I ORAL PRESENTATIONS

Topic 5: Urinary and Faecal Incontinence (I)
Chair: Maureen Coggrave, Inder Perkash

Introduction Lecture:
FAECAL INCONTINENCE AFTER SPINAL CORD INJURY
Maureen Coggrave RN, MSc

Bowel dysfunction is common after spinal cord injury (SCI) (Krogh et al. 1997) and the
resulting faecal incontinence and constipation may have a major impact on quali-ty of
life (Correa G I & Rotter K P 2000; Lynch A C et al. 2001) ). Effective manage-ment of
the neurogenic bowel to prevent faecal incontinence is fundamental to both successful
rehabilitation and reintegration into the community. However, even bowel management
which successfully avoids both incontinence and constipation may car-ry a burden of
excessive time spent on care and dependency on others in this very intimate function,
and may not prevent a number of secondary related issues.

Conservative methods of management are the most frequently used approach; these
include the use of a pre-emptive routine, dietary measures, oral laxatives and physi-cal
or pharmaceutical stimulation of the rectum and digital evacuation of stool ((Consortium
for spinal cord medicine 1998;Stiens S, Bergman S, & Goetz L L 1997)Consortium for
spinal cord medicine 1998). Other assistive techniques such as the stimulation of the
gastro-colic reflex and abdominal massage may be employed. An individualised
combination of these interventions appears to be satisfactory for a majority of SCI
individuals but may prove ineffective for a minority.

Where conservative methods are ineffective options include irrigation of the bowel via
the anus or via a surgically constructed stoma, colostomy (Stone et al. 1990) or functional
electrical stimulation.

This talk will present the evidence for bowel management interventions after spinal
cord injury and identify areas for further research.

45/5 Bowel function in persons with long standing spinal cord injury

Savic G1, Charlifue S2, Glass C3, McColl MA4, Frankel HL1
1National Spinal Injuries Centre, Stoke Mandeville, UK,
2Craig Hospital, Englewood, USA,
3Regional Spinal Injuries Centre, Southport, UK,
4Queen’s University, Kingston, Canada

Aim: To analyse bowel function problems reported by persons with long standing
spinal cord injury (SCI).

Method: 373 participants from UK, USA and Canada were interviewed in the 2002
follow-up of the International Study of Ageing with SCI.

Results: The sample was 85% male, mean age was 58.7 and mean duration of injury
35.9 years, 35% had tetraplegia (Frankel grade A, B or C), 44% paraplegia (Frankel A,
B or C) and 21% an incomplete lesion (Frankel D). On direct questioning, the majority
of participants (94%) reported having one or more problems with their bowel function:
bowel accidents (63%), constipation (54%), incomplete emptying (40%), flatulence
(47%), bloating (35%), etc. However, only 11% said that bowel function significantly
affected their day to day life. Deterioration in bowel function over the three year study
period (1999-2002) was reported by 37% of all the participants, mainly as an increase
in one or more of the following: severity and/or frequency of constipation, frequency of
bowel accidents and amount of time and/or effort required to complete the bowel
programme. Improvement in bowel function was reported by 9% and attributed to
change in method of bowel emptying and additional management strategies. The three
countries differed in methods of bowel emptying and additional management strategies
used, in the number of reported problems and in the effects of bowel function on daily
life.

Conclusions: The most frequently reported problems, which also got worse over time,
were bowel accidents and constipation.
Acknowledgements: Supported by the Ontario Neurotrauma Foundation, Canada
and partly by the Centers for Disease Control, USA, National Institute on Disability and
Rehabilitation Research, USA and Stoke Mandeville Hospital Charitable Fund, UK.

46/5 Rectal compliance changes with afferent nerve stimulation in SCI

Chung E.A.L.; Balasubramaniam A.V.; Woodhouse J.B.; Emmanuel AV;
Craggs MD.
The Spinal Research Centre, Spinal Injuries Unit, Royal National Orthopaedic
Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, HA7 4LP

Background
Constipation and faecal incontinence are highly prevalent amongst SCI patients.
Contributing to the development of these symptoms is the loss of supra-sacral
neurological control in SCI, resulting in aberrant sacral reflexes. Electrical sacral nerve
stimulator implanted devices (Medtronic SNS and Finetech/Brindley SARSI ) are used
in clinical practice, improving symptoms in functional and SCI patients. The
mechanism behind this improvement is unclear. We hypothesize that sacral afferent
stimulation may influence rectal compliance.

Methods
8 male SCI subjects studied, with injuries of greater than 2 years duration and between
C5-L1. A pulse generator was attached via pre-gelled surface electrodes to the dorsal
penile nerve (DPN), in order to achieve purely afferent pudendal nerve stimulation.
Rectal distension in 50ml steps was undertaken with simultaneous pressure
recordings. This was then repeated with afferent nerve stimulation at parameters
chosen for their effects on bladder function.

Results
Neuromodulation resulted in significant increased rectal compliance with increasing
distension (see graph) (p<0.005, 2-way ANOVA). This effect seems more marked at
higher levels of distension.

Conclusion
Afferent sacral stimulation alters rectal function (compliance) in SCI patients. This
provides insight into the mechanisms of action of sacral nerve stimulation and offers
hope for therapy in SCI patients.

Rectal Distension Compliance Changes
Control vs Neuromodulation With DPN
0 50 100 150 200 250 300 350
10
20
30
Rectal Compliance Control
Rectal Compliance + DPN Stim
n=8
Rectal Volume ml
Rectal Compliance
ml/mmHg

47/5 Symptoms of Bowel Dysfunction in Spinal Cord Injured Patients

G. Bazzocchi, P.F. Almerigi, E. Poletti, I. Baroncini, P. Salucci, P. Pillastrini, M.
Menarini
Spinal Cord Unit - Montecatone Rehabilitation Institute – Imola, University of
Bologna – Italy

During 2004, 75 consecutive patients (57 males, 42 paraplegic, 33 tetraplegic, mean
age 46 years, range 19-76 years) reported unsatisfactory bowel habit in spite of the
therapy with laxative, suppositories and/or enema. Every patient was evaluated by
means of Rome II Diagnostic Criteria for Intestinal Functional Disorders [Gut 1999; 45
(Suppl II): II43-II47], a complete proctological examination, anorectal manometry and
Intestinal Transit Study. Four types of bowel disorders were recognized: (A) obstructed
defecation due to anatomic diseases as rectal prolapse or rectocele; (B) constipation
owing to colonic dysfunction; (C) evidences for incomplete evacuation and/or time >1
hour for rectal emptying; (D) fecal incontinence and/or anal soling. No relationship
between the four abnormalities of bowel habit with type, level of the injury, ASIA scores
and characteristics of bladder disorder was found. In the 44.5% of the female versus
the 24.% of males (p=.02, Fisher’s Exact Test) the patho-physiologic mechanism
underlying the intestinal disorder was not related to the neurologic damage “di per sè”.
The present study shows that: 1) constipation and fecal incontinence are not
exhaustive for describing “neurogenic bowel” clinical pictures. 2) conversely from
bladder disorder, further factors besides spinal cord injury seem to play a role in the
occurrence of bowel dysfunction.

48/5 Sacral Anterior Root Stimulator Implants (SARSI): Their effect on
patterns of bowel management in patients with spinal cord injury

L.Q. Liu, E.A.L. Chung; M. Coggrave; J. Bycroft; C. Norton; A.V. Emmanuel;
M.D. Craggs
The Spinal Research Centre, Spinal Injuries Unit, Royal National Orthopaedic
Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, HA7 4LP.

Background
SARSIs are used in SCI for bladder control and emptying, by stimulating S2,3,4. SCI
results in high levels of bowel dysfunction. Bowel management in SCI patients is
protracted and distressing. We report effects that SARSI has on bowel management.

Methods
An adapted questionnaire (from existing database) completed by SARSI patients.
Matching sex, age, time/level of injury to controls, allowed for comparative analysis.

Results
Response;86%(24/28): 75%male, median age;45(30-76). Constipation prevalence; no
difference between SARSI patients and controls(29%vs46%). 14 SARSI subjects
reported constipation pre-implantation: 7 reported symptom normalisation after
implantation. More SARSI patients spent less than 30minutes on bowel management
(54%vs88%,p<0.05). No SARSI patients spent more than an hour on bowel
management vs 25% controls (p<0.05). SARSI patients required fewer management
steps, 50% reporting a reduction post-implant. Bowel management satisfaction was
similar. More controls reported excess bowel management time as being the reason
for dissatisfaction (88%vs17%,p<0.05). SARSI patients expected greater
improvement, as their reason for dissatisfaction.

Conclusions
• SARSI patients require less time and fewer steps in bowel management.
• Satisfaction: no difference between the two groups – due to increased expectation
in the SARSI group?
• There maybe a role for specific neuromodulation of bowel efferents to improve
function and management.

49/5 Community management of neurogenic bowel function after spinal
cord injury in the UK

M. J. Coggrave, C. S. Norton, J. Wilson-Barnett
The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK.

Following spinal cord injury (SCI), altered bowel physiology and loss of voluntary
control over bowel function have a very significant impact on the lives of injured
individuals; despite this, little is known regarding long term bowel management and its
outcomes in the UK.

A postal survey was conducted at one spinal cord injury unit in the south of England.
The questionnaire addressed bowel management methods, secondary complications,
dependency, impact of bowel dysfunction and satisfaction with bowel care. More than
900 responses were received.

The mean age of the sample was 50 years; mean duration of injury 17 years and 73%
of respondents were male. Almost 77% reported that they were satisfied or very
satisfied with their bowel management. Duration of bowel care was 1 hour or less for
80% of respondents, at least monthly faecal incontinence was reported by 15%.
Haemorrhoids (36%), Autonomic Dysreflexia (31%) and constipation (41%) were the
most commonly reported secondary complications. The presence of haemorrhoids was
associated with manual evacuation (P=0.035), glycerine suppositories (P=0.006), anorectal
stimulation (P=0.001) and increasing time since injury (P=0.03).

The levels of complications reported in this study are lower than those reported in other
studies but the bowel remains a source of morbidity for many and despite the high level
of satisfaction reported, continues to diminish quality of life.
Funded by a research training fellowship provided by Action Medical Research.

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