Neurogenic bowel dysfunction in patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease

Exciting new features have been described concerning neurogenic bowel dysfunction,including interactions between the central nervous system,the enteric nervous system,axonal injury,neuronal loss,neurotransmission of noxious and non-noxious stimuli,and the fields of gastroenterology and neurology.Patients with spinal cord injury,myelomeningocele,multiple sclerosis and Parkinson's disease present with serious upper and lower bowel dysfunctions characterized by constipation,incontinence,gastrointestinal motor dysfunction and altered visceral sensitivity.Spinal cord injury is associated with severe autonomic dysfunction,and bowel dysfunction is a major physical and psychological burden for these patients.An adult myelomeningocele patient commonly has multiple problems reflecting the multisystemic nature of the disease.Multiple sclerosis is a neurodegenerative disorder in which axonal injury,neuronal loss,and atrophy of the central nervous system can lead to permanent neurological damage and clinical disability.Parkinson's disease is a multisystem disorder involving dopaminergic,noradrenergic,serotoninergic and cholinergic systems,characterizedby motor and non-motor symptoms.Parkinson's disease affects several neuronal structures outside the substantia nigra,among which is the enteric nervous system.Recent reports have shown that the lesions in the enteric nervous system occur in very early stages of the disease,even before the involvement of the central nervous system.This has led to the postulation that the enteric nervous system could be critical in the pathophysiology of Parkinson's disease,as it could represent the point of entry for a putative environmental factor to initiate the pathological process.This review covers the data related to the etiology,epidemiology,clinical expression,pathophysiology,genetic aspects,gastrointestinal motor dysfunction,visceral sensitivity,management,prevention and prognosis of neurogenic bowel dysfunction patients with these neurological diseases.Embryological,morphological and experimental studies on animal models and humans are also taken into account.

Diet in neurogenic bowel management:A viewpoint on spinal cord injury

The aim of this review is to offer dietary advice for individuals with spinal cord injury(SCI)and neurogenic bowel dysfunction.With this in mind,we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy,autonomic dysreflexia and neurogenic bladder.In addition,SCI is often associated with a sedentary lifestyle,which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation,including cardiovascular and chronic kidney diseases.The Mediterranean diet,along with exercise and dietary supplements,has been suggested as an anti-inflammatory intervention in individuals with SCI.However,individuals with chronic SCI have a daily intake of whole fruit,vegetables and whole grains lower than the recommended dietary allowance for the general population.Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake;therefore,this finding could explain the low consumption of plant foods.Low consumption of fibre induces dysbiosis,which is associated with bothendotoxemia and inflammation.Dysbiosis can be reduced by exercise and diet in individuals with SCI.Therefore,to summarize our viewpoint,we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines.Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI,chronic kidney diseases,chronic pain and irritable bowel syndrome.We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength,flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits.Finally,dietary advice for Paralympic athletes is suggested.

Outcomes of bowel program in spinal cord injury patients with neurogenic bowel dysfunction

In this study, we aimed to determine gastrointestinal problems associated with neurogenic bowel dysfunction in spinal cord injury patients and to assess the efficacy of bowel program on gastrointestinal problems and the severity of neurogenic bowel dysfunction. Fifty-five spinal cord injury patients were included in this study. A bowel program according to the characteristics of neurogenic bowel dysfunction was performed for each patient. Before and after bowel program, gastrointestinal problems（constipation, difficult intestinal evacuation, incontinence, abdominal pain, abdominal distension, loss of appetite, hemorrhoids, rectal bleeding and gastrointestinal induced autonomic dysreflexia） and bowel evacuation methods（digital stimulation, oral medication, suppositories, abdominal massage, Valsalva maneuver and manual evacuation） were determined. Neurogenic bowel dysfunction score was used to assess the severity of neurogenic bowel dysfunction. At least one gastrointestinal problem was identified in 44（80%） of the 55 patients before bowel program. Constipation（56%, 31/55） and incontinence（42%, 23/55） were the most common gastrointestinal problems. Digital rectal stimulation was the most common method for bowel evacuation, both before（76%, 42/55） and after（73%, 40/55） bowel program. Oral medication, enema and manual evacuation application rates were significantly decreased and constipation, difficult intestinal evacuation, abdominal distention, and abdominal pain rates were significantly reduced after bowel program. In addition, mean neurogenic bowel dysfunction score was decreased after bowel program. An effective bowel program decreases the severity of neurogenic bowel dysfunction and reduces associated gastrointestinal problems in patients with spinal cord injury.

Short Term Evaluation of a Novel Eletronic Transanal Irrigation System in Patients with Neurogenic Bowel Dysfunction Previously Exposed to Transanal Irrigation Systems

Introduction： Neurogenic bowel dysfunction is one of the most distressing consequences of the spinal cord injury. Transanal irrigation has proven to be a treatment for many such individuals, but there are some patients with sub-optimal response to it. Our aim was to evaluate the satisfaction, safety, perception and compliance of a new transanal irrigation device, Navina Smart system featuring an electronically driven pump with a digital control. Material and methods： Twenty-eight patients who had previously used, or were currently using transanal irrigation were enrolled. They were trained to use the Navina Smart system and were thereafter treated for four weeks. Patient perception, compliance and level of satisfaction were assessed at baseline and at the end of treatment. Results： At the end of treatment 68% of patients were still using the system and 50% of ITT （intended to treat） wished to continue using the system. Navina Smart was well tolerated with no adverse effects in the cohort. Patient perception of the Navina Smart system was positive in 67%. Conclusions： Navina Smart system was shown to be safe, tolerable and effective in two-thirds of patients who were unsatisfied with their previous bowel care and was associated with an increase in the patient＇s independence.

Predictive factors for compliance with transanal irrigation for the treatment of defecation disorders

AIM To investigate compliance with transanal irrigation(TAI) one year after a training session and to identify predictive factors for compliance.METHODS The compliance of one hundred eight patients [87 women and 21 men; median age 55 years(range 18-83)] suffering from constipation or fecal incontinence(FI) was retrospectively assessed. The patients were trained in TAI over a four-year period at a single institution. They were classified as adopters if they continued using TAI for at least one year after beginning the treatment or as non-adopters if they stopped. Predictive factors of compliance with TAI were based on pretreatment assessments and trainingprogress. The outcomes of the entire cohort of patients who had been recruited for the TAI treatment were expressed in terms of intention-to-treat.RESULTS Forty-six of the 108(43%) trained patients continued to use TAI one year after their training session. The patients with FI had the best results, with 54.5% remaining compliant with TAI. Only one-third of the patients who complained of slow transit constipation or obstructed defecation syndrome continued TAI. There was an overall discontinuation rate of 57%. The most common reason for discontinuing TAI was the lack of efficacy(41%). However, 36% of the patients who discontinued TAI gave reasons independent of the efficacy of the treatment such as technical problems(catheter expulsion, rectal balloon bursting, instilled water leakage or retention, pain during irrigation, anal bleeding, anal fissure) while 23% said that there were too many constraints. Of the patients who reported discontinuing TAI, the only predictive factor was the progress of the training(OR = 4.9, 1.3-18.9, P = 0.02).CONCLUSION The progress of the training session was the only factor that predicted patient compliance with TAI.