Management of Faecal Incontinence and Constipation in Adults with Central Neurological Diseases

A Cochrane review [Abstract] 1 included 20 studies with a total of 902 people. Eight trials were performed in people with spinal cord injuries, two in people with Parkinson's disease, two in people with multiple sclerosis, two in institutionalised people with a mix of conditions and six in people with stroke.

• Oral medications: There was evidence from 3 trials that people with Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (psyllium) (MD -2.2 bowel motions, 95% CI -3.3 to -1.4; 3 trials, n=81) or oral laxative (isosmotic macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32; one trial, n=57) are used compared with placebo. One trial (n=7) in people with spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular neostigmine-glycopyrrolate (anticholinesterase plus an anticholinergic drug) with placebo (MD 23.3 min, 95% CI 4.68 to 41.92).
• Rectal stimulants: One trial (n=15) in people with spinal cord injuries compared two bisacodyl suppositories, one polyethylene glycol-based (PGB) and one hydrogenated vegetable oil-based (HVB). The trial found that the PGB bisacodyl suppository significantly reduced the mean defaecation period (PGB 20 min vs. HVB 36 min, p<0.03) and mean total time for bowel care (PGB 43 min vs. HVB 74.5 min, p<0.01) compared with the HVB bisacodyl suppository.
• Physical interventions: There was evidence from one trial (n=31) that abdominal massage statistically improved the number of bowel motions in people who had a stroke compared with no massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A feasibility trial (n=30) with multiple sclerosis also found evidence to support the use of abdominal massage. Constipation scores were statistically better with the abdominal massage during treatment although this was not supported by a change in outcome measures (for example the neurogenic bowel dysfunction score). One trial (n=18) in people with spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 min, 95% CI 7.35 to 51.25). There was evidence from one trial (n=87) that for people with spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved constipation scores, neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 min, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.
• Other interventions: In one trial in stroke patients (n=146), there appeared to be a short term benefit (less than 6 months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education vs. routine care), but this did not persist at 12 months. A trial in individuals with spinal cord injury (n=68) found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment), inconsistency (heterogeneity in patients, interventions and outcomes) and imprecise results (limited study size for each comparison).

References

• Coggrave M, Norton C, Cody JD. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database Syst Rev 2014;1():CD002115. [PubMed].