Recommendations(Grade B)
• A regular bowel programme should be implemented to prevent constipation, rectal overdistension and faecal incontinence.
Conclusions (LOE 3)
• Impaired function of the external anal sphincter and decreased volumes of rectal distention required to inhibit the internal anal sphincter or both may contribute to faecal incontinence in multiple sclerosis (LOE 3).
• Increased thresholds of conscious rectal sen- sation in some incontinent patients may contribute to faecal incontinence by impai- ring the recognition of impending defecation (LOE 3).
within the peripheral nervous system occurs. Recent electrophysiological and histological studies in rats have revealed that chronic SCI induces various phe- notypic changes in bladder afferent neurons such as: somal hypertrophy along with increased expression of neurofilament protein; and increased excitability due to the plasticity of Na+ and K+ ion channels. It is also suggested that the changes in bladder reflex pathways following SCI are influenced by neural- target organ interactions probably mediated by neu- rotrophic signals originating in the hypertrophied bladder [11]. All these changes cause an alteration in the functioning of the LUT. Yoshiyama et al (LOE 4) observed that in rats after SCI 55% of the animals exhibited uninhibited bladder contractions before voiding. Compared with control rats, SCI rats had larger volume thresholds and voided volumes. Although SCI rats had larger micturition pressures, residual volumes were increased and voiding effi- ciency was decreased [12]. This study allows extra- polating the results to humans;, however, of course it does not represent a long-term longitudinal study. Studies describing the various dysfunctional patterns of the LUT functions following SCI have been done. Kaplan et al [13] (LOE 3) studied the relationship between the clinical neurological level, bladder and sphincter behaviour on video-urodynamic studies in 489 patients with spinal cord lesions due to a variety of causes. They conclude that the clinical neurologi- cal examination alone is not an adequate barometer to predict neurourological dysfunction and that video-urodynamic evaluation provides a more preci- se diagnosis for each patient. Wyndaele [14] (LOE 3)compared, in 92 patients with spinal cord lesion out of spinal shock, the data from a clinical neurolo- gical examination of the lumbosacral area with the data from a full urodynamic investigation. He concluded that clinical neurological examination gives useful information which acceptably corres- ponds with the LUT function. However to decide on a detailed individual diagnosis, clinical examination was insufficient. Urodynamic tests were found necessary for a profound evaluation of the function of different parts of the lower urinary tract and their interaction. Perlow et al (LOE 3), described the results of combined cystometry and perineal EMG in 75 consecutive, traumatic SCI patients [15]. In patients with spinal injuries at vertebral level T7 or above a reflex neurologic (overactive) bladder even- tually developed. In those with vertebral level inju- ries T11 or below a lower motor neuron bladder dys- function developed. Injuries at the vertebral levels
T8, T9, and T10 represent a gray zone; and, depen- ding on adjacent soft tissue injury, in these patients an upper or lower motor neuron bladder dysfunction developed. They found that detrusor sphincter dys- synergy was present in 68% of the patients with upper motor neuron lesion. In a study by Weld et al (LOE 3) a retrospective analysis of 316 patients was performed [16]. It was found that 94.9% of patients with suprasacral injuries demonstrated overactivity and/or detrusor sphincter dyssynergia, 41.8% had low bladder compliance 40.3% had high detrusor leak point pressures. On the other hand 85.7% of patients with sacral injuries manifested areflexia, 78.6% had low compliance, and 85.7% had high leak point pressures. For combined suprasacral/sacral injuries 67.7% had detrusor overactivity and/or detrusor sphincter dyssynergia, 27.3% areflexia and 57.6% low compliance, high leak point pressure was observed in 60.7% of these patients. O’Flynn (LOE 2/3) presented an analysis of a large group (562) SCI patients, and found the prevalence of outflow obs- truction to be 30%, with a correlation with comple- teness and thoracic localisation of the lesion [17]. The factor of paramount importance is the occurren- ce of upper urinary tract changes, secondary to the LUT dysfunction, as it is an important prognostic factor for survival of these patients. Ruutu et al (LOE 3) found upper urinary tract changes in 30% of patients after SCI [18]; death rate due to renal failu- re was however very low (0.5%). In another paper by this author (Ruutu et al) 42% of patients had some degree of upper tract pathological changes on excre- tory urograms, and 40% of these patients had at least one febrile urinary tract infection per year [19]. Ger- ridzen et al (LOE 3) evaluated 140 patients after SCI (8 years post injury on the average) [20]. Two patient groups were identified. In group 1 patients with an areflexic bladder, 17.5% had significant upper tract deterioration. Maximum detrusor pressure during urine storage in group 1 with abnormal upper tracts was significantly higher than in those with normal kidneys. Group 2 included patients with an overacti- ve bladder. Sixteen % of them had documented upper tract deterioration. Maximum detrusor contraction pressure during voiding in group 2 was significantly higher in those with abnormal upper tracts secondary to neurologic outflow obstruction.
3. T
REATMENTTreatment does not differ from that in other neurolo- gic dysfunctions and aims at keeping the pressure in the bladder low, the capacity of the bladder suffi-
cient, the bladder emptying as complete as possible and preventing occurrence of urinary tract infection. Continence can usually be obtained. The choice of treatment should be made on full urodynamic inves- tigation with video and/ or EMG if available (LOE 2).
4. R
ECOMMENDATIONS FOR FUTURE RESEARCHStudies on the true prevalence of LUT neurologic dysfunction in SCI patients should be performed.
1. P
ATHOPHYSIOLOGY(LOE 3)
Regarding anorectal physiology following SCI, the colon in patients with a complete SCI of the thoracic region demonstrated an abnormal stretch response similar to that described in the bladder [1]. Rectal compliance and basal resting sphincter pressures were lower than normal values; anorectal manome- try demonstrated a pattern of sphincter activity simi- lar to that recorded in the patients’ cystometrograms, however there was no definite relationship to bowel dysfunction. In addition, the anorectal dysfunction in those with high SCI seems to be due to increased rec- tal contraction and anal relaxation in response to low distending volumes, reduced rectal sensation and loss of conscious external anal sphincter control; whereas those with low SCI lesions produced lower increase in sphincter pressure with Valsalva and squeezing, increased rectal compliance in response to rectal distention and reduced rectal sensation. This reduced sphincter response may contribute to the higher incidence of faecal incontinence reported by these patients [2].
2. E
PIDEMIOLOGY(LOE 3)
In long term SCI, annual incidence of gastrointesti- nal problems increased from 5.3% in those < 30 years old and 9.0% in those 40-49, to 15.3% in those > 60 years old. It also showed a slight increase in fre- quency between the 10th and 30th year post injury [3]. Faecal incontinence was significantly more pre- valent in the tetraplegia group (p=0.003), while constipation was significantly more frequent in the paraplegia group (p=0.001). According to the self- reports, bowel accident occurred in 38.5% of those using abdominal pressure, in 36.4% of those using chemical stimulation, in 26.1% of those using digital stimulation and in 18% of those having nearly nor-
mal bowel emptying. Physicians diagnosed faecal incontinence much less [overall 6.3%, with digital stimulation 8.5%, with chemical stimulation 3.0%, with abdominal pressure 7.7%, and nearly normal 0%] [4].
Han et al investigated chronic gastrointestinal pro- blems and bowel dysfunction in 72 traumatic SCI patients. Constipation was the commonest problem, affecting 43% of patients, while difficulty with eva- cuation (33%) and post-prandial discomfort (33%) were the next most frequent. Fourteen % had faecal incontinence due to urgency [5]. However, bowel dysfunction was not related to age, duration or the neurological level of injury.
In the study of Krogh et al [6], questionnaires were sent out to 589 patients with spinal cord lesion. Seventy two % responded. Eighty one % of the patients lacked a normal desire to defecate, and 75% experienced faecal incontinence, though most only had a few episodes of faecal incontinence.
3. Q
UALITY OF LIFE–Q
OL (LOE 3)
The most common gastro-intestinal problems that impair the quality of life (QoL), as found in 34/127 patients with spinal cord lesion and gastro-intestinal problems, were poorly localized abdominal pain (14%) and difficulty with bowel evacuation (20%). Hemorrhoids (74%), abdominal distention (43%), and autonomic dysreflexia arising from the gastroin- testinal tract (43%) were also common, but had a les- ser impact on lifestyle [7].
Chronic GI problems had an extensive impact on ADL such as restricted diet (80%), restricted outdoor ambulation (64%) and unhappiness with bowel care (62%). Patients in the study by Han et al performed bowel care once per 3 days and needed an average of 42 minutes to do this [5]. In another study, 48% nee- ded more than 15 minutes for defecation, while 80% of male paraplegics and 46% of male tetraplegics ranked bladder and bowel problems as their greatest functional losses after loss of mobility [8]. In the study of Krogh et al [6], 30% regarded colorectal complaints to be worse than both bladder and sexual dysfunction.
According to the controlled and comparative, ques- tionnaire based study of Lynch et al [9], faecal urgency and time spent at the toilet were also signi- ficantly higher for the SCI group: 92.3% of controls were never affected by faecal incontinence, compa- red with only 43.9% of SCI patients (p<0.0001). 8.1% of SCI patients had their everyday live affected