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


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.
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.
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

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.

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

1. Chung EA, Emmanuel AV, Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury, Prog Brain Res, 2006;152:317–33.
2. Krassioukov A, Eng JJ, Claxton G, et al., Neurogenic bowel management after spinal cord injury: a systematic review of the evidence, Spinal Cord, 2010;48:718–33.
3. Williams R, Rigby AS, Airey M, et al., Multiple sclerosis: it [sic] epidemiological, genetic, and health care impact, J Epidemiol Community Health, 1995;49:563–9.
4. Verhoef M, Lurvink M, Barf HA, et al., High prevalence of incontinence among young adults with spina bifida: description, prediction and problem perception, Spinal Cord, 2005;43:331–40.
5. Finnerup NB, Faaborg P, Krogh K, Jensen TS, Abdominal pain in long-term spinal cord injury, Spinal Cord, 2008;46:198–203.
6. Glickman S, Kamm MA, Bowel dysfunction in spinal-cord-injury patients, Lancet, 1996;347:1651–3.
7. Stone JM, Nino-Murcia M, Wolfe VA, Perkash I, Chronic gastrointestinal problems in spinal cord injury patients: a prospective analysis, Am J Gastroenterol, 1990;85:1114–9.
8. Hennessey A, Robertson NP, Swingler R, Compston DA, Urinary, faecal and sexual dysfunction in patients with multiple sclerosis, J Neurol, 1999;246:1027–32.
9. Nortvedt MW, Riise T, Frugård J, et al., Prevalence of bladder, bowel and sexual problems among multiple sclerosis patients two to five years after diagnosis, Mult Scler, 2007;13:106–12.
10. Hinds JP, Eidelman BH, Wald A, Prevalence of bowel dysfunction in multiple sclerosis. A population survey, Gastroenterology, 1990;98:1538–42.
11. Banwell JG, Creasey GH, Aggarwal AM, Mortimer JT, Management of the neurogenic bowel in patients with spinal cord injury, Urol Clin North Am, 1993;20:517–26.
12. Camilleri M, Bharucha AE, Gastrointestinal dysfunction in neurologic disease, Semin Neurol, 1996;16:203–16.
13. Stiens SA, Bergman SB, Goetz LL, Neurogenic bowel dysfunction after spinal cord injury: clinical evaluation and rehabilitative management, Arch Phys Med Rehabil, 1997;78(Suppl. 3):S86–102.
14. Krogh K, Nielsen J, Djurhuus JC, et al., Colorectal function in patients with spinal cord lesions, Dis Colon Rectum, 1997;40:1233–9.
15. Leduc BE, Spacek E, Lepage Y, Colonic transit time after spinal cord injury, J Spinal Cord Med, 1997;20:416–21.
16. Nino-Murcia M, Stone JM, Chang PJ, Perkash I, Colonic transit in spinal cord-injured patients, Invest Radiol, 1990;25:109–12.
17. Collings S, Norton C, Women’s experiences of faecal incontinence: a study, Br J Community Nurs, 2004;9:520–3.
18. Pan Y, Liu B, Li R, et al., Bowel dysfunction in spinal cord injury: current perspectives, Cell Biochem Biophys, 2014;69:385–8.
19. DeLisa JA, Kirshblum S, A review: frustrations and needs in clinical care of spinal cord injury patients, J Spinal Cord Med, 1997;20:384–90.
20. Coggrave M (Editor), Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury, S.C.I.C.o.t.U.K.a, Ireland, 2012, Coloplast Ltd: UK, 1–56.
21. Benevento BT, Sipski ML, Neurogenic bladder, neurogenic bowel, and sexual dysfunction in people with spinal cord injury, Phys Ther, 2002;82:601–12.
22. Coggrave M, Norton C, Management of faecal incontinence and constipation in adults with central neurological diseases, Cochrane Database Syst Rev, 2013;12:CD002115.
23. Coggrave M, Norton C, Wilson-Barnett J, Management of neurogenic bowel dysfunction in the community after spinal cord injury: a postal survey in the United Kingdom, Spinal Cord, 2008;47:323–33.
24. Emmanuel AV, Krogh K, Bazzocchi G, et al., Consensus review of best practice of transanal irrigation in adults, Spinal Cord, 2013;51:732–8.
25. Suares NC, Ford AC, Systematic review: the effects of fibre in the management of chronic idiopathic constipation, Aliment Pharmacol Ther, 2011;33:895–901.
26. Markland AD, Palsson O, Goode PS, et al., Association of low dietary intake of fiber and liquids with constipation:evidence from the National Health and Nutrition Examination Survey, Am J Gastroenterol, 2013;108:796–803.
27. Cameron KJ, Nyulasi IB, Collier GR, Brown DJ, Assessment of the effect of increased dietary fibre intake on bowel function in patients with spinal cord injury, Spinal Cord, 1996;34:277–83.
28. Peters HP, De Vries WR, Vanberge-Henegouwen GP, Akkermans LM, Potential benefits and hazards of physical activity and exercise on the gastrointestinal tract, Gut, 2001;48:435–9.
29. de Oliveira, EP, Burini RC, The impact of physical exercise on the gastrointestinal tract, Curr Opin Clin Nutr Metab Care, 2009;12:533–8.
30. Speelman AD, van de Warrenburg BP, van Nimwegen M, et al., How might physical activity benefit patients with Parkinson disease?, Nat Rev Neurol, 2011;7:528–34.
31. Meshkinpour H, Selod S, Movahedi H, et al., Effects of regular exercise in management of chronic idiopathic constipation, Dig Dis Sci, 1998;43:2379–83. 32. Wald A, Constipation in the Primary Care Setting: Current Concepts and Misconceptions, Am J Med, 2006;119:736–9.
33. Robertson G, Meshkinpour H, Vandenberg K, et al., Effects of exercise on total and segmental colon transit, J Clin Gastroenterol, 1993;16:300–3.
34. Aaronson MJ, Freed MM, Burakoff R, Colonic myoelectric activity in persons with spinal cord injury, Dig Dis Sci, 1985;30:295–300.
35. Menardo G, Bausano G, Corazziari E, et al., Large-bowel transit in paraplegic patients, Dis Colon Rectum, 1987;30:924–8.
36. Walter SA, Morren GL, Ryn AK, Hallböök O, et al., Rectal pressure response to a meal in patients with high spinal cord injury, Arch Phys Med Rehabil, 2003;84:108–11.
37. Sinclair M, The use of abdominal massage to treat chronic constipation, J Bodyw Mov Ther, 2011;15:436–45.
38. Han TR, Kim JH, Kwon BS, Chronic gastrointestinal problems and bowel dysfunction in patients with spinal cord injury, Spinal Cord, 1998;36:485–90.
39. Coggrave M, Neurogenic continence. Part 3: Bowel management strategies, Br J Nurs, 2008;17:962–8.
40. Ayaş S, Leblebici B, Sözay S, et al., The effect of abdominal massage on bowel function in patients with spinal cord injury, Am J Phys Med Rehabil, 2006;85:951–5.
41. Albers B, Cramer H, Fischer A, et al., [Abdominal massage as intervention for patients with paraplegia caused by spinal cord injury–a pilot study], Pflege Z, 2006;59:2–8.
42. McClurg D, Hagen S, Hawkins S, et al., Abdominal massage for the alleviation of constipation symptoms in people with multiple sclerosis: a randomized controlled feasibility study, Mult Scler, 2011;17:223–33.
43. Jeon SY, Jung HM, [The effects of abdominal meridian massage on constipation among CVA patients], Taehan Kanho Hakhoe Chi, 2005;35:135–42.
44. Brookes SJH, Chen BN, Costa M, Humphreys CMS, Initiation of peristalsis by circumferential stretch of flat sheets of guinea-pig ileum, J Physiol, 1999;516:525–38.
45. Liu Z, Sakakibara R, Odaka T, et al., Mechanism of abdominal massage for difficult defecation in a patient with myelopathy (HAM/TSP), J Neurol, 2005;252:1280–2.
46. Lämås K, Lindholm L, Stenlund H, et al., Effects of abdominal massage in management of constipation—A randomized controlled trial, Int J Nurs Stud, 2009;46:759–67.
47. Rendeli C, Ausili E, Tabacco F, et al., Polyethylene glycol 4000 vs. lactulose for the treatment of neurogenic constipation in myelomeningocele children: a randomized-controlled clinical trial, Aliment Pharmacol Ther, 2006;23:1259–65.
48. Zangaglia R, Martignoni E, Glorioso M, et al., Macrogol for the treatment of constipation in Parkinson’s disease. A randomized placebo-controlled study, Mov Disord, 2007;22:1239–44.
49. Geders JM, Gaing A, Bauman WA, Korsten MA, The effect of cisapride on segmental colonic transit time in patients with spinal cord injury, Am J Gastroenterol, 1995;90:285–9.
50. Jost WH, Schimrigk K, Cisapride treatment of constipation in Parkinson’s disease, Mov Disord, 1993;8:339–43.
51. Krogh K, Jensen MB, Gandrup P, et al., Efficacy and tolerability of prucalopride in patients with constipation due to spinal cord injury, Scand J Gastroenterol, 2002;37:431–6.
52. Korsten MA, Rosman AS, Ng A, et al., Infusion of Neostigmine- Glycopyrrolate for Bowel Evacuation in Persons with Spinal Cord Injury, Am J Gastroenterol, 2005;100:1560–5.
53. Rosman AS, Chaparala G, Monga A, et al., Intramuscular neostigmine and glycopyrrolate safely accelerated bowel evacuation in patients with spinal cord injury and defecatory disorders, Dig Dis Sci, 2008;53:2710–3.
54. Shafik A, Recto-colic reflex: role in the defecation mechanism, Int Surg, 1996;81:292–4.
55. Shafik A, El-Sibai O, Shafik IA, Physiologic basis of digital-rectal stimulation for bowel evacuation in patients with spinal cord injury: identification of an anorectal excitatory reflex, J Spinal Cord Med, 2000;23:270–5.
56. Korsten MA, Singal AK, Monga A, et al., Anorectal stimulation causes increased colonic motor activity in subjects with spinal cord injury, J Spinal Cord Med, 2007;30:31–5.
57. Wang F, Frisbie JH, Klein MA, Solitary rectal ulcer syndrome (colitis cystica profunda) in spinal cord injury patients: 3 case reports, Arch Phys Med Rehabil, 2001;82:260–1.
58. Kewalramani LS, Autonomic dysreflexia in traumatic myelopathy, Am J Phys Med, 1980;59:1–21.
59.House JG, Stiens SA, Pharmacologically initiated defecation for persons with spinal cord injury: effectiveness of three agents, Arch Phys Med Rehabil, 1997;78:1062–5.
60. Dunn KL, Galka ML, A comparison of the effectiveness of Therevac SB and bisacodyl suppositories in SCI patients’ bowel programs, Rehabil Nurs, 1994;19:334–8.
61. Frisbie JH, Improved bowel care with a polyethylene glycol based bisacadyl suppository, J Spinal Cord Med, 1997;20:227–9.
62. Paris G, Gourcerol G, Leroi AM, Management of neurogenic bowel dysfunction, Eur J Phys Rehabil Med, 2011;47:661–76.
63. Deutekom M, Dobben AC, Plugs for containing faecal incontinence, Cochrane Database Syst Rev, 2012;4:Cd005086.
64. Malone PS, Ransley PG, Kiely EM, Preliminary report: the antegrade continence enema, Lancet, 1990;336:1217–8.
65. Koyle MA, Kaji DM, Duque M, et al., The Malone antegrade continence enema for neurogenic and structural fecal incontinence and constipation, J Urol, 1995;154:759–61.
66. Worsøe J, Christensen P, Krogh K, et al., Long-term results of antegrade colonic enema in adult patients: assessment of functional results, Dis Colon Rectum, 2008;51:1523–8.
67. Meurette G, Lehur P-A, Coron E, Regenet N, Long-term results of Malone’s procedure with antegrade irrigation for severe chronic constipation, Gastroenterol Clin Biol, 2010;34:209–12.
68. Basson S, Zani A, McDowell S, et al., Antegrade continence enema (ACE): predictors of outcome in 111 patients, Pediatr Surg Int, 2014;30:1135–41.
69. Myers JB, Hu EM, Elliott SP, et al., Short-term outcomes of Chait Trapdoor for antegrade continence enema in adults, Urology, 2014;83:1423–6.
70. Imai K, Shiroyanagi Y, Kim WJ, et al., Satisfaction after the Malone antegrade continence enema procedure in patients with spina bifida,Spinal Cord, 2014;52:54–7.
71. Teichman JM, Zabihi N, Kraus SR, et al., Long-term results for Malone antegrade continence enema for adults with neurogenic bowel disease, Urology, 2003;61:502–6.
72. Christensen P, Kvitzau B, Krogh K, et al., Neurogenic colorectal dysfunction – use of new antegrade and retrograde colonic wash-out methods, Spinal Cord, 2000;38:255–61.
73. Teichman JM, Harris JM, Currie DM, Barber DB, Malone antegrade continence enema for adults with neurogenic bowel disease,J Urol, 1998;160:1278–81.
74. Cowlam S, Watson C, Elltringham M, et al., Percutaneous endoscopic colostomy of the left side of the colon, Gastrointest Endosc, 2007;65:1007–14.
75. Nasher O, Hill RE, Peeraully R, et al., Peristeen® Transanal Irrigation System for Paediatric Faecal Incontinence: A Single Centre Experience, International Journal of Pediatrics, 2014;2014:954315.
76. Christensen P, Bazzocchi G, Coggrave M, et al., A randomized, controlled trial of transanal irrigation versus conservative bowel management in spinal cord–injured patients, Gastroenterology, 131(3):738–47.
77. Preziosi G, Storrie J, Boulos P, Emmanuel A, Peristeen® transanal irrigation in patients with multiple sclerosis, Gut, 2011;60(Suppl. 1):A29–A29. 78. Faaborg PM, Christensen P, Kvitsau B, et al., Long-term outcome and safety of transanal colonic irrigation for neurogenic bowel dysfunction, Spinal Cord, 2009;47:545–9.
79. Christensen P, Krogh K, Buntzen S, et al., Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence, Dis Colon Rectum, 2009;52:286–92.
80. Brindley GS, Polkey CE, Rushton DN, Sacral anterior root stimulators for bladder control in paraplegia, Paraplegia, 1982;20:365–81. 81. Kutzenberger J, Surgical therapy of neurogenic detrusor overactivity (hyperreflexia) in paraplegic patients by sacral deafferentation and implant driven micturition by sacral anterior root stimulation: Methods, indications, results, complications, and future prospects, Acta Neurochirurgica, Supplementum, 2007;333–9.
82. Sauerwein D, Operative therapy of the spastic bladder: Sacral deafferentation and anterior root stimulation, Urologe - Ausgabe A, 1990;29:196–203.
83. Varma JS, Binnie N, Smith AN, et al., Differential effects of sacral anterior root stimulation on anal sphincter and colorectal motility in spinally injured man, Br J Surg, 1986;73:478–82.
84. Binnie NR, Smith AN, Creasey GH, Edmond P, Constipation associated with chronic spinal cord injury: The effect of pelvic parasympathetic stimulation by the Brindley stimulator, Paraplegia, 1991;29:463–9.
85. MacDonagh RP, Sun WM, Smallwood R, et al., Control of defecation in patients with spinal injuries by stimulation of sacral anterior nerve roots, Br Med J, 1990;300:1494–7.
86. Kachourbos MJ, Creasey GH, Health promotion in motion: improving quality of life for persons with neurogenic bladder and bowel using assistive technology, SCI Nurs, 2000;17:125–9.
87. Worsøe J, Rasmussen M, Christensen P, Krogh K, Neurostimulation for Neurogenic Bowel Dysfunction, Gastroenterol Res Pract, 2013;2013:8.
88. Gourcerol G, Vitton V, Leroi AM, et al., How sacral nerve stimulation works in patients with faecal incontinence, Colorectal Dis, 2011;13:e203–e211.
89. Griffin KM, Pickering M, O’Herlihy C, et al., Sacral nerve stimulation increases activation of the primary somatosensory cortex by anal canal stimulation in an experimental model, Br J Surg, 2011;98:1160–9.
90. Sheldon R, Kiff ES, Clarke A, et al., Sacral nerve stimulation reduces corticospinal excitability in patients with faecal incontinence, Br J Surg, 2005;92:1423–1.
91. Schurch B, Reilly I, Reitz A, Curt A, Electrophysiological recordings during the peripheral nerve evaluation (PNE) test in complete spinal cord injury patients, World J Urol, 2003;20:319–22.
92. Jarrett MED, Matzel KE, Christiansen J, et al., Sacral nerve stimulation for faecal incontinence in patients with previous partial spinal injury including disc prolapse, Br J Surg, 2005;92:734–9.
93. Holzer B, Rosen HR, Novi G, et al., Sacral nerve stimulation for neurogenic faecal incontinence, Br J Surg, 2007;94:749–53.
94. Gstaltner K, Rosen H, Hufgard J, et al., Sacral nerve stimulation as an option for the treatment of faecal incontinence in patients suffering from cauda equina syndrome, Spinal Cord, 2008;46:644–7.
95. Mentes BB, Yüksel O, Aydin A, et al., Posterior tibial nerve stimulation for faecal incontinence after partial spinal injury: preliminary report, Tech Coloproctol, 2007;11:115–9.
96. Leroi AM, Siproudhis L, Etienney I, et al., Transcutaneous electrical tibial nerve stimulation in the treatment of fecal incontinence: a randomized trial (CONSORT 1a), Am J Gastroenterol, 2012;107:1888–96.
97. Safadi BY, Rosito O, Nino-Murcia M, et al., Which stoma works better for colonic dysmotility in the spinal cord injured patient?, Am J Surg, 2003;186:437–42.
98. Munck J, Simoens CH, Thill V, et al., Intestinal stoma in patients with spinal cord injury: a retrospective study of 23 patients, Hepatogastroenterology, 2008;55:2125–9.
99. Branagan G, Tromans, Finnis D, Effect of stoma formation on bowel care and quality of life in patients with spinal cord injury, Spinal Cord, 2003;41:680–3.
100. Rosito O, Nino-Murcia M, Wolfe VA, et al., The effects of colostomy on the quality of life in patients with spinal cord injury:a retrospective analysis, J Spinal Cord Med, 2002;25:174–83.
101. Randell N, Lynch AC, Anthony A, et al., Does a colostomy alter quality of life in patients with spinal cord injury? A controlled study, Spinal Cord, 2001;39:279–82.
102. Preziosi G, Emmanuel A, Neurogenic bowel dysfunction: pathophysiology, clinical manifestations and treatment, Expert Rev Gastroenterol Hepatol, 2009;3:417–23.
Keywords: Neurogenic bowel dysfunction, bowel dysfunction, hypererflexic bowel, areflexic bowel, upper motor neuron bowel syndrome,lower motor neuron bowel syndrome