Practical bowel management in Multiple

SclerosisDr Maureen Coggrave PhD, MSc, RN

Research FellowFlorence Nightingale School of Nursing and Midwifery

Learning outcomes• Understand concept of neurogenic bowel

dysfunction (NBD) as seen in people with MS• Appreciate impact of NBD on quality of life• Understand the importance of case finding • Be aware of assessment methods in NBD• Be aware of potential methods of

management, particularly conservative interventions

• Be aware of resources to support management2

Normal Bowel Control: enteric nervous system

• Enteric nerves are primary mediators of movement and sensation in the gut

• Myenteric (Auerbach’s) plexus: between muscle layers: motility (peristalsis) + inhibits sphincters

• Submucosal (Meissner’s) plexus: secretion & blood flow• >100 million nerves• Not under conscious control

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Normal bowel control: autonomic nervous systemParasympathetic –stimulates motility

• Rest and Digest• Vagus - ascending and left transverse colon• Parasympathetic fibres in pelvic nerve from S2-4 to descending colon

and rectum

Sympathetic – inhibits motility • Fight or flight

Both modulated by higher centres in the brain4

Normal Intestinal Physiology

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Input -food ~2000ml-secretion ~7000ml

Output ~200ml

90% colonic reabsorption

Peristalsis• Almost all in one direction• Stimulated by distension (or

irritation, or parasympathetic stimulation)• With circular muscle tonic,

longitudinal contraction shortens the bowel• With longitudinal muscle

tonic, circular contraction propels lumenal content

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Influences on colonic transit

• Ingestion of food – gastrocolic response• Diet and fluids• Time of Day• Genetics and the microbiome• Emotion

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Influences of emotion(Almay 1951)

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Structure of the anus

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Rectum

IAS

A EAS

Anal sphincters

Internal anal sphincter• Condensation of colonic smooth

muscle• ~3mm thick, 3cm long• Continuous electrical activity (falls

during sleep) - greatest in lower IAS• Reduced activity with rectal distension

(recto-anal inhibitory reflex)

External anal sphincter• Provides voluntary control of

defaecation• Striated muscle, innervated by

pudendal nerve• Fatigable• Rectal distension results in

• increased activity initially• eventually activity diminishes and stops

completely (a spinal reflex)

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Sampling - subconscious• Every 10 minutes rectal distension

leads to relaxation of upper IAS• Rectal contents are exposed to anal

mucosa (~10secs); • Incontinence does not occur due to

recruitment of EAS activity• Higher slow wave activity in lower IAS

pushes contents back into rectum

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Anal canal angulation

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Voluntary control

Maintained via sacral nerves (S2-S4) to anal canal and pelvic floor

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Normal defecation Full rectum – conscious awareness Appropriate social context sought (conscious!) and await next giant

migrating peristaltic contraction Adopt correct posture Raise intra-abdominal pressure Anal sphincters relax Rectum contracts to expel stool Should pass soft formed stool with minimal effort External anal sphincter “snaps shut” after completion “Normal” 3 times / day to 3 times / week

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What is ‘neurogenic bowel dysfunction’?Faecal incontinence and/or constipation due to a chronic condition of the central nervous system:• Multiple sclerosis• Stroke• Spinal cord injury or damage• Spina Bifida• Cerebral Palsy• Cauda Equina Syndrome• Parkinson’s Disease

Prevalence of Faecal incontinenceMS – 25-50% (Hinds 1990, Chia 1995)

SCI - 30- 75% (Glickman 1996, Krogh 1997, Menter 1997, Lynch 2000, LeDuc 2002)

Spinal Bifida-32-53% (Malone 1994, McDonnell 2000, Verhoef 2005)

Stroke - 23% (Brocklehurst 1985; Nakayama 1997; Harari 2003)

Cerebral palsy and Parkinson's – unknown

UK community based study - 5.7% of women, 6.2% of males, increased with age (Perry 2002)

Prevalence constipationMultiple Sclerosis - up to 35-70% (Hennessey 1999; Hinds 1990; Chia 1995, DasGupta 2003)

SCI - 42 - 80% (Glickman 1996; Krogh 1997; Menter 1997; Harari 2000)

Parkinson's disease -50% (Chen et al 2015)

Spina Bifida – 32-53% (Malone 1994; McDonnell and McCann 2000)

Cerebral Palsy – 56 % (Turk et al 1997)

General UK population - 8.2%, more frequent in women (Probert 1995)

Around 20% of the elderly (Thompson 1980 Heaton 1993)

US and Canada – 1.9 – 27% (Higgins 2004)

Impact of neurogenic injury or disease on bowel function• Enteric system - usually remains functionally intact • Extrinsic System

• Lost or altered descending input from the brain and from the autonomic system

• Lost or altered sensation of need for defaecation• Slowing of stool passage through the bowel• Evacuation disorders due to altered reflexes

• Lost or altered voluntary control of defaecation

Sensory nerves

Motor nerves

Reflex arc

Reflex bowel function

Flaccid bowel function (Anterior root exit zones)

Upper motor neurone damage• Leads to reflex bowel function

• Damage to the spinal cord at or above T12 results in a reflex bowel and normal or increased anal sphincter pressure

• Reflex pathways are intact and reflex functions of the anorectum are preserved

• Conservative management is based on stimulation of reflexes• Digital rectal stimulation, suppositories, micro enemas

• Soft formed stool – Bristol Scale 4• Risk of recto-anal dyssynergia (puborectalis paradoxical contraction, pelvic floor

dyssynergia)• Inability to relax pelvic floor and anal sphincters voluntarily• Rectum may empty automatically when full and reflexes are triggered• Sensation and voluntary control are lost

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Lower motor neurone damage• Leads to flaccid bowel function –

• Damage to spinal nerves at or below L1 (Cauda Equina) result in a flaccid descending colon and ano-rectum and relaxed anal sphincter

• Absence of reflex functions• High risk of faecal incontinence through lax sphincter.• Rectum may not empty fully even when stimulated

• Conservative management is based on manual evacuation of stool – rectal stimulation digitally or with suppository is ineffective

• Firmer stool – Bristol Scale 3• Sensation and voluntary control are lost

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Quality of life

‘Establishing an effective bowel program is critical because incontinence may interfere with a patient’s physical, psychological, social, recreational and sexual function’ (DeLisa + Kirshblum 1997)

Societal norms - taboo socially unacceptable area of bodily function Stigma – psycho-emotional factors for individual

Loss of usual adult control – shame, embarrassment Using ‘invasive’ techniques Impact of prolonged toileting, dietary restriction, lack of accessible toilets

Fear of FI – Devastation of a public accident – more shame and embarrassment! Fine dividing line constipation / FI Pressure to ensure adequate regular evacuation to avoid faecal

impaction Physical impact – odour, ‘pads’, hygiene, skin care…

Quality of life• Community re/integration

• work, study, leisure

• Dependency• Control• Dignity

• Health and wellbeing

Case findingAsk the patient about their bowel!What are the patient’s priorities?What are the most bothersome symptoms?Patient knowledge and educationSelf management supportKnow your local services Know your limitations - refer on if you are unable to manage the problem

Assessment - Outcome measuresFrequency of episodes of incontinenceStool form recorded using the Bristol Stool Form ScaleDuration of management episodesIs the patient as independent as possible?Feedback from the patient regarding satisfaction and perceived autonomyNeurogenic Bowel Dysfunction Score (Krogh et al 2005)

Assessing for bowel managementCurrent bowel function•Sensation•Voluntary motor control•Reflex or flaccid bowel

Previous medical historyMedicationHow are they coping now? – what have they tried in the past?

•Diet and fluids• Ability to eat a full diet• Actual dietary intake – fibre/five a day

•Activity• general mobility• exercise• standing• passive movements

•Communication•Cognitive ability•Level of independence•Lifestyle – impact on cultural, sexual, vocational roles•Psychological and emotional factors

Assessment of constipation

Symptom review• Frequency• Urge• Consistency (BSFS)• Mucus• Blood• Incomplete evacuation• Straining• Digitation (PR/PV)• Laxative use

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Physical assessment methods

• Bowel and diet diaries • DRE – • Obvious anal disorders• Amount and consistency of stool• Anal tone• Paradoxical contraction during

straining• Gut transit studies• Anorectal physiological

assessment• Evacuation of simulated

stool/Defecating proctogram31

Current Options

StomaSARS

Sacral nerve modulation/stimulation?Antegrade colonic irrigation/

percutaneous endoscopic colostomyTransanal irrigation

Rectal interventions- digital stimulation, digital evacuation, suppositories, small enemas

Prokinetic agents???

Adapted from MASCIP Neurogenic bowel Guidelines 2012

Routine, diet and fluids, lifestyle alterations, laxatives, constipating medicines

Prucalopride, domperidone, erythromycin

Conservative or first line interventions –

Diet and fluids• Evidence for benefit of fibre minimal

• Increased fibre increases faecal incontinence in the elderly (Ardron & Main 1990)

• Immobile individuals prone to soft impaction (Barratt 1988)• Fibre can cause bloating & flatulence• 40gm wheat bran SCI patients, 3 weeks, no change in transit time or

stool weight (Cameron et al, 1996)

• ‘Five a day’ and 2 portions of wholegrain – trial and error• Fluid intake - sufficient fluid intake to produce ‘straw

coloured’ urine, reflecting bladder management needs

Conservative or first line interventions – Establish a routine• Always in collaboration with the individual

• Frequency depends on• Response to management i.e. episodes of incontinence, constipation• Type of bowel dysfunction

– flaccid bowel usually requires daily or sometimes twice daily evacuation to maintain continence

– reflex function can be managed on a daily or alternate day routine• Not less than alternate days - less frequent or irregular bowel

management may contribute to constipation (Coggrave 2007a)• Time of day should fit in with individual’s activities – does not have

to be in the morning

Conservative or first line interventionsGastrocolic reflex• Reflex response to food or drink entering the stomach• Results in an increase in muscular activity throughout the gut

(Harari 2004) which can result in movement of stool into the rectum

• Response may be reduced or absent in individuals with spinal cord injury (Nino-Murcia et al)

• Commence bowel care 20-30 minutes after food or warm drink• Response is strongest after breakfast

Conservative or first line interventions –Abdominal massage• Massage abdomen following the lie of the colon (Ayas et

al 1996, McClurg 2010)• Technique helps to promote peristalsis, thus moving stool

into the rectum and relieving flatulence• Use while waiting for suppositories/enema to work• Use between episodes of digital rectal stimulation or

digital removal of stool

Conservative or first line interventions –Rectal stimulantsProvide the trigger for evacuation – control over timing – in patients with reflex bowel function• suppositories -

• glycerin, • bisacodyl

• enemas – • Microlax• Phosphate – only in special circumstances

Conservative or first line interventions –Digital rectal stimulation• Both pharmacological and digital rectal stimulation usually

required• Technique to increase the reflex muscular activity in the rectum

and relax the anal sphincter in patients with reflex bowel function• Used by 35-50% of individuals with neurogenic bowel dysfunction

(Han et al 1998)• Gentle circular motion of a gloved, lubricated finger for 20-30

seconds• Repeat approximately every 5 minutes until bowel has emptied • Can be carried out sitting over the toilet or in lying position

Conservative or first line interventions –Digital removal of stool• To break up or remove stool (Kyle et al 2005)

• Most commonly used single intervention (Coggrave 2007)

• Associated with shorter duration of bowel care and fewer episodes of faecal incontinence (Haas et al 2005)

• Individuals using digital evacuation in conjunction with digital stimulation 70% less likely to suffer from incontinence (Haas et al 2005)

• Single gloved lubricated finger

Conservative or first line interventions –Oral laxatives• Two broad groups:

• Laxatives to prevent constipation: taken regularly in small quantities to maintain correct stool form• Dioctyl – softener and stimulant• Lactulose - osmotic• Movicol/Laxido – iso osmotoc softener• Fybogel – bulker, absorbs liquid

• Stimulant laxatives to prepare for evacuation – taken before evacuation only • Senna• Bisacodyl

For a reflex bowel• Stimulant laxatives can be taken 8 - 12 hours before hand if

needed• Stimulate gastro-colic reflex if possible i.e. 20 mins after NG

feed or oral intake• Insert rectal stimulant if using• Abdominal massage• Spontaneous reflex evacuation • Digital rectal examination (DRE) – to check whether any stool

remains• Ano-rectal stimulation if stool remains • DRE – to check whether any stool remains and repeat as

required• Digital removal of faeces (DRF) if required

For a flaccid bowel• Stimulant laxatives can be taken 8 - 12 hours before

hand if needed• Stimulate gastro-colic reflex if possible i.e. 20 mins

after NG feed or oral intake• Abdominal massage• Digital rectal examination (DRE)• Digital removal of faeces (DRF)• DRE – to check whether any stool remains• Repeat DRF/DRE as required

Biofeedback• Package including information about bowel

dysfunction• One to one training sessions for muscle control• Sometimes actual biofeedback• Wiesel et al (2000)

• fewer than 50% benefitted, all constipated, mild or quiescent disease did best, very small sample

• Preziosi 2011 – 46% of 39 participants had improved bowel symptoms, depression and anal squeeze

Anal plug• Adjunct rather than alternative• Can be uncomfortable to insert

and when in place• May not stay in place• Can increase control, reduce skin

and odour problems• Can promote a more normal

stool(Bond 1998)

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Qufora IrriSedo Mini

Transanal Irrigation What is irrigation?A process of facilitating evacuation of faeces from the bowel by passing water (or other liquids) in via the anus in a quantity sufficient to reach beyond the rectum

PeristeenQufora

Navina

Before defecation After ”normal” defecation

Non NBD bowel

SCI patient

Christensen P et al. Dis Colon Rectum 2003; 46: 68-76. Figures 2 & 3 pages 70-71:

Scintigraphy – pre and post irrigation with Peristeen

Practical use• Used over toilet/commode – unless using bed system• Self or carer delivered• Frequency• Regular alternate day regime – neurogenic bowel (Christensen et al 2006)• Flexibly for symptomatic relief (Gardner et al 2004)

• Tap water is usual irrigant – bottled water if tap not fit to drink• Volume – Average 700 but10-2000 mls reported (Christensen

2006,2009 Del Popolo 2008• Use of laxatives – neuro bowel• 29% reduced (Del Popolo 2008)• no change (Christensen 2006)

• Irrigation requires compliance and discipline • Therapeutic and informative staff input essential

Safety• Adverse effects are rare• Potential risk of bowel perforation• Most pronounced when starting irrigation and where disease is present

• Risk per procedure currently estimated at ~ 1 per 50,000 irrigations (0.0002%)

• But as irrigation performed daily or alternate days risk is cumulative

• Patients should be advised of potential risk balanced against more invasive procedures

Problems with irrigation

• Expelling catheter/cone from rectum• Frequent bursting of balloon• Leakage of fluid around the balloon/cone• Abdominal pain• Faecal incontinence• ‘Doesn’t work’• ‘Don’t like it’

Practical use of TAI• Around 50% of those who try TAI stop using it• Currently not possible to predict success (Christensen 2008)• Can be successful in individuals with a range of disability• Individual assessment is essential• Low risk but perforation has been reported (Biering-Sørensen 2008) • Blunt trauma from catheter insertion and over inflation of balloon are possible

• Hands-on teaching is essential• Support and persistence are required when establishing the

new routine• Irrigation is not for every one!

Emmanuel A et al 2013. Consensus review of best practice of transanal irrigation in adults. Spinal Cord 51, 732–738

Percutaneous endoscopic colostomy

• Minimally invasive procedure • Mostly used to treat recurrent sigmoid

volvulus and acute colonic pseudo obstruction

• Also for faecal incontinence and constipation where other strategies have failed but less effective (NICE 2007)

• High infection rate and should only be used in carefully selected cases

• Numbers undertaken in MS unknown (Cowlam et al 2007, Gauderer 2002)

Antegrade Continence Enema (Teichman 1998, Yang 2000, Christensen 2002 )

• Continent catheterisable stoma formed from the appendix or caecum,

• May reduce the duration of bowel care and incidence of faecal incontinence (Teichman et al 1998 & 2003, Yang 2000, Gerharz et al 1997, Krogh 1998, Christensen et al 2000, Bruce et al 1999)

• Common in children with spina bifida but few ACEs reported in adults with neurogenic bowel dysfunction

• Failure rate in some studies is high (Gerharz et al 1997).

Sacral/pudendal Nerve Stimulation

• Continuous stimulation of the sacral nerves

• Improves faecal incontinence

• Requires intact pathways between sacrum and bowel

• Beneficial in incomplete spinal cord injury

(Jarrett 2005, Kenefick 2004)

Colostomy

Colostomy/ileostomyThe percentage of SCI individuals with colostomy very small – around 2.4% in the UK (Coggrave 2007) – number in MS unknown

Coggrave et al 2008, 92 respondents (62%) response• Reasons for colostomy: 68% cite prolonged bowel care, 53% FI, 29% constipation• 15% cite carer difficulties!• Significant reduction in AD, duration of care, dependency, laxative use, dietary manipulation but 31% still use laxatives• Significant increase in satisfaction (p=<.001), ability to live with bowel care and reduced impact on daily life• 53% felt their stoma was not formed at the right time • 11% of these would have preferred surgery a year earlier, 28% up to 5 years, 30% up to 10 years, 32% earlier still

(Frisbie 1986, Stone 1990, Safadi 2003, Branagan 2003, Saltzstein 1990, Craven 1998, Randall 2001)

Outcomes after stoma

Duration of bowel care significantly reduced (p=<.001)Need for assistance (dependence) significantly reduced (p=.007) Use of laxatives significantly reduced (p=.005)Manipulation of diet significantly reduced p=<.001

Coggrave et al 2012

Outcomes since stoma formation• Minor management problems –

• Ballooning (66%), pancaking (40%), faecal leakage (22%), skin soreness (24%)

• Mucous discharge from rectum was reported by 46%•Managed with

• Pads 26%, Washouts 26%, Digital rectal stimulation 24%• Suppositories 9.5%, Enemas 5%, Digital evacuation 5%• Hydrocortisione enema 2%

• Up to 25% of ostomates may require further surgery• i.e. hernia repair, excision of rectum

Coggrave et al 2012

Managing in the context of disabilityPhysical•Reduced mobility – paralysis, fatigue, weakness, spasticity• Impaired balance and flexibility•Reduced/absent manual dexterity•Accessibility issues•Dependency

Psychological/emotional• Fear and anxiety•Depression/lack of engagement•Cognitive ability• Lack of / readiness for knowledge

Community provision of support for bowel management

Whose job is it?• District Nurses and other community NHS staff – workloads and priorities• Agency carers – training, competence issues• Personal assistants – direct payments – flexibility, stability and control• Family carers – spouses…

CCG funding – does it exist? Do we make the case?

Follow up and reassessmentProlonged bowel careFaecal incontinenceConstipation and impactionSkin damagePainLoss of mobility– agingChanging neurology Reduced independence Carer issues

ConclusionNBD is manageable!Case finding is essential!Work with the patients’ goals and support self managementRefer on when requiredComplex community issues

http://www.mascip.co.uk/guidelines.aspx