From the Guidelines
Neurogenic bowel dysfunction should be managed with a stepwise approach, starting with conservative therapies such as dietary modifications, bowel training, and medications, as these will benefit approximately 25% of patients. The management of neurogenic bowel dysfunction involves a comprehensive approach that includes dietary modifications, bowel training, and medications.
Key Components of Management
- Increasing fiber intake to 25-35 grams daily and maintaining adequate hydration with 2-3 liters of fluid per day
- Establishing a consistent bowel routine, typically 30-60 minutes after meals when the gastrocolic reflex is strongest
- Using stool softeners like docusate sodium (100-300 mg daily), osmotic laxatives such as polyethylene glycol (17 grams in 8 ounces of water daily), or stimulant laxatives like bisacodyl (5-15 mg orally or 10 mg rectally) for constipation-predominant neurogenic bowel
- Considering antidiarrheal medications like loperamide (2-4 mg as needed, maximum 16 mg daily) and use of suppositories or mini-enemas for fecal incontinence
- Pelvic floor retraining with biofeedback therapy is recommended for patients who do not respond to conservative measures 1
- Sacral nerve stimulation should be considered for patients with moderate or severe fecal incontinence who do not respond to conservative measures and biofeedback therapy 1
Additional Considerations
- Digital stimulation or manual disimpaction may be necessary in some cases
- Transanal irrigation systems or surgical interventions such as colostomy may be required in more severe cases
- Physical therapy focusing on abdominal massage and pelvic floor exercises can help stimulate bowel motility These approaches work by compensating for the disrupted neural pathways between the brain and bowel that normally control defecation, helping to establish predictable bowel movements and prevent complications like impaction, incontinence, and autonomic dysreflexia.
Surgical Interventions
Surgical options may be considered in patients who have failed conservative therapy, with sacral nerve stimulation being a safe and effective option for fecal incontinence 1.
From the Research
Management of Neurogenic Bowel Dysfunction
The management of neurogenic bowel dysfunction (NBD) involves a multi-faceted approach, including conservative and surgical treatments.
- Conservative management begins with establishing an effective and regular bowel regime by optimizing diet and laxative use 2.
- If conservative management is insufficient, transanal irrigation has been shown to reduce NBD symptoms and improve quality of life 2, 3, 4.
- Pharmacological interventions, such as prokinetic agents, have strong evidence for success in treating chronic constipation 5.
- Digital stimulation has been found to be effective in short-term follow-up 4.
- Patient-reported efficacy of colostomy alone or in combination with other surgeries appears evident in terms of patient's satisfaction and quality of life over time 4.
Surgical Options
Surgical options are available for patients who do not respond to conservative management, including:
- Colostomies 5, 4
- Malone anterograde continence enemas 5, 3
- Sacral anterior root stimulator implantations 5
- Graciloplasties 5
- Artificial bowel sphincters 5
- Cecostomy 3
Treatment Selection
The selection of treatment for NBD depends on various factors, including the underlying cause of the condition, the severity of symptoms, and patient preferences 3, 4, 6.
- Transanal irrigation is a safe and effective management option that does not require surgery 3.
- Antegrade enemas can be carried out via cecostomy tube or Malone anterograde continence enema with similar fecal continence outcomes 3.
- The choice of treatment should be balanced case by case, considering clinical history, setting of use, and bowel management protocol 4, 6.