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Neurogenic Bowel

Medical Management

Initial Management

Daily intestinal massage, 20 minutes daily can be very effective for constipation.  It can lead to total or partial constipation relief in 90% of patients.

Neurogenic Bowel initial management diagram

Neurogenic Bowel initial management diagram

Figures courtesy of Guy’s and St Thomas’ NHS Trust

 

Steps:

  1. Stroke upwards 3 times.
  2. Stroke towards the bottom of your tummy 3 times
  3. Effleurage or circular stroking
  4. Palmer kneading (one hand performs a circular movement, quickly followed by the other, moving down the stomach)
  5. As Step 4 but moving up the stomach
  6. Repeat steps 4 and 5
  7. Stroking
  8. Hand vibrations over the belly button area

Oral Interventions

  • Optimize fluid and fiber intake to help achieve desired stool consistency
  • Fiber accelerates colon transit time, protects the microbiota, softens stool, and reduces straining
  • Fiber supplementation using psyllium and Miralax helps to prevent fecal incontinence
  • Start with  2 teaspoons of whole psyllium husks daily (1 lb.costs roughly $10)  
  • And 1 teaspoon of PEG 3350 (4.25grams) daily (the brand name is MiralaxR).  Alternative to using psyllium is to use Methylcellulose fiber (CitrucelR)
  • Slowly increase the PEG (MiralaxR) dose by ¼ teaspoon every three days until daily bowel movements are achieved up to a maximum of 4 teaspoons (or one capful; 17 grams) daily.
  • During titration, use a rectal suppository or enema if a bowel movement has not occurred  in two days

Rectal Interventions

  1. Start by daily digital removal of stool with an index finger, prior to using a daily sup.

For patients with adequate rectal tone

  1. Daily Glycerin and bisacodyl [brand name is Dulcolax] suppositories are often effective.
  2. Small volume rectal enemas with docusate, work better than glycerin or bisacodyl suppositories.
  3. Phosphate enemas can be used when fecal impaction occurs.  Such enemas are not to be used regularly.

For patients with poor rectal tone

  1. For patients with poor rectal tone and have failed rectal suppositories and traditional enemas, a Transanal Irrigation Enema (TAE) is typically very effective.
  2. TAE is a high volume enema that reaches beyond the rectum, which is combined with balloon mechanism in the rectum that plugs the outlet and prevents the fluid from leaking out the rectum.
  3. We prefer the Peristeen® (Coloplast, Minneapolis, MN) all-in-one device. It includes a water bag connected to a hand control unit with a pump for regulating both the catheter balloon inflation and the water infusion (see Figure on right).  A 500ml to 1000ml bag of tap water is then gravity drained through the catheter into the rectum. Median evacuation time takes roughly 60 minutes.
    Peristeen all-in-one device