From the Guidelines
The best next step in managing constipation after spinal cord injury with residual spastic tetraparesis is typically digital stimulation, followed by a progressive approach if needed. This approach is based on the principle of starting with the least invasive, most physiologic methods first. Digital stimulation involves inserting a gloved, lubricated finger into the rectum and moving it in a circular motion against the rectal wall to trigger the defecation reflex. This should be performed daily or every other day, ideally 20-30 minutes after a meal to take advantage of the gastrocolic reflex. If digital stimulation is insufficient, transanal irrigation would be the next appropriate step, using devices that flush the bowel with water to promote evacuation. Manual disimpaction should be reserved for cases of fecal impaction and performed carefully to avoid rectal trauma. Sacral nerve stimulation is generally considered only after conservative approaches have failed, as it's more invasive and requires surgical implantation, and there is no evidence that SNS improves bowel symptoms or rectal evacuation in defecatory disorders 1. A comprehensive bowel program should include:
- Adequate fluid intake (2-3 liters daily)
- High-fiber diet (25-30g daily)
- Regular timing of bowel care
- Possibly medications like stool softeners (docusate sodium 100mg twice daily) or osmotic laxatives (polyethylene glycol 17g daily) as needed. This stepped approach prioritizes the patient's quality of life, minimizing morbidity and mortality by avoiding unnecessary invasive procedures and promoting a physiologic bowel routine.
From the Research
Management of Constipation after Spinal Cord Injury
The management of constipation after spinal cord injury, particularly with residual spastic tetraparesis, involves a multifaceted approach.
- The first step is to establish a daily bowel program, which may include manual removal of stool, as well as adjustments to rectal and oral medications, fluid, fiber, and activity levels 2.
- Digital-rectal stimulation is a technique that can be utilized during bowel care to open the anal sphincter and facilitate reflex peristalsis 3.
- Transanal irrigation is a promising non-pharmacological intervention that can help reduce constipation and fecal incontinence 4.
- Pharmacological interventions, such as prokinetic agents, may be considered when conservative management is not effective, and are supported by strong evidence for the treatment of chronic constipation 4.
- Sacral nerve stimulation is not mentioned as a primary treatment option in the provided studies, but may be considered in certain cases.
Considerations for Individualized Care
It is essential to note that bowel management is complex and multifaceted, and needs to be individualized to the patient, taking into account their specific condition, symptoms, and response to treatment 2, 5.
- A comprehensive history and examination are necessary to define impairments, disabilities, and handicaps pertinent to neurogenic bowel dysfunction 3.
- The development of an individualized bowel program should involve a combination of various pharmacological, mechanical, and surgical interventions, as needed, to prevent complications and ensure successful management and compliance 5.