Neurogenic Bowel CareNeurogenic Bowel CareNursing PerspectivesNursing Perspectives

TO HoiTO Hoi--ChuChu

Nurse Consultant (Urology)Nurse Consultant (Urology) PresidentPresidentDivision of Urology Department of SurgeryQueen Elizabeth Hospital

HK College of Urological NursingHK College of Urological Nursingwww.hkcun.orgwww.hkcun.org

Queen Elizabeth HospitalHONG KONG

tohc@ha.org.hktohc@ha.org.hk

SequelaSequela of Spinal Cord Injury (SCI)of Spinal Cord Injury (SCI)SequelaSequela of Spinal Cord Injury (SCI)of Spinal Cord Injury (SCI) SCI may interrupt communication between the

nerves in the spinal cord, that control bladder & bowel function, and the brain

results in bladder or bowel dysfunction that is termed "neurogenic bladder" or "neurogenic bowel" bowel"

Urology nurses are the professional to take care f i bl dd d i b l of neurogenic bladder and neurogenic bowel

dysfunctioni b l d f ti i l d f l neurogenic bowel dysfunction includes fecal

incontinence, constipation, bowel frequency and lack of bowel movementslack of bowel movements

Complications & problems related to Complications & problems related to neurogenic bowel dysfunctionneurogenic bowel dysfunction

Faecal incontinenceFaecal incontinence Faecal incontinenceFaecal incontinence

ConstipationConstipation

Abdominal painAbdominal pain

Autonomic dysreflexiaAutonomic dysreflexiayy

Up to 23% of individuals with chronic SCI have required hospitalization for evaluation or treatment required hospitalization for evaluation or treatment of complications of neurogenic bowel

5-10% of the deaths associated with SCI are due to gastrointestinal complications

Harari D, Minaker KL (2000) Megacolon in patients with chronic spinal cord injury. Spinal Cord. 38, 6, 331-339.

Complications & problems related to Complications & problems related to neurogenic bowel dysfunctionneurogenic bowel dysfunction

Protracted duration in toiletingProtracted duration in toileting Protracted duration in toiletingProtracted duration in toileting

Damage to colorectal structuresDamage to colorectal structures•• Haemorrhoids Anal fissures Rectal prolapses MegacolonHaemorrhoids Anal fissures Rectal prolapses Megacolon•• Haemorrhoids, Anal fissures, Rectal prolapses, MegacolonHaemorrhoids, Anal fissures, Rectal prolapses, Megacolon

Pressure ulcer formationPressure ulcer formation

FallsFalls

Limiting social life, poor social adjustmentLimiting social life, poor social adjustmentg , p jg , p j

Barrier to employment or education opportunitiesBarrier to employment or education opportunities

I t f ith l ti itiI t f ith l ti iti Interfere with sexual activitiesInterfere with sexual activities

Dependence on caretakers for toiletingDependence on caretakers for toiletingHarari D, Minaker KL (2000) Megacolon in patients with chronic spinal cord injury. Spinal

Cord. 38, 6, 331-339.

Basic conservative managementBasic conservative managementBasic conservative managementBasic conservative managementDietary management 20 - 35 grams fibre daily is recommendation for

older children, adolescents and adultsP li d h f fib i f i d Peeling can reduce the amount of fibre in fruits and vegetables

Any increase in fibre should be gradually done over Any increase in fibre should be gradually done over a 4 to 6 weeks period to prevent a bloated feeling and too much gas

Fluid managementM i t i t t t i id f t f ilit t Maintains water content inside faeces to facilitate bowel movement through the digestive system, drink fluid 2 Litre / daydrink fluid 2 Litre / day

Marlett JA, McBurney MI, Slavin JL. Position of the American Dietetic Association: Health Implications of Dietary Fiber. J Am Diet Assoc. 2002; 102(7): 993-1000.

Tips to Effectively manageTips to Effectively managea Bowel programa Bowel program

Positioning: Upright on commode if possible (gravity assists stool

expulsion and peristaltic activity is greater when upright)

On Left lateral position with knees bent the upper leg higher On Left lateral position with knees bent, the upper leg higher than the lower to expose the anus & avoid damaging the anal canal

Privacy: In relax manner, and not to be rushed for bowel care

The more tense you are, the more difficult for bowels emptying

A hurried bowel care will increase the likelihood of an A hurried bowel care will increase the likelihood of an unplanned bowel movement later in the day

Bowel care should be performed with an empty bladder in order Bowel care should be performed with an empty bladder in order to avoid bowel related UTI

Tips to Effectively manageTips to Effectively managea Bowel programa Bowel program

Timing: Timing: A regular and consistent time to perform bowel care will

train the bowels

Time of routine: 30 - 60 minutes after meals or drinking warm liquids, take

advantage of the gastro colic reflexadvantage of the gastro-colic reflex

Frequency: D il til ti t bli h d ith t b kth h Daily until routine established without breakthrough accidents, then every other day or every third day as tolerated

A program greater than every 3 days may lead to hard stools and constipation

Activity levelActivity levelActivity levelActivity level

keep adequate physical activities

increase abdominal muscular tone & stimulate peristalsis

Assistance maneuverAssistance maneuverAssistance maneuver Assistance maneuver

Abdominal massageAbdominal massage

Valsalva maneuverValsalva maneuver Valsalva maneuverValsalva maneuver

Gastro-colic response

Bending

Lifting

Push-ups Push-ups

Faecal incontinence managementFaecal incontinence managementFaecal incontinence managementFaecal incontinence managementBiofeedback

Transrectal electrostimulationPalmer 1997 Palmer 1997

55 children mean age 6.7 y.o. myelodysplasia & faecal incontinencey y p

Daily transrectal electrostimulation 36.3% complete success, 54.5%

moderate successmoderate success No untoward effects

Anal plug

Palmer LS, Richards I and Kaplan WE. Transrectal Electrostimulation Therapy for Neuropathic Bowel Dysfunction Palmer LS, Richards I and Kaplan WE. Transrectal Electrostimulation Therapy for Neuropathic Bowel Dysfunction in Children With Myelomeningocele. J Uro. 1997 Apr; 157(4): 1449in Children With Myelomeningocele. J Uro. 1997 Apr; 157(4): 1449--1452, 1452,

Timed toiletingTimed toiletingTimed toiletingTimed toileting

Regularly sit for at least 5 minutes on the toilet after each meal (3 times daily) to use the gastro-colic reflex to initiate a bowel movementcolic reflex to initiate a bowel movement

Shepherd K, Hickstein R and Shepherd R: Neutrogena faecal incontinence in children with spina bifida: rectosphincteric responses and evaluation of a physiological rationale for management, including biofeedback

diti i A t P di t i J 1983 19 97conditioning. Aust Pediatric J 1983; 19: 97.

Rectal suppositoriesRectal suppositoriesRectal suppositoriesRectal suppositories

Suppositories have to be inserted between the stool and the rectal wall to have optimal effect

Digital removal of faecesDigital removal of faecesDigital removal of faecesDigital removal of faeces Laxatives the night before, the stool will have moved

to the lower bowel & rectum ready for emptying the to the lower bowel & rectum ready for emptying the next morning

and suppositories/ enema 1 hour prior to the pp / pprocedure in an effort to promote rectal stimulation

hooking faeces with a gloved lubricated finger & gently removing faeces from the rectum gently removing faeces from the rectum

hard stool: f l t ti til • remove faeces one lump at a time until no more

faecal matter can be felt solid faecal mass: solid faecal mass:

• push finger into the middle of the mass, split it & remove small pieces with a hooked finger until no p gmore faecal matter can be felt

Digital rectal stimulationDigital rectal stimulationDigital rectal stimulationDigital rectal stimulation

For reflexic bowel dysfunction (UMN) For reflexic bowel dysfunction (UMN)

Laxatives the night before Laxatives the night before

Suppositories / enema 1 hour before the procedure Suppositories / enema 1 hour before the procedure

Watson R (1997) Clinical Nursing and related sciences. London, Bailliere Tindall.Powell M, Rigby (2000) Management of bowel dysfunction, evacuation difficulties. Nursing Standard. 14, 4, 47-51.

Digital rectal stimulationDigital rectal stimulationDigital rectal stimulationDigital rectal stimulation Insert gloved lubricated finger ½ to 1 inch into the g g

rectum. Wait for the internal anal sphincter to relax ~ 30 secondsG tl t t th fi 6 8 ti i i l ti Gently rotate the finger 6-8 times in a circular motion, maintaining contact with rectal wall, and withdrawStimulation can be repeated every 5 to 10 minutes Stimulation can be repeated every 5 to 10 minutes (≤ 5 sets of stimulation) until the bowel is emptied

Gentle abdominal massage valsalva manuevre & Gentle abdominal massage, valsalva manuevre, & manual evacuation may be used to assist bowel emptying

Precautions for digital removal of faeces & Precautions for digital removal of faeces & digital rectal stimulationdigital rectal stimulation

may cause autonomic dysreflexia (AD) in individuals with spinal cord lesions T6 or above

consider using a topical anesthetic gel to decrease this risk

monitor for acute elevation of blood pressure, symptoms of autonomic dysreflexia: pounding symptoms of autonomic dysreflexia: pounding headache, piloerection

If t l bl di i / t f If any rectal bleeding or signs / symptoms of autonomic dysreflexia occurs, stop the procedure immediately and inform doctor for treatment

Precautions for digital removal of faeces & Precautions for digital removal of faeces & digital rectal stimulationdigital rectal stimulation

Injury to the rectal lining or anal sphincter if performed forcefully in a person with impaired p y p psensation

use plenty of lubricant and to be gentle use plenty of lubricant and to be gentle

Make sure you have short nailsy

Retrograde colonic irrigationRetrograde colonic irrigationRetrograde colonic irrigationRetrograde colonic irrigation

faecal disimpaction before starting the faecal disimpaction before starting the bowel cleansing program

Slowly instill lukewarm tap water into the bowel through an irrigation set & Foley catheter Foley catheter

Bowel opening by massaging the bd i i i t lti di ti abdomen in an isoperistaltic direction,

following the course of the colon

cleanse only the distal part of the colon

Retrograde colonic irrigationRetrograde colonic irrigationRetrograde colonic irrigationRetrograde colonic irrigation

l ft l t l iti left lateral position

Empty patient’s bladder or move the urinary d i i f h l drainage equipment away from the anal area

Falls prevention

Pressure sore prevention

use a well lubricated rectal catheter and insert up use a well lubricated rectal catheter and insert up the colon as far as possible

NEVER PUSH THE CATHETER AGAINST RESISTANCE

Retrograde colonic irrigationRetrograde colonic irrigationRetrograde colonic irrigationRetrograde colonic irrigation

Initially irrigations are given on a daily basis Initially, irrigations are given on a daily basis

If successful frequency can be reduced to once If successful, frequency can be reduced to once every 2 days

irrigation volume is 500 ml at the beginning

but can be increased up to 2 liter, for adults, if necessarynecessary

Ziskind, A. and Gellis, S. S.: Water intoxication following tap water enemas. Am J Dis Child,1958; 96: 699.

Precautions forPrecautions for enemas / irrigationsenemas / irrigationsPrecautions for Precautions for enemas / irrigationsenemas / irrigations

Absolute contraindications: Acute active inflammatory bowel disease

Known obstructing rectal or colonic mass

Rectal or colonic surgical anastomosis within the l 6 hlast 6 months

Severe cognitive impairment (unless carer available to supervise/administer)

Potential complications related to Potential complications related to enemas / irrigationsenemas / irrigations

Bowel perforation due to pushing too hard on the wall Bowel perforation due to pushing too hard on the wall of rectum (sensation is lacking in SCI patients)

R t l bl di d t t ti h h id Rectal bleeding due to traumatic push or haemorroids

Autonomic dysreflexia may happen if large volume of denema used

• monitor for acute elevation of blood pressure, signs f i d fl ior symptoms of autonomic dysreflexia

Water intoxication or electrolyte disturbances may occur

Scald to bowel lining if fluid inserted is too hot

Use of laxatives or additives for Use of laxatives or additives for enemas / irrigationsenemas / irrigations

Tap water is suitable for most patients Tap water is suitable for most patients

However, young children (under 13 years) and ti t ith l t l t di t b h ld any patient with electrolyte disturbances should

use normal saline

If t l d t t t l t i If water alone does not promote rectal emptying, phosphate enema may be added to the irrigation water

However, this should not be introduced until water alone has been tried for at least 1 month

Calculation of enema volumefor enemas / irrigationsfor enemas / irrigations

In 1958, Ziskind and Gellis

The enema volume was calculated at 3.5% of body weight or 350 to 2,000 mly g

No significant changes in serum sodium or chloride were noted chloride were noted

Due to the uncertain sodium level of softened water in any home families advise to use water in any home families, advise to use untreated tap water

the safest egimen has not et been established the safest regimen has not yet been established

periodic evaluation of serum electrolytes

Malone antegrade continence enema Malone antegrade continence enema (MACE)(MACE)

Furlan 2007: MACE procedure has the best long-

term outcome in terms of• the likelihood of an improvement in

bowel function, complication rate, reduction in autonomic dysreflexia reduction in autonomic dysreflexia episodes and patient preferences

O ll h b hi h Overall success has been as high as 90% in both pediatric & adults patients with myelodysplasia and/or patients with myelodysplasia and/or neurogenic bowel dysfunction F l JC U b h DR d F hli MG O i l f i b lFurlan JC, Urbach DR and Fehlings MG. Optimal treatment for severe neurogenic bowel

dysfunction after chronic spinal cord injury: a decision analysis. British Journal of Surgery 2007; 94: 1139–1150

Malone antegrade continence enemaMalone antegrade continence enemaMalone antegrade continence enemaMalone antegrade continence enema improved QoL related to faecal incontinence or improved QoL related to faecal incontinence or

intractable constipation

independence on others for toileting independence on others for toileting

decreased toileting time

cleanse almost the entire colon, reducing the risk of fecal soiling & constipationg p

autonomic dysreflexia resolved postoperativelyELIZABETH B YERKES RICHARD C RINK SHELLY KING MARK P CAIN MARTIN KAEFER AND ANTHONY J CASALE TAP WATER AND THE MALONEELIZABETH B. YERKES, RICHARD C. RINK, SHELLY KING, MARK P. CAIN, MARTIN KAEFER AND ANTHONY J. CASALE:TAP WATER AND THE MALONE

ANTEGRADE CONTINENCE ENEMA: A SAFE COMBINATION? J Uro. October, 2001; 166: 1476–1478Schreiber, C. K. and Stone, A. R.: Fatal hypernatremia associated with the antegrade continence enema procedure. J Urol, 1999; 162: 1433.Ziskind, A. and Gellis, S. S.: Water intoxication following tap water enemas. Am J Dis Child,1958; 96: 699.Griffiths, D. M. and Malone, P. S.: The Malone antegrade continence enema. J. Ped. Surg., 1995; 30: 68.Mor, Y., Quinn, F. M. J., Carr, B., Mouriquand, P. D., Duffy, P. G. and Ransley, P. G.: Combined Mitrofanoff and antegrade continence enema procedures for urinary and fecal

i i J U l 1997 158 192incontinence. J. Urol., 1997: 158: 192.TEICHMAN, JOEL M. H.; HARRIS, J. MANSEL; CURRIE, DONALD M.; BARBER, DOUGLAS B. MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE. J Uro, October, 1998; 160(4): 1278-1281.Vande Velde S,Van Biervliet S, Van Renterghem K, Van Laecke E, Hoebeke and Van Winckel M. Achieving Fecal Continence in Patients With Spina Bifida: A Descriptive Cohort

Study. J Uro, Dec 2007; 178:2640-2644.

Malone antegrade continence enemaMalone antegrade continence enemaMalone antegrade continence enemaMalone antegrade continence enema• Faecal disimpaction before starting the bowel cleansing

programprogram Isolated report of fatal hypernatremia after irrigation with

normal saline Water intoxication with hyponatremia, mental status

changes may occur Elizabeth BY et al.(2001) reported tap H20 & MACE is a

safe combination in her cohort of 71 patients of mean age 126.4 months FU 3.5 years

Complications:• stomal stenosis, stomal leakage, false passage & bowel , g , p g

obstruction, metabolic complications related to colonic irrigation

Prevention of stomal stenosis: regular stomal calibration Prevention of stomal stenosis: regular stomal calibration with 12Fr Nelaton catheter 2-3 times a day

Our local experience on Malone antegrade continence enema

4 patients - 3 girls and 1 boy, aged 8-12 (mean 9.5) years - underwent MACE Feb - Sep 2006

spinal dysraphism in all 4 patients

ch onic int actable constipation (4) & fecal chronic intractable constipation (4) & fecal incontinence (3)

M F/U 69 25 ( 66 73) th Mean F/U was 69.25 (range 66-73) months

All 4 patients performed antegrade continence enema i d d tl 1 2 d ( 1 5 d )independently every 1-2 days (mean 1.5 days)

Lukewarm tap water was used without laxatives or ipurgatives

Our local experience on Malone antegrade continence enemaMean volume of tap water required was 875 ml (range Mean volume of tap water required was 875 ml (range 600 - 1200)

Mean time used for irrigation was 45 minutes (range 15 - Mean time used for irrigation was 45 minutes (range 15 60)

Mean time duration to develop a regular bowel t tt 6 75 th ( 6 9)movement pattern was 6.75 months (range 6 – 9)

All experienced no fecal incontinence from stoma or rectumrectum

All enjoyed no constipationSerum sodium level of all patients was within normal Serum sodium level of all patients was within normal range

1 stomal stenosis requiring self dilation daily since 36 1 stomal stenosis requiring self dilation daily since 36 months after the MACE procedure

Thank youThank you