INCONTINENCE IN NEUROPATHIC PATIENTS
3. BOWEL PROGRAMME /BOWEL CARE
In 1998, the Consortium for Spinal Cord Medicine  published the “Neurogenic Bowel (NBo) Management in Adults with Spinal Cord Injury (SCI)” Clinical Practice Guideline (CPG). Later in 2005, to improve an adherence to the CPG recommendations through a targeted implementation strategy, Goetz et al  did a multi-site clinical trial study at 6 Veterans Affairs SCI centers. The CPG adherence was determined from medical record review for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). In focus groups before the intervention, the barriers were identified by SCI providers and then, two specific implementation strategies were chosen to address: the development and dissemination of a standardized documentation template and the development of a patient-mediated intervention to enhance guideline adherence. Because of the effective chart-based reminders, there was significant increase in overall adherence to recommendations related to NBo between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations: patient history, physical examination and docu- mentation but the overall adherence of documentation was still low (40%). Moreover, it was found that other 3 recommendations i.e., functional assessment, education and competency, had high-rate of adherence in all 3 phases.
a) Mechanical stimulations for bowel movements
1. DIGITAL RECTAL STIMULATION
Digital rectal stimulation (DRS), a gentle and slow rotation or circular movement of finger, is recom-
III. CONSERVATIVE TREATMENT
Table 15. Shows diagnostic tests recommended for assessing faecal incontinence according to Bharucha’s review (2006) 
Tests To measure For identifying
Manometry Resting pressure Internal anal sphincter function
Squeeze pressure External anal sphincter function
Recto-anal pressure gradient Defecation function
Rectal balloon expulsion test Defecation function - constipation
Endoanal ultrasound Anal sphincter pathology, esp. internal
Magnetic resonance imaging (MRI) External sphincter atrophy
Dynamic MRI Excessive pelvic floor mobility
Barium defecography Rectal evacuation and puborectalis
contraction; excessive perineal descent or a rectocele.
mended for reflex bowel as an adjunctive to facilitate bowel evacuation . It dilates an anal canal and relaxes puborectalis muscle, thus decreases the ano- rectal angle and reduces outflow resistance to the passage of stool. Korsten et al (2007)  applied DRS, with a gloved finger fully inserted into the anal canal and distal rectum and contacted with the anal mucosa; each lasted for 1 minute with a 2-minute interval between successive DRS, to measure colonic motility by using a manometric catheter affixed endoscopically to the spleen flexure. In addition, evacuation of barium oatmeal paste was assessed simultaneously using fluoroscopic techniques. In 6 SCI patients, the results showed that the mean number (+/- SEM) of peristaltic waves per minute increased from 0 at baseline to 1.9 (+/- 0.5/min) during DRS and 1.5 (+/- 0.3/min) during the period immediately after cessation of DRS (P < 0.05). The frequency of contractions, as well as amplitude of contractions, during or immediately after DRS was not significantly different; peristaltic contractions disappeared 5 minutes after the cessation of DRS; and the manometric changes in response to DRS were accompanied by expulsion of barium oatmeal paste in every subject by the fifth DRS. This proved that DRS contributes to bowel evacuation in individuals with SCI in part by increasing left-side colonic motility.
However, mechanical stimulation may cause local trauma and induce autonomic dysreflexia (AD) in SCI individuals. Furusawa et al (2007) studied the relationship between bowel manoeuvres and AD in cervical SCI patients and demonstrated that insertion of rectal medication induced a significant increase in systolic BP, which persisted during additional DRS; furthermore, the manual removal of stool induced AD, with maximal increases of systolic BP. However, after the end of stool flow the insertion of a finger into the anus did not cause a further increase in systolic BP which recovered to pre-program values within 5 min after defecation. The combined effects of rectal and/or anal sphincter distension and uninhibited rectal contraction in response to the manual removal of stool are assumed to induce AD. According to the CPG , if the elevated systolic blood pressure is less than 150 mmHg, gently instill a topical anaesthetic agent into the rectum, wait for 2 minutes, gently remove the stool; if AD becomes worse, stop manual evacuation, instill additional topic anesthetic and recheck the rectum for the presence of the stool after 20 minutes
b) Chemical stimulants
According to the meta-analysis review done by Coggrave et al (2006) to determine the effects of management strategies for faecal incontinence (FI) and constipation in people with neurological diseases affecting the central nervous system. Most of the ten trials were identified were small and of poor quality. Oral medications for constipation were the subject of
four trials. Cisapride does not seem to have clinically useful effects in people with SCI (three trials). Psyllium was associated with increased stool frequency in people with Parkinson’s disease but did not alter colonic transit time (CTT) (one trial). Prucalopride, an enterokinetic did not demonstrate obvious benefits in this patient group (one study). Some rectal preparations to initiate defaecation produced faster results than others (one trial). Different time schedules for administration of rectal medication may produce different bowel responses (one trial). Mechanical evacuation may be more effective than oral or rectal medication (one trial). The clinical significance of any of these results is difficult to interpret.
During the last 3 years there has been no research study on the effectiveness of such medications in patients with neurogenic bowel dysfunction (NBoD). c) Assistive techniques for defecation
1. ABDOMINAL MASSAGE
Another assistive technique usually applied to enhance bowel movement is abdominal massage in a clockwise motion up the ascending colon, across the transverse colon, and down the descending colon . To investigate its effect on clinical aspects of NBoD and CTT, Aya? et al (2006) did an uncontrolled clinical trial in 24 SCI patients whom were placed on a standard bowel program (phase I), after which abdominal massage was added to the regimen (phase II). In phase I, 45.8% had abdominal distention and 41.7% had FI; corresponding results for phase II were 12.5% and 16.7% (P = 0.008 and 0.031, respectively) and no significant differences between the proportions of patients with difficult intestinal evacuation or abdominal pain or in mean time required for bowel evacuation in phase I vs. phase II. The mean frequencies of defecation in phases I and II were 3.79 +/- 2.15 (2.75-4.55) and 4.61 +/- 2.17 (3.67-5.54) bowel movements per week, respectively (P = 0.006). Mean total CTT decreased from 90.60 +/- 32.67 (75.87-110.47) hrs in phase I to 72 +/- 34.10 (58.49- 94.40) hrs in phase II (P = 0.035). According to this study, abdominal massage is an effective technique in enhancing bowel movement and defecation and thus reducing bowel accident, FI in SCI persons.
2. ANAL STIMULATION WITH WATER STREAMS(LOE 3)
In 2007, Uchikawa et al (2007) reported the effectiveness of a newly modified washing toilet seat equipped with a CCD camera monitor and an electronic bidet to facilitate precise hitting of the anal area with water streams to stimulate bowel movement in patients SCI who were at least 5 months post acute injury, and could change their position on the toilet seat while watching the monitor. The stimulation was provided for a maximum of 30 minutes. Bowel movement was successfully induced in 15 of the 20 patients (75%) and success was not related
significantly to injury level, ASIA impairment scale, or ability to voluntarily squeeze. Moreover, no complications were observed and time needed for successful bowel movement was shortened in 11 of 13 patients as they usually spent more than 30 minutes before stimulation.
3. TRANSANAL/ TRANSRECTAL IRRIGATION
Christensen et al (2006) did a prospective, multi- center, randomized controlled trial (RCT) involving 5 specialized European SCI centers, and 87 SCI patients with NBoD were randomly assigned to either transanal irrigation (TAI) using the Peristeen Anal Irrigation system with 750-1,500 ml of tepid water in 42 patients and conservative bowel management, scheduled bowel care at least every 2 days, at the same time of the day and after ingestion of food and liquid, diet modification, adequate fluid, regular physical activity; and laxatives or constipating medicine when necessary as recommended in the American CPG (2) in 45 patients for a 10-week trial period. Results showed that the TAI improved constipation, FI, and symptom- related QOL much better than conservative bowel management. In addition, urinary tract infection (UTI) was less in the TAI group than in the conservative group (5.9% versus 15.5%, P = .0052); AD tended to be less in the TAI group because the underlying faecal impaction was tested; and wheelchair users and those confined to be seem to have the highest benefit of the TAI. However, half from the TAI group discontinued due to failure of the TAI.
Later in 2008, Del Popolo et al (2008)  did a multi- center study in Italy to evaluate the effect of the Peristeen Anal Irrigation. Twenty-four of 36 SCI patients with NBoD became less dependent on their caregiver; 28.6% of 32 who completed the study reduced or eliminated their use of pharmaceuticals; 68% and 63% of the patients reported successful outcome with FI and constipation respectively. Moreover, there was a significant increase in patients’ opinion of their intestinal functionality, QoL score and satisfaction.
To evaluate the outcome of transrectal irrigation (TRI) using 200-600 ml of lukewarm tap water without salt, Mattsson and Gladh (2006) did a clinical trial in 40 myelomenigocele (MMC) children with NBoD (21 boys, 19 girls; aged 10 months to 11 years). The TRI was given by the Stoma Cone Irrigation set or Colotip daily or every second day. A questionnaire on the effects on FI, constipation and self-management was completed by the parents, 4 months-8 years (median 1.5 years) after start. Effects on rectal volume, anal sphincter pressure and plasma sodium were evaluated before and after the start of irrigation. At follow-up, 35 children remained on TRI, four had received appendicostomy, while one defecated normally; 85% of all, the TRI worked satisfactorily, but a majority found it very time consuming and only one child was
able to perform it independently. All children were free of constipation; most (35/40) were also anal continent. Rectal volume and anal sphincter pressure improved, while plasma sodium values remained within the normal range. They concluded that TRI with tap water was a safe method to resolve constipation and FI in children with MMC and NBoD, but it did not help children to independence at the toilet.
4. APPLIANCE/ASSISTIVE TECHNIQUES FOR