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Neurogenic bladder and bowel are two critical autonomic complications following traumatic spinal cord injury (TSCI). Chronic lower urinary tract and bowel dysfunctions can lead to secondary complications, drastically affect the quality of life and significantly increase the risk of hospital readmission and mortality. Other than symptomatic treatments, a few effective therapies are available. Combined acupuncture and moxibustion therapy has positive effects on improving nerve repair and functional recovery in the early phases following TSCI. However, whether it is effective for TSCI-related chronic urinary and bowel dysfunctions remains unknown. This report presents the case of a 26-year-old male patient who experienced neurogenic bladder and bowel dysfunction following TSCI due to an accidental fall from height for more than 10 months and visited our department for combined acupuncture and moxibustion therapy. After 48 treatment sessions, he regained voluntary urination and defecation to a large extent. Urodynamic testing showed recovered bladder compliance and improved detrusor contractility. Symptom assessment with the Qualiveen Short-Form and neurogenic bowel dysfunction scores demonstrated reduced symptom severity. This case suggests that combined acupuncture and moxibustion therapy might help to restore the physiological functions of the lower urinary and digestive tracts following TSCI and might be a promising alternative for the treatment of neurogenic bladder and bowel dysfunction in patients with TSCI.

Background: Neurogenic bowel dysfunction (NBD), like fecal incontinence and constipation, is a common symptom of disease in patients with multiple sclerosis (MS). The NBD score is a validated symptom-based questionnaire consisting of 10 multiple-choice questions. The aim of this study was to validate the Dutch version of the NBD score in patients with MS, creating an objective measuring tool of bowel dysfunction. Methods: Translation and validation of the NBD score was performed according to standardized guidelines. Adult patients with MS visiting a urology department completed a set of questionnaires (test): the NBD score, the Fecal Incontinence Quality of Life scale (FIQL), the Fecal Incontinence Severity Index (FISI), and the EQ-5D 3-Level questionnaire (EQ-5D-3L). After 1 to 2 weeks, the questionnaires were completed again (retest). A control group recruited at a general practitioner’s practice completed the questionnaires once. Data were analyzed for measurement properties. Results: Sixty-one patients and 50 controls were included. Content validity was adequate, internal consistency was moderate (Cronbach α = 0.57 and 0.41), and reproducibility was excellent (interclass correlation coefficient = 0.78). Criterion validity was confirmed; the NBD score correlated moderately/strongly with the FIQL, FISI, and EQ-5D-3L. The NBD scores in the patient group were significantly higher than those in the control group, demonstrating good construct validity. Conclusions: The Dutch version of the NBD score showed moderate to good validity and good reliability for assessment of NBD in patients with MS.

Purpose: The aim of this study was to evaluate the prevalence of bowel/bladder dysfunction in multiple sclerosis (MS) and its associations with cognitive impairment.Methods: We prospectively enrolled 150 MS patients. Patients were administered the Symbol Digit Modality Test (SDMT), the Neurogenic Bowel Dysfunction Score (NBDS), and the Actionable Bladder Symptom Screening Tool (ABSST). The associations between bowel/bladder dysfunction and cognitive function were assessed through hierarchical regression models using the SDMT and clinicodemographic features as independent variables and NBDS and ABSST scores as dependent variables.Results: The prevalence of bowel/bladder deficits was 44.7%, with 26 patients (17.3%) suffering from bowel deficits and 60 patients (40%) from bladder deficits. The total NBDS and ABSST scores were correlated with the SDMT (β=-0.10, P

Background: Neurogenic bowel dysfunction (NBD) following spinal cord injury (SCI) represents a major source of morbidity, negatively impacting quality of life and overall independence. The long-term changes in bowel care needs are not well-reported, preventing consensus on the natural course and optimal management of NBD following injury. Objectives: To understand the changes in bowel management needs over time following SCI. Methods: A retrospective observational study using the National Spinal Cord Injury Model Systems database evaluated the degree of independence with bowel management at discharge from inpatient rehabilitation across time (1988–2016). The prevalence and consecutive trajectory of bowel management was also evaluated at discharge and at each 5-year follow-up period, for 25 years. Results: The majority of individuals discharged from inpatient rehabilitation (n = 17,492) required total assistance with bowel management, a trend that significantly increased over time. However, by 5-years post injury, there was a significant shift in bowel management needs from total assistance to modified independence. In those with consecutive 25-year follow-up data (n = 11,131), a similar shift in bowel management to a less dependent strategy occurred even at chronic time points post injury, primarily in individuals with paraplegia and classified as motor and sensory complete. Conclusion: The findings of this study highlight the need for providing continued multipronged interventions (e.g., rehabilitative, educational, psycho-social) at the different stages of SCI to support individuals not only in the immediate years after discharge but also well into the chronic stages after injury.

BACKGROUND: After the surgical treatment of children for anorectal malformations, spinal pathology, and Hirschsprungs disease, their quality of life is significantly reduced due to fecal incontinence. For patients with persistent defecation disorders, the Bowel Management program is offered. AIM: This study analyzes the Bowel Management program implemented in the clinic. MATERIALS AND METHODS: A prospective analysis of the program used in children after surgical correction of malformations was conducted. The program comprised the following components: lectures for patients/parents, hospitalization, irrigography with water-soluble contrast, teaching patients/parents about cleansing enemas, keeping a bowel movement diary, plain abdominal X-ray, changing the recipe for enema solution, monitoring the effectiveness, and correcting recommendations. RESULTS: A total of 66 children from 1.5 to 17 years old were treated. Three groups were identified: (I) anorectal malformations (n = 26), (II) spinal pathology (n = 30), and (III) Hirschsprungs disease (n = 10). The results were considered satisfactory if the bowel cleansing procedure was painless for the child and did not cause stress reactions; the parents were satisfied with the result of the prescribed program if after the enema a sufficient amount of stool was removed within 45 minutes, there were no episodes of defecation during the day. With the help of the Rome IV revision criteria, fecal incontinence was noted in all cases against the background of stool retention. In 11 (16.7%), there was no fecal incontinence even in cases of prolonged stool retention. A correlation was found between high lesions (in the lumbar spine) in spinal hernias with the absence of fecal incontinence with prolonged stool retention compared with the low sacral localization of the hernia. In group I, 91.7% had spinal cord fixation. In group II, 86.7% had it, and none were present in group III. The effectiveness of the program was 83.3%. CONCLUSION: The Bowel Management is easy to use and effective in 83% of patients. It can be recommended for the rehabilitation of children with defecation disorders, fecal incontinence after surgical correction of congenital malformations (anorectal malformations, spinal pathology and Hirschsprung's disease).

Aim: Spinal cord injury (SCI) patients may have intestinal dysmotility and digestive symptoms that are associated with small intestinal bacterial overgrowth (SIBO). The aim of this study is to describe the prevalence of SIBO in SCI patients and the risk factors of its development. Methods: Twenty-nine consecutive SCI patients were studied (10 women/19 men; mean age 47 years), 16 with subacute injuries (1 year). Nine patients were affected by tetraplegia and 15 by paraplegia. Each patient underwent a glucose breath test according to the North American Consensus and the presence of abdominal symptoms was evaluated during the test. The results were compared with 15 non-neurological patients with SIBO. Results: Six patients tested positive for SIBO (21%), all of them affected by SCI in the subacute phase, 6/16 vs 0/13 in the chronic phase (p < 0.05) and the majority with tetraplegia, 5/9 vs 1/19 with paraplegia (p < 0.05). No statistically significant relationship was found with other clinical characteristics. All the tests were positive for methane or mixed (methane and hydrogen), while only 67% of the controls had methane-predominant production. (p > 0.05). Conclusion: SCI patients can develop SIBO, more frequently in the subacute phase and in tetraptegic patients, highlighting a high production of methane. This complication should be considered in neurogenic bowel management. (C) 2021 Elsevier Espana, S.L.U. All rights reserved.

OBJECTIVES This retrospective study aimed to determine the effectiveness of sacral neuromodulation (SNM) on neurogenic lower urinary tract dysfunction (NLUTD) and analyze the predictive factors. MATERIALS AND METHODS From January 2012 to January 2020, 152 subjects with NLUTD from four medical centers in China received SNM test stimulation. Subjects were assessed via bladder diaries, postvoid residual volumes (PRVs) and neurogenic bowel dysfunction (NBD) scores before and during the testing period. Patients who showed a minimum 50% improvement in symptoms through the SNM test phase were eligible for permanent SNM implantation. RESULTS The pooled success rate for chronic urinary retention was 31.0% (40/129), which was significantly lower (p

Background: Neurogenic bowel dysfunction (NBD) caused by spinal cord injury (SCI) is a major life limiting issue for many patients. However, studies detailing the factors contributing to bowel problems are scarce. The aim of this cross-sectional questionnaire-based study was to evaluate the associations between different aspects of bowel problems and characteristics of SCI, such as time since injury (TSI), level of injury (LOI), and the cause of injury. Methods: Two questionnaires (the NBD score questionnaire and the Cleveland clinic constipation system score questionnaire) were administered to complete, traumatic patients with SCI that matched the designated criteria. The total scores and the subscales were then regressed to TSI and LOI, and the distribution patterns of NBD score severity according to LOI and cause of injury were shown in a diagram. Results: Within the subscales of the NBD score, frequency of defecation, digital stimulation or evacuation of the anorectum, and perianal skin problems were all significantly and positively correlated with the TSI, yet the frequency of fecal incontinence was negatively associated with this variable. Moreover, uneasiness, headache, or perspiration during defecation and regular use of drops against constipation were negatively associated with the LOI. In the diagrams, patterns of NBD score severity were similar according to LOI, but visibly differed according to cause. With respect to the CCCS score (Cleveland Clinic Constipation Scoring System), the score itself was shown to be positively associated with TSI. Within the subscales, difficulty, time spent in lavatory, and duration of constipation were positively correlated with TSI. Furthermore, type of assistance was negatively associated with the LOI. Conclusion: Different characteristics of SCI, TSI, LOI, and cause, each are significantly and distinctly associated with different aspects of the bowel problems that patients with SCI face.

Objectives To map and characterize the nature of the evidence on the use of digital rectal stimulation for bowel management in individuals with spinal cord injury (SCI). Data Sources Five electronic databases were searched (ie, MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and Cochrane Incontinence Group) from 1990 to November 2019. Study Selection Articles that provided information on the use of digital rectal stimulation either alone or in combination with treatments were included. Title and abstract screening was split between 2 reviewers after reaching consensus on the first 100 studies screened. Full-texts were reviewed independently by 2 reviewers. Discrepancies were resolved by a third reviewer. Data Extraction The data extraction form was developed by 2 reviewers and piloted. Data were extracted by one reviewer and checked for accuracy by a second reviewer. Data Synthesis A total of 4841 studies were screened, including 425 full text articles; 33 articles were identified. Thirty-two studies focused solely on individuals with SCI and 1 study explored the experiences of caregivers of individuals with SCI. The majority of participants were aged between 30 and 59 years old. Most studies used quantitative methods (n=30, 91%). Fourteen of the studies (42%) were cross-sectional. Within experimental or quasiexperimental designs, digital rectal stimulation was commonly studied as an adjunct to other methods such as suppositories or enemas. Incontinence and defecation time were the most commonly examined outcomes. Conclusion There were few studies found that focus on digital rectal stimulation. Further studies examining experience, effectiveness, complications, and long-term outcomes are warranted.

Study design Cross sectional. Objectives To identify variables associated with severe bowel symptoms in spinal cord injured people. Setting National cohort. Methods Adult spinal cord injured (SCI) people were recruited for an online registry and 1373 were included for analysis. Univariate analysis and logistic regression was used to evaluate associations between severity of bowel symptoms and variables. Bowel symptoms were assessed by the Neurogenic Bowel Dysfunction (NBD) score and patients scoring ≥14 were categorized as having severe bowel symptoms. Autonomic dysreflexia (AD) severity was measured using a six item questionnaire and reported as total AD score (0-24). Bladder management was categorized as: voiding, clean intermittent catheterization (CIC), surgery (augmentation/diversion) or indwelling catheter. Results Severe bowel symptoms were reported in 570 (42%) On multivariable logistic regression, every point increase of AD total score was associated with 5% increased odds of having more severe bowel symptoms [OR 1.05 95% CI 1.03-1.10]. Type of bladder management was also associated with more severe symptoms (p = 0.0001). SCI people with indwelling catheters (OR = 2.16, 95% CI 1.40-3.32) or reconstructive surgery (OR = 1.79, 95% CI 1.08-3.32) were almost twice as likely to report more severe bowel symptoms than those performing CIC.

Neurogenic bowel dysfunction, including hyperreflexic and areflexic bowel, is a common complication in patients with spinal cord injury (SCI). We hypothesized that removing part of the colonic sympathetic innervation can alleviate the hyperreflexic bowel, and investigated the effect of sympathectomy on the hyperreflexic bowel of SCI rats. The peri-arterial sympathectomy of the inferior mesenteric artery (PSIMA) was performed in T8 SCI rats. The defecation habits of rats, the water content of fresh faeces, the intestinal transmission function, the defecation pressure of the distal colon, and the down-regulation of Alpha-2 adrenergic receptors in colon secondary to PSIMA were evaluated. The incidence of typical hyperreflexic bowel was 95% in SCI rats. Compared to SCI control rats, PSIMA increased the faecal water content of SCI rats by 5–13% (P

Background: Bowel dysfunction, including constipation and fecal incontinence, is prevalent in individuals with multiple sclerosis (MS), adversely affecting quality of life and increasing caregiver burden. How health care professionals (HCPs) identify, assess, and manage people with MS with bowel dysfunction is understudied. This study explored how HCPs think about, assess, and manage bowel dysfunction in individuals with MS. Methods: Semistructured interviews were conducted with 18 HCPs from different professional disciplines and clinical specialties recruited from UK National Health Service primary, secondary, and tertiary care services using purposive and chain referral sampling through professional networks. One participant worked for a bladder and bowel charity. Data were analyzed using thematic analysis. Results: Views differed regarding responsibilities for providing bowel care. Participants thought individuals with MS should notify HCPs of bowel symptoms and take responsibility for self-management where possible, with family caregivers required to help with bowel care. Although people with MS were often referred to bladder and bowel specialists when a crisis point was reached, earlier referral was called for by these HCPs. There were variations in assessment processes, treatment options offered, and service provision. Participants thought HCPs needed more education on bowel dysfunction, bowel care should take a high priority, and evidence-based clinical guidelines and referral pathways would improve service delivery. Conclusions: The HCPs caring for individuals with MS see many with bowel dysfunction, and there is variation in care and service provision; HCPs require more education, evidence-based clinical guidelines, and referral pathways to improve case finding, assessment, and management of these symptoms for individuals with MS.

Financial support provided by the Craig H. Neilsen Foundation.© Copyright 2020, Paralyzed Veterans of AmericaThese guidelines have been prepared based on scientific and professional information ava...

The current literature on neurogenic bowel will be addressed with a specific focus on spina bifida population. Topics will include bowel management, clinical care pathways, variation in care, quantification of dysfunction, and quality of life outcomes. There have been several recent studies that retrospectively review the outcomes from a national spina bifida registry as well as ongoing work regarding the development and validation of quality of life (QOL) instruments for the neurogenic populations. These studies have highlighted the significance of any fecal incontinence and its negative effect on QOL. Although there has been a recent increase in publications regarding this neurogenic population, a significant amount of further work is required. Through multi-institutional collaboration and standardization of care pathways, there can be significant advances in the care of these patients.

Gut microbiota are the candidate biomarkers for neurogenic bowel dysfunction (NBD) in patients with spinal cord injury (SCI). We aimed to identify the common features between patients with varying degree of thoracic SCI and healthy individuals and subpopulations of microbiota correlated with the serum biomarkers. Twenty-one patients with complete thoracic SCI (CTSCI), 24 with incomplete thoracic SCI (ITSCI), and 24 healthy individuals (HC) were enrolled in this study. Fresh stool samples and clinical data were collected from all participants, and their bowel functions with SCI were assessed. Microbial diversity and composition were analyzed by sequencing the 16S rRNA gene. The features of gut microbiota correlated with the serum biomarkers and their functions were investigated. The mean NBD score of patients with CTSCI was higher than that of patients with ITSCI. Diversity of the gut microbiota in SCI group was reduced, and with an increase in the degree of damage, alpha diversity had decreased gradually. The composition of gut microbiota in patients with SCI was distinct from that in healthy individuals, and CTSCI group exhibited further deviation than ITSCI group compared to healthy individuals. Four serum biomarkers were found to be correlated with most differential genera. Patients with thoracic SCI present gut dysbiosis, which is more pronounced in patients with CTSCI than in those with ITSCI. Therefore, the gut microbiota profile may serve as the signatures for bowel and motor functions in patients with thoracic SCI., GRAPHICAL ABSTRACT

Objectives Most individuals with spinal cord injury have neurogenic bowel dysfunction, which includes slowed colonic motility and has a significant impact on their health and quality of life. Bowel management typically includes mechanical rectal distension to evoke a recto-colic reflex and promote bowel emptying. Electrical stimulation could replace this mechanical distension. The purpose of this study was to determine the feasibility of evoking colonic activity using electrical stimulation. Materials and methods Acute experiments were conducted in eight neural-intact cats under chloralose anesthesia. Patterned electrical stimulation was administered via electrodes placed on the surface of the distal colon or proximal colon. Distal and proximal colon pressures were measured using saline-filled balloon catheters. Outcome measures included peak colonic pressure; time to onset of response; and time to peak pressure compared to baseline without stimulation. Results Stimulation elicited colonic activity in all animals. Peak colon pressures were 15 ± 28 cmH2 O and were proportional to stimulation amplitudes. Time to onset and time to peak pressure were 13 ± 19 s and 37 ± 49 s, respectively, and were not significantly affected by stimulus parameters. Proximal colon stimulation only resulted in pressure responses from the proximal colon, but distal colon stimulation resulted in both proximal and distal responses in 40% of trials. Adding isoflurane anesthesia removed this proximal response to distal stimulation. Conclusions Distal colon stimulation evoked colonic activity. The dependence of this response on stimulation location and anesthesia suggests that responses were reflex mediated. Colonic stimulation may have the potential to improve colonic motility for individuals with neurogenic bowel dysfunction.

Background: Little information is available in spinocerebellar ataxias (SCAs) regarding pelvic organ symptoms. The aim of this study was to characterize the lower urinary tract (LUT) and bowel dysfunction in autosomal dominant spinocerebellar ataxias. Methods: Patients with confirmed SCAs attending a tertiary care service were approached about LUT and bowel complaints, and completed validated questionnaires: urinary symptom profile (USP), QualiveenShort form, International Prostate Symptom Score, and Neurogenic Bowel Dysfunction Score. SCA3 and SCA7 patients with urological complaints additionally underwent urodynamic studies (UDS). Patients’ characterization included demographic, clinical (Scale for the Assessment and Rating of Ataxia (SARA), Inventory of Non-Ataxia Signs (INAS)), and genetic variables. Descriptive and comparative analyses were performed. Results: Fifty-one patients participated: SCA1 (n = 4), SCA2 (n = 11), SCA3 (n = 13), SCA6 (n = 17), and SCA7 (n = 6). The prevalence of self-reported LUT symptoms was 60.8% (n = 31), whereas LUT symptoms was reported in 86.3%(n = 44) using the USP. Both storage and voiding symptoms were reported, urinary frequency and urgency being the most frequent (n = 34, 68%). Although LUT symptoms were most often classed as mild (n = 27, 61.4%), they impacted QoL in 38 patients (77.6%). Of these, 21 (55.3%) were not on pharmacological treatment for urinary dysfunction. Most common abnormalities in UDS (n = 14) were detrusor overactivity (storage phase) and detrusor underactivity (voiding phase). Bowel symptoms were less common (31.4%, n = 16) and of mild severity. Conclusion: LUT symptoms are prevalent in SCA patients and impact QoL, whereas bowel symptoms tend to be mild. These symptoms are overlooked by patients and physicians due to the complexity of neurological involvement in SCA, and therefore a multidisciplinary management approach should be adopted.

Study design: This is a prospective validation study. Objectives: The neurogenic bowel dysfunction (NBD) score is a widely used symptom-based questionnaire evaluating bowel dysfunction and its impact on quality of life (QoL) in spinal cord-injured patients. This study aimed to translate and validate a Dutch-language NBD score in patients with SCI. Setting: Patients with SCI visiting the urology department or general practitioner (GP) in Rotterdam, the Netherlands. Methods: Standardized guidelines were followed for the translation and validation process of the NBD score. Adult patients with SCI visiting our urology department were asked to participate by filling in a set of questionnaires: the NBD score, the Fecal Incontinence Quality of Life scale (FIQL), the Fecal Incontinence Severity Index (FISI), and the European Quality of life 5-Dimension 3-Level questionnaire (EQ-5D-3L) at baseline and 1–2 weeks afterward. A control group recruited at a GP office completed the questionnaires once. The following measurement properties were evaluated: content validity, internal consistency, reproducibility, criterion-, and construct validity. Results: Fifty-eight patients and 50 references were included. Content validity was adequate, internal consistency was moderate (Cronbach’s alpha 0.56 and 0.30) and reproducibility was adequate (ICC 0.87). Criterion validity was confirmed; NBD score correlated significantly with the FIQL, FISI, and EQ-5D-3L. NBD scores in the patient group were significantly higher than in references, demonstrating good construct validity. Conclusions: The Dutch-language version of the NBD score showed moderate to good measurement properties, and therefore is a reliable tool to measure bowel dysfunction in patients with SCI. We recommend standardized usage of this questionnaire for clinical evaluation and research purposes.

Bowel dysfunction after chronic spinal cord injury (SCI) is a common source of morbidity and rehospitalization. Typical complications include constipation, fecal impaction, incontinence, abdominal distention, autonomic dysreflexia, and the necessity of interventions (i.e., suppositories, digital stimulation) to defecate. Numerous surveys have confirmed that the remediation of bowel complications is more highly valued for quality of life than improvements in walking. Much of what is known about bowel function after SCI for diagnosis and research in humans has been gained using anorectal manometry (ARM) procedures. However, ARM has been underutilized in pre-clinical animal work. Therefore, a novel combination of outcome measures was examined in the current study that incorporates functional output of the bowel (weekly fecal measurements), weight gain (pre-injury to terminal weight), and terminal ARM measurement with external anal sphincter electromyography under urethane anesthesia. The results indicate higher fecal output after contusion during the sub-acute period (4-7 days) post-injury, changes in the composition of the feces, and functionally obstructive responses in a specific section of the rectum (increased baseline pressure, increased frequency of contraction, and reduced ability to trigger a giant contraction to a distension stimulus). These results demonstrate significant bowel dysfunction in the rodent SCI contusion model that is consistent with data from human research. Thus, the combined measurement protocol enables the detection of changes and can be used, with minimal cost, to assess effectiveness of therapeutic interventions on bowel complications.

The guidelines (AWMF register number: 179-004) on neurogenic bowel dysfunction (NBD) in spinal cord injury of the German-speaking Medical Society for Paraplegiology is addressed to all persons who care for people with congenital or acquired paraplegia with NBD. In particular, doctors, nurses and therapists are addressed. The multiprofessionally developed guidelines (involving neurourologists, visceral surgeons, gastroenterologists, health and nursing staff, nutritionists and associated professional societies in the review process) provides practical support for the care of patients with NBD. Definitions and up to date knowledge on the diagnostics of NBD as well as on the necessary conservative bowel management are conveyed in order to ensure the competent treatment of patients with NBD. The concept of NBD and its clinical implications are described. Drug interventions and surgical procedures are explained in brief and recommendations are given. The main objective of the present guidelines is to prevent complications including fecal incontinence and constipation and thus to positively influence the quality of life of those affected. Helpful appendices, which can be used in everyday life, complete the guidelines.

We present a case involving a catastrophic injury that resulted from a completely obstructed airway when an examinee choked on food. She had cardiopulmonary arrest and developed a hypoxic-ischemic encephalopathy associated with profound neurological losses. The evaluation of the consequences of severe central nervous system injury necessitates evaluation and rating of all the sequelae of that injury. The first step is clinical assessment, followed by thoughtful application of these data to the processes and criteria provided in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). The approaches discussed in the fifth and sixth editions of the AMA Guides are similar.

Context Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families. Objective To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction. Evidence acquisition We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management. Evidence synthesis Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories. Conclusions Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children’s Continence Society. Patient summary Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.

Neurogenic bowel has received surprisingly little attention. Among individuals with spinal cord injury, bowel function is considered a major physical and psychological problem that stems from the severe negative impact on social life and mobility. With transanal irrigation, individuals with neurogenic bowel have received an additional tool that may simplify life and improve independence. A recent survey showed that as many as 37% of the spinal cord injury patients interviewed had not heard about transanal irrigation. It should be a high priority at spinal cord injury centers to support patients with the right tools for proper bowel management and care.

To describe management options used for neurogenic bowel dysfunction (NBD) in patients with spinal cord injury (SCI). Approach to treatment for NBD in SCI is primarily derived from traditional approaches and historical guidelines. Large formal randomized control trials and recent high-quality studies on NBD management are sparse. Advances in SCI research are transitioning focus to emerging technologies as well as addressing quality of life (QOL). Recent literature suggests that ongoing challenges remain in NBD management as it pertains to QOL, social activities, and life participation. The current and traditional approaches to NBD have led to relative success in maintaining continence and minimizing associated complications in the SCI population. Management should remain rooted in identifying patient goals and working toward improving QOL. As newer practices emerge, providers should continue to critically review existing and novel recommendations for NBD management.

To compare the quality of life (QoL) in children with spina bifida with a control group of their peers using a validated questionnaire, the Neurogenic Bowel Dysfunction Score (NBDS). The NBDS questionnaire was prospectively distributed to children attending a multi-disciplinary Spina Bifida clinic and healthy controls attending pediatric urology clinics. A score (out of 41) was assigned to each child based on their responses to the validated questionnaire. A lower score indicates better bowel function-related quality of life. SPSS software (v.25) was used for all statistical analysis. There were 98 respondents to the questionnaire, 48 children with spina bifida and 50 controls. The average age of respondents was 7.88 years (3–16 years). Of those with Spina Bifida, 33 (69%) were on retrograde rectal irrigations, [19 (58%) Peristeen® system, 11 (33%) tube rectal irrigations, and 3 (9%) Willis system], 6 (12%) were on laxatives, and 9 (19%) were on no treatment. The median NBDS for Spina Bifida patients was significantly higher 13.5 (2–32) compared to the control group 2 (0–26, p

Aims The aim of this study is to identify factors associated with urinary incontinence (UI) in a community sample of young nulligravid women. Methods This was a secondary analysis from a cross-sectional survey-based study of cisgender women aged 18 to 25 years recruited through a national registry of research volunteers. Participants completed validated questionnaires assessing toileting behaviors, lower urinary tract symptoms (LUTS), and bowel symptoms. Women were excluded from analysis if currently pregnant, any prior pregnancy, cystectomy, or any neurologic disease including spinal cord injury, stroke, or multiple sclerosis. Analyses determined the prevalence of symptoms and evaluated candidate risk factors for UI. Results Final analyses included 964 women (mean age, 22.6 ± 2.0). Monthly UI was identified in 295 (30.6%) subjects, with mixed UI being the most common (56.9%; n = 168). Seventy-two women (7.4%) reported fecal incontinence (FI) and 24 (3.5%) women reported both UI and FI. After multivariable regression modeling, UI was associated with an intermittent urine stream and the delayed voiding toileting behavior subscale. Conclusions UI in this cohort of young nulliparous women was highly prevalent and warrants further study as to the cause. Therapeutic guidelines to prevent UI and LUTS may need to be adjusted by targeting populations earlier than traditionally considered.

Background: Spinal cord injury often results in neurogenic bowel dysfunction (NBD). NBD is associated with constipation and faecal incontinence, as well as loss of sensation, faecal loading and faecal leakage, and it has a severe impact on healthcare resources and patient quality of life. NBD is treated conservatively with medication, suppositories, physiotherapy, digital rectal stimulation and digital removal of faeces. Conservative options are not always effective and long-term may lead to haemorrhoids, rectal bleeding, mucosal prolapse and faecal soiling. The National Institute for Health and Care Excellence recommends the use of the Peristeen transanal irrigation system, which instills lukewarm water into the colon via a balloon catheter to stimulate regular and complete bowel movements. Aim: To assess the impact of transanal irrigation with Peristeen on the symptoms and treatments of NBD, as well as patient quality of life and satisfaction, in a regional spinal injury centre. Method: Patients were asked to complete an adapted NBD assessment at consultation when they were prescribed Peristeen and at 8-week follow up. Answers to 10 questions on symptoms and treatment were individually weighted to provide a bowel dysfunction score, excluding two Likert-type questions on quality of life. Results: Patient numbers undergoing digital evacuations once or more a week decreased by more than 50%, and medication use decreased slightly. Patients reported a decrease in the following symptoms: peri-anal skin problems (9%); uneasiness, sweating or headaches (20%); uncontrollable flatus (27%); rectal bleeding (30%); faecal soiling (37%) and involuntary defecation (46%). Mean total bowel dysfunction score decreased by 11.6 from 20.4 to 8.8, and those with dysfunction categorised as severe decreased by 64% from 80% to 16%. Average negative emotional wellbeing improved from 4.0 to 1.2, and mean satisfaction increased from 3.2 to 7.3. Conclusion: According to the study findings, Peristeen is observed to improve quality of life in spinal NBD, and it is effective at reducing both associated symptoms and the need for digital rectal stimulation and digital removal of faeces.

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D). Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines. Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental. Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Individuals with spinal cord injuries or disorders (SCI/D), whether of traumatic or nontraumatic cause, require multidisciplinary management by their care team to achieve optimal health outcomes. SCI/D is relatively rare in the general population and primary care providers (PCPs) may not have extensive experience managing people with these disorders. Spinal cord injuries, impair the body's autonomic and biomechanical performance by interrupting the communications to and from major bodily systems. This article provides a framework to help PCPs understand how these changes impact their patient's physiologic function and subsequent risks for health complications with guidance for initial treatment approaches.

PURPOSE: Neurogenic bowel dysfunction (NBD) affects 80% of individuals with spina bifida. Performing and disseminating research on NBD to reach the appropriate audience is difficult given the variability among medical specialties managing NBD. This study aimed to identify which medical specialties and types of providers are currently managing NBD in the United States. METHODS: A survey was developed and sent to 75 spina bifida clinics. Surveys queried which specialty was primarily responsible for medical and surgical management of NBD and any others that assist in NBD care. The license and certification level of the providers were collected. Descriptive statistics were performed to describe the results. RESULTS: Response rate was 68%. Urology was the leading specialty primarily responsible for NBD management (39%) followed by rehabilitation medicine and developmental pediatrics (22% and 20%, respectively). Physicians were the primary providers of care followed by nurse practitioners (54% vs 31%). Urology performs 65% of NBD surgeries. CONCLUSION: Multiple specialties and providers are involved in NBD management with variation among clinics. Development of improved NBD care should include a spectrum of specialties and providers. Dissemination of research should be aimed at multiple specialty groups.

Disorders of bowel function are prevalent, particularly among patients with spinal cord injuries and other neurological disorders. An individual's bowel control significantly impacts quality of life, as predictable bowel function is necessary to actively and independently participate in everyday activities. For many patients with bowel dysfunction, initial lifestyle adjustments and other conservative therapeutic interventions (eg, digital stimulation, oral laxatives, suppositories) are insufficient to reestablish regular bowel function. In addition to these options, rectal irrigation (RI) is a safe and effective method of standard bowel care that has been used for several decades in adults and children suffering from bowel dysfunction associated with neurogenic or functional bowel etiologies. Rectal irrigation is an appropriate option when conservative bowel treatments are inadequate. Unlike surgical options, RI can be initiated or discontinued at any time. This report summarizes the clinical, humanistic, and economic evidence supporting the use of RI in clinical practice, noting features (eg, practical considerations, patient education) that can improve patients' success with RI treatment.

Charcot spinal arthropathy is a progressively degenerative joint disorder of the vertebrae. Historically, it was a common consequence of tertiary syphilis. Currently, it is a rare complication of spinal cord injury (SCI). We present the case of a 28-year-old patient with paraplegia who developed progressive, neurogenic bowel dysfunction due to Charcot spinal arthropathy. Our patient had upper motor neuron bowel syndrome secondary to SCI which advanced to lower motor neuron bowel syndrome. Charcot spinal arthropathy should be considered as a possible cause for symptom progression in SCI patients. This case illustrates the connection between Charcot spine and lower motor neuron dysfunction in the setting of prior upper motor neuron dysfunction.

Financial support provided by the Craig H. Neilsen Foundation.© Copyright 2020, Paralyzed Veterans of AmericaThese guidelines have been prepared based on scientific and professional information ava...

Objective: To explore the association between bowel dysfunction and use of laxatives and opioids in an acute rehabilitation setting following spinal cord injury (SCI). Methods: Data was collected regarding individuals with acute traumatic/non-traumatic SCI over a two-year period (2012–2013) during both the week of admission and discharge of their inpatient stay. Results: An increase in frequency of bowel movement (BM) (p = 0.003) and a decrease in frequency of fecal incontinence (FI) per week (p &lt, 0.001) between admission and discharge was found across all participants. There was a reduction in the number of individuals using laxatives (p = 0.004) as well as the number of unique laxatives taken (p &lt, 0.001) between admission and discharge in our cohort. The number of individuals using opioids and the average dose of opioids in morphine milligram equivalents (MME) from admission to discharge were significantly reduced (p = 0.001 and p = 0.02, respectively). There was a positive correlation between the number of laxatives and frequency of FI at discharge (r = 0.194, p = 0.014), suggesting that an increase in laxative use results in an increased frequency of FI. Finally, there was a significant negative correlation between average dose of opioids (MME) and frequency of BM at discharge, confirming the constipating effect of opioids (r = −0.20, p = 0.009).

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Objective: In order to encourage the inclusion of bladder and bowel outcome measures in preclinical spinal cord injury (SCI) research, this paper identifies and categorizes 1) fundamental, 2) recommended, 3) supplemental and 4) exploratory sets of outcome measures for pre-clinical assessment of bladder and bowel function with broad applicability to animal models of SCI. Methods: Drawing upon the collective research experience of autonomic physiologists and informed in consultation with clinical experts, a critical assessment of currently available bladder and bowel outcome measures (histological, biochemical, in vivo functional, ex vivo physiological and electrophysiological tests) was made to identify the strengths, deficiencies and ease of inclusion for future studies of experimental SCI. Results: Based upon pre-established criteria generated by the Neurogenic Bladder and Bowel Working Group that included history of use in experimental settings, citations in the literature by multiple independent groups, ease of general use, reproducibility and sensitivity to change, three fundamental measures each for bladder and bowel assessments were identified. Briefly defined, these assessments centered upon tissue morphology, voiding efficiency/volume and smooth muscle-mediated pressure studies. Additional assessment measures were categorized as recommended, supplemental or exploratory based upon the balance between technical requirements and potential mechanistic insights to be gained by the study. Conclusion: Several fundamental assessments share reasonable levels of technical and material investment, including some that could assess bladder and bowel function non-invasively and simultaneously. Such measures used more inclusively across SCI studies would advance progress in this high priority area. When complemented with a few additional investigator-selected study-relevant supplemental measures, they are highly recommended for research programs investigating the efficacy of therapeutic interventions in preclinical animal models of SCI that have a bladder and/or bowel focus.

A prospective single arm study. Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI. A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center. Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated. The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score. MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.

AIM: The formation of a diverting stoma of the bowel in patients with spinal cord injury (SCI) is a useful option in managing problems associated with prolonged bowel care, pressure ulcers and neurogenic bowel. This descriptive study examines surgical outcomes and the effect on an individual's health-related quality of life (HrQoL) in this complex group of patients. METHODS: Data were retrospectively collected in all patients with SCI who underwent a diverting stoma at Prince of Wales Hospital, Sydney, between January 2013 and January 2018 via a self-report questionnaire developed specifically for the study. RESULTS: Forty-three individuals were identified of whom 26 responded. 73% were men with a mean age of 45 years. The reasons for stoma formation included sacral pressure ulcer (50%), prolonged bowel care (35%), faecal incontinence (19%), constipation (8%), autonomic dysreflexia (8%), carer difficulties (8%) and haemorrhoids (4%). 76% of patients reported an improvement in HrQoL with 72% scoring their satisfaction with a stoma ≥ 8/10. CONCLUSION: While stoma formation is often seen as a treatment of last resort, our study has shown that it is an effective management option for a number of conditions post-SCI. It can improve HrQoL and has a high level of satisfaction amongst patients. Ideally, patients who could potentially benefit from a stoma should be identified early and receive appropriate education and counselling to help facilitate informed and timely decision-making and reduce adverse bowel related impact on quality of life and adjustment post-SCI.

A prospect cohort and case-control was employed to (1) establish a neurogenic bowel (NB) program after spinal cord injury (SCI) in the acute care setting; (2) examine clinician knowledge ability to deliver the NB program; and (3) evaluate patient knowledge, satisfaction, and quality of life. Educational in-service describing NB clinical practice guidelines (CPGs) and order set was delivered to staff followed by a pre-/post-education, 3- and 12-month survey. The patient intervention followed 24 patients with NB to evaluate the program and compared to 28 retrospective case-control patients followed by a pre-/post-intervention survey to measure knowledge of SCI, NB program and quality of life. Injury information and bowel medication use was compared between cases and controls. Clinician knowledge of NB CPGs improved. There were no significant clinical differences between patient groups. Patient knowledge and satisfaction improved post-intervention. Education to staff and patients is imperative to facilitate a NB program to meet the needs for individuals with SCI.

Open neural tube defects or myelomeningoceles are a common congenital condition caused by failure of closure of the neural tube early in gestation, leading to a number of neurologic sequelae including paralysis, hindbrain herniation, hydrocephalus and neurogenic bowel and bladder dysfunction. Traditionally, the condition was treated by closure of the defect postnatally but a recently completed randomized controlled trial of prenatal versus postnatal closure demonstrated improved neurologic outcomes in the prenatal closure group. Fetal surgery, or more precisely maternal-fetal surgery, raises a number of ethical issues that we address including who the patient is, informed consent, surgical innovation and equipoise as well maternal assumption of risk. As the procedure becomes more widely adopted into practice, we suggest close monitoring of new fetal surgery centers, in order to ensure that the positive results of the trial are maintained without increased risk to both the mother and fetus.

Background When born with spina bifida, there are numerous neurologic disorders that accompany this birth defect, including neurogenic bowel. Proactive, systematic, and rational approaches can lead to continence and a more functional lifestyle [1]. Methods Based on the evidence in the literature and expert experience, our approach to bowel management was developed as a step by step, individualized approach. This was converted to a decision tree for easy guidance of treatment decisions. The approach includes teaching patients and families normal bowel function, changes resulting from neurogenic bowel, common pitfalls in bowel management, and techniques that may improve outcomes. The decision tree, starting with dietary management, breaks into a two-fold attack, oral and rectal. Our data as part of the National Spina Bifida Patient Registry (NSBPR) database was compared to public data from the NSBPR. Results Preliminary data from the NSBPR in 2011 reported bowel continence in 42.1% (n = 898) compared to our clinical outcomes of 72.1% (n = 43). As the variable of bowel continence was further defined and more patients were enrolled, the clinic results were comparable to the national reports. Conclusion Consistency among providers and caregivers is critical to evaluating the management of continence in spina bifida. While this protocol warrants further evaluation, it is offered as an evidence-based, step by step, approach to bowel management in spina bifida with good outcomes for patient management.

Context: It is often a challenge to counsel parents with children operated for spina bifida aperta in developing countries. Data regarding the efficacy of simple measures and preventive are scarce. Aims: The aim of this study is to study such children for the incidence, prevalence of bowel bladder dysfunction, and the quality of life (QOL) in children who are involved with a multidisciplinary team in India. Materials and Methods: All children with spina bifida occulta were followed – QOL questionnaires (PIN Q, modified Barthels activities of daily living , and the visual analog score [VAS]) were used. Interventions, such as clean intermittent catheterization (CIC), bowel enemas, and surgical procedures, were studied. Results: A total of 68 children were assessed. Twenty-nine of these children over five were evaluated with QOL scores. The prevalence of incontinence of bowel and bladder was studied. The primary outcomes included the QOL scores, and the various surgical options help bowel and bladder management. Hydronephrosis in 17.95% of children

Background: Colostomy formation can solve complications of bowel management following spinal cord injury (SCI). Newly injured patients at this spinal unit have chosen colostomy as a preferred option for bowel management. Objectives: To discover the reasons patients choose colostomy formation early following SCI and make comparison with those choosing it later, and to establish whether early colostomy is safe and advisable. Methods: Medical and nursing records of patients with SCI who chose to have a colostomy during the period 2005–2016 were examined retrospectively. Data were gathered concerning reasons for choosing a colostomy, early and later complications, the need for further surgery, and independence with bowel care before and after surgery. Patients were divided into two groups: those who chose a colostomy “early” during inpatient rehabilitation and those who chose it “later” as is traditional. Results: Reasons for choosing colostomy differed. Reducing reliance on caregiver and independence were of more importance to the early group; the later group chose colostomy to solve bowel care problems. Early complication rates in both groups were low. Longer term complications were higher in the early group, with the most common complication being rectal discharge. Parastomal hernia rates were low in both groups, as was the need for further surgery. Colostomy formation led to 20.8% of all patients gaining independence with bowel care. Conclusion: This study found colostomy to be a safe and effective option when performed early after SCI and demonstrates colostomy can be a means of gaining independence and making bowel care easier and more acceptable to the newly injured patient.

Concerns regarding anatomical anomalies and worsening neurological symptoms have prevented widespread use of epidural catheters in patients with low level spina bifida. We hypothesize that thoracic epidural placement in the T9 to T10 interspace is safe and decreases narcotic requirements following major open lower urinary tract reconstruction in patients with low level spina bifida.We reviewed consecutive patients with low level spina bifida who underwent lower urinary tract reconstruction and received epidurals for postoperative pain control. Controls were patients with low level spina bifida who received single injection transversus abdominis plane blocks and underwent similar procedures. Complications of epidural placement, including changes in motor and sensory status, were recorded. Opioid consumption was calculated using equivalent intravenous morphine doses. Mean and maximum pain scores on postoperative days 0 to 3 were calculated.Ten patients with low level spina bifida who underwent lower urinary tract reconstruction with epidural were matched to 10 controls with low level spina bifida who underwent lower urinary tract reconstruction with transverse abdominis plane block. Groups were demographically similar. All patients had full abdominal sensation and functional levels at or below L3. No epidural complications or changes in neurological status were noted. The epidural group had decreased opioid consumption on postoperative days 0 to 3 (0.75 mg/kg vs 1.29 mg/kg, p = 0.04). Pain scores were similar or improved in the epidural group.Thoracic epidural analgesia appears to be a safe and effective opioid sparing option to assist with postoperative pain management following lower urinary tract reconstruction in individuals with low level spina bifida.

Objectives: To identify and classify tools for assessing the influence of neurogenic bowel dysfunction (NBD) on quality of life (QoL) after spinal cord injury (SCI). Methods: In this systematic review, MEDLINE/PubMed, CINAHL, and PsycInfo were searched to identify studies assessing the influence of NBD on QoL (or related construct) after SCI. Two independent reviewers screened titles and abstracts, and both reviewers classified tools as subjective or objective according to Dijkers' theoretical QoL framework. Results: Seventy-two studies were identified, and 35 studies met the inclusion criteria. Five objective measures assessed the influence of NBD on QoL, which were validated for use in SCI, but no measure was condition-specific to NBD. Eight measures were classified as subjective tools; two had an established reliability and validity for SCI while six had some psychometric evidence for use in the SCI population. Five subjective measures (NBD score, Burwood QoL Questionnaire, Impediments to Community Integration [ICI] Scale, SCI-QoL Bowel Management Difficulties, and Survey of Neurogenic Bowel Characteristics) were developed specifically for SCI. The NBD score showed sensitivity to the influence of NBD on QoL in experimental trials. Conclusion: Thirteen tools assessed the influence of NBD on QoL in SCI. Although not developed specifically for SCI, the Health Utility Index (HUI-III) was the only tool identified that provided data on “QoL as utility” on the impact of NBD. The validated NBD score was the only condition-specific tool to assess QoL as “subjective well-being.” Further validation of existing tools could help to inform practice and policy related to resource allocation for bowel care post SCI.

Patients with neurogenic bladder frequently also have bowel dysfunction and a simultaneous urologic and colorectal reconstruction is possible. We present our experience with combined reconstructive procedures using robot-assisted laparoscopy, and demonstrate the utility of a minimally invasive approach that considers both the bowel and bladder management of these patients.We retrospectively reviewed all patients who underwent combined bowel and urologic reconstruction at our institution since the start of our multidisciplinary robotic program.Seven patients were identified in our cohort with a mean age of 6.4 years (3.8-10.1 years). Six patients had myelomeningocele and 1 had caudal regression. Malone appendicostomies were placed in all 7 patients. A split appendix technique was used as a conduit in 5 patients, in situ appendix in 1, and neoappendicostomy with cecal flap in 1. Six patients had a Mitrofanoff appendiceal conduit created, while 1 patient had a sigmoid colovesicostomy for urinary diversion. Five patients required bladder neck repair. One patient had stenosis of the Mitrofanoff and one patient had an anastomotic leak of the sigmoid anastomosis. The average operating time was 526 minutes (313-724 minutes). The median length of stay (LOS) was 5 days (4-7 days), excluding one outlier who suffered an anastomotic leak and had an extended LOS (50 days). All patients who underwent continent bladder reconstruction are dry on their current catheterizing regimen, 6/7 are clean with antegrade flushes.Patients with neurogenic bladder often have coexisting bowel dysfunction, which provides an opportunity to reconstruct both organ systems simultaneously and achieve social urinary and bowel continence. Before committing to any intervention, the surgeon should consider both the urologic and gastrointestinal needs of the patient, and perform the needed procedures simultaneously. We describe a number of combined operations aimed at bowel and bladder management that can be performed safely using robot-assisted laparoscopy.

Bowel dysfunction in patients with multiple sclerosis (MS) is highly prevalent. Constipation and fecal incontinence can coexist and alternate, impacting on the patient's quality of life and social interactions, as well as burdening the caregivers. The cost for the health care providers is also significant, with increased number of hospital admissions, treatment-related costs, and hospital appointments. The origin is multifactorial, and includes alteration of neurological pathways, polypharmacy, behavioral elements, and ability to access the toilet. Every patient with MS should be sensitively questioned about bowel function, and red flag symptoms should prompt adequate investigations. Manipulation of life style factors and establishment of a bowel regime should be attempted in the first place, and if this fails, other measures such as biofeedback and transanal irrigation should be included. A stoma can improve quality of life, and is not necessarily a last-ditch option. Antegrade colonic enemas can also be an effective option, whilst neuromodulation has not proved its role yet. Effective treatment of bowel dysfunction improves quality of life, reduces incidence of urinary tract infection, and reduces health care costs.

Purpose: This article aims to present a standardization of the technique of transanal therapeutic irrigation, which is an old technique that has passed through history and is now used as a medical procedure to assist in the treatment of defecation disorders. Methods: This protocol was developed in patients with myelomeningocele submitted to the standard transanal therapeutic irrigation technique, in accordance with the protocol established at the Clinic of defecation disorders at a public university hospital in Brazil. The presented standard technique highlights the following topics: preparation of the patient before the treatment; interdisciplinary approach; training of the patient or the family member responsible for the patient and the step-by-step technique itself. The research ethics committee at the university approved this study. Discussion: Transanal therapeutic irrigation is indicated in neurogenic bowel dysfunctions and functional disorders of defecation. Training the patient or a family member responsible for irrigation is performed on three consecutive days, all of them supervised by the nurse. This technique aims to re-establish control over defecation and bowel function, and consists in an infusion of warm tap water through the anus, which allows the patient to evacuate daily the stool and keep the colon empty for longer periods. This avoids fecal incontinence and increases the quality of life of patients with defecation disorders. Conclusion: Transanal therapeutic irrigation is an effective, well-tolerated and safe procedure, which is better compared to the standard clinical care. Resumo: Objetivo: Este artigo tem como objetivo apresentar uma padronização da técnica de irrigação transanal terapêutica, uma técnica antiga que passou pela história e tem sido utilizada como procedimento médico para auxiliar no tratamento de distúrbios de defecação. Métodos: Este protocolo foi desenvolvido em pacientes com mielomeningocele submetidos à técnica de irrigação terapêutica transanal padrão, de acordo com o protocolo estabelecido na Clínica de Distúrbios da Defecação de um hospital universitário público no Brasil. A técnica padrão apresentada destaca os seguintes tópicos: preparação do paciente antes do tratamento; Abordagem interdisciplinar; treinamento do paciente ou do membro da família responsável pelo paciente e a técnica passo a passo em si. O comitê de ética em pesquisa da universidade aprovou este estudo. Discussão: A irrigação transanal terapêutica está indicada nas disfunções intestinais neurogênicas e nos distúrbios funcionais da defecação. O treinamento do paciente ou de um familiar responsável pela irrigação é realizado em três dias consecutivos, todos supervisionados por uma enfermeira. Esta técnica visa restabelecer o controle sobre a evacuação e a função intestinal, e consiste em uma infusão de água da torneira quente através do ânus, que permite ao paciente evacuar diariamente as fezes e manter o cólon vazio por períodos mais longos. Isso evita a incontinência fecal e aumenta a qualidade de vida dos pacientes com distúrbios de defecação. Conclusão: A irrigação terapêutica transanal é um procedimento efetivo, bem tolerado e seguro, o qual é melhor quando comparado ao tratamento clínico padrão. Keywords: Spinal cord injuries, Fecal incontinence, Constipation, Quality of life, Stomas, Therapeutic irrigation, Palavras-chave: Traumatismos da medula espinhal, Incontinência fecal, Constipação, Qualidade de vida, Estomas, Irrigação terapêutica