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Pelvic Floor: Coloproctology

A randomized, controlled trial of transanal irrigation versus conservative bowel management in spinal cord-injured patients.
Christensen P, Bazzocchi G, Coggrave M, Abel R, Hultling C, Krogh K, Media S, Laurberg S
Gastroenterology. 2006 Sep;131(3):738-47.

Background & Aims: Bowel dysfunction in patients with spinal cord injury often causes constipation, fecal incontinence, or a combination of both with a significant impact on quality of life. Transanal irrigation improves bowel function in selected patients. However, controlled trials of different bowel management regimens are lacking. The aim of the present study was to compare transanal irrigation with conservative bowel management (best supportive bowel care without irrigation). Methods: In a prospective, randomized, controlled, multicenter trial involving 5 specialized European spinal cord injury centers, 87 patients with spinal cord injury with neurogenic bowel dysfunction were randomly assigned to either transanal irrigation (42 patients) or conservative bowel management (45 patients) for a 10-week trial period. Results: Comparing transanal irrigation with conservative bowel management at termination of the study, the mean (SD) scores were as follows: Cleveland Clinic constipation scoring system (range, 0-30, 30 = severe symptoms) was 10.3 (4.4) versus 13.2 (3.4) (P = .0016), St. Mark's fecal incontinence grading system (range, 0-24, 24 = severe symptoms) was 5.0 (4.6) versus 7.3 (4.0) (P = .015), and the Neurogenic Bowel Dysfunction Score (range, 0-47, 47 = severe symptoms) was 10.4 (6.8) versus 13.3 (6.4) (P = .048). The modified American Society of Colorectal Surgeon fecal incontinence scores (for each subscale, range is 0-4, 4 = high quality of life) were: lifestyle 3.0 (0.7) versus 2.8 (0.8) (P = .13), coping/behavior 2.8 (0.8) versus 2.4 (0.7) (P = .013), depression/self perception 3.0 (0.8) versus 2.7 (0.8) (P = .055), and embarrassment 3.2 (0.8) versus 2.8 (0.9) (P = .024). Conclusions: Compared with conservative bowel management, transanal irrigation improves constipation, fecal incontinence, and symptom-related quality of life.


A multicentre study of the management of disorders of defecation in patients with spina bifida.
Lemelle JL, Guillemin F, Aubert D, Guys JM, Lottmann H, Lortat-Jacob S, Moscovici J, Mouriquand P, Ruffion A, Schmitt M
Neurogastroenterol Motil. 2006 Feb;18(2):123-8.

Patients with spinal dysraphism may have severe constipation and faecal incontinence. The impact of antegrade colonic enema (ACE) in the management of patients with spina bifida (SB) is analysed. In a multicentre cross-sectional study, constipation, faecal incontinence and faecal management were described. Cases surgically treated were identified. Data were collected from 423 patients, of whom 230 did not use any manoeuvre or laxatives to assist evacuation. Conventional treatment was used in 193 patients, including digital extraction in 39%, retrograde enema in 21% and oral laxatives in 52%. For intractable constipation and overflow of faecal incontinence, 47 patients were treated with ACE, of whom 41 used the method at a mean time of interview of 4.1 +/- 1.9 years after ACE operation; six abandoned ACE for conventional management. With ACE, faecal continence was significantly improved compared with conventional management, and neither retrograde rectal enema nor digital extraction were required. The conduit was fashioned to the right colon in 32 cases and to the left colon in nine cases. This study provides information on a multicentre experience in bowel management in SB patients. Whatever the technique used, ACE has improved faecal status compared with conventional therapy.