FAECAL INCONTINENCE AND BOWEL PROBLEMS

• Methods

Using MEDLINE we identified English-language journal articles and reviews published from 2000 to April 2008, looking for the keywords myelomeningocele, fecal incontinence, management.

a) Pathophysiology

Voluntary control of defecation requires rectal sensation, peristalsis and adequate anorectal sphincter function. Neurological defects in patients with spinal lesions may affect one or more of these components resulting in different types of defecation disorders: fecal incontinence, chronic constipation or both. Incontinence is one of the major stigmas affecting patients born with myelomeningocele [1].

b) Prevalence

Bowel dysfunction occurs in most children with spinal cord impairment from disease or injury.

c) Management (LOE 3)

Although many different regimens have been used to manage this problem none has had universal success. Behavioural modification and laxatives failed to achieve an acceptable result because of the persistence of soiling. A small dose of laxatives alone accomplished nothing while administering a large dose to an incontinent patient only resulted in profound embarrassment [2]. Bearing in mind that none of these patients can resist the push of peristalsis, the most effective therapy is the emptying of the colon, which takes at least 24–48 h to refill again.

The main goal, to empty the colon as much as possible to achieve continence during the next 24–48 h, can be achieved nowadays by two ways, (A) by a retrograde colonic enema (RCE) using a special ballon catheter or (B) an operative procedure which allows an antegrade continence enema (ACE).

1. CONSERVATIVE

• The retrograde colonic enema (RCE)

In neurological fecal incontinence the standard enemas are difficult if not impossible to administer because there is inability to retain the enema which flows out involuntarily through the weak anus during its instillation.

Therefore a catheter system, which allows to perform the retrograde colonic enema, has been developed by industry, the application of which can easily be applied either by the parents or even by children over the age of 7–8 years. Not all children tolerate this procedure, in some of them colonic peristalsis creates pains. However the reported results are good according to Eire et al. [3], in 1998.

• Regular surveillance, from infancy, with

urodynamics and renal ultrasound is mandatory. However the exact timing is not definied. One must observe the general rules for neurogenic bladder(B)

• Early initiation of conservative measures

(clean intermittent catheterization, anti muscarinic medication) generally provides protection of the upper urinary tract (B)

• Surgery is reserved for failed conservative

treatment ( B)

• Myelomenigocele is one of the commonest

birth defects (LOE 1)

• Incidence decreased by folate ingestion

(LOE 2)

• Most have bladder dysfunction which can

lead to incontinence and / or upper tract deterioration (LOE 3)

• Majority will derive significant benefit from

Shandling et al. [4] reported 100% success in using the enema continence catheter in the management of his patients with spina bifida.

These authors regard the RCE as one of the best conservative methods of treatment for relieving fecal incontinence originating from myelomeningocele and other neurological problems within intestinal dysfunction.

With intravesical electrical stimulation (IVES) also concomitant improvement in fecal incontinence was observed in children with myelomeningocele and IVES is regarded by some as another viable option for controlling fecal incontinence in these children [5]. Biofeedback was introduced for use in children with intact rectal sensation [6], but recent trials have reported less encouraging results [7]. “Digital disimpaction” is unpleasant to perform and only succeeds in emptying the distal rectal ampulla.

2. OPERATIVE

• The antegrade colonic enema (ACE)

The impact of antegrade colonic enema (ACE) [8] in the management of patients with myelomeningocele was analysed recently by Lemelle et al [1]. 47 patients were treated with ACE, of whom 41 used the method at a mean time of 4.1± 1.9 years after the ACE operation: only six abandoned ACE for conventional management. With ACE, faecal incontinence was significantly improved compared with conventional management and neither retrograde rectal enema nor digital extraction were required.

In most cases, ACE was performed using the appendix or the caecum. Among the

47 patients operated with the ACE procedure, six patients (12,8%) stopped performing antegrade enema for various reasons, from conduit problems due to stomal stenosis or catheterization difficulties, lack of motivation or “too long time to empty the enema” in one case. Antegrade colonic enema was applied before, concomitantly or after urinary incontinence surgery in 5, 27 and 10 cases respectively. Antegrade enema was performed at most three times a week, tap water was used in the majority of patients. Mean volume for ACE was 1.2 L (range 0,25–3,0 L). Mean enema time for colonic washout with ACE was 50 ± 19 min (range 15–90 min), however mean washout duration for ACE tended to be shorter with implantation of the conduit on the left-segment of the colon. Casale et al. [9] were unable to find any differences in the continence rate or stomal complications between total reconstruction (ACE and continent urine stoma) or staged reconstruction. However, because of shared pathology the authors believe, that most patients benefit from intervention in the gastrointestal and the genitourinary tract. Therefore, a major advantage of total continence reconstruction is avoidance of the

morbidity of a second major surgical procedure (LOE 3).

Nevertheless, conventional treatment should be tested first, and the efficacy of retrograde enemas may be a predictor of the efficacy of ACE on bowel management. Moreover, percutaneous endoscopic insertion is fully reversible and does not present drawbacks and encountered with the catheterizable conduit [2]. Nevertheless, experience with the Malone procedure has proved that a suitable continent and catheterizable conduit can be obtained with an appropriate technique. In selected and motivated patients, and with the help of a specialist nurse providing close support in the postoperative period, surgical ACE procedure might be preferred according to the surgeon´s experience.

• Sacral neuromodulation has been recently described also in the therapy of these patients, but the persistence of continence control and tolerance of the patient need to be evaluated for a prolonged period of time(). Sacral neuromodulation may only be successful in a small selected number of patients, in whom preserved anatomy of the sacral nerves permits placement of the electrodes on the sacral nerves [10].

d) Quality of life – QoL (LOE 3)

As no absolute indication has been defined for ACE, other criteria should be used to evaluate clinical outcome of bowel management, including health – related quality of life (HRQoL). This assessment should be performed prospectively when ACE produce is planned and performed during pre and post-operative periods.

According to Eire et al. (1998) ACE procedure and RCE can be the best options for achieving the best social integration. For wheelchair users and other selected patients the ACE (being faster and easier) is better than the retrograde continence enema which needs some help in its use [3,6].

CONCLUSIONS (LOE 3)

• Neurologic bowel dysfunction and bowel

problems incl. fecal incontinence and constipation are prevalent among myelomeningocele patients.

• Fecal incontinence and methods of bowel

care affect the QoL and social activities of myelomeningocele patients.

• The main goal, to empty the colon as much

as possible to achieve continence during the next 24–48 h, can be achieved nowadays either by retrograde colonic enema (RCE) using a special ballon catheter or by an operative procedure which allows an antegrade continence enema (ACE).

RECOMMENDATIONS B/C