in the amount of nursing
time for persons requiring assistance and less time to perform bowel care for the
independent individual. The total bowel care time with the polyethylene glycol-based
suppository is significantly less compared to hydrogenated vegetable oil-based bisacodyl
suppositories.21–23
Dietary Fibre—There is level 4 evidence (from 1 case series; N=11)24 that high fibre diets
may cause colonic transit time to increase, rather than decrease (Table 3). Results of the one
case series suggest that increasing dietary fibre in SCI patients does not have the same effecton bowel function as has been previously demonstrated in individuals with normalfunctioning bowels. The effect may actually be the opposite of the desired result.24
Therefore, adding more fibre alone does not improve bowel function.

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Reflex Stimulation of the GI Tract—Digital rectal stimulation is often used as an
adjunct to laxatives and enemas to facilitate bowel evacuation. There is level 4 evidence(from 1 pre-post study; N=6) (Table 4) that digital rectal stimulation increases motility in theleft colon by activating preserved anorectal colonic reflexes.25
Abdominal Massage—There is level 4 evidence (from 1 pre-post study; N=24) that
abdominal massage significantly shortened total colonic transit time, reduced abdominal
distension and increased frequency of bowel movements per week (Table 5).26 Ayas et al.26
first established baseline values with 24 subjects who participated in a 3-week standard
bowel program in which they received a standard diet containing 15–20 g of fiber/day andunderwent daily digital stimulation. Patients then received at least 15 minutes of daily
abdominal massage for a minimum of 15 days. The massage began at the cecum andextended along to the length of the colon to the rectum.

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Assistive Devices—Assistive devices have been evaluated as means to improve bowel
evacuation in individuals with SCI. These include a standing table and a modified toilet seat
(2 studies, aggregate N=21) (Table 6). There is level 5 evidence (from 1 case report with one
subject) that a standing table alleviates constipation in individuals with SCI.27 Hoenig et al.
27 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. Thereis level 4 evidence (from 1 post-test study) that a washing toilet seat with visual feedback
can reduce time spent on bowel care.28 Uchikawa et al.28 developed a new procedure toinduce bowel movements using a toilet set equipped with an electronic bidet that provides
water flow to the anorectal area. A camera and light are included to facilitate location of theanorectal area.

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Irrigation Techniques—Six studies (aggregate N=445) evaluated irrigation techniques toimprove bowel management (Table 7).29–34 There is level 4 evidence (from 1 case series
study evaluating 31 persons with SCI) that supports using pulsed water irrigation(intermittent rapid pulses) to remove stool in individuals with SCI.29 There is also level 1
evidence (from 1 large good quality multi-site RCT with 87 subjects),30 level 4 evidence(from 2 pre-post study evaluating 55 and 32 persons with SCI),31,32 and level 5 evidence(from an observational study)33 that support the use of the transanal irrigation (TAI)systems. In the RCT, the Peristeen Anal Irrigation system (Coloplast A/S, Kokkedal,
Denmark), showed reduced frequency of lower urinary traction, improved fecal continence,and reduced constipation after 10 weeks of use when compared to the conservative bowel
treatment (Paralyzed Veterans of America Clinical Practice Guidelines for Bowel
Management).30 Positive responses were greatest in the more severely impaired participants
who used a wheelchair or were confined to bed (versus ambulatory participants). Findings
were similar after 10 and three weeks of use in the two pre-post studies.31,32 In the Del
Popolo et al.32 study, 9 out of 32 study subjects also either reduced or eliminated their use ofpharmaceuticals. In the observational study, Faaborg et al.33 found 98 of the 211 patients
had successful outcomes after a mean follow-up of 19 months, and 74 patients weresuccessfully using irrigation techniques after three years. In this study, successful outcomes
were defined as irrigation still being used during follow-up, patients who used irrigation
until they died, and patients whose symptoms had resolved while using irrigation
techniques. Finally, there is level 4 evidence (from 1 retrospective review) that the Enema
Continence Catheter can be used to treat the neurogenic bowel with improved fecal
continence and improved quality of life34 (see figure 2 for a diagram of the ECC).
Functional Electrical and Magnetic Stimulation of Skeletal Muscles—Six studies(aggregate N = 74) evaluated electrical or magnetic stimulation on skeletal muscles as amodality to improve colonic transit time in SCI with one study being an RCT (Table 8).35–
40

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There is level 1 evidence (from 1 good quality RCT) that external electrical stimulation of
the abdominal wall muscles can improve bowel management for individuals withtetraplegia.35 They used an overnight abdominal belt with embedded electrodes to provide
the stimulus. Level 2 evidence also exists (from a prospective controlled trial), where 25
minutes of electrical simulation of the abdominal muscles per day, five days a week, foreight weeks, resulted in accelerated colonic transit times when compared to the placebo
control group.36 There is supporting lower evidence as Lin et al.37,38 showed that the use of
external abdominal functional magnetic stimulation reduced colonic transit time inindividuals with SCI.
There is level 4 evidence (from 1 pre-post study with two subjects) that posterior tibial nerve
stimulation improves bowel management for those with incomplete SCI.39 While
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preliminary results for posterior tibial nerve stimulation appear promising, it is important tonote that the statistical significance of the improvements in clinical and physiologicalparameters were not reported and the study involved only two subjects.39 Level 4 evidence
also exists for the use of functional magnetic stimulation on the thorax and lumbosacral
nerves (simulation placed at T9 and L3 spinal processes) to reduce colonic transit times andself-reported symptoms of constipation.40
Pharmacological AgentsTen studies (aggregate N =199) evaluated the effect of treatment strategies using
pharmacology to enhance bowel management (Table 9).41–50 These studies addressed thechronic constipation following SCI and used agents to promote transit through the GI tract.
Of all the bowel management literature, studies involving pharmacological agents had thehighest quality with 6 of the 10 studies being small, but good quality RCTs (PEDro≥6).

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There is level 1 evidence (from 2 RCTs)41,42 and level 2 evidence (from 1 RCT)43 thatcisapride significantly reduces colonic transit time for chronic constipation. There is also
level 1 evidence (from 1 good quality RCT)44 that prucalopride increases stool frequency,
improves stool consistency and decreases gastrointestinal transit time. Prucalopride is a
novel, highly selective serotonin receptor agonist with enterokinetic properties that facilitatecholinergic and excitatory non-adrenergic, non-cholinergic neurotransmission.44 There islevel 2 evidence (from 1 controlled trial which was not randomized; N=20)45 that
intravenous administration of metoclopramide corrects impairments in gastric emptying.
Metoclopramide is a potent dopamine receptor antagonist with prokinetic properties andSegal et al.45 found that impaired gastric emptying is correlated with decreased drug
absorption. There is level 1 evidence (from 2 good quality RCTs)46,47 in support of the useof neostigmine (a reversible cholinesterase inhibitor) or the combination of neostigmine andglycopyrrolate. When administered intravenously, Korsten et al.46 found both neostigmine
and the combination of neostigmine/glysopyrrolate to improve stool expulsion over normal
saline. Similarly, Rosman et al.47 found the combination to reduce total bowel evacuation
time over placebo injections. There is level 1 evidence (from 1 good quality RCT with 71
participants) that fampridine (selective potassium channel blocker) can increase the numberof days with bowel movements in approximately one-fifth of the subjects.48
Surgical Treatments

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Implantation of Electrical Stimulation Systems—Six studies (aggregate N = 71)
evaluated the effects of surgical implantation of electrical stimulation systems (Table 10).51–
56 There is level 2 evidence (from 1 prospective, non-randomized controlled trial)51 that
support the use of sacral anterior root stimulation to reduce severe constipation in complete
injuries. Binnie et al.51 had found that an implanted Brindley stimulator did not reduce orocaecal time for individuals with SCI. However, subjects in the stimulator group did
experience a significant increase in defecation compared to the SCI group.
Furthermore, recent pre-post studies using sacral nerve root stimulation yielded
improvements in bowel function, including the ability to evacuate spontaneously,52 reduced
bowel program times,53 elimination of autonomic dysreflexia related to bowel management,
53 increased quality of life,53 and elimination of manual help for defecation.54 Similarly,
level 4 evidence exists in support of sacral nerve stimulation in the treatment of faecal
incontinence in patients suffering from cauda equine syndrome.55 Gstaltner et al.55 found an
improved faecal continence, quality of life, and deliberate retention of faeces in all subjects.
There is level 4 evidence (from 1 pre-post study with results from only one subject
presented) that the Praxis FES system for skeletal muscle stimulation paired with extradural

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electrodes for bowel and bladder stimulation increases the frequency of defecation anddecreases time required for bowel care.56
Colostomy—A colostomy is the surgical formation of an artificial anus by connecting thecolon 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. Nine studies (aggregate N =590) examined the effect of colostomy after SCI(Table 11).57–65 Given the ethical nature of this treatment (i.e., few safe options once theyreach the point of requiring a colostomy), most studies are pre-post or retrospective innature. There is level 4 evidence (from five studies),56–60 and level 5 evidence (from one
study)64 that colostomy reduces the number of hours spent on bowel care. There is level 4
evidence (from 1 retrospective pre-post study)57 that colostomy greatly simplifies bowel
care routines. There is level 4 evidence (from 1 case study)60 that colostomy reduces thenumber of hospitalizations caused by gastrointestinal problems and improves physicalhealth, psychosocial adjustment and self-efficacy areas within quality of life. Similarly, level
4 and 5 evidence exists (from a post study and an observational study) that colostomy
improves the independence, and thus quality of life, of SCI patients.64,65

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The Malone Antegrade Continence Enema and the Enema Continence
Catheter—The Malone Antegrade Continence Enema (MACE) is an approach using asurgically-created entry into the large intestine to irrigate the intestine (see figure 3). The
procedure involves connecting the appendix to the abdominal wall and fashioning a valve
mechanism that allows catheterization of the appendix, but avoids leakage of stool throughit, thus forming an appendicostomy.66 Consequently, a catheter can be introduced to thepatient through the stoma and an enema administered.34 Due to the wash-out effect andperhaps the stimulated colonic peristaltic, the colon and rectum will empty, thus preventing
fecal incontinence and constipation.34 Three retrospective studies (aggregate N=42)
examined the effect of MACE on bowel function (Table 12).34,67–68 There is level 4
evidence (from 3 retrospective reviews) that MACE successfully treats the neurogenic
bowel and patients reported improvements including improved fecal continence, less time
for bowel evacuation, reduced autonomic dysreflexia and improved quality of life.34,67–68

DISCUSSION
The management of bowel disorders, and in particular, the constipation that is so common in
SCI patients, has remained essentially unchanged for several decades. This systematic
review, however, has revealed some new areas of promise, including new assistive devices
such as irrigation techniques and electrical stimulation.

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This review identified 52 studies on neurogenic bowel management strategies. A multifaceted approach is generally the first conservative approach to neurogenic bowel
management which generally includes evacuation schedules, diet and fluid intake
recommendations, as well as digital evaluation. As some form of multi-faceted approach is
now standard of care, a trial which does not include some diet/fluid recommendations is not
ethical. From the results of the three pre-post studies on multi-faceted bowel management, it
is apparent that the protocols are highly individualized, and although there is generally abenefit, the results can be varied among participants.
Coggrave et al.2 reported that digital evacuation was the most common intervention(reported by 56% of the 1334 participants with SCI). One study25 showed that digital rectal
stimulation increases peristaltic waves in the left colon, thus increasing motility in thissegment. Gastro-colonic and ano-rectal reflexes can be successfully incorporated into abowel routine for individuals with SCI. It is well-known that following breakfast, a gastricSpinal Cord. Author manuscript; available in PMC 2011 June 18.

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distention can activate bowel motility and morning defecation.69,70 Furthermore, digitalano-rectal stimulation has been shown to be useful in bowel evacuation following spinal
cord injury,71 and is potentially useful in bowel management following SCI. At least in part,an anorectal colonic reflex that results in enhanced contractions of the descending colon andrectum may contribute to bowel evacuation in individuals with SCI. Stimulation via
abdominal massage appears to have some promising outcomes on colonic function, andcontrolled trials are feasible for this intervention and need to be done.
Conservative treatment may also include diet, although the study by Cameron et al.24 sends
a cautionary message that dietary fibre may have different effects in people with SCI
compared to able-bodied persons. Therefore, adding more fibre alone does not improvebowel function.

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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 promising technique and consists of supplying intermittent,
rapid pulses of warm water into the rectum to break up stool impactions and to stimulate
peristalsis.29 Pulsed irrigation evacuation is a safe and effective method for individuals withSCI who develop impactions or do not have an effective bowel routine.29 The one large,
multi-site RCT showed that transanal irrigation reduces time spent on bowel management,
dependency on others for help, and the frequency of defecation-related symptoms (i.e.
abdominal pain, anorectal pain, nausea).30 In addition, transanal irrigation appears toalleviate fecal incontinence and constipation more so than conservative bowel management.
30

Electrical or magnetic stimulation devices can be expensive, and are not readily accessible
to patients. These devices generally have weak evidence. The exception was the stimulation
which used an abdominal belt with embedded electrodes and resulted in reduced bowel time.
35

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Often, medication is considered a later resort (although prior to surgery), with its use
reserved for persons with severe constipation and where modification of the conservative
bowel program has failed. Prokinetic agents are presumed to promote transit through the GI
tract, thereby decreasing the length of time needed for stool to pass through the intestinesand increasing the amount of stool available for evacuation. Pharmacological studies werehigh quality (good quality RCTs) with positive results for Cisapride (the most commonlyused), prucalopride, metoclopramide, neostigmine (administered both with and without
glycopyrrolate), and fampridine. Chemical rectal agents (suppositories) are used commonlyby persons with SCI to maintain or enhance a successful bowel management program. 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 thecolon. The most commonly used laxative suppositories contain 10 mg of bisacodyl powder
distributed within a hydrogenated vegetable-oil base (HVB).19 However, polyethylene
glycol-based suppositories appear to be more effective than those in hydrogenated vegetableoil-based bisacodyl supporities.20–22
Because conservative or pharmacological management of neurogenic bowel dysfunction is
successful in 67% of the SCI population,72 surgical interventions provide an option for thosewith severe chronic constipation or when conservative management fails. Surgicalinterventions such as implantation of electrodes, colostomies, and the MACE procedure are
options to treat chronic severe constipation when conservative management is ineffective.
While no studies have determined the best time to reevaluate the effectiveness ofconservative management strategies, one year post injury is likely a good time to determine

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if surgical interventions will provide better outcomes.72 Han et al.73 report 93% of
individuals have a stable bowel management status 12 months post SCI, and similarly,
Lynch et al.1 report that after 12 months, bowel function does not change significantly withtime or age.
The outcomes from implanted electrical stimulation techniques (implantation of epineural
electrodes for skeletal muscle activation, and implantation of epidural or anterior sacral root
electrodes) requires consideration as the participants in these trials are most often
individuals who do not respond well to conservative management and/or have a history
bowel complications.40 Thus, any improvements from this select group might be viewed
with encouragement, given their lack of response to other treatments. Because of theinvasiveness of these surgical procedures, control groups were not included in the implanted
stimulator studies. However, in the future studies, investigators should be encouraged torandomize participants once implanted with the electrodes into a period of “on-stimulation”
versus “off-stimulation”. Such a design would permit interpretation of potential placebo
effects of the surgery and instrumentation.

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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 ofmanaging severe and chronic GI problems, and perianal pressure ulcers in persons with SCI.
Our systematic review shows that colostomies reduce the number of hours spent on bowelcare,57–61 reduces the number of hospitalizations caused by GI problems,60 and bowel carerelated complaints,57 simplifies bowel care routine,57 and improves quality of life.59,60,64 In
addition, many patients wished to have the colostomy done earlier.61 As described by Safadi
et al.,65 the left colostomy may be preferred because it preserves colic surfaces to absorb
water and prevent dehydration, thus, feces are less liquid and discharges less frequent thanwith right colostomies. Using a decision analysis to examine the optimal treatment forchronic refractory constipation in SCI, Furlan et al.,72 found that the MACE procedure had
the best long term outcomes (reduced complication rates, lower incidence of autonomic
dysreflexia, and fitted with patient preferences). As more data becomes available, however,results could change upon further critical evaluation of the impact of surgical interventions
on the patient’s well-being.

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Multi-faceted bowel management programs are the first approach to neurogenic bowel
programs and are supported by lower levels evidence (pre-post studies). Often, more than
one procedure is necessary for individuals that are unable to develop an effective bowel
routine. Digital rectal stimulation is often incorporated within these multi-faceted programs
and increases motility in the left colon in individuals with SCI. Diet and fluid intake areimportant components of multi-faceted bowel management programs, although there is aneed for further research to examine the optimal level of dietary intake in spinal cord injured
patients. Transanal irrigation is a promising technique to reduce constipation and fecal
incontinence. When conservative management is not effective, prokinetic agents such as
cisapride, prucalopride, metoclopramide, neostigmine, and fampridine are supported bystrong evidence for the treatment of chronic constipation in persons with SCI. Surgicalinterventions such as colostomy, MACE and implanted stimulators are not routinely used,although all are supported by lower levels of evidence (pre-post studies) in reducing bowelrelated complications and improving quality of life.

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Acknowledgments
We would like to acknowledge the support we received from the SCI Solutions Network and the Ontario
Neurotrauma Foundation. JJE is supported by Career Scientist awards from the Michael Smith Foundation for
Health Research and the Canadian Institutes of Health Research (CIHR MSH-63617). BMS is supported by a CIHR
graduate scholarship.

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Figure 1. Schematic diagram of the GI Tract

Parasympathetic innervation is provided by the Vagus (CNX) from the esophagus to thespleenic corner of the large intestine. Innervation of the GI tract after the spleenic corner isprovided by the sacral part of the parasympathetic nervous system (S2 – S4). Sympathetic
innervation to the upper GI tract is provided by the SPNs localized within the upper thoracic
spinal segment (T1–T5); the small and a large intestine are controlled by SPNs localized
within the T6–T12 spinal segments.

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Figure 2. Schematic diagram of the Enema Continence Catheter

A catheter is inserted into the rectum and a balloon is inflated to hold the catheter in place
during the administration of an enema. After installing the enema, the balloon is deflated,the catheter is removed, and the bowel content will empty.

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Figure 3. Diagram of the Malone Anterograde Continence Enema (MACE)

The MACE procedure involves a surgical operation to bring out the appendix through theskin thereby forming an appendicostomy. An enema may be introduced through theabdominal wall stoma. The enema produces a wash-out effect and stimulates colon
peristalsis, which then evacuates the contents in the colon.

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Table 1

Multifaceted Programs

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Author Year; Country
Score
Research Design
Total Sample Size

Methods

OutcomeCoggrave et al. 2006;18 United
Kingdom
Downs & Black score=17Pre-post
N=17

Population: Mean age: 41.24 years, range 19–59;
Level of injury: 8 cervical; 8 thoracic, and conus
medularis; motor compete.
Treatment: Modified progressive bowel
management protocol designed by Badiali et al.
(1997)
OM: Number of episodes requiring laxative andduration of bowel management episodes.

1

Protocol increased successful bowel
management episodes without the useof laxatives and decreased episodes
requiring laxatives.

2

Duration of bowel management
episodes decreased as did the numberof episodes requiring manual
evacuation.

Correa & Rotter 2000;17 Chile
Downs & Black score=13
Pre-post
N=38

Population: Age range=19–71; 21 complete, 10
incomplete; 2/21 tetraplegic and 19/21 paraplegic.
Treatment: Intestinal program administration
OM: DIE scale; GI symptoms.

1

DIE reduced from 26.5% to 8.8%, GI
symptoms, and manual extraction
reduced from 53% to 37%.

Badiali et al. 1997;16 Italy
Downs & Black score=13
Pre-post
N=10

Population: Mean age: 33 years, range 20–60;
Level of injury: C3-L4.
Treatment: Modified diet, water intake, andevacuation schedule.
OM: bowel movement frequency, CTT.

1

Bowel frequency increased at the endof training.

2

Reduction in gastrointestinal transit
time.

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OM = Outcome measures; CTT = Colonic transit time; DIE = Difficult Intestinal Evacuation; GI = gastrointestinal

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Table 2

Suppositories

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Manuscript

Author Year; Country
Score
Research Design
Total Sample Size

Methods

House & Stiens 1997;19
USA
PEDro=7RCT
N=15Population: Mean age: 45, range 26–61; Level of
injury: 9 cervical, 6 thoracic, 11 complete, 4
incomplete.
Treatment: 10mg HVB or 10mg PGB.
OM: time to flatus, flatus to stool flow, defecation
period1

PGB significantly less time than HVB.

2

No significant differences in flatus tostool flow.

3

PGB suppositories significantly
decreased bowel care time.

Stiens et al. 1998;22 USA
Downs & Black score=18
Non-randomized crossover controlled
N=14

Population: Mean age: 53.4 years; Level of injury:
C3-L1, 4 incomplete, 10 complete.
Treatment: PGB or HVB suppositories
OM: Time to flatus; flatus to stool flow; defecation
period; clean up; total bowel care time.

1

Time to flatus: HVB=31 min, PGB=12min; Defecation period: HVB=58 min,
PGB=32 min; Total bowel care time:
HVB=102 min, PBG=51.2 min.

2

Digital stimulations required for thebowel care sessions: HVB=5.0, PGB=3.2.

Frisbie 1997;21 USA
Downs & Black score=16
Prospective controlled trial
N=19

Population: Age: mean 64 years, range 41–81; Levelof injury: 15 cervical and 4 thoracic (T1-7), 15 motor
complete.
Treatment: PGB or HVB
OM: Average time for complete bowel evacuation.

1

All patients experienced a shortening ofbowel care time with PGB. Average time
for bowel evacuation was 2.4 hours with
HVB, 1.1 hours with PGB.

Dunn & Galka 1994;20
USA
Downs & Black score=12
Case Series
N=14

Population: Age range: 27–67; Level of injury: C5L1, 5 tetraplegics, 9 paraplegics.
Treatment: Bisacodyl and Theravac SB.
OM: bowel management time; bowel problems.

1

Mean evacuation times were lower withthe use of Theravac SB than with
Bisacodyl.

Amir et al. 1998;23 USA
Downs & Black score=9
Cohort
N=7Population: Age range: 21–76; Level of injury: C4T12, 6 tetraplegics, 1 paraplegic.
Treatment: One week of therapy with one of thefollowing: 1) two bisacodyl; 2) two glycerin; 3) one
mineral oil enema; or 4) one Theravac SB.
OM: Total colonic and segmental CTT.

1

Total CTT significantly reduced with
Theravac SB, no significant difference
between Theravac SB and mineral oil
enema but both had significantly shorter
CTT than bisacodyl or glycerin.

2Theravac SB had the shortest CTT and
was best for symptom reduction.

Outcome

OM = Outcome measures; HVB = hydrogenated vegetable-oil base; PBG = polyethylene glycol base; CTT = Colonic transit time

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Table 3

Dietary Fibre

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Author Year; Country
Score
Research Design
Total Sample Size
Cameron et al. 1996;24
Australia
Downs & Black score=10
Case Series
N=11

Methods

Population: Age range: 19–53yrs; Level of
injury: C4-T12; 1 incomplete and 10 complete; 7tetraplegics and 4 paraplegics.
Treatment: Increased fibre intake (40g Kellogg’s
All Bran).
OM: Stool weight, CTT and segmental transit
time, bowel evacuation time and fibre intake.

Outcome1

Fibre intake increased from 25g to 31g
per day.

2

Mean CTT increased from 28.2 hours to42.2 hours.

3

Rectosigmoid CTT increased from 7.9 to
23.3 hours.

4

No change in stool weight andevacuation time.

OM = Outcome measures; CTT = colonic transit time

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Table 4

Reflex Stimulation

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Author Year; Country
Score
Research Design
Total Sample Size
Korsten et al. 2007;25 USA
Downs & Black score=12Pre-post
N=6

Methods

Population: Mean age: 50.2, range 44–50;
Level of injury: C5-T10; 4 paraplegics, 2
tetraplegics.
Treatment: DRS
OM: Colorectal monometry: mean number of
peristaltic waves per minute; amplitude ofcontractions; colonic motility

Outcome1

Increase in peristaltic waves/min during DRS(1.9±0.5/min) and after DRS (1.5±0.3/min)average amplitude was 43.4±2.2 mmHg (range
0.7–250).

2Peristaltic contractions in the left colon wereaccompanied by increased motility.

OM = Outcome measures; DRS = digital rectal stimulation

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Table 5

Abdominal Massage

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Author Year; Country
Score
Research Design
Total Sample Size

Methods

Ayas et al. 2006;26 Turkey
Downs & Black score=18
Pre-post
N=24

Population: Mean age: 39.8, range 33.1–46.6; Level of
injury: C4 to L3; 15 complete; 9 incomplete.
Treatment: Abdominal massage from the cecum to therectum.
OM: CTT, frequency of defecation.

Outcome1

Mean frequencies of defecation
increased from 3.79±2.15 to
4.61±2.17 per week.

2

CTT decreased from 90.60±32.67
hours to 72±34.10 hours.

OM = Outcome measures; CTT = colonic transit time

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Table 6

Assistive Devices

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Author Year; Country
Score
Research Design
Total Sample Size

Methods

Hoenig et al. 2001;27 USA
Downs & Black score=15
Case Report
N=1

Population: 62-year-old male with T12-L1,
paraplegia.
Treatment: Standing table, 5 times/week.
OM: Frequency of bowel movements and length ofbowel care episodes.

1

Bowel movements increased from 10
to 18.

2

The time spent on bowel care reduced
from 21 to 13 minutes.

Uchikawa et al. 2007;28 Japan
Downs & Black score=13
Post-test
N=20

Population: Mean age: 46.3, range 18–73; Level of
injury: 11 cervical, 7 thoracic, 2 lumbar.
Treatment: toilet seat equipped with an electronic
bidet, a light, and camera monitor.
OM: Time for bowel movement, residual stool.

1

75% (15 subjects) of participants
decrease time of bowel routine to lessthan 30 min compare to only 35% (7subjects) with usual bowel care.

Outcome

OM = Outcome measures

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Table 7

Irrigation Techniques

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Author Year; Country
Score
Research Design
Total Sample Size

Methods

Outcome

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Manuscript

Population: TAI group: mean age: 47.5; Level of
injury: T10- S1, 23 complete and 12 incomplete.
Conservative management group: Mean age: 50.6
years; T10-S1, 23 complete and 22 incomplete.
Treatment: TAI (Peristeen Anal Irrigation system)or conservative management (PVA clinicalguidelines) for 10 weeks.
OM: CCCSS, FIGS, fecal incontinence score.

1

TAI group scored better on symptomrelated quality-of-life tool, CCCSS,
FIGS, and NBD.

2

Improvement found in the TAI group
was not confined to the more physicallyable patients.

3

The frequency of urinary tract infection
was lower in the TAI group.

Christensen et al. 2008;31
USA
Downs & Black score = 20
Pre-Post
N = 55Population: Mean age 47.5 ± 15.5; Level of
injury: 61 supraconal, 37 complete, 25 incomplete
Treatment: TAI (Peristeen Anal Irrigation) for 10
weeks
OM: CCCSS; FIGS; and NBD.

1

CCCSS, FIGS and NBD scores
improved.

2

TAI significantly reduced constipation,
improved anal continence, and improved
symptom-related QoL.

Christensen et al. 2000;34
Denmark
Downs & Black score=17
Retrospective interviews andcase series
N=29; 19 SCI patients

Population: ECC group: Mean age: mean 39.9,
range 7–72; Level of injury: T2–T11, conal or
cauda equina injuries (n=15). MACE group: Meanage: 32.8, range 15–66; Level of injury: C5-T2(n=4).
Treatment: ECC vs. MACE
OM: colorectal function, practical procedure,
impact on daily living and QoL, generalsatisfaction

1

The ECC was successful in 53% ofparticipants (8 subjects)

2

The MACE procedure was successful in
75% of participants (3 subjects).

3

Successful treatment with the ECC or the
MACE led to significant improvements
in QoL.

Del Popolo et al. 2008;32 Italy
Downs & Black score = 14
Pre-Post
N = 32

Population: Median age: 31.6, 13 complete, 14
incomplete
Treatment: TAI (Peristeen Anal Irrigation) for a 3
weeks
OM: QoL; use of pharmaceuticals; incidence ofincontinence and constipation; abdominal pain or
discomfort

1

Significant increase in QoL scores andimprovement of constipation.

2

Significant decrease in abdominal pain
and incidence of incontinence.

3

Nine patients reduced or eliminatedpharmaceutical use.

Population: Median age 49, range 7–81; Etiology:
74 traumatic, 32 spinal bifida, 29 prolapsedintervertebral disk, 38 other, 38 non-SCI.
Treatment: TAI
OM: Rate of success (treatment was successful if:
1) currently using TAI; 2) the patient used TAI
until death; or 3) symptoms resolved while using
TAI)

1

42 patients stopped TAI in the first 3
months.

2

Success in 98 patients after 19 months;
and 73 patients after 3 years of follow
up.

3

Abdominal pain, minor rectal bleeding,and general discomfort were observed in
101 patients.

Population: Age: n/a; Level of injury: 8
tetraplegic, 4 complete; 23 paraplegic, 9 complete.
Treatment: Pulsed irrigation
OM: Efficacy of technique, outpatient use.

1

Success in removing stool in all but threepatients.

2

Eleven patients had multiple procedures.

Christensen et al. 2006;30
Denmark
PEDro score=7Randomized control trial
N=87

Faaborg et al. 2008;33
Denmark
Downs & Black score = 13
Observational
N = 211

Puet et al. 1997;29 USA
Downs & Black score=12
Case Series
N=31

PMC Canada Author

OM = Outcome measures; TAI = transanal irrigation; CCCSS = Cleveland Clinic Constipation Scoring System; FIGS = St Mark’s Fecal
Incontinence Grading System; NBD = neurogenic bowel dysfunction; QoL = quality of life; PVA = Paralyzed Veterans of America; ECC = Enema
continence catheter; MACE = Malone antegrade continence enema.

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Page 24

Table 8Functional Electrical and Magnetic Stimulation of Skeletal Muscles

PMC Canada Author Manuscript

Author Year; Country
Score
Research Design
Total Sample Size

Methods

Outcome

PMC Canada Author Manuscript
Manuscript

Korsten et al. 2004;35 USA
PEDro=6RCT
N=8Population: Mean age: 48, range 34–62 years; 6
tetraplegics, 2 paraplegics.
Treatment: Abdominal belt with embedded
electrodes, used for 6 bowel care sessions over 2
weeks. Subjects did not know whether the device
was activated or not.
OM: Time to first stool, time for total bowel care.

1

Activation of the abdominal belt
significantly reduced the time to first stool
and time for total bowel care.

2Time to first stool and time for total bowel
care was significantly shortened in 6
subjects with tetraplegia, but not in the 2subjects with paraplegia.

Hascakova-Bartova et al.
2008;36 Belgium
Downs & Black score = 21
Prospective Controlled Trial
N = 10Population: Mean age: 42, range 23–61; Level of
injury C3-T10.
Treatment: Abdominal NMES, administered for 25
minutes per day, 5 days a week, for 8 weeks
OM: EMG; FVC; CTT

1

NMES decreased FVC in the treatmentgroup but not in the control group.

2

NMES accelerated CTT in the ascending,transverse, and descending colon.

Lin et al. 2001;37 USA
Downs & Black score=12Pre-post
N=15

Population: Mean age: n/a; Level of injury: C3-L1
Treatment: Protocol 1: FMS on the transabdominal
and lumbosacral regions. Protocol 2: 5-weekstimulation period.
OM: Rectal pressure and total and segmental transit
times.

1

Rectal pressures increased withsacrolumbar stimulation, and withtransabdominal stimulation.

2

The mean CTT decreased from 105.2 to89.4 hours after 5 week of stimulation.

Lin et al. 2002;38 USA
Downs & Black score=11
Pre-post
N=9

Population: Mean age: 42; Level of injury: C3–C7(n=4) and 5 able bodied controls.
Treatment: FMS along T9 spinous process.
OM: Rate of gastric emptying.

1

Gastric emptying half/time of poststimulation was significantly shorter in
SCI subjects than the baseline (84±11 minversus 59±13 min).

2

There was also a significant improvementin the percentage of gastric emptying with
FES at 20, 60, 90 and 120 min incompression at baseline.

Tsai et al. 2009;40 Taiwan
Downs & Black score = 19
Pre-Post
N = 22

Population: Mean age: 46.7, range 22–65).
Treatment: FMS of the thorax and lumbosacral
nerves, in 20-minute sessions twice daily for 3
weeks.
OM: CTT; Knowles-Eccersley- Scott Symptom
Questionnaire

1Mean CTT decreased from 62.6 h to 50.4
h2

Mean scores on the Knowles- EccersleyScott Symptom Questionnaire decreased
from 24.5 to 19.2 points

Mentes et al. 2007;39
TurkeyDowns & Black score=13
Pre-post
N=2

Population: 51-year-old woman (discectomy for
lumbar disc herniation), and a 31-year-old man (10year history of lumbar cavernous haemangioma).
Treatment: 30 minutes of tibial nerve stimulation
every other day for 4 weeks, then repeated every 2months for 3 times.
OM: physiologic, clinical and QoL parameters.

1

Patients showed improvements in Wexner
FI score, FIQL score, clinical parametersand physiological measurements.
Significance of improvements notreported in this study.

OM = Outcome measures; NMES = neuromuscular electrical stimulation; EMG = Electromyography; FVC = Forced vital capacity; CTT = colonictransit times; n/a = information not available; FMS = functional magnetic stimulation; FIQL = faecal incontinence quality of life scales; QoL =quality of life

PMC Canada Author
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Page 25

Table 9Pharmacological Agents

PMC Canada Author Manuscript

Author Year; Country
Score
Research Design
Total Sample Size

Methods

OutcomeRosman et al. 2008;47 USA
PEDro = 8RCT
N=7Population: Mean age 46.9, range 30 – 56 yrs; Levelof injury: cervical and thoracic.
Treatment: Injections of neostigmine andglycopyrrolate for 1 week, wash-out period for 1 week,
and placebo for 1 week.
OM: Total bowel evacuation time; time to first flatus,
beginning of stool flow, end of stool flow.

1

Injections significantly reduced total
bowel evacuation time, time to first
flatus, time to beginning and end ofstool flow.

Geders et al. 1995;42 USA
PEDro=8RCT
N=9Population: Mean age: SCI group 58.8; Controls 63.4;
2 paraplegics, 7 tetraplegics
Treatment: Cisapride or placebo administered in oral
doses.
OM: CTT, questionnaire on type, frequency, andseverity of clinical symptoms.

1

CTT was significantly longer in SCI
group.

2

Subjects with a normal CTT
demonstrated no benefit to theadministration of cisapride.

3

Five quadriplegic subjects with initialabnormal total CTT improved their left
CTT following treatment.

PMC Canada Author Manuscript
Manuscript
PMC Canada Author

Rajendran et al. 1992;41
USA
PEDro=8RCT
N=14Population: Age range: 19–71; Level of injury: C4L2; 7 tetraplegics and 7 paraplegics.
Treatment: Oral administration of cisapride four times
per day for four days, and placebo.
OM: Gastric emptying or MCTT.

1

No delay or improvement in gastric
emptying was observed after theadministration of cisapride.

2

Cisapride resulted in normalization of
the tetraplegic subjects’ MCTT.

Krogh et al. 2002;44
Denmark
PEDro=7RCT
N=22Population: Mean age: 34.7 (placebo group), 36.5
(1mg group), 44.3 (2mg group).
Treatment: Prucalopride 1mg or placebo, taken once
daily for four weeks; and Prucalopride 2mg or placebo
for four weeks.
OM: Constipation; urinary habit; constipation severity
and symptoms; CTT.

1

Constipation severity increased withplacebo; decreased with prucalopride.

2

Improvement in frequency of bowel
movements over 4 weeks in the 2 mggroup.

3

Four patients (2 mg group) reported
moderate/severe abdominal pain.

Korsten et al. 2005;46 USA
PEDro score=6
RCT
N=13

Population: Mean age: 46; range 25–69; Level of
injury C4-T12; 5 tetraplegic, 8 paraplegic, 12 motor
complete, 5 sensory complete.
Treatment: Normal saline, 2 mg neostigmine, or
combination of 2 mg neostigmine and 0.4 mg
glycopyrrolate.
OM: Bowel evacuation.

1

Normal saline was least effective forbowel evacuation.

2

Mean time to evacuation was 11.5 minafter neostigmine and 13.5 min after
the combination of neostigmine andglycopyrrolate.

Cardenas et al. 2007;48 USA
PEDro score=6
RCT
N=91

Population: Group 1: Mean age: 44, range 23–66;
Group 2: Mean age: 42, range 21–67; Group 3: Meanage: 38, range 19–61; Level of injury: 73 cervical, 18
thoracic.
Treatment: 8 weeks; group 1: Fampridine, sustained
release, 25 mg twice a day; group 2: 40 mg twice aday; group 3: Placebo.
OM: Number of days with bowel movement.

1

Significantly larger number of subjects
in groups 1 and 2 had an increase in thenumber of days with bowel movements
compared to subjects in the placebogroup. Number of days increase notreported.

De Both et al. 1992;43
Netherlands
PEDro score=5
RCT
N=10

Population: Mean age: 35.8, range 19–63; Level of
injury: C6-L1.
Treatment: Group 1: Cisapride 10 mg four times
daily; Group 2: placebo
OM: Defecation frequency, consistency of stools,
percentage of defecations preceded by digital
stimulation or suppository, CTT

1

No difference in number of defecations
per week.

2

Significant improvement in ease ofevacuation in both the cisapride andplacebo, and reduction in CTT withcisapride.

3

Consistency of stools changed
significantly with cisapride.

Spinal Cord. Author manuscript; available in PMC 2011 June 18.

Krassioukov et al.

PMC Canada Author Manuscript

Author Year; Country
Score
Research Design
Total Sample Size

Page 26

Methods

Outcome4

Cisapride and placebo had no effect on
digital reflex stimulation or suppositoryuse.

Binnie et al. 1988;49 UK
Downs & Black score=12Pre-post
N=10

Population: Mean age: 34.1, range 20–45yrs; Level of
injury: C4-T10, all complete.
Treatment: Intravenous injection of 10 mg cisapride.
After at least 48 hours subjects were administeredcisapride orally.
OM: CTT.

1

CTT was reduced from 185±86.3 to123±77.0 hours.

Longo et al. 1995;50 USA
Downs & Black score =9Pre-post
N=15

Population: Mean age: n/a; Level of injury: 12
tetraplegics, 3 paraplegics.
Treatment: 20mg cisapride, three times per day forone month.
OM: Anorectal manometry; bowel movements;
intestinal transit time.

1

6/12 had improved symptoms of
constipation. 9/12 had reduced the timeneeded for a bowel movement.

2

No worsening of constipation.

3

6/12 had a 10% or more increase in
resting anal canal pressure.

Population: Age range 20–55; Level of injury: 11
tetraplegic, 9 paraplegic, all complete.
Treatment: Liquid meal, then within 2 weeks,
ingested 2nd liquid meal with intravenously
administered metoclopramide.
OM: Half time of gastric emptying, GE patterns in theearly and later phases.

1

Mean GE half time for a liquid meal
decreased in the quadriplegic subjects
from 104.8 min to 18.8 min after
treatment.

2

In the paraplegic subjects, a
pretreatment mean GE of 111.5 min
decreased to 29.1min.

Segal et al. 1987;35 USA
Downs & Black score=9Prospective Controlled Trial
N=20, Control N=8

PMC Canada Author Manuscript
Manuscript

OM = Outcome measures; CTT = Colonic transit time; MCTT = mouth to cecum transit time; GE = gastric emptying

PMC Canada Author
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Page 27

Table 10

Implanted Electrical Stimulation Systems

PMC Canada Author Manuscript

Author Year; Country
Score
Research Design
Total Sample Size

Methods

Outcome

PMC Canada Author Manuscript
Manuscript

Chia et al. 1996;52 Singapore
Downs & Black score=14
Pre-post
N=8

Population: Mean age: 40, range 20–53 years; Levelof injury: C4-T11.
Treatment: Implantation of anterior sacral roots
electrodes.
OM: Bowel frequency, laxative use, suppository use,need for digital evacuation, anorectal monometry

1

6 patients had improved bowel
function: 4 were able to evacuate
spontaneously after stimulation

2

The 6 patients with improved bowel
routine also showed a positive
rectoanal pressure difference
immediately after stimulation.

Kachourbos & Creasey 2000;53
USA
Downs & Black score=12Pre-post
N= 16

Population: Patients with a history of bowel
complications
Treatment: Implantation of sacral roots electrodes(S1–S3) with rhizotomy.
OM: Bowel program times; QoL.

1

Bowel program times were reduced
from 5.4 hours per week to 2.0
hours.

2

Subjects had an overall improvement
in QoL.

Gstaltner et al. 2008;55 Austria
Downs & Black score = 11
Pre-Post
N = 11

Population: Mean age: 46; Level of injury: n/aTreatment: Implantation of sacral roots electrodes
OM: The Wexner Score for faecal continence; QoL.

1

Five subjects had permanent
implantations.

2

Improved faecal continence,deliberate retention of faeces, andperianal sensitivity in all fivesubjects.

3

Improved quality of life.

Population: Mean age: 33, range 21–49; Level of
injury: 10 thoracic, 2 cervical, all complete.
Treatment: Implanted Brindley-Finetech intraduralsacral anterior root stimulator
OM: Full defecation1

Six patients achieved full defecation.

2

Reduced time to complete
defecation.

3

All were free from constipation.

Binnie et al. 1991;51 UK
Downs & Black score=8
Prospective Controlled Trial
N=27

Population: Group 1: Mean age: 29.1, range 22–38;
non-SCI. Group 2: Mean age: 34.1, range 20–45;
Level of injury C4-T10; Group 3: Mean age: 36.3,
range 20–50; Level of injury: C5-T3.
Treatment: Brindley anterior sacral root stimulator
implanted in Group 3.
OM: CTT, fecal water content, and frequency ofdefecation.

1

No significant difference in CTT
between all groups.

2Group 3 had a significant increase indefecation frequency versus group 2.

Johnston et al. 2005;56 USA
Downs & Black score = 14
Pre-post
N=3; however, only 2 had
neurogenic bowel outcome
measures and results presented
only for 1

Population: Age range: 17–21; Level of injury: T3–
T8, complete.
Treatment: Stimulation of skeletal muscles for
upright mobility. Two subjects also received
extradural electrodes for bowel management.
OM: Rectum and anal sphincter pressures, quantityof stool passed, bowel evacuation time, andevacuation satisfaction.

1

Stimulation at S3 increased anal
sphincter and rectal pressure

2

Daily use of stimulation significantly
improved bowel management withincreased frequency of defecation,
decreased amount of time requiredfor bowel evacuation, and improved
satisfaction.

MacDonagh et al. 1990;54 UK
Downs & Black score=10Pre-post
N=12

PMC Canada Author

OM = Outcome measures; CTT = colonic transit times; n/a = information not available; QoL = quality of life

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Page 28

Table 11

Colostomy

PMC Canada Author Manuscript
PMC Canada Author Manuscript
Manuscript
PMC Canada Author

Author Year; Country
Score
Research Design
Total Sample Size

Methods

Randell et al. 2001;62 New
Zealand
Downs & Black score=17
Post-test
N=52

Population: Age range: 22–87; Level of injury:
10 cervical, 16 lumbar/lower thoracic.
Treatment: 26 subjects with colostomy, 26
subjects without colostomy.
OM: QoL: systemic symptoms, emotional, social,
work and bowel function.

1

No significant difference between the 2groups in general well being, emotional,social or work functioning.

Kelly et al. 1999;59 United
Kingdom
Downs & Black score=15
Case series
N=14

Population: Mean age at time of operation: 54.8,
range 20–65; Level of injury: C4-T11; 3 cervical,
10 thoracic, 1 lumbar.
Treatment: Left iliac fossa colostomy (n=12) andright iliac fossa ileostomy (n=2).
OM: Time spent on bowel care per week;
independence in bowel care; QoL.

1

Colostomy patients: mean time spent onbowel care per week decreased;
independence with bowel care increased;
quality of life improved in 10 patients

2

Ileostomy patients: no change in meantime spent on bowel care per week.

Munck et al. 2008;64 Belgium
Downs & Black score = 13
Observational
N=23

Population: Age range at stoma formation: 22–
72; Level of injury: cervical to lumbar.
Treatment: Intestinal stoma formation.
OM: Bowel care, QoL.

1

Average time spent on bowel care per
week decreased from 5.95 hr to 1.5 hr

2

3/10 reported cutaneous irritations and 1
reported detachment of the pocket

3

9/10 had easier bowel care, and 6 hadgreater independence

Population: Case (colostomy): Age range: 20–89;
Controls (regular bowel routine): Age range: 20–
89; Level of injury: n/aTreatment: Colostomy
OM: Bowel care-related items; QoL.

1

Mean responses to the QoL items werehigh but a large number of respondents inboth groups expressed dissatisfaction withbowel care.

2

No difference between groups in bowel
care outcomes or bowel-related QoL items

Safadi et al 2003;65 USA
Downs & Black Score = 12
Post test
N=45

Population: Mean age: 55.9; 21 tetraplegic, 24paraplegic.
Treatment: right and left colostomy andileostomy
OM: QoL, CTT, bowel care time1

CTT was significantly longer in the rightcolostomy.

2

In all surgeries, QoL increased and bowel
care time decreased

Branagan et al. 2003;61 UK
Downs & Black score=11
Case Series
N=32

Population: Mean age at injury: 28.9; Level of
injury: 10 cervical, 18 thoracic, 3 lumbar.
Treatment: Colostomy.
OM: Bowel care; results of surgery

1Time spent on bowel care per week
decreased from 10.3 to 1.9 hours.

2

18 patients experienced greater
independence. 25 patients wished they had
been offered a stoma earlier. No patientswanted a stoma reversal.

Stone et al. 1990;58 USA
Downs & Black score=11
Case Series
N=7

Population: Mean age: 51.6; Level of injury C4T10.
Treatment: Colostomy
OM: Bowel care time.

1

Time spent on bowel care decreased
dramatically.

Frisbie et al. 1986;57 USA
Downs & Black score=9
Post-test
N=20

Population: Median age: 55, range 27–75; Levelof injury: 9 cervical, 11 thoracic.
Treatment: Colostomies or ileostomies.
OM: Bowel care time, bowel care frequency,
bowel care related complaints.

1

Bowel care frequency increased, bowel
care duration lowered.

2

Except for foul odor, bowel carecomplaints decreased post-operation.

Rosito et al. 2002;60 USA
Downs & Black score=8Case Series
N=27

Population: Mean age: 62.9; Level of injury: C4L3, 17 complete and 10 incomplete injuries.
Intervention: Colostomy
OM: QoL questionnaire1

QoL significantly improved.

2

Lowered number of hospitalizations by
70.4%.

Luther et al. 2005;63 USA
Downs & Black score=12
Post-test
N=370

OutcomeSpinal Cord. Author manuscript; available in PMC 2011 June 18.

Krassioukov et al.

PMC Canada Author Manuscript

Author Year; Country
Score
Research Design
Total Sample Size

Page 29

Methods

Outcome3

OM = Outcome measures; QoL = quality of life; n/a = information not available.

PMC Canada Author Manuscript
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PMC Canada Author
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Time spent on bowel care was reduced.

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Page 30

Table 12The Malone Antegrade Continence Enema

PMC Canada Author Manuscript

Author Year; Country
Score
Research Design
Total Sample Size

Methods

Outcome

PMC Canada Author Manuscript
Manuscript

Christensen et al. 2000;34
Denmark
Downs & Black score=17
Retrospective interviews andcase series
N=29; 19 SCI patients

Population: ECC group: Mean age: mean
39.9, range 7–72; Level of injury: T2–T11,
conal or cauda equina injuries (n=15). MACE
group: Mean age: 32.8, range 15–66; Level of
injury: C5-T2 (n=4).
Treatment: ECC vs. MACE
OM: colorectal function, practical procedure,
impact on daily living and QoL, generalsatisfaction

4

The ECC was successful in 53% ofparticipants (8 subjects)

5

The MACE procedure was successful in
75% of participants (3 subjects).

6

Successful treatment with the ECC or the
MACE led to significant improvements
in QoL.

Teichman et al. 2003;68 USA
Downs & Black score=15
Retrospective review
N=6; 3 SCI patients

Population: Mean age: 36, range 29–47; Levelof injury: T5 complete, C6 complete, C7
incomplete
Treatment: MACE
OM: Bowel incontinence; subjective patientsatisfaction.

1

2 SCI subjects experienced fecal
incontinence prior to the operation. Postoperative, both became continent.

2

All SCI subjects were satisfied with theiroutcomes and rated their QoL higher.

3

All subjects reduced toileting times.

1

3 SCI subjects experienced fecal
incontinence prior to the operation. Postoperative, all became continent.

2

All subjects were able to evacuate within
30 minutes.

Teichman et al. 1998;67 USA
Downs & Black score=8Retrospective review
N=7; 4 SCI patients

Population: Mean age: mean 32.5, range 22–47; Level of injury: C6 complete, C7
incomplete, T5 complete, C6.
Treatment: MACE
OM: Number of fecal incontinence episodes
per week; Time for evacuation.

OM: Outcome measures; ECC = Enema continence catheter; MACE = Malone antegrade continence enema.

PMC Canada Author
Spinal Cord. Author manuscript; available in PMC 2011 June 18.