VOL: 103, ISSUE: 26, PAGE NO: 47
Maureen Coggrave, PhD, MSc, RGN, is research fellow, The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury and senior lecturer, Burdett Institute of Gastrointestinal Nursing, King's College London
Bowel dysfunction after spinal cord injury (SCI) can cause constipation, faecal incontinence or a combination of bo...
Bowel dysfunction after spinal cord injury (SCI) can cause constipation, faecal incontinence or a combination of both and has a negative impact on quality of life. Difficulties with managing bowel function are often worsened by limited mobility and impaired hand function, so that assistance is needed with this area of care.
Management of neurogenic bowel problems usually relies on a regular routine of pre-emptive bowel care, which may include a combination of dietary manipulation, oral laxatives, digital rectal stimulation, suppositories or micro-enemas and manual evacuation. This conservative care is effective for most people with SCIs. However, some individuals have to spend prolonged periods of time on bowel care or may experience abdominal pain or discomfort associated with bowel evacuation, faecal incontinence and symptoms of autonomic dysreflexia during bowel care.
Autonomic dysreflexia occurs in people whose SCI is at the level of the sixth thoracic spinal segment or above. Noxious stimulation of the sympathetic nervous system - due most commonly to distension of abdominal organs such as the bladder or bowel - can result in sweating, chills, bradycardia and rapidly rising blood pressure, which can result in stroke or death.
Transanal bowel irrigation is a way of facilitating the evacuation of faeces from the bowel by introducing water (or other fluids) into the colon via the anus in a quantity sufficient to reach beyond the rectum. It is thought to result in an emptying of the descending colon as well as the sigmoid and rectum. Due to the volume of fluid used, the procedure is conducted over the toilet or commode.
The study aimed to compare transanal irrigation with conservative care in a prospective, randomised, multicentre trial.Method
The project took place in a total of five SCI centres in Europe (Germany, Italy, Sweden, Denmark, UK). Eighty-seven people with an SCI and one or more of the problems listed above gave informed consent to take part in the study. The participants were randomly allocated to either continue with their usual conservative care (45 individuals), or to try irrigation (42 individuals) using a new kit called Peristeen Anal Irrigation (Coloplast) (Box 1).
Participants allocated to the irrigation system were trained by the study nurses and used the kit under supervision on 1-3 occasions before taking it home. Bowel management was discussed and optimised for those continuing with conservative care. Baseline information about each participant's bowel management and related problems, and their quality of life was collected at the start of the study. The two groups were similar in all respects.
Once a week the participants completed a telephone questionnaire about their bowel care and its impact on their lives. The study lasted for 10 weeks to allow participants using the irrigation to settle into their new routine. Data collected over the last four weeks were used to evaluate the trial.Results
Thirty-seven participants who were allocated to use transanal irrigation and 44 allocated to conservative care completed the trial. Irrigation was performed daily by six individuals, every second day by 18 and 1-3 times a week by 13 participants. Warm tap water was used for irrigation; the average volume used for irrigation was 700ml but ranged from 200 to 1,500ml.
The irrigation group reported less constipation (p=0.001) and less faecal incontinence (p=0.01) than the conservative group and spent less time managing their bowel care (p=0.04). Low-grade symptoms associated with autonomic dysreflexia were reduced and no participants suffered a dysreflexic episode while using the irrigation. The irrigation group reported fewer urinary tract infections (p=0.005) and were more satisfied with their bowel care than those using conservative care (p=0.02). In addition, their quality of life was better (p=<0.001).
Five individuals reported sometimes having difficulty inserting the rectal catheter and one reported always having difficulty. Six individuals occasionally had problems with expulsion of the catheter while three always had problems. Leakage of fluid around the catheter was the most frequent problem, reported as sometimes being a problem by seven participants and always being a problem by eight.Discussion and conclusion
Transanal irrigation aims to empty the left side of the colon. This reduces the chances of incontinence between bowel management episodes and so increases the control the person has over the timing and frequency of their bowel evacuation. Regular emptying of the rectum and sigmoid colon prevents constipation, so whether an individual's main problem is faecal incontinence, constipation or both, they can benefit from irrigation.
It is important to realise that the participants in this study had been struggling, often for many years, with their bowel management and had severe problems. Many people with SCI-related bowel problems manage well with conservative care, and so may not need irrigation. As such, irrigation does not replace conservative care as the first-choice management strategy after SCI. What it does mean is that there is now another option to offer individuals for whom bowel care has become a significant problem. Until now, where conservative care has failed, the only alternative has been surgical intervention. In patients with SCIs this has usually involved the formation of a colostomy. Antegrade continence enemas, which are rarely used by adults with SCI, or percutaneous endoscopic colostomy, are emerging options that have yet to be established in this patient group.
The difficulties experienced by some participants using the irrigation system underline that it will not suit everyone. Much help from knowledgeable nurses is essential, both in teaching patients how to conduct irrigation and giving ongoing support.
This trial is important as it provides evidence for the use of bowel irrigation in individuals with neurogenic bowel problems after SCI. Irrigation did not provoke autonomic dysreflexia in any individual in the trial, and appeared to reduce sympathetic nervous system-related symptoms associated with bowel care, such as headache, flushing, sweating, dizziness and discomfort.
The link between bladder and bowel function is recognised but poorly understood. The reduced rate of urinary tract infections in the irrigation group may be due to the removal of impacted stool, which promotes bladder emptying, but this needs further study.
From the results it is not possible to predict which individuals might benefit from irrigation; people with different levels of injury participated in the study. However, users do need to be able to sit upright over a toilet or commode for their bowel care. The kit can be used by those with SCIs or by carers. As we gain experience with irrigation in patients with SCIs we will be better able to identify those for whom it is most likely to be successful.
Compared with conservative bowel management, using transanal irrigation improved constipation, faecal incontinence and quality of life related to bowel dysfunction.
- The research was supported by Coloplast Ltd.FURTHER READINGCoggrave, M. et al (2006) Management of faecal incontinence and constipation in adults with central neurological diseases. The Cochrane Database of Systematic Reviews, Issue 2. Art. No. CD002115. DOI: 10.1002/14651858.CD002115.pub3.Consortium for Spinal Cord Medicine (1998) Neurogenic bowel management in adults with spinal cord injury. Clinical practice guidelines. Spinal Cord Medicine; 21: 248-293.Kavchak-Keyes, M.A. (2000) Autonomic hyperreflexia. Rehabilitation Nursing; 25: 1, 31-35.