Persons with SCI require assistance with emptying their bowels regularly. Forms of assistance include the use of medications, suppositories, digital stimulation and/or mini-enemas. Clinical experience shows that despite their best efforts, some persons with SCI are unable to achieve an effective, regular bowel routine and thus, other methods may be explored. Pulse water irrigation is one such technique and consists of supplying intermittent, rapid pulses of warm water into the rectum to break up stool impactions and to stimulate peristalsis (Puet et al. 1997). Christensen et al. (2006) assessed the use of the newly developed Peristeen Anal Irrigation system (Coloplast A/S, Kokkedal, Denmark) for transanal irrigation. The system consists of a rectal balloon catheter, a manual pump, and a water container. The catheter is inserted into the rectum and the balloon inflated to hold the catheter in place while a tap water enema is administered with the manual pump (Christensen et al. 2006).

Table 6: Irrigation Techniques for Neurogenic Bowel After Spinal Cord Injury

Discussion

Pulsed irrigation evacuation is a safe and effective method for individuals with SCI who develop impactions or do not have an effective bowel routine (Puet et al. 1997). Compared to conservative bowel management practices outlined by the Paralyzed Veterans of America, transanal irrigation, through the use of the Peristeen Anal Irrigation System, reduces time spent on bowel management, dependency on others for help, and the frequency of defecation-related symptoms (i.e. abdominal pain, anorectal pain, chills, nausea, dizziness, pounding headache, sweating, facial flushing, general discomfort)  (Christensen et al. 2006). In addition, transanal irrigation appears to alleviate fecal incontinence and constipation more so than conservative bowel management (Christensen et al. 2006). Christensen et al. (2008) and Del Popolo et al. (2008) found similar results. Del Popolo et al. (2008) also found that 9 out of their 32 subjects either reduced or eliminated their use of pharmaceuticals. Finally, Christensen et al. (2000), found that the Enema Continence Catheter can be used to treat the neurogenic bowel with improved fecal incontinence and quality of life.

Conclusion

• There is level 4 evidence (from 1 case series study) (Puet et al. 1997) that supports using pulsed water irrigation (intermittent rapid pulses) to remove stool in individuals with SCI.
• There is level 1 evidence (from 1 RCT) (Christensen et al. 2006) that supports the use of transanal irrigation (Peristeen Anal Irrigation system) over conservative bowel treatment (as outlined by the Paralyzed Veterans of America clinical practical guidelines).
• There is level 4 evidence (from 1 case series study, and one post-test) (Faaborg et al. 2008; Christensen et al. 2000) that supports the use of an Enema Continence Catheter to treat the neurogenic bowel.

• Pulsed water irrigation may remove stool in individuals with SCI and transanal irrigation alleviates constipation and fecal incontinence. Often, more than one procedure is necessary for individuals that are unable to develop an effective bowel routine.