Colorectal motility and defecation after spinal cord injury in humans

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Abstract

Following spinal cord injury, colorectal problems are a significant cause of morbidity, and chronic gastrointestinal problems remain common with increasing time after injury. Although many cord-injured patients achieve an adequate bowel frequency with drugs and manual stimulation, the risk and occurrence of fecal incontinence, difficulties with evacuation, and need for assistance remain significant problems. The underlying physiology of colorectal motility and defecation is reviewed, and consequences of spinal cord injury on defecation are reported. A discussion of present management techniques is undertaken and new directions in management and research are suggested. There is need for more intervention in regard to bowel function that could improve quality of life, but there is also a need for more research in this area.

Introduction

Bowel dysfunction following spinal cord injury is increasingly recognized as an area of major physical and psychological difficulty. Surveys of spinal cord-injured people show that bowel function is as much of a problem as loss of mobility or sexual function. The problem is twofold as, not only does spinal cord injury result in changes to bowel motility and sphincter control, but also the concurrent loss of mobility and gross motor dexterity makes bowel management a major life-limiting problem.

Immediately after spinal cord injury, colorectal problems are a significant cause of morbidity, and chronic gastrointestinal problems remain common with increasing time after injury (Stone et al., 1990a). The inability to defecate normally means that bowel care often occupies a significant part of the day, and, although many cord-injured people achieve an adequate bowel frequency with drugs and manual stimulation, the risk and occurrence of fecal incontinence, difficulties with evacuation, and need for assistance remain significant life-limiting problems (Stone, Nino-Murcia, Wolfe, & Perkash (1990a), Stone, Wolfe, Nino-Murcia, & Perkash (1990b); Levi et al., 1995; Glickman and Kamm, 1996; Han et al., 1998; Lynch et al., 2001).

Long-term gastrointestinal complications can develop in cord-injured people. Fecal impaction is common. Diverticular disease and volvulus are more frequent and are perhaps related to higher intracolonic pressures in those with upper motor neuron lesions. The occurrence of hemorrhoids and mucosal prolapse was also identified by Lynch et al. (2000c) as occurring more frequently after spinal cord injury by an incidence of hemorrhoidectomy of 9% compared with a control group incidence of 1.5% (p<0.001). This may be multifactorial due to altered anorectal tone or trauma with manual evacuation, and is a frequent source of bleeding or autonomic dysreflexia.

Spinal cord-injured people rate difficulties with bowel management as similar to problems associated with loss of mobility and sexual function. Hanson and Franklin (1976) reported that 80% of male paraplegics and 46% of male tetraplegics would rank bladder and bowel as their greatest functional loss after loss of mobility. It was interesting that when they asked the same question to spinal unit staff, only 39% ranked bladder and bowel problems as high.

Survey data shows that 61% of cord-injured people would spend more than 15 min per day toileting, compared with only 9% of controls (Lynch et al., 2001). Those doing manual evacuations spend the longest time. Half of all cord-injured people need assistance with toileting. The need for assistance with toileting relates very closely with level of injury and has implications for provision of carers and dependence on family members. It is recognised that having family members perform such intimate tasks can be emotionally charged and negatively affect family interrelationships. This was significantly associated with the reported perception that bowel function was a source of distress.

Section snippets

Colonic function following spinal cord injury

Questionnaires exploring bowel function in spinal injured people have found that over half of those with an injury above the second lumbar segment (L2) suffer from constipation (DeLooze et al., 1998). People with higher injuries defecate less frequently compared to those with lower injuries and the general population. It is apparent that even with medications and other methods, spinal cord-injured people do not achieve a bowel motion frequency similar to a control population. Changes to the

Continence

The incidence of fecal incontinence in people with spinal cord injury is more common than in the general population. When compared to matched controls by using standardized scoring systems, the mean fecal incontinence score was higher for cord-injured people than controls (p<0.0001), and for complete spinal cord injury compared with incomplete injury (p=0.0023). Having fecal incontinence also impacts on the quality of life of those with a spinal cord injury more frequently than of

Current management strategies

The approach to bowel management after spinal cord injury should address specific issues such as fecal incontinence, constipation and functional mobility. This must be within the context of the patient as a whole person and consider his/her cultural, social, sexual and vocational roles. A bowel care regimen needs to be generated that fits the person's long-term routine. The aim should be effective colonic evacuation without fecal incontinence or other complications. Regularity of evacuation

Future objectives for the investigation and management of bowel dysfunction

Bowel dysfunction has a major impact on the quality of life for many people with spinal cord injury. This difficulty has been shown to improve with appropriate early identification and management of their problems. Interview and clinical examination can generate an impression of their general bowel function and identify problems such as constipation, fecal impaction, anal fissures and hemorrhoids. Simple tests of anorectal function are available that can be performed on all cord-injured people

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