Bowel Dysfunction: Assessment and Management in Neurological Patients

Alison BardsleyContinence Advisor

Clinical Editor – Continence UK

Supported by an Educational Grant from:

Prevalence & Epidimiology• Stroke

– Commonest cause of neurological damage– Faecal incontinence reported by 23% of 135 consecutive stroke patients– Older people, women and those with severe strokes most at risk

• Multiple Sclerosis– Two thirds of patients will complain of bowel problems– 70% of people report monthly episodes of incontinence– Prevalence of faecal incontinence/constipation between 39% & 73%

• Spinal cord injury– Up to 95% will require at least one therapeutic procedure to initiate defaecation– 50% need help to manage their bowel– Up to 80% of spinal cord injury patients complain of constipation– 15-25% report faecal incontinence

• Parkinson’s disease– Constipation and evacuation difficulties are common– Up to 50% have slow transit or evacuation type constipation

• Autonomic neuropathy (disease or degeneration of autonomic nervous system for example diabetes)

– Constipation reported in 12-88% of diabetic patients– 20% of diabetics complain of faecal urgency and incontinence– Evidence of decreased rectal sensation or impaired function of anal sphincters

Neurophysiology of gastro-intestinal tract

• Extrinsic nervous control:– Autonomic nervous system (smooth muscle,

involuntary)• Parasympathetic and sympathetic fibres

– Somatic nerves (voluntary)• Supply motor and sensory control to large bowel &

pelvic floor

Neurophysiology (cont)

• Enteric Nervous system– Internal nervous system of the gut– Modulated via autonomic system to brain– Can mediate reflux activity independent of

central nervous system – Role in control of:

• Motility• Blood flow• Water and electrolyte transport• Acid secretion in digestive tract

Neurogenic bowel

• Bowel dysfunction due to:– Neuropathological process (e.g. spinal cord

injury)– Common causes unrelated to neurological

disease (e.g. low dietary fibre)– A combination of neuropathalogical and

common causes– Frontal lobe damage – emotional disturbance,

social relationships, reduced awareness, lack of voluntary control of pelvic floor.

Assessment

• Environment

• Individual

• Bowel

Environment

• Appropriate• Clean• Warm• Well lit• Toilet paper• Access• Help required?• Home/work• Involve multidisciplinary

team

Individual

• Impairment• Cognitive function• Mood/depression• Coping strategies• Concordance• Quality of life• Concomitant disease

Bowel

Bowel symptoms Bowel diary

DATE TIME Type of stool ~ use number on chart

Quantity of stoolLarge (L)Medium (M)Small (S)None (N)

Did you strainYesNo

Soiled Underwear Type & dose of LaxativeNumber of

times during the day

Type of soiling(Stained/loose/solid)

Physical examination

• Digital Rectal examination– Anal/rectal tone– Sensation– Presence of faeces– Rectal prolapse

• Bowel transit• Anorectal manometry

Bowel management programmes

• Safe, private and pleasant environment

• Appropriate equipment / home adaptations

• Prevention of pressure damage

• Carers required?

• Scheduled bowel evacuation

• Diet and fluid intake

• Catheterisation

Assistive methods

• Abdominal massage

• Valsalva manoeuvre

• Deep breathing and leaning forward

• Digital ano-rectal stimulation

• Manual evacuation

• Biofeedback

• Rectal irrigation

AUTONOMIC DYSREFLEXIAUnique to spinal injury above T6

SYMPTOMS Headaches Severe hypertension Flushing above the lesion Sweating below the lesion Blotching of the skin Nasal congestion Bradycardia / tachycardia Palpitations Dilation of the pupils

Consent and legal issues

Lawful Consent

• Consent should be given by someone with the mental ability to do so

• sufficient information should be given to the patient

• Consent must be freely givenConsiderations – • Adults unable to give consent • Children

Dietary management

General Recommendations

• Dietary fibre: 18 to 30 g per day

• Fluid intake: 1.5 to 2 litres per day

• Fruit and vegetables: 5 portions per day

Types of Fibre

SOLUBLE FIBRE: • Effectively broken down by

enzyme-producing bacteria to produce energy, gas & bulky stools.

• Soluble Fibre forms a gel-like substance which binds to other substances in the gut.

• Lowers cholesterol levels.• Slows down entry of

glucose into the blood, thus improving blood sugar control

• INSOLUBLE FIBRE• Less easily broken down

by bacteria.• Holds water very

effectively (up to 15 x its weight) therefore adds weight to stool.

• ‘Natures Broom’ has protective effects on the gut.

Fibre?

Medication treatment of Constipation

• LaxativesChoice of agent will depend on

– Presenting symptoms– Nature of complaint– Efficacy– Side –effects– Speed of action– Patient acceptability– Compliance– Cost

Types of laxatives

• Bulk forming

– Fybogel®, Celvevac® Normacol®, Regulan®

Act like dietary fibre increasing water content and faecal mass – increase stool

weight and frequency

Usually work within 24 -36 hours

Stimulant Laxatives

• Senna, Bisacodyl, co-danthramer, co-danthrasate, dioctyl, docusol

Stimulate an increase in colonic motility (peristalsis) and mucus secretion

Rapid acting 8-12 hours

Best taken in evening or at bedtime

Osmotic/iso-osmotic Laxatives• Lactulose and Magnesium salts – Osmotic

Act by drawing fluid from the body into the bowel by osmosis

• MOVICOL® - iso-osmotic

MOVICOL increases stool water content and directly triggers colonic propulsive activity and defaecation.

4 in 1 mode of action: Bulks, softens, stimulates and lubricates.

Rectal stimulants

• Bisacodyl and Glycerine

Used alone or in combination with digital stimulationPredictable

Consider a suppository inserter if hand function insufficient

Anal Irrigation

• Complete system for managing neurogenic bowel dysfunction.

• Proven reduction of faecal incontinence and constipation • Self-administration of the system increases the patients’

independence, dignity and quality of life.

How does irrigation help in bowel management ?

Before emptying After Emptying

Faecal incontinence

• Address non-neurological causes– Anal sphincter damage– Infectious diarrhoea

• Exclude constipation or impaction

Conservative Measures

Patient education Bowel habit Defaecation posture Review medications (many can cause problems of hard

or loose stool) Diet & fluids Toilet facilities Support Practical management

Anti-Diarrhoeals

Loperamide up to 16mg (8 tablets) daily if stool loose

Take care not to constipate Half hour before meals At night for morning urgency PRN before going out Codeine phosphate an alternative Diarrhoea may need investigating

Loperamide

Reduces faecal incontinence & stool weight Improves stool consistency Raises resting pressure (Read et al, 1982) Increases water absorption, slows transit Decreases IAS & EAS relaxation upon rectal

distension (Rattan & Culver, 1987) May deliberately stop spontaneous evacuation &

empty with evacuants (Tobin & Brocklehurst, 1986)

Managing Faecal Incontinence

• No easy answers

• Difficult to disguise smells and prevent soreness

• Products

• Skin care

• Odour control

• Support

Anal Plug Many cannot tolerate due

to discomfort Not suitable for patients

with frequency, diarrhoea or inflammation

Can use up to 12 hrs Very good for a few May be most suitable for

those with less sensation (neurological)

Conclusion

• Healthcare professionals play a key role:– Promoting

independence– Support– Link/co-ordination with

other services– Advice and information

Any questions?

Contact details:

alison.bardsley@continence-uk.com

For further information and handouts

www.continence-uk.com

Our thanks go to Norgine Pharmaceuticals Ltd. for providing an educational grant to support this

workshop