1. Bowel Dysfunction: Assessment and Management in Neurological Patients Alison Bardsley Continence Advisor Clinical Editor – Continence UK Supported by an Educational Grant from:

2. Prevalence & Epidimiology Stroke –Commonest cause of neurological damage –Faecal incontinence reported by 23% of 135 consecutive stroke patients –Older people, women and those with severe strokes most at risk Multiple Sclerosis –Two thirds of patients will complain of bowel problems – 70% of people report monthly episodes of incontinence –Prevalence of faecal incontinence/constipation between 39% & 73% Spinal cord injury –Up to 95% will require at least one therapeutic procedure to initiate defaecation –50% need help to manage their bowel –Up to 80% of spinal cord injury patients complain of constipation –15-25% report faecal incontinence Parkinson’s disease –Constipation and evacuation difficulties are common –Up to 50% have slow transit or evacuation type constipation Autonomic neuropathy (disease or degeneration of autonomic nervous system for example diabetes) –Constipation reported in 12-88% of diabetic patients –20% of diabetics complain of faecal urgency and incontinence –Evidence of decreased rectal sensation or impaired function of anal sphincters

3. Neurophysiology of gastro- intestinal tract Extrinsic nervous control: –Autonomic nervous system (smooth muscle, involuntary) Parasympathetic and sympathetic fibres –Somatic nerves (voluntary) Supply motor and sensory control to large bowel & pelvic floor

4. Neurophysiology (cont) Enteric Nervous system –Internal nervous system of the gut –Modulated via autonomic system to brain –Can mediate reflux activity independent of central nervous system –Role in control of: Motility Blood flow Water and electrolyte transport Acid secretion in digestive tract

6. Neurogenic bowel Bowel dysfunction due to: –Neuropathological process (e.g. spinal cord injury) –Common causes unrelated to neurological disease (e.g. low dietary fibre) –A combination of neuropathalogical and common causes –Frontal lobe damage – emotional disturbance, social relationships, reduced awareness, lack of voluntary control of pelvic floor.

7. Assessment Environment Individual Bowel

8. Environment Appropriate Clean Warm Well lit Toilet paper Access Help required? Home/work Involve multidisciplinary team

9. Individual Impairment Cognitive function Mood/depression Coping strategies Concordance Quality of life Concomitant disease

10. Bowel Bowel symptoms Bowel diary DATETIMEType of stool ~ use number on chart Quantity of stool Large (L) Medium (M) Small (S) None (N) Did you strain Yes No Soiled UnderwearType & dose of Laxative Number of times during the day Type of soiling (Stained/ loose/ solid)

11. Physical examination Digital Rectal examination –Anal/rectal tone –Sensation –Presence of faeces –Rectal prolapse Bowel transit Anorectal manometry

12. Bowel management programmes Safe, private and pleasant environment Appropriate equipment / home adaptations Prevention of pressure damage Carers required? Scheduled bowel evacuation Diet and fluid intake Catheterisation

13. Assistive methods Abdominal massage Valsalva manoeuvre Deep breathing and leaning forward Digital ano-rectal stimulation Manual evacuation Biofeedback Rectal irrigation

14. AUTONOMIC DYSREFLEXIA Unique to spinal injury above T6 SYMPTOMS  Headaches  Severe hypertension  Flushing above the lesion  Sweating below the lesion  Blotching of the skin  Nasal congestion  Bradycardia / tachycardia  Palpitations  Dilation of the pupils

15. Consent and legal issues Lawful Consent Consent should be given by someone with the mental ability to do so sufficient information should be given to the patient Consent must be freely given Considerations – Adults unable to give consent Children

16. Dietary management General Recommendations Dietary fibre: 18 to 30 g per day Fluid intake: 1.5 to 2 litres per day Fruit and vegetables: 5 portions per day

17. Types of Fibre SOLUBLE FIBRE: Effectively broken down by enzyme-producing bacteria to produce energy, gas & bulky stools. Soluble Fibre forms a gel- like substance which binds to other substances in the gut. Lowers cholesterol levels. Slows down entry of glucose into the blood, thus improving blood sugar control INSOLUBLE FIBRE Less easily broken down by bacteria. Holds water very effectively (up to 15 x its weight) therefore adds weight to stool. ‘Natures Broom’ has protective effects on the gut.

18. Fibre?

19. Medication treatment of Constipation Laxatives Choice of agent will depend on –Presenting symptoms –Nature of complaint –Efficacy –Side –effects –Speed of action –Patient acceptability –Compliance –Cost

20. Types of laxatives Bulk forming – Fybogel®, Celvevac® Normacol®, Regulan® Act like dietary fibre increasing water content and faecal mass – increase stool weight and frequency Usually work within 24 -36 hours

21. Stimulant Laxatives Senna, Bisacodyl, co-danthramer, co- danthrasate, dioctyl, docusol Stimulate an increase in colonic motility (peristalsis) and mucus secretion Rapid acting 8-12 hours Best taken in evening or at bedtime

22. Osmotic/iso-osmotic Laxatives Lactulose and Magnesium salts – Osmotic Act by drawing fluid from the body into the bowel by osmosis MOVICOL® - iso-osmotic MOVICOL increases stool water content and directly triggers colonic propulsive activity and defaecation. 4 in 1 mode of action: Bulks, softens, stimulates and lubricates.

23. Rectal stimulants Bisacodyl and Glycerine Used alone or in combination with digital stimulation Predictable Consider a suppository inserter if hand function insufficient

24. Anal Irrigation Complete system for managing neurogenic bowel dysfunction. Proven reduction of faecal incontinence and constipation Self-administration of the system increases the patients’ independence, dignity and quality of life.

25. How does irrigation help in bowel management ? Before emptying After Emptying

26. Faecal incontinence Address non- neurological causes –Anal sphincter damage –Infectious diarrhoea Exclude constipation or impaction

27. Conservative Measures l Patient education l Bowel habit l Defaecation posture l Review medications (many can cause problems of hard or loose stool) l Diet & fluids l Toilet facilities l Support l Practical management

28. Anti-Diarrhoeals l Loperamide up to 16mg (8 tablets) daily if stool loose l Take care not to constipate l Half hour before meals l At night for morning urgency l PRN before going out l Codeine phosphate an alternative l Diarrhoea may need investigating

29. Loperamide l Reduces faecal incontinence & stool weight l Improves stool consistency l Raises resting pressure (Read et al, 1982) l Increases water absorption, slows transit l Decreases IAS & EAS relaxation upon rectal distension (Rattan & Culver, 1987) l May deliberately stop spontaneous evacuation & empty with evacuants (Tobin & Brocklehurst, 1986)

30. Managing Faecal Incontinence No easy answers Difficult to disguise smells and prevent soreness Products Skin care Odour control Support

31. Anal Plug l Many cannot tolerate due to discomfort l Not suitable for patients with frequency, diarrhoea or inflammation l Can use up to 12 hrs l Very good for a few l May be most suitable for those with less sensation (neurological)

32. Conclusion Healthcare professionals play a key role: –Promoting independence –Support –Link/co-ordination with other services –Advice and information

33. Any questions? Contact details: alison.bardsley@continence-uk.com For further information and handouts www.continence-uk.com Our thanks go to Norgine Pharmaceuticals Ltd. for providing an educational grant to support this workshop