Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5256_Библиотеки_им_академика_М_И_Перельмана.pdf
183
the trunk) can facilitate evacuation in patients with anorectal constipation with sec-
ondary overow fecal incontinence [6] (see Chap. 6). Defecation position is also
dependent on the person’s postural stability and function, and can be facilitated by
the selection of an appropriate commode [3].
9.4.4 Medication Management
9.4.4.1 Oral Medications
The advanced practice nurse has a key role in patient education and collaboration
with other health care professionals (e.g., physician, pharmacist) regarding medica-
tion management of neurogenic bowel dysfunction. As detailed in Chap. 6, the
medications for impaction, i.e., anorectal constipation with secondary overow
fecal incontinence, (stimulant and osmotic laxatives) also have a role in the manage-
ment of neurogenic bowel dysfunction [2, 3, 6]. Stimulant and osmotic laxatives can
help with slow-transit time and anorectal constipation with secondary overow
fecal incontinence, but their impact on fecal incontinence is not as well established
[6]. Prokinetics, which enhance bowel peristalsis, can be used in neurogenic bowel
dysfunction to enhance transit time [2, 6]. The authors of a simplied algorithm for
neurogenic bowel dysfunction in patients with spinal cord injury and multiple scle-
rosis recommend that, due to limited research with these populations, osmotic laxa-
tives be used before stimulants and prokinetics, and based on individualized
assessment of the patient [2].
9.4.4.2 Rectal Medications
Rectal medications are very commonly part of a bowel management plan for
patients with neurogenic bowel dysfunction so that bowel movement timing can be
planned to promote continence [2, 3, 7]. They can be used alone and in combina-
tion with oral medications [2]. Suppositories or enemas can be used for patients
with neurogenic bowel dysfunction to trigger bowel evacuation. Suppositories act
as an irritant and a stimulant [7]. Glycerin suppositories are considered a mild
stimulant, while bisacodyl suppositories deliver a stimulant laxative to the rectal
wall [2, 7]. Guidelines suggest selecting the lowest level of stimulation needed,
although this must be balanced against the amount of digital stimulation or digital
removal of feces required [2, 7]. Small volume enemas, also called micro or mini
enemas, are an alternative to suppositories and contain the active ingredients of
docusate sodium, glycerol, and polyethylene glycol [2]. Of note, large volume
phosphate enemas (e.g., sodium phosphate or soapsuds) are not recommended for
long-term use due to the risk of triggering autonomic dysreexia, watery stools,
abdominal cramping, and trauma from overdistention [3, 7]. Evidence is inconclu-
sive on the effectiveness of suppositories compared to enemas [2, 3, 7].
Considerations include patient preference, dexterity to manage a suppository or the
enema, and anal tone [1].
9 Management ofFecal Incontinence inAdults withNeurogenic Bowel Dysfunction
184
9.4.5 Digital Rectal Stimulation andEvacuation
Specic techniques can also be considered to assist with bowel evacuation when
additional efforts to empty the rectal contents may be required, and are often
employed by patients with spinal cord injuries [2]. Digital rectal stimulation involves
inserting a gloved, lubricated nger into the anal canal using a circular motion for
20 to 30s, to cause a reex contraction of the colon and rectum [2, 19]. Digital
stimulation is used most often in patients with reexic bowel [2, 3]. Manual stool
evacuation is performed to physically remove stool from the rectum with a lubri-
cated gloved nger and is used in patients with areexic bowel [2].
Using the heel or palm of the hand on the abdomen to massage the bowel con-
tents through the colon towards the rectum can be useful for some patients with
multiple sclerosis, but not those with spinal cord injury [3]. Similarly, a Valsalva
maneuver to provide additional pressure to move the bowel contents along the colon
may be considered, but not in patients with spinal cord injury [3]. Appropriate
assessment and caution are advised for the above strategies to avoid trauma to the
anal region (e.g., anal ssures, hemorrhoids) and responses such as autonomic dys-
reexia [2].
9.5 Transanal Irrigation
The advancement of transanal irrigation systems over the last few decades has
brought signicant opportunity for symptom management to patients with neuro-
genic (and non-neurogenic) bowel dysfunction. The principle of transanal irrigation
is to promote evacuation by introducing tepid tap water into the rectum and lower
colon to soften/liquefy stool [2, 6]. Several manufacturers have created systems to
instill water via a short catheter or cone that is inserted into the rectum [2, 7]. Some
catheters are self-retaining with balloon inations, attached via tubing to a water
bag, and connected to a pump or gravity system to introduce the water [2]. The
mechanical effect of the washout and/or the stimulation of a colonic mass move-
ment are the likely causes facilitating evacuation of stool once the catheter or cone
is removed [2, 7, 20, 21]. The systems can deliver low (up to 250ml) or high
(between 250 and 1500ml) water volumes, with the lower volumes emptying the
rectum and higher volumes emptying the left colon from the splenic exure to the
rectum [2].
Transanal irrigation is recommended for patients with neurogenic bowel dys-
function who have not had satisfactory results with their standard bowel manage-
ment plan, in particular patients with spinal cord injuries and multiple sclerosis [2,
3, 6, 11]. Irrigation can be used for fecal incontinence, constipation, and long dura-
tions of bowel evacuation. Patients with neurogenic bowel can administer the irriga-
tion themselves, or be supported by their care partner/provider [22]. Lowering the
risk of fecal incontinence is often a high priority for patients, and use of transanal
irrigation is a key consideration to reduce this risk [23]. In a survey study of 143
participants with neurogenic bowel dysfunction, Nafees etal. [23] identied that the
M. Northwood and N. Cotterill
185
Fig. 9.2 Qufora IrriSedo
Klick (left side) and
Qufora IrriSedo MiniGo
(right side). (Reproduced
with permission from
Qufora A/S)
Fig. 9.3 Peristeen® Plus
system. (Reproduced with
permission from
Coloplast Ltd)
main attributes for choosing transanal irrigation were reducing the risk of fecal
incontinence, the frequency of use (every other day as opposed to daily), and reduc-
ing urinary tract infections. Selecting the best product for the person depends on the
clinical experience and judgement of the advanced practice nurse, the patient’s spe-
cic clinical and lifestyle needs and preferences, affordability and/or benet cover-
age, and the products that are available locally. Examples of two systems are
presented in Figs.9.2 and 9.3.
9.5.1 Evidence ofEffectiveness ofTransanal Irrigation
Only one multicenter randomized controlled trial has been conducted to evaluate
transanal irrigation [24]. The study, based on 87 participants with spinal cord injury
and neurogenic bowel dysfunction, offers compelling evidence of a positive
9 Management ofFecal Incontinence inAdults withNeurogenic Bowel Dysfunction
186
transanal irrigation effect when compared to standard bowel care [24]. After a
10-week trial, participants using transanal irrigation had signicantly improved
(lower) mean scores compared to participants using conservative bowel manage-
ment program on the Cleveland Clinic constipation scoring system (10.3 (standard
deviation (SD)=4.4) compared to 13.2 (SD =3.4)), on St. Mark’s fecal inconti-
nence grading system (5.0 (SD=4.6) versus 7.3 (SD=4.0) respectively, and on the
Neurogenic Bowel Dysfunction Score (10.4 (SD=6.8) compared to 13.3 (SD=6.4))
[24]. Recently, two new integrative literature reviews provide insights regarding
transanal irrigation use, implementation [25], and wider considerations including
humanistic and economic factors [26]. The reviews supported the use of transanal
irrigation, identifying advantages such as improved patient satisfaction, improved
quality of life for both patient and care partner, and reduced episodes of inconti-
nence, defecation difculties, time involved in bowel management, and dependency
[25, 26]. One review cited an economic evaluation of the lifetime costs of using
transanal irrigation for patients with spinal cord injuries in the United Kingdom and
found that irrigation was less costly than conservative bowel management [26, 27].
The reviews provide the most robust evaluation of available evidence in this eld.
However, given the poor overall quality of the literature (i.e., small samples, weaker
designs), the reviews importantly identify the need for high-quality qualitative and
quantitative studies to inform care in this area [25, 26].
9.5.2 Patient Education onTransanal Irrigation
Supporting the patient and their care partner to use the transanal irrigation system is
a key role for the advanced practice nurse [26]. Transanal irrigation systems provide
patient-facing instructions and should be followed carefully to maximize effect and
safety. In particular, the risks of rectal perforation need to be explained and dis-
cussed, even though the risk is low [28, 29]. Once transanal irrigation is chosen, the
consultation with the patient should not be rushed, ensuring enough time for ques-
tions. High-quality preparation and teaching of transanal irrigation will increase the
success of the procedure and reduce anxiety [26]. Clear commitment from patients
and health care providers, as well as a willingness to overcome practical challenges,
are important, particularly during the pivotal early experiences of transanal irriga-
tion [26].
After initial education, patients and/or their care providers/partners will take
about 6–8 weeks to become procient in using the system and will likely require
coaching over time, preferably in their home environment [25, 26]. Once the patient
commences transanal irrigation, timely follow-up and review is critical. Undoubtedly,
fresh questions will emerge for the patient that need addressing. Follow-up assess-
ment may identify practical problems or a need to adjust irrigating uid volume or
combine transanal irrigation with laxatives [21]. Attention to teaching and technical
issues experienced at an early stage is likely to increase the sustainability of trans-
anal irrigation [30], and continuity of the advanced practice nurse during this period
of learning is helpful [26].
M. Northwood and N. Cotterill
187
The advanced practice nurse will want to consider how well patients will adhere
to and continue to use transanal irrigation when presenting as an option for discus-
sion. Long-term adherence to transanal irrigation is moderate, with discontinuation
being common [25, 26]. Adherence was investigated in a retrospective study of 108
participants using transanal irrigation for constipation or fecal incontinence; 43%
continued to use irrigation after 1 year [30]. Of the 108 participants, 38% had a
neurogenic bowel. Those who continued beyond a year tended to use it for fecal
incontinence. Reasons for stopping transanal irrigation were technical issues, lack
of efcacy, and constraints on time [30]. Likewise, Juul and Christensen [31] identi-
ed similar ndings in their study of 507 participants using transanal irrigation. At
12-month follow-up, 43% continued using irrigation [31]. What is not yet clear
within the literature are the specic criteria that can predict those who are likely to
most benet from and sustain transanal irrigation in the longer term, or the type of
support by an advanced practice nurse that can facilitate long-term use and benets.
9.6 Optional Treatments
When maintaining fecal continence remains problematic, despite the implementa-
tion of effective strategies to maximize stool consistency and evacuation habits,
further intervention can be considered. This section includes the optional treatments
of biofeedback and sacral neuromodulation. In keeping with an evidence-informed
approach to decision making, the advanced practice nurse would consider if these
treatments are available and affordable in the patient’s context and of interest to the
patient to pursue. Biofeedback is discussed in Chap. 6, and neuromodulation in
Chap. 12, so the evidence presented in this section is specic to patients with fecal
incontinence and neurogenic bowel dysfunction.
9.6.1 Biofeedback
Biofeedback is used to support recruitment and awareness of pelvic oor muscles to
improve strength, sensation, and coordination [1, 2, 32]. While biofeedback is rec-
ommended in best practice guidelines as treatment for fecal incontinence, little evi-
dence exists for patients with neurogenic bowel dysfunction [1, 2, 6, 32].
Consequently, it is more often considered as an option in patients with multiple
sclerosis or incomplete spinal cord injuries [1, 2].
9.6.2 Sacral Neuromodulation
Sacral neuromodulation from a surgically implanted stimulation device has
increased in use over the past 25years and has become a rst-line surgical option
for many patients with fecal incontinence [26, 33]. The general success of sacral
neuromodulation is attributed to outcomes of over 50% of patients reporting
9 Management ofFecal Incontinence inAdults withNeurogenic Bowel Dysfunction
188
long-term cure, and minimal surgical risk. Costs and availability of this proce-
dure, however, must be considered. Regarding neurogenic bowel dysfunction,
neuromodulation has primarily been studied in patients with incomplete spinal
cord injury [2] and is not recommended in the best practice guideline for fecal
incontinence management in spinal cord injury because of the lack of controlled
trials in this population and data on patients with complete spinal cord injury [3].
From an equity perspective, not all centers provide this highly specialized treat-
ment, so it is not available to all patients with neurogenic bowel dysfunc-
tion [2, 3].
9.7 Surgical Management
Where conservative measures fail to result in sufcient management of fecal incon-
tinence, surgical options are available. Outcomes vary, however, and the emphasis
should be on exhausting all conservative strategies before considering surgery.
Appropriate assessment is essential to maximize results. In the best practice treat-
ment pyramid (see Fig.9.1), the authors note that inclusion of surgical procedures
together at the top of the pyramid does not mean that they are interchangeable or
hierarchical, but rather careful discussion must occur with the surgeon and the
patient to arrive at an individualized treatment plan [2]. The advanced practice nurse
has a role in counselling patients regarding the available options, in partnership with
their medical team, and ensuring patients arrive at an informed decision regarding
their further treatment.
Fecal continence relies on a complex interplay between neural and muscular
control. Even with extensive efforts to optimize lifestyle and dietary factors, incom-
petent muscular and neural function can diminish the potential for success and may
require more intensive intervention, including surgery [6]. Surgical options for
patients with neurological disease are very similar to those without, with the main
aim being to improve decits or to provide a manageable alternative when this is not
possible otherwise. The main surgical procedures are detailed in Chap. 12 and
include:
• Anatomical surgeries—anal sphincter repair
• Neural procedures—sacral nerve stimulation
• Alternative solutions—colostomy formation, antegrade continence enema (ACE)
The antegrade continence enema is not detailed elsewhere and thus is explained
here. The antegrade continence enema is a procedure creating a continent colonic
stoma. It uses the principles of antegrade colonic washout through a catheterizable
channel to enable the bowel to be emptied at a convenient time and exert more con-
trol over bowel activity [34]. This procedure, performed laparoscopically, has docu-
mented success among patients with spinal cord injuries [3]. The main complication
associated with antegrade continence enema is the possibility of stoma stenosis.
This procedure may not be available at every healthcare center [2].
M. Northwood and N. Cotterill
189
The role of colostomy for fecal incontinence is described in Chap. 12. Colostomy
is recommended for patients when other treatments have failed or they have experi-
enced serious complications [2, 3]. Evidence suggests that for patients with spinal
cord injury, a colostomy can improve quality of life and independence, and reduce
the hours spent on bowel care [1, 2, 7]. The surgeon would consider the position of
the stoma related to the seated position of the person with spinal cord injury in a
wheelchair [7].
9.8 Quality ofLife Considerations
Quality of life is a signicant consideration with regard to all the above treatment
interventions where the impact of the interventions themselves must not be over-
looked. The evaluation of quality-of-life outcomes is recommended to evaluate
patients’ perceived benets or disadvantages. Along with the assessment of incon-
tinence symptom outcomes, evaluation of quality of life is necessary to under-
stand improvements or deterioration from the person’s perspective [35]. The
advanced practice nurse has a particular role in ensuring quality of life impact is
considered for each patient in terms of their presenting symptoms and potential
consequences of treatment. Education and the provision of advice to enable
patients to make balanced decisions regarding their care are vital components of
the specialist role.
Box 9.1 Summary of Interventions for Fecal Incontinence in Adults with
Neurogenic Bowel Dysfunction
Initial conservative interventions
• Diet, ber, and uid intake optimization
• Planned time of defecation
• Medication management
– Oral medications
– Rectal medications
• Digital rectal stimulation and evacuation
• Transanal irrigation
Optional treatments
• Biofeedback
• Sacral neuromodulation
Surgical interventions
• Anal sphincter repair
• Colostomy formation
• Antegrade continence enema
9 Management ofFecal Incontinence inAdults withNeurogenic Bowel Dysfunction
190
A number of questionnaires are available to enable patients to self-report their
bowel symptoms and impact on quality of life; however, none have been developed
specically for use in patients with neurological conditions that include an evalua-
tion of the impact on quality of life [35]. The Neurogenic Bowel Dysfunction Score
enables scoring of symptom severity only and was developed for use in people with
spinal cord injury [36]. One study has reported that the questionnaire lacks content
validity for people with multiple sclerosis [37]. A patient reported outcome measure
of symptom and quality of life impact for people with neurological causes of fecal
incontinence is therefore required.
9.8.1 When toRefer
Primary care providers should refer patients with neurogenic bowel dysfunction for
specialist care. Most patients with neurogenic bowel dysfunction will require a ter-
tiary interprofessional approach for much of their care. If patients do not respond to
initial management, referrals to colorectal surgery, physical medicine, or urogyne-
cology may be warranted for further investigations (such as manometry, ultrasound,
MRI, and EMG) and more complex management.
Boxes 9.2 and 9.3 present example case studies for managing fecal incontinence
in patients with neurogenic bowel dysfunction.
Box 9.2 Case Study 1: Sally
Sally was in her early twenties when it was discovered that the cause of her
lower extremity weakness was a benign spinal cord tumor in the sacral region.
She underwent a resection of the tumor, received rehabilitation post-
operatively, but had signicant bowel and bladder sequelae. Sally was unable
to empty her bladder or bowels independently without intervention.
Intermittent urinary catheterization was initiated, and she was able to achieve
mastery of the technique quickly with the support of an advanced practice
continence nurse. Sally’s bowel management was more challenging. She was
taking stool softeners as prescribed to prevent becoming constipated.
When Sally saw the advanced practice nurse at a follow-up appointment,
she revealed that her feces were soft and pasty with the consistency of peanut
butter. She was unable to completely pass her bowel on her own due to the
level of her previous lesion, and the use of a suppository was ineffective. She
did not want to use an enema. Sally discussed her frustration and discomfort
as she was spending a long time on her morning bowel routine.
The advanced practice continence specialist nurse discontinued the stool
softeners with a goal to achieve a more manageable consistency for manual
evacuation. She recommended that Sally also supplement her diet with a
small amount of psyllium dietary ber to potentially assist with a more com-
plete evacuation and ensure her stool did not become too hard. At her next
appointment, Sally reported her satisfaction with the management strategies
that made her feces easier to digitally remove.
M. Northwood and N. Cotterill
191
References
1. Hakim S, Gaglani T, Cash BD.Neurogenic bowel dysfunction: the impact of the central ner-
vous system in constipation and fecal incontinence. Gastroenterol Clin. 2022;51(1):93–105.
2. Magnuson FS, Christensen P, Krassioukov A, Rodriguez G, Emmanuel A, Kirshblum S, etal.
Neurogenic bowel dysfunction in patients with spinal cord injury and multiple sclerosis—an
updated and simplied treatment algorithm. J Clin Med. 2023;12(22):6971.
Box 9.3 Case Study 2: Luis
Luis is 48years old and sustained a T5 spinal cord injury following a car
crash. He underwent intensive rehabilitation in a spinal injury unit. Luis’s
bladder care was managed with a suprapubic catheter (his preference as
opposed to intermittent self-catheterization). After discharge, Luis lived in an
adapted single-storey apartment along with equipment to enable his
independence.
Luis is receiving support from a home care nursing team. His bowel man-
agement plan is done three times weekly. The plan involves using a bisacodyl
suppository along with digital stimulation. The success of this plan has varied,
and lately, he has not always had a complete evacuation. Often, the home care
nurse needed to visit twice on the bowel care days. Luis had been feeling
down, missing his old home and his previous routines. His primary nurse had
been encouraging Luis to transfer to a toilet for evacuation, but he felt nervous
and uncertain with his existing commode.
Luis’s advanced practice nurse from the rehabilitation team made a follow-
up home visit. The nurse shared with Luis that he was keen for him to try
transanal irrigation. Luis said he had heard about this procedure from some
friends who were using it and was willing to do it. He said he appreciated
talking with the nurse about his bowel care and the new approach because he
was starting to feel sad about his situation.
Together, they selected a system that he would be able to manage indepen-
dently, and the advanced practice nurse provided pre-education. Recognizing
that the early period in learning transanal irrigation is critical to success and
longer-term adherence, the advanced practice nurse was present during the
rst three times that Luis used his new transanal irrigation system with his
agreement. They had to adjust the amount of water gradually to achieve good
results. The home care team supported Luis in obtaining the needed supplies
and applying for benets to cover the cost of the transanal irrigation system.
An occupational therapist was brought in to re-assess Luis’s current com-
mode and to provide suggestions for better seating balance. The advanced
practice nurse worked with the home care nursing team so they could support
Luis with irrigation, as needed. His success bolstered his mood.
9 Management ofFecal Incontinence inAdults withNeurogenic Bowel Dysfunction
192
3. Johns J, Krogh K, Rodriguez GM, Eng J, Haller E, Heinen M, etal. Management of neuro-
genic bowel dysfunction in adults after spinal cord injury: clinical practice guideline for health
care providers. J Spinal Cord Med. 2021;44(3):442–510.
4. Zandalasini M, Pelizzari L, Ciardi G, Giraudo D, Guasconi M, Paravati S, etal. Bowel dysfunc-
tions after acquired brain injury: a scoping review. Front Hum Neurosci. 2023;17:1146054.
5. National Collaborating Centre for Methods and Tools (NCCMT). A model for evidencein-
formed decision making in public health. [fact sheet]; 2018. Available from: https://www.
nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf
6. Bliss D, Mimura T, Berghmans B, Barucha A, Carrington E, Engberg S, Hunter K, Santoro G,
Kumaran T, Sakakibara R, Emmanuel A, Paniker J. . Clinical assessment, conservative man-
agement, specialized diagnostic testing, and quality of life for fecal incontinence: update on
research and practice recommendations. Continence. 2024;9:101063.
7. Kurze I, Geng V, Böthig R.Guideline for the management of neurogenic bowel dysfunction in
spinal cord injury and other central neurological conditions. Spinal Cord. 2022;60(5):435–43.
8. Alvino B, Arianna F, Assunta B, Antonio C, Emanuele D, Giorgia M, etal. Prevalence and
predictors of bowel dysfunction in a large multiple sclerosis outpatient population: an Italian
multicenter study. J Neurol. 2022;269(3):1610–7.
9. Koutsouraki E, Theodoros K, Eleni G, Marianna K, Areti N, Ariadni K, etal. Autonomic ner-
vous system disorders in multiple sclerosis. J Neurol. 2023;270(8):3703–13.
10. National Institute for Health and Care Excellence. Faecal incontinence in adults: management;
2007. Available from: https://www.nice.org.uk/guidance/cg49.
11. National Institute for Health and Care Excellence. Faecal incontinence in adults: quality stan-
dard; 2014. Available from: https://www.nice.org.uk/guidance/qs54.
12. Sakakibara R, Kishi M, Ogawa E, Tateno F, Uchiyama T, Yamamoto T, etal. Bladder, bowel,
and sexual dysfunction in Parkinson’s Disease. Parkinson’s Disease. 2011;2011(1):924605.
13. Harari D, Coshall C, Rudd AG, Wolfe CDA.New-onset fecal incontinence after stroke: preva-
lence, natural history, risk factors, and impact. Stroke. 2003;34(1):144–50.
14. Canadian Stroke Best Practices. Acute Stroke Management Toronto, Ontario 2022. Available
from: https://www.strokebestpractices.ca/recommendations/acute- stroke- management/
inpatient- prevention- and- management- of- complications- following- stroke.
15. Li J, Yuan M, Liu Y, Zhao Y, Wang J, Guo W.Incidence of constipation in stroke patients: a
systematic review and meta-analysis. Medicine. 2017;96(25):e7225.
16. Spina Bida Association. Lifespan bowel management protocol: a guide to bowel manage-
ment for clinicians who care for individuals with spina bida and neurogenic bowel; 2023.
Available from: https://www.spinabidaassociation.org/.
17. Riegel B, Jaarsma T, Stromberg A.Theory of self-care of chronic illness. 5th ed. Springer
Publishing; 2024.
18. Bliss D, Mimura T, Berghmans B, Bharucha A, Carrington E, Hunter K, Kumaran T, Sakakibara
R, Santoro G, Emmanuel A, Paniker J. In Cardozo L, Rovner E, Wagg A, Wein A, Abrams P,
editors. Assessment and conservative management of faecal incontinence and quality of life in
adults. 7th ed; Bristol, UK: International Continence Society; 2023. p. 1573–673.
19. Emmanuel A.Managing neurogenic bowel dysfunction. Clin Rehabil. 2010;24(6):483–8.
20. Bazzocchi G, Giuberti R. Irrigation, lavage, colonic hydrotherapy: from beauty center to
clinic? Tech Coloproctol. 2017;21(1):1–4.
21. Christensen P, Krogh K, Buntzen S, Payandeh F, Laurberg S. Long-term outcome and
safety of transanal irrigation for constipation and fecal incontinence. Dis Colon Rectum.
2009;52(2):286–92.
22. Kurze I, Geng V, Böthig R.Guidelines for management of neurogenic bowel dysfunction in
individuals with a spinal cord injury and other central neurological conditions. Spinal Cord.
2022;60(5):435–43.
23. Nafees B, Lloyd AJ, Ballinger RS, Emmanuel A.Managing neurogenic bowel dysfunction:
what do patients prefer? A discrete choice experiment of patient preferences for transanal irriga-
tion and standard bowel management. Patient Prefer Adherence [Internet]. 2016;10:195–204.
M. Northwood and N. Cotterill