Gastroenterology

Gastroenterology

Volume 131, Issue 3, September 2006, Pages 738-747
Gastroenterology

Clinical–alimentary tract
A Randomized, Controlled Trial of Transanal Irrigation Versus Conservative Bowel Management in Spinal Cord–Injured Patients

https://doi.org/10.1053/j.gastro.2006.06.004Get rights and content

Background & Aims: Bowel dysfunction in patients with spinal cord injury often causes constipation, fecal incontinence, or a combination of both with a significant impact on quality of life. Transanal irrigation improves bowel function in selected patients. However, controlled trials of different bowel management regimens are lacking. The aim of the present study was to compare transanal irrigation with conservative bowel management (best supportive bowel care without irrigation). Methods: In a prospective, randomized, controlled, multicenter trial involving 5 specialized European spinal cord injury centers, 87 patients with spinal cord injury with neurogenic bowel dysfunction were randomly assigned to either transanal irrigation (42 patients) or conservative bowel management (45 patients) for a 10-week trial period. Results: Comparing transanal irrigation with conservative bowel management at termination of the study, the mean (SD) scores were as follows: Cleveland Clinic constipation scoring system (range, 0–30, 30 = severe symptoms) was 10.3 (4.4) versus 13.2 (3.4) (P = .0016), St. Mark’s fecal incontinence grading system (range, 0–24, 24 = severe symptoms) was 5.0 (4.6) versus 7.3 (4.0) (P = .015), and the Neurogenic Bowel Dysfunction Score (range, 0–47, 47 = severe symptoms) was 10.4 (6.8) versus 13.3 (6.4) (P = .048). The modified American Society of Colorectal Surgeon fecal incontinence scores (for each subscale, range is 0–4, 4 = high quality of life) were: lifestyle 3.0 (0.7) versus 2.8 (0.8) (P = .13), coping/behavior 2.8 (0.8) versus 2.4 (0.7) (P = .013), depression/self perception 3.0 (0.8) versus 2.7 (0.8) (P = .055), and embarrassment 3.2 (0.8) versus 2.8 (0.9) (P = .024). Conclusions: Compared with conservative bowel management, transanal irrigation improves constipation, fecal incontinence, and symptom-related quality of life.

Section snippets

Patients

Between December 2003 and June 2005, 87 patients (Figure 1 and Table 1) with spinal cord injury and neurogenic colorectal dysfunction were randomly assigned to either transanal irrigation or conservative bowel management. Patients were recruited from 5 spinal cord injury centers in 5 European countries (Spinalis, Karolinska Sjukhuset, Stockholm, Sweden; Montecatone Rehabilitation Institute, Bologna, Italy; Orthopädische Universitätsklinik, Heidelberg, Germany; National Spinal Injuries Centre,

Results

Of the 124 eligible patients, 37 patients could not be included in the study. Therefore, 87 patients were included and randomly assigned to the 2 treatment groups: 45 patients to conservative bowel management and 42 patients to transanal irrigation (Figure 1). At baseline, there was no systematic difference between groups on comparing outcome parameters (Table 2).

Of the 45 patients in the conservative bowel management group, 2 patients discontinued before training with the specialist nurse; one

Discussion

Bowel dysfunction exerts a major impact on the life situation of patients with spinal cord injury.1, 2, 4 The present study is the largest randomized, controlled, multicenter trial addressing bowel management in patients with spinal cord injury. The aim of the study was to compare transanal irrigation with conservative bowel management, defined as best supportive bowel management without using irrigation.

Before the study, many of the patients had struggled with bowel dysfunction for years. With

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