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© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_9
9
Management ofFecal Incontinence
inAdults withNeurogenic Bowel
Dysfunction
MelissaNorthwood
andNikkiCotterill
Abstract
Neurogenic bowel dysfunction is a common complication in patients with spinal
cord injury, multiple sclerosis, and other neurological conditions, which includes
fecal incontinence, constipation, and abdominal pain. This chapter explains the
management of fecal incontinence in patients with neurogenic bowel dysfunc-
tion for the advanced practice continence nurse. Informed by a practical treat-
ment algorithm based on best practice guidelines, this chapter addresses initial
conservative strategies that include standard bowel management and transanal
irrigation. Optional treatments, such as biofeedback and sacral neuromodulation,
will be detailed. As well, surgical interventions for patients who fail to respond
well to conservative treatment will be described. The aim is to provide an evi-
dence-informed decision-making approach for the advanced practice continence
nurse to consider in care of patients with neurogenic bowel dysfunction, includ-
ing patient preferences and actions, research evidence, the clinical setting, and
health care resources.
M. Northwood (*)
School of Nursing, McMaster University, Hamilton, ON, Canada
e-mail: northwm@mcmaster.ca
N. Cotterill
School of Health and Social Wellbeing, College of Health, Science and Society,
University of the West of England, Bristol, UK
e-mail: Nikki.Cotterill@uwe.ac.uk
Chapters author from the rst edition of this book:
Sharon Eustice, now Consultant Nurse Bladder and Bowel Specialist Service Cornwall Partnership
NHS Foundation Trust, Cornwall, UK; Tamara Dickinson, Nurse Practitioner, UT Southwestern
Medical Center Dallas, TX, US.
178
9.1 Introduction
Neurogenic bowel dysfunction is a broad term that includes fecal incontinence, con-
stipation, and abdominal pain, occurring in patients with spinal cord injury, benign
or neoplastic central nervous system pathology, spina bida, cauda equine syn-
drome, multiple sclerosis, acquired brain injury, Parkinson’s disease (including
atypical Parkinsonism disorders), and stroke [1]. Normal defecation is largely
dependent on intact and properly functioning neurologic pathways, and neurogenic
bowel dysfunction is caused by a number of impairments, including autonomic dys-
function, sensory decits, motor function paralysis, and immobility [2, 3]. Living
with both a neurological disease and fecal incontinence can have a negative impact
on quality of life and well-being [2, 4]. Given that the pathophysiology of neuro-
genic bowel dysfunction is complex, resulting in different symptom presentations
for patients related to the type and extent of neurological disease, management and
treatment options must be individually tailored [1]. The advanced practice nurse
will also consider patient preferences and actions, research evidence, their clinical
setting, and the availability of health care resources in the creation of a person-
centered care plan [5]. Conservative treatment of neurogenic bowel dysfunction that
supports self-care is the focus of specialist management with the goal of regular,
planned bowel evacuation to maintain health and well-being and prevent inconti-
nence and complications [6, 7]. Refer to Fig.9.1 for a simplied treatment algo-
rithm for neurogenic bowel dysfunction and Box 9.1 for a summary of possible
interventions.
Optional and experimental treatments can be considered based on patient prefer-
ence and availability. No special permission is required to reuse all or part of an
Fig. 9.1 Simplied treatment algorithm for neurogenic bowel dysfunction in patients with spinal
cord lesions or multiple sclerosis [2]
M. Northwood and N. Cotterill
179
article published by MDPI publishers, including gures and tables. This gure was
part of an article that was published under an open-access Creative Commons CC
BY license, and any part of the article may be reused without permission provided
that the original article is clearly cited. Reuse of an article does not imply endorse-
ment by the authors or MDPI.
9.2 How Neurologic Disease Affects Defecatory Dysfunction
Neurogenic bowel dysfunction can be classied according to the location of the
lesion or disease. Reexic bowel typically occurs with damage to the brain or spinal
cord above the sacral reex center (S2) and patients tend to have increased tone of
the external anal sphincter muscle and increased tone of the rectum [3]. While are-
exic bowel is usually related to a lesion at or below S2 and patients have reduced
tone of the external anal sphincter muscle and rectum [3]. Signs and symptoms of
reex neurogenic bowel dysfunction include a loss of sensation, inability to post-
pone defecation and voluntarily control the external sphincter, prolonged colonic
transit time, and contraction of the pelvic oor and external sphincters during def-
ecation [2, 3]. This results in constipation and fecal incontinence due to defecation
occurring reexively when the rectum is distended by retained stool [2]. Areexic
bowel dysfunction is characterized also by a lack of sensation and inability to post-
pone defecation, poor emptying of the rectum, and a hypotonic rectum [3]. In this
case, patients experience constipation and frequent fecal incontinence due to
reduced anal sensation and laxity of the external sphincter [2]. Constipation can
occur in both reexic and areexic bowel and contribute to fecal incontinence [3].
In patients with spinal cord injury, the level and completeness of the injury affect
the presentation of neurogenic bowel and are also related to other factors, such as
the length of time from injury, the presence of other chronic conditions, and age [3].
The prevalence of neurogenic bowel in patients with spinal cord injury is estimated
at 80%, with fecal incontinence reported by 27–86% [2, 3].
Multiple sclerosis is a progressive central neurological disease that affects both
the brain and spinal cord, impacting both autonomic and voluntary control of the
bowel [8]. Neurogenic bowel dysfunction in patients with multiple sclerosis involves
slow gut transit, pelvic oor dyssynergia, and rectal hyposensitivity [8]. Longer
disease duration and higher levels of disability tend to be associated with neuro-
genic bowel dysfunction, yet patients with shorter durations may also have symp-
toms [9]. Bowel problems are also inuenced by medications, mobility, and other
chronic conditions [8]. Up to two-thirds of patients with multiple sclerosis have
neurogenic bowel symptoms, including constipation (37–66%) and fecal inconti-
nence (15–51%) [2, 9].
Limited evidence exists on neurogenic bowel dysfunction in patients with
acquired brain injuries. A recent scoping review noted that the incidence of fecal
incontinence in patients with acquired brain injuries was higher in the acute and
rehabilitation phases of treatment (41–68%), reduced to 12–36% at discharge, and
5% at 1 year after discharge [4]. However, patients with acquired brain injury are
9 Management ofFecal Incontinence inAdults withNeurogenic Bowel Dysfunction
180
identied as a high-risk group in need of assessment of fecal incontinence in best
practice guidelines [10, 11].
Neurogenic bowel dysfunction likely plays a role in other neurologic conditions,
such as Parkinson’s disease and stroke. Parkinson’s disease is a movement disorder,
but autonomic disorders, including neurogenic bowel, are common in patients with
Parkinson’s, with the incidence of constipation between 20% and 81% [12].
Furthermore, patients with Parkinson’s disease can experience dystonia of the stri-
ated external anal sphincter muscle [2]. Limited evidence exists regarding fecal
incontinence in patients with stroke, though best practice guidelines note that an
assessment and management plan for constipation or fecal incontinence should be
implemented during the acute stroke management phase [13, 14]. A cross-sectional
study determined that modiable risk factors for fecal incontinence after stroke
included constipating medications and accessibility to the toilet [13]. Fecal inconti-
nence is common initially after stroke, affecting 40% of patients with stroke and
between 10% and 19% 6 months after the event [13]. Constipation affects almost
half of patients with stroke (48%) [15]. As with other neurological conditions, the
interaction of other contributing factors with the condition, such as polypharmacy,
impaired mobility, and impaired cognition, inuences the development of fecal
incontinence.
9.3 Special Considerations forAssessment, Care Planning,
andPatient Education
There are a number of assessment considerations for care of the person with neuro-
genic bowel dysfunction in addition to the usual clinical assessment of fecal incon-
tinence (see Chap. 5). Assessment of bowel function should be conducted more
frequently during the acute phase of the neurological injury and/or diagnosis and
rehabilitation [2]. Re-assessment should occur at least annually and with changes in
the patient’s condition, physical ability, and onset or worsening of symptoms [2].
The assessment phase should include questions regarding the current bowel man-
agement plan, including its impact on predictable and effective elimination, as well
as prior bowel management plans [3]. The presence of constipation and rectal
impaction should also be assessed (anorectal constipation with secondary overow
fecal incontinence), including signs that the bowel is not emptying well, such as
change in stool pattern, change in stool consistency, change in appetite or intake,
and straining to have a bowel movement [6, 16]. Assessments for patients with neu-
rogenic bowel dysfunction should also include the status of recommended screen-
ing procedures (i.e., colon cancer screening), so change in bowel function is not
wrongly attributed to the neurological condition [11].
Complications related to ineffective bowel emptying and techniques used to pro-
mote bowel regularity (e.g., digital stimulation/evacuation) must also be considered
in the assessment of the person with neurogenic bowel dysfunction. These
M. Northwood and N. Cotterill
181
complications include abdominal pain, anal bleeding, anal ssures, autonomic dys-
reexia (in patients with spinal cord injury above T6), pressure ulcers, fecal impac-
tion with loose bowel movements, hemorrhoids, urinary tract infections, megacolon/
megarectum, and atulence [7].
The ability to use hands and arms, ne motor skills, balance, mobility, and
cognition are important to assess as they relate to the person’s ability to learn
about healthy bowel habits and enact the bowel management plan independently
or to direct a care partner or health care professional [3]. Care partners’ knowl-
edge and abilities to support the bowel management plan are important factors in
care planning. Toilet accessibility in the patient’s home and community should
also be considered, including an assessment of the need for adaptive aids (e.g.,
commode) [3].
Patient education and care planning efforts are strengthened when the person has
the knowledge, condence, and skills to perform self-care. Strategies that the
advanced practice nurse can employ include providing simple verbal and written
instructions for each step of the bowel management plan and having the person and/
or their care partner report back the steps or enact the plan with the nurse present
[16]. To promote self-care, the advanced practice nurse should cover the following
topics in their patient education: health promoting practices, including how to detect
symptoms that indicate effectiveness of the bowel management plan; monitoring
practices, such as interpreting those symptoms requiring action; and responding to
adverse symptoms when they occur, such as knowing how to contact the nurse [17].
The acceptability and feasibility of the management plan to the patient and/or their
care partners must be addressed by the advanced practice nurse. Personal circum-
stances and nancial implications need to be evaluated for barriers to the achieve-
ment of potentially successful interventions.
9.4 Initial Conservative Management
Conservative treatment of neurogenic bowel dysfunction that supports self-care is
the focus of the advanced practice nurse’s management. An individualized bowel
management plan is considered best practice in the care of patients with neurologi-
cal conditions, given the variation in patients’ goals and preferences, extent of neu-
rological disease, diet, exercise, and physical function [2]. Initial conservative
management could potentially include: modication of diet, ber, and uid intake;
planned time of defecation; medications (oral and rectal laxatives); digital stimula-
tion/evacuation; and transanal irrigation [2, 3, 6, 18]. Education about and samples
of absorbent products are a useful adjunct to most management approaches to lessen
concerns about potentially visible leakage, especially during the time of establish-
ing an effective routine [6, 16, 18]. Emotional support and empathy are critical,
given the profound impact that fecal incontinence can have on a person’s self-
esteem and well-being [6].
9 Management ofFecal Incontinence inAdults withNeurogenic Bowel Dysfunction
182
9.4.1 Expected Outcomes
In the presence of neurological disease, expected outcomes for bowel care are to
avoid fecal incontinence and regulate bowel evacuation. Additionally, expected out-
comes are the absence of complications, such as skin breakdown, constipation, anal
ssures, and autonomic dysreexia.
9.4.2 Diet, Fiber, andFluid Intake Optimization
Information and advice are required to establish a regular, healthy, balanced diet to
optimize bowel motility and subsequent stool consistency, yet there is no high-
quality evidence on dietary supplementation and neurogenic bowel dysfunction [2,
3, 7, 18]. Dietary management advice needs to be tailored to the requirements of the
individual and adjusted to achieve the desired stool consistency [2, 3, 7, 18]. A high
ber diet could lead to increased bloating and atulence, so it is recommended to
gradually introduce ber and assess tolerability and impact on stool consistency and
incontinence [2, 3]. For patients with reexic bowel, soft-formed stool is the goal,
while for patients with areexic bowel, continence is facilitated by rm stool that is
easier to digitally remove than very soft stool [2]. Digital (or manual) stool removal
is done by gently scooping out feces in the rectum using a nger in a disposable
glove covered with lubricant. Stool may need to be broken up into smaller pieces
and removal repeated several times. The patient typically sits on the toilet during the
procedure.
Practice guidelines suggest that maintaining adequate hydration is important to
the management of neurogenic bowel dysfunction [2]. The amount of uid con-
sumption must be individualized, considering the bladder management plan and
bladder symptoms [2, 7]. Specic bowel irritants should be avoided, such as caf-
feine, alcohol, and articial additives that can cause looser stools.
9.4.3 Planned Time ofDefecation
Identifying a regular time for emptying the bowel promotes the establishment of an
achievable pattern. Advantage should be taken of the gastrocolic reex, which can
be used to tailor the optimal elimination time for the individual [3]. Having a bowel
movement once a day or on alternate days is advised, but there is no normal fre-
quency that must be achieved, and the person’s lifestyle and premorbid bowel pat-
terns should be considered in planning [3]. Promoting privacy and good positioning
that exploits gravity to achieve bowel emptying is a further area of patient education
that can be overlooked, but is key to the establishment of a routine [19]. There are
no high-quality studies on the effectiveness of a defecation position; however,
guidelines suggest that a knees-up position (knees elevated at a 60-degree angle to
M. Northwood and N. Cotterill