by incontinence, compared with 0.4% of controls. Those with complete injuries were more likely to have incontinence affect their life than those with incomplete injuries.
Byrne et al [10] used the Direct Questioning of Objectives QoL measure in 118 patients with neuro- logic FI. The most frequent QoL problem concerned the ability to get out of home, to socialize outside of home, to go shopping, and not to have to worry about the location of the nearest toilet while out of home (34%). At least one of these four objectives was sta- ted by 72% of patients. Only 31% of patients nomi- nated an objective related to the physical act of soi- ling. The ability to travel (29%), exercise including walking (25%), performing home duties (19%), family and relationships (22%), and job (13%) were less frequently cited by patients.
4. C
ONSERVATIVE BOWEL MANAGEMENT(LOE 3)
In the study of Han et al [5] 43% of the patients took oral medication, and 36% controlled their diet. Usual methods of bowel care were anal massage (35%), finger enema (18%), rectal suppository (15%) and unaided self-defaecation with/without oral medica- tion and abdominal massage (29%). Krogh et al [6] found that 65% of SCI patients also used digital eva- cuation or stimulation.
Kirschblum et al [11] retrospectively studied bowel care practices in 100 chronic SCI patients. Eighty percent of the patients performed digital stimulation, 72% reported use of suppositories, 56% used oral medications, and Colace and senokot were usually used in combination. Only 13% of the patients used dietary modifications to regulate their bowel pro- gram. Forty-six percent reported performing their bowel program on alternate days and 24% performed a daily program. 77% were able to perform their pro- gram in less than 45 minutes. Patients had only mini- mal constipation and diarrhea, and few had difficul- ty with evacuation.
According to Lynch et al [9], 43.2% of SCI patients (n = 467) and 23.2% of controls from the general community (n = 668) took extra fibre with no chan- ge in fibre use with time since injury, or incontinen- ce. Laxatives were used by 39% of SCI patients, compared with 4% of controls (P<0.0001). The use became more frequent with increasing time since
injury (p=0.005), but not with age (p=0.95), or incontinence score (P=0.10). Enemas were used by 10.9%, with approximately twice as many patients with complete injuries using them compared to those with incomplete injuries (p<0.0001). Regular manual evacuation was more frequent among those with complete SCI (67%) compared to those with incomplete (25.4%). In addition, 62.7% of SCI patients used digital stimulation, 15% used supposi- tories and 82.3% of those with higher injuries requi- red assistance, compared with 14.3% of those with complete lumbosacral lesions.
Regarding the level of lesion, patients with LMN tend to suffer more difficulties in the management of their neurologic bowel than those with UMN. It has been suggested that more intensive and aggressive bowel care programs should be provided for SCI patients with LMN lesions [12].
Recommendation : Grade B/C • Colorectal problems deserve more attention
in the treatment of SCI patients.
• Impact on QoL, especially in bowel care and social activities, should be included in the assessment of colorectal dysfunction and faecal incontinence in SCI patients.
• Goals of bowel management should be per- son-centred and aimed at social bowel conti- nence and prevention of gastrointestinal complications.
• Appropriate bowel programme/manage- ment should be properly designed to each person and adequate training should be pro- vided.
Conclusions (LOE 3)
• Neurologic bowel dysfunction and bowel problems including faecal incontinence and constipation, are prevalent among SCI per- sons.
• Faecal incontinence and methods of bowel care affect the QoL and social activities of SCI persons.
• Bowel care and bowel management used among SCI persons vary.
Data on prevalence are scarse. In 1976 Sharr et al [1] reported a series of 34 patients with lumbar spondy- losis and spinal stenosis associated with chronic bladder symptoms including incontinence.
Lumbar spondylosis comprises the degenerative hypertrophy of the ligamentous, cartilaginous and osseous structures of the lumbar spine. In its more advanced forms, this disorder often causes chronic and progressive symptoms which generally evolve slowly over months to years. Patients typically seek medical help when intractable leg pain develops, yet when questioned, about 50 % of patients report symptoms of bladder dysfunction including inconti- nence, urinary hesitancy, nocturia or frequent urina- ry tract infections. In some patients, these symptoms may be overlooked or attributed to primary urologi- cal disorders such as benign prostatic obstruction. These urological symptoms may indicate the presen- ce of significant cauda equina dysfunction. When intractable leg pain develops lumbar decompressive laminectomy is the treatment of choice. The goal of surgery is relief of leg pain and paresthesias. Some patients also have reported improvement in bladder function [2].
Sharr et al [1] reported that after lumbar decompres- sive laminectomy 75 % of their patients experienced some improvement in bladder function. Interesting enough urodynamics were of limited value and the diagnosis of neurologic bladder depended as much on the medical history as on the results of the urolo- gical and neurological investigation.
Experimental studies in this field are scarse. Dela- marer et al [3] studied urological function in dogs after experimental cauda equina compression. They reported that an acute 75 % constriction of the thecal sac led to severe changes on cystometrography with detrusor acontractility, increased bladder capacity and clinical urinary incontinence. Urodynamics
revealed an acontractile neurologic bladder in ani- mals subjected to an acute 75 % constriction of the cauda equina, but urodynamics were basically nor- mal in animals subjected to lesser degrees (25 % and 50 %) of cauda equina constriction.
Only recently Inui et al [4] evaluated prospectively the relationship between the degree of cauda equina compression and the prevalence of neurologic blad- der in patients with lumbar spinal stenosis and lum- bar disc herniation. Thirty-four consecutive patients admitted for treatment for lumbar spinal stenosis or lumbar disc herniation underwent urodynamic stu- dies, and CT-scans after myelography were obtained to determine the degree of cauda equina compres- sion. The cross-sectional area and the anteroposterior diameter of the dural sac were measured at their smallest transverse area. Twenty (58,8 %) of the 34 patients were diagnosed with a positive neurologic bladder. There was no significant difference in the cross-sectional area of dural sac between the patients with or without neurologic bladder; however the dural sac anteroposterior diameter in patients with neurologic bladder was significantly shorter than in patients with negative neurologic bladder. A critical size for dural sac of patients with neurologic bladder was revealed as 8 mm in this study.Therefore the authors conclude that the dural sac anteroposterior diameter might be an important factor predicting neurologic LUT dysfunction in these patients (LOE 3).
In a prospective study of Deen et al [2] patients with lumbar stenosis and LUT dysfunction had a broad spectrum of symptoms. Of the 20 patients evaluated 16 complained of nocturia, 10 of incontinence, 6 had a feeling of incomplete or the need for double voi- ding, 5 reported urinary frequency, 3 urinary hesitan- cy, 2 urinary urgency and 1 had frequent urinary tract infection.
Kawaguchi et al [5] found urinary incontinence as the most characteristic symptom in patients with lumbar spinal stenosis and neurologic bladder. These authors also stated that patients with a neurologic LUT dysfunction had a more severe neurologic dis- turbance compared with those without symptoms indicative for LUT dysfunction.
Hellstrom et al [6] evaluated voiding dysfunction and urodynamic findings in 18 consecutive patients (12 men and 6 women, mean age 55) with clinically