Bowel Dysfunction and Management

Manual Evacuation of Faeces

Manual evacuation of faeces involves the use of a single gloved and lubricated finger to remove faeces from the rectum. It is used by individuals with both hyperreflexic and areflexic bowel dysfunction. Coggrave et al. (2009) (n=1334) reported that manual evacuation of faeces for people with SCI was found to be the most commonly used intervention, carried out by 56% of respondents. A systematic review (Solomons & Woodward 2013) found that digital stimulation and digital removal of faeces were associated with the lowest rates of unplanned bowel evacuations and less time spent on bowel care (Haas et al. 2005) and concluded that digital removal of faeces is a necessary component of bowel care for many individuals with SCI.

Discussion

Solomons and Woodward (2013) reviewed 7 articles which used manual evacuation as part of a bowel management protocol. They found that manual evacuation was very commonly used in individuals with SCI (Menter et al. 1997; Coggrave et al. 2006; Coggrave et al. 2009), and was effective in reducing the number of unplanned bowel evacuations (Haas et al. 2005), but had a high self-reported rate of constipation (Menter et al. 1997). Conversely, Haas et al. (2005) reported a decrease in bowel evacuation time with manual evacuation. It is worth noting that the GP diagnosis of constipation in Menter et al. (1997) was significantly lower than the self-reported rate of constipation.

Conclusion

Manual evacuation is a key method in conservative bowel management practice and is commonly and widely employed. It reduces number of unplanned bowel evacuations. There is conflicting evidence on the effect of manual evacuation on duration of bowel evacuation.

Digital evacuation of stool is a very common intervention for bowel management after SCI, reducing duration of bowel management and fecal incontinence.

Authors; Country

Date included in the review

Total Sample Size

Types of Articles

Score

 Methods

Databases

Level of Evidence

 Conclusions
Solomons & Woodward 2013;

Britain

Systematically reviewed articles from electronic databases no date limits applied

N=7

Type of study:

1 RCT

4 case-controls

1 cross-sectional

1 case-control

AMSTAR: 2

 Method: Systematic literature review of the quality of evidence available on fecal manual evacuation for individuals with SCI.

Databases: CINAHL, British Nursing index, EMBASE, Medline

Level of evidence: Methodological quality not assessed
  1. There have been 2 multicentre studies of bowel management programs involving digital removal of feces. One descriptive longitudinal study of outpatients from 2 centres determined that digital removal of feces and digital stimulation had the highest self-reporting of constipation. The other study included data collected from multiple SCI centres in 4 German-speaking countries and found that digital removal of feces and were associated with the lowest rates of unplanned bowel evacuations and led to less time spent on bowel care.
  2. Bowel protocols should not be carried out rigidly but rather should be used in guided experimentation to assist the SCI patient to find a bowel management program that works for them.
  3. Digital rectal removal of feces remains a necessary intervention for many patients. More research and training are needed on this and other neurogenic bowel management.
  4. The low status of bowel care in nursing and wider society needs to be challenged so that people with SCI can benefit from high quality bowel care and associated improvements in quality of life.

Author Year; Country
Score
Research Design
Total Sample Size		 Methods Outcome
Coggrave et al. 2009;

UK

Pre-post

N=1334

 Population: 1334 SCI outpatients aged 19-91 yrs.

Treatment: Postal survey

Outcome measures: method of evacuation; number of interventions used before finding a successful protocol; assistance with bowel care.
  1. 56% of respondents used digital rectal evacuation; 36% stimulant laxatives, 15% osmotic, 6% bulk formers, 3% stool softeners.
  2. Median number of interventions used by an individual was 3.
  3. More than 1/3 of respondents needed assistance with bowel care.
  4. Digital evacuation was associated with better outcomes in independent individuals with thoracic lesions.
Correa & Rotter 2000;

Chile

Pre-post

N=38

 Population: Age: range 19-71 yrs; 21 participants with complete injuries (2 with tetraplegia and 19 with paraplegia), 10 with incomplete injuries, 7 with conus medullaris and cauda equina; Duration of injury: range 5 months -16 yrs.

Treatment: Intestinal program administration with 6-month follow-up. The program involved monthly evaluations of the patient’s intestinal function, symptoms and complications. Patients were educated on inadequate practices of evacuation and medications were changed when appropriate. Manual evacuation was discouraged as high-risk.

Outcome Measures: Difficult Intestinal Evacuation (DIE) scale; colonic transit time; anorectal manometry; recto-colonoscopy; GI symptoms.
  1. Participants felt their DIE scores after their SCI worsened (from 2.6% to 26.3%) compared to before their SCI (based on subjective recall).
  2. The most frequent GI symptom was abdominal distention. The incidence of abdominal distention was reduced from 50% to 23.5% after the program.
  3. With the intestinal program, the incidence of DIE was reduced from 26.3% to 8.8% and episodes of manual extraction was reduced from 53% to 37%.
  4. An objective to eliminate use of manual evacuation, stimulant laxatives and/or enemas was successful in that 19 patients were using manual evacuation daily pre-trial while only 8 did post-trial.
Haas et al. 2005;

Switzerland

Cross-sectional

N=837

 Population: 837 SCI patients (642M, 186F) from 29 rehabilitation facilities in Austria, Germany, the Netherlands and Switzerland. Injury level: 42% cervical, 45.3% thoracic, 12.7% lumbar.

Treatment: questionnaire

Outcome measures: method of evacuation, rate of incontinence, rate of bowel symptoms
  1. Oral laxatives were significantly associated with increased unplanned bowel evacuations and longer episodes of bowel care.
  2. Fewer unplanned evacuations were significantly associated with manual removal and/or digital rectal stimulation.
  3. Manual evacuation associated significantly with shorter duration of bowel evacuation (<60 min).
Menter et al. 1997;

UK

Retrospective longitudinal

N=221

 Population: 221 SCI patients; 29% tetraplegia (ASIA A/B/C), 49% had paraplegia (ASIA A/B/C) and the remaining 21% were classified as having incomplete, ASIA D paraplegia or tetraplegia.

Treatment: questionnaire, physical examination, physiological measurements.

Outcome measures: medical records, bowel management techniques.
  1. 80% of individuals with paraplegia, 68% with tetraplegia and 23% with incomplete SCI used manual evacuation.
  2. Those who used manual evacuation or digital stimulation self-reported the highest rate of constipation at 44.4% and GI pain at 41.5%, but a lower rate of incontinence at 26.1%.
  3. GP diagnosed just 14.1% constipation for patients who used manual evacuation or digital stimulation, in contrast to the self-reported %.
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