Evaluation and Treatment of Neurogenic Bowel Dysfunction – A Review

European Neurological Review, 2016;11(2):109–15 DOI: https://doi.org/10.17925/ENR.2016.11.02.109

Abstract:

Neurogenic bowel dysfunction is a severely troubling entity for patients with neurological disease or injury. The complex symptom cluster presents a challenge, not only for the patients but also for the treating clinician. Without intervention, patients are bound to have a reduced quality of life, and experience social impacts and secondary complications that come along with it. A careful initial assessment provides an idea of symptom severity and is crucial for successful rehabilitation. The mainstay of treatment remains a conservative approach of managing faecal incontinence or optimising the mechanics of defecation to improve patient’s quality of life. This article attempts to provide a comprehensive review of existing literature on pathophysiology, assessment and management of neurogenic bowel dysfunction.
Keywords: Neurogenic bowel dysfunction, bowel dysfunction, hypererflexic bowel, areflexic bowel, upper motor neuron bowel syndrome,lower motor neuron bowel syndrome
Disclosure: Lalit Kumar, Eleni Athanasakos and Anton Emmanuel have nothing to disclose in relation to this article. No funding was received in the publication of this article. This article involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors.
Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.
Received: May 03, 2016 Accepted August 25, 2016
Correspondence: Anton V Emmanuel, GI Physiology Unit, Lower Ground Floor, EGA Building, University College Hospital, 25 Grafton Way, London, WC1E 6DB, UK. E: a.emmanuel@ucl.ac.uk
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit.

The term ‘neurogenic bowel’ encompasses the manifestations of bowel dysfunction resulting from sensory and/or motor disturbances1 due to central neurological disease or damage. Neurogenic bowel dysfunction (NBD) is a particularly common occurrence in patients with spinal cord injury (SCI), spina bifida and multiple sclerosis (MS) and has been found to worsen progressively in these conditions.2–4 Its main symptoms include constipation, faecal incontinence (FI),5 evacuation difficulties or a combination of these.4,6–8

The significant impact of NBD on patient’s life is evident from the number of patients reporting bowel symptoms. For instance, about 95% of SCI patients report constipation,5 75% report at least one episode of FI per year whereas 5% report a daily occurrence of incontinence. The prevalence of constipation and/or FI among MS patients ranges from 20% to 73%.9,10 A similar high occurrence of FI ranging from 30% to 50% has been reported in Parkinson’s disease (PD) patients. There is little doubt that NBD affects both the physical and psychological aspects of quality of life and its early recognition and management are vital.

Pathophysiology
Damage to the spinal cord or brain can interrupt neural pathways. Location and severity of such damage are the key factors in determining colorectal function and the nature and extent of subsequent symptoms. However, it should be kept in mind that symptoms are not always easy to determine and can change with time. For instance, in MS there are often multiple lesions, which keep changing over time and in SCI the precise level of injury is often not clear during the early stages due to spinal shock, which can last up to 6 weeks. Moreover, the nervous system, being a complex entity, does not always present a fixed clinical pattern even in the same disease or trauma patterns. Broadly, neurogenic bowel symptoms are divided into two patterns depending upon the level of disease or injury being above or below the conus medullaris.

Supraconal disorder – ‘upper motor neuron bowel syndrome’ or ‘hyperflexic bowel’
This pattern is seen in patients who have disease/injury above the conus medullaris and involves loss of supraspinal inhibitory input resulting in hypertonia of colorectum. The increase in colonic wall, pelvic floor and anal tone results in reduced colonic compliance, overactive segmental peristalsis and underactive propulsive peristalsis.11–13 As the peristalsis and haustral movements become less effective the transit slows down throughout the colon.14–16 The spastic constricted state of the external anal sphincter (EAS) worsens the situation further by causing retention of stool. The combination of these physiological responses to supraconal injury makes constipation a dominant gut symptom.

Infraconal disorder – ‘lower motor neuron type’ or ‘areflexic bowel’
Infraconal lesions are a consequence of disruption of autonomic motor nerves due to damage to parasympathetic cell bodies in the conus medullaris or their axons in the cauda equina. This is characterised by loss of colorectal tone and attenuated rectoanal inhibitory reflex, resulting

in a cyclical pattern of insensate rectal filling and progressive rectal distension eventually leading to FI.5 Furthermore, the incontinence is not helped by a reduction in resting and squeeze pressure due to flaccid anal sphincters and laxity of pelvic floor muscles which allows excessive descent of pelvic contents reducing the anorectal angle and opening the rectal lumen.13

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Keywords: Neurogenic bowel dysfunction, bowel dysfunction, hypererflexic bowel, areflexic bowel, upper motor neuron bowel syndrome,lower motor neuron bowel syndrome