Research: bowel symptoms and transanal irrigation

Preziosi et al. Transanal irrigation for bowel symptoms in patients with multiple sclerosis. Dis Colon Rectum. 2012;55(10):1066-73.

BACKGROUND: Constipation and faecal incontinence affect 68% of MSers, but management is empirical. Transanal irrigation has been used successfully in MSers with neurogenic bowel dysfunction.

OBJECTIVE: The aim of this study was to evaluate the effect of transanal irrigation on the bowel symptoms and general health status in these MSers and the characteristics of those that had successful treatment and to obtain data for power calculations necessary for future randomized controlled studies.

DESIGN: This was a prospective observational study in which pre- and posttreatment questionnaires (bowel symptoms and health status) were compared. MSers for whom treatment resulted in at least 50% improvement in bowel symptoms were considered responders. Baseline variables including anorectal physiology tests and rectal compliance were compared between responders and nonresponders.

MSERS: Included were 30 MSers who had MS and constipation, faecal incontinence, or both.

INTERVENTION: Transanal irrigation was performed.

MAIN OUTCOME MEASURES: The primary outcomes measured were the Wexner Constipation and Wexner Incontinence scores. The secondary outcomes was the SF-36 health survey. All scores were recorded before and after 6 weeks of treatment.

RESULTS: At 6 weeks post-treatment, the Wexner Constipation score significantly improved (12 (8.75/16) pretreatment vs 8 (4/12.5) post-treatment, p = 0.001), as well as the Wexner Incontinence score (12 (4.75/16) pretreatment vs 4 (2/8) post-treatment, p < 0.001). The SF-36 score did not improve significantly (51.3 ± 7.8 pretreatment vs 50.4 ± 7.8 posttreatment, p = 0.051).  16 MSers were responders and had higher baseline Wexner Incontinence scores (14 (11/20) responders vs 9 (4/15) nonresponders, p = 0.038) and SF-36 (53.9 ± 6.3 responders vs 47.9 ± 7.8 nonresponders, p = 0.027), as well as greater maximum tolerated volume to rectal balloon distension (310 (220/320) mL responders vs 168 (108/305) mL nonresponders, p = 0.017) and rectal compliance (15.2 (14.5/17.2) mL/mmHg responders vs 9.2 (7.2/15.3) mL/mmHg nonresponders, p = 0.019).

LIMITATIONS: This study was limited by its small sample size and the lack of control group with alternative treatment.

CONCLUSIONS: Transanal irrigation is effective to treat bowel symptoms in MSers. Responders (53%) had higher baseline incontinence symptoms and better perception of their health, as well as a more capacious and compliant rectum.

Chronic constipation, faecal urgency and incontinence are frequent in MSers. The aetiology is multifactorial: 

  1. Dysfunction of descending cortical modulation. Interruption of the normal cortical inhibition of colonic motility generates uncontrolled peristalsis (contraction and relaxation of the gut) and can lead to diarrhoea or too loose stools 
  2. Disturbed extrinsic afferent and efferent autonomic pathways due to abnormalities in the spinal cord, particularly in progressive MS 
  3. Reduced mobility and medications use for treating MS-related symptoms i.e. bladder dysfunction, pain and spasticity, can worsen constipation.

"This study highlights the problem of bowel dysfunction that is common in MS in particular in  progressive disease. The aim is to have a regular bowel action, either daily or at least every 2 days. The main problem in MS is bowel hypomotility (slow or sluggish movements); MS-related constipation therefore needs to be treated with prokinetic agents,  i.e. drugs that increase the muscular action of the bowel.  The most common prokinetic agent I prescribe is senna. Prokinetic agents often need to be taken with bulking (fibre) and loosening (liquid) agents. Loosening agents keep liquid in the bowel, for example lactulose or polyethyelene glycol (Movicol). It is important to realise that dehydrating yourself to control your bladder problems can make constipation worse; therefore you need to drink adequate quantities of water throughout the day. Similarly drugs to help your bladder dysfunction, pain and spasticity may make constipation worse. Therefore if you are constipated your medications need to be reviewed . Some MSers become so constipated that they get faecal impacted and go onto develop intermittent overflow diarrhoea; i.e. the bacteria in the bowel liquefies the stool above the impaction and the liquid overflows past the impaction. A typical history is periods of constipation, punctuated by episodes of diarrhoea. Faecal impaction is a serious problem and sometimes warrants admission to hospital to treat."

"Faecal urgency, and urgency incontinence, is also a big problem; if you have to go you have to go. This is best treated by developing a bowel routine and trying to evacuate your bowels at a regular time of day, typically in the morning. This can be aided by using something to stimulate the bowels. I typically use start with glycrine suppositories or mini-enemas. If the latter fails I may elect to use transanal irrigation. Transanal irrigation sounds terrible, but in MSers who need it often makes a massive difference to the quality of their lives and gives them some control back to tackle a problem that often leaves them stranded at home.  I have therefore lowered my threshold for trying it, particularly as I have seen the benefits some MSers derive from it."

"Bowel dysfunction is one of the many symptomatic problems that may be avoided by preventing or delaying the development of disability. This is another reason to actively manage your MS with DMTs. Preventing disability, i.e bowel dysfunction, is better that treating it."

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