Cell Biochem Biophys (2014) 69:385388
DOI 10.1007/s12013-014-9842-6
REVIEW PAPER
Bowel Dysfunction in Spinal Cord Injury: Current Perspectives
Yuehai Pan Bin Liu Ruijun Li Zhixin Zhang
Laijin Lu
Published online: 19 February 2014
Springer Science+Business Media New York 2014
Abstract Permanent disruptions of gastrointestinal
function are very common sequel of spinal cord injury
(SCI). When motor and sensory nervous integrity are
severely affected, neurogenic gastrointestinal dysfunction
is an inevitable consequence. Autonomic nervous system
miss function has significantly diminished or lost sensory
sensations followed with incomplete evacuation of stool
from the rectal vault, immobility, and reduced anal
sphincter tone all of those predisposing to increased risk of
fecal incontinence (FI). The FI is, beside paralysis of
extremities, one of the symptoms most profoundly affect-
ing quality of life (QOL) in patients with SCI. We are
reviewing current perspectives in management of SCI,
discussing some pathophysiology mechanisms which could
be addressed and pointing toward actual practical concepts
in use for evaluation and improvements necessary to sus-
tain SCI patients QOL.
Keywords Spinal cord injury
Bowel dysfunction

Gastrointestinal dysfunction
Fecal incontinence
Introduction
Spinal cord-injured (SCI) patients have delayed colonic
motility and severely impaired anorectal dysfunction
resulting in functional obstruction, constipation, and fecal
incontinence (FI) or a combination of all above mentioned
[1]. We are here exploring pathogenesis, functional and
Y. Pan
B. Liu (&)
R. Li
Z. Zhang
L. Lu
Department of Hand Surgery, The First Hospital of Jilin
University, 1 Xinmin Street, Changchun 130021,
Peoples Republic of China
e-mail: drbinliuchina@163.com
morphological pathology, and several approaches currently
used in management of SCI. Traumatic SCI (TSCI) cases
have standard definition as those involving any primary or
secondary diagnosis of an acute traumatic lesion of the
spinal cord or cauda equina using ICD-9-CM18 diagnosis
codes 806.0806.9 and 952.0952.9, fulfilling the
requirements of case definition for TSCI provided by the
Centers for Disease Control and Prevention (CDC) [2].
Since it is not yet possible to treat initial cause in the SCI
condition, all the treatments are of palliative nature, which
are traditionally considered by different authors time and
resource consuming.
SCI Epidemiology
By February 2013, data estimated annual incidence of SCI
with exclusion those who die at the scene of accident are
*40 cases per million persons in the U.S., which are in
absolute number 12,000 new cases each year [3].
Approximately 250,000 Americans are living with the
typically devastating neurological deficits and debilitating
somatic and autonomic reflexes that develop in chronic SCI
[2]. Regarding the overall prevalence, the number of peo-
ple who are alive in 2013 and have SCI has been estimated
to be *273,000 persons (range 238332,000 persons) [1,
3]. These are incidence, and estimates obtained from dif-
ferent studies. The data from the National SCI Database are
actively in surveillance from 1973, and in their estimate,
13 % of new SCI cases are in the U.S. being in database
29,096 persons who sustained SCI. Currently majority of
SCI has trauma origin. The SCI has as chronic complica-
tions, and it is usually associated with additionally debili-
tating conditions presumed to be of the similar prevalence
as in the general population. But current investigations
found that it is highly probable that subclinical stages of
123
386
these chronic diseases may become overt with the onset of
the SCI due to the stress associated with the trauma [4]. It
has been reported that cardiovascular disease often remains
undiagnosed in SCI patients due to their physical inactivity
and impaired sensations, which increase the risk of disease
progression and shorten overall survival [57]. Gastroin-
testinal symptoms usually present in SCI patients are
constipation, fecal incontinence, and fecal impaction, later
being one of the most common complications reported in
39 % of the patients [8].
Colorectal Physiology and Pathophysiology in SCI
Spinal cord injury causes anorectal problems, whose
pathophysiology still remains poorly characterized. A
comprehensive method in evaluation of spino-anorectal
function is still lacking. The neuropathophysiology of
bowel dysfunction in SCI has been evaluated in different
studies by motor-evoked potentials (MEP) of anus and
rectum, trans-spinal magnetic stimulation, and anorectal
physiology [8, 9]. Some previous studies of colorectal
pathophysiology demonstrated that distension of the
descending colon can be associated with an increase in
rectal tone known as the colorectal reflex [10, 11]. the presence of megacolon. Its also has its limitation, and
Rectal distension provokes an opposite effect, and it
reduces colonic tone and phase motor activity, being
termed the rectocolic reflex. There are opposite findings main advantage of colon transit time is that it can evaluate
on reflex reproducibility. While Law et al. [10] have shown
that the rectocolic response is clear and reproducible, while
colorectal response being more subtle, studies from Suttor
et al. [11] demonstrated a clear and definitive colorectal
response and a more variable rectocolic response. The
exact neural pathways involved are unknown. Neither these
reflexes in humans nor the role of the spinal cord is clear.
Patients with complete SCI can be observed as human
model of SCI and its neural pathways because of preserved
local intrinsic pathways. It is important to emphasis
necessity for additional studies of enteric motor reflexes in
patients with SCI because of their clinical importance.
Intestinal motor response to food ingestion has been
well documented. Nevertheless, controversy remains
regarding neural mechanisms involved. Several manomet-
ric studies explored colonic meal response in healthy
subjects and SCI patients indicating a cephalic or central
nervous system (CNS) response [12, 13]. Some of them
failed to demonstrate a gastrocolonic response to sham
feeding which is in favor of response independent of CNS
involvement [14]. Findings of impaired colonic tonic
response which correlates to the colonic motor response to
meal ingestion have opposite tendency leaning toward
perception of the CNS participation in the normal gastro-
colonic response [15]. The gastrorectal response has been
explored in relatively less number of studies, which when
123
Cell Biochem Biophys (2014) 69:385388
summarized predominately explored healthy subjects [16]
and only in small number SCI patients [17].
Evaluation Methods of Bowel Dysfunction in SCI
Patients
Prior to the management of bowel dysfunction, it is
important to accurately evaluate it. There are a few meth-
ods known for such purpose. The colon transit time is
known as an objective method for evaluating the motility
of the colon [18]. The most widely used method in
assessment of the bowel pattern is taking the clinical his-
tory. However, this can be highly variable since being
dependable on patients subjective symptoms. It has been
reported in the literature that peoples memory of their
bowel habit is inaccurate in certain number of cases and
has low index of correlation with the colon transit time, a
proved objective method for its evaluation [19]. Since
every method has its limitations, the inspectors must be
aware of this possible miss interpretation in order to attain
accuracy. Another simple and less time consuming method
is plain abdominal radiography used for evaluating the
distribution of faces in the colon and the visualization of
the colon transit time is for the moment the most objective
method for evaluating the motility of the colon. Perhaps the
total colon motility as well as segmental colon motility
which is important in patients with SCI. In addition to the
bowel patterns, the constipation score has to be evaluated
according to the Rome II Diagnostic Criteria which
includes projection of the bowel frequency (during one
week period), the presence of straining, lumpy, or hard
stools, the presence of incomplete evacuation sensation and
sensation of anorectal obstruction, and the need for addi-
tional manual maneuvers to facilitate defecation. Mor-
phological stool characteristics are also recorded as well
[20].
Management of Fecal Incontinence in Spinal Cord
Injury
Initial management of FI includes, prior to clinical
assessment, the evaluation of level of lesion. By these
criteria, lesions can be divided into few groups: the first
comprising cauda equina lesion (this occurs in settings of
lumbar disk prolaps) or peripheral nerve lesion (in radical
pelvic surgery), suprasacral spinal cord lesion occurring
most frequently in trauma and group of suprapontine
lesions characteristic for Parkinson disease [3, 21].
Clinical assessment commonly includes patients history
(pre-morbid bowel function algorithm), physical and neu-
rological examination, functional assessment, and basic
386
these chronic diseases may become overt with the onset of
the SCI due to the stress associated with the trauma [4]. It
has been reported that cardiovascular disease often remains
undiagnosed in SCI patients due to their physical inactivity
and impaired sensations, which increase the risk of disease
progression and shorten overall survival [57]. Gastroin-
testinal symptoms usually present in SCI patients are
constipation, fecal incontinence, and fecal impaction, later
being one of the most common complications reported in
39 % of the patients [8].
Colorectal Physiology and Pathophysiology in SCI
Spinal cord injury causes anorectal problems, whose
pathophysiology still remains poorly characterized. A
comprehensive method in evaluation of spino-anorectal
function is still lacking. The neuropathophysiology of
bowel dysfunction in SCI has been evaluated in different
studies by motor-evoked potentials (MEP) of anus and
rectum, trans-spinal magnetic stimulation, and anorectal
physiology [8, 9]. Some previous studies of colorectal
pathophysiology demonstrated that distension of the
descending colon can be associated with an increase in
rectal tone known as the colorectal reflex [10, 11]. the presence of megacolon. Its also has its limitation, and
Rectal distension provokes an opposite effect, and it
reduces colonic tone and phase motor activity, being
termed the rectocolic reflex. There are opposite findings main advantage of colon transit time is that it can evaluate
on reflex reproducibility. While Law et al. [10] have shown
that the rectocolic response is clear and reproducible, while
colorectal response being more subtle, studies from Suttor
et al. [11] demonstrated a clear and definitive colorectal
response and a more variable rectocolic response. The
exact neural pathways involved are unknown. Neither these
reflexes in humans nor the role of the spinal cord is clear.
Patients with complete SCI can be observed as human
model of SCI and its neural pathways because of preserved
local intrinsic pathways. It is important to emphasis
necessity for additional studies of enteric motor reflexes in
patients with SCI because of their clinical importance.
Intestinal motor response to food ingestion has been
well documented. Nevertheless, controversy remains
regarding neural mechanisms involved. Several manomet-
ric studies explored colonic meal response in healthy
subjects and SCI patients indicating a cephalic or central
nervous system (CNS) response [12, 13]. Some of them
failed to demonstrate a gastrocolonic response to sham
feeding which is in favor of response independent of CNS
involvement [14]. Findings of impaired colonic tonic
response which correlates to the colonic motor response to
meal ingestion have opposite tendency leaning toward
perception of the CNS participation in the normal gastro-
colonic response [15]. The gastrorectal response has been
explored in relatively less number of studies, which when
123
Cell Biochem Biophys (2014) 69:385388
summarized predominately explored healthy subjects [16]
and only in small number SCI patients [17].
Evaluation Methods of Bowel Dysfunction in SCI
Patients
Prior to the management of bowel dysfunction, it is
important to accurately evaluate it. There are a few meth-
ods known for such purpose. The colon transit time is
known as an objective method for evaluating the motility
of the colon [18]. The most widely used method in
assessment of the bowel pattern is taking the clinical his-
tory. However, this can be highly variable since being
dependable on patients subjective symptoms. It has been
reported in the literature that peoples memory of their
bowel habit is inaccurate in certain number of cases and
has low index of correlation with the colon transit time, a
proved objective method for its evaluation [19]. Since
every method has its limitations, the inspectors must be
aware of this possible miss interpretation in order to attain
accuracy. Another simple and less time consuming method
is plain abdominal radiography used for evaluating the
distribution of faces in the colon and the visualization of
the colon transit time is for the moment the most objective
method for evaluating the motility of the colon. Perhaps the
total colon motility as well as segmental colon motility
which is important in patients with SCI. In addition to the
bowel patterns, the constipation score has to be evaluated
according to the Rome II Diagnostic Criteria which
includes projection of the bowel frequency (during one
week period), the presence of straining, lumpy, or hard
stools, the presence of incomplete evacuation sensation and
sensation of anorectal obstruction, and the need for addi-
tional manual maneuvers to facilitate defecation. Mor-
phological stool characteristics are also recorded as well
[20].
Management of Fecal Incontinence in Spinal Cord
Injury
Initial management of FI includes, prior to clinical
assessment, the evaluation of level of lesion. By these
criteria, lesions can be divided into few groups: the first
comprising cauda equina lesion (this occurs in settings of
lumbar disk prolaps) or peripheral nerve lesion (in radical
pelvic surgery), suprasacral spinal cord lesion occurring
most frequently in trauma and group of suprapontine
lesions characteristic for Parkinson disease [3, 21].
Clinical assessment commonly includes patients history
(pre-morbid bowel function algorithm), physical and neu-
rological examination, functional assessment, and basic
Cell Biochem Biophys (2014) 69:385388
exam (stool exam and plain film abdomen if indicated).
Finally thorough assessment also has to evaluate environ-
mental factors which comprise toilet accessibility, assistive
device, carriers support, and attitude-distance.
Bowel function is usually assessed at baseline and at
termination of analysis period using some of the current
scoring systems such as the Cleveland Clinic Constipation
Scoring System (CCCSS; 030, 30 severe symptoms),
St. Marks Fecal Incontinence Grading System (FIGS; 024,
24 severe symptoms), and the Neurogenic Bowel Dys-
function score (NBD; 047, 47 severe symptoms) [2225].
There are different modalities for treating FI in patients
with SCI. Conservative treatments can include diet adjust-
ments, medications, biofeedback, massage, transanal irri-
gation, electro-stimulation, and anal plug. But there has been
established progressive nature of FI symptoms, finally
needing different therapeutic options [2630]. Clinical
therapeutic options are colostomies, graciloplasties, artificial
bowel sphincters, Malone anterograde continence enemas,
and sacral anterior root implantation stimulators [3134].
Based on presumed diagnosis, further treatment is applied.
Though bowel dysfunction in overall population is not
rare event and can be labeled as common complication of
SCI, the number of studies addressing this issue is scarce.
The importance of gas-trointestinal (GI) problems has been
relatively ignored; perhaps, this can be explained by non-
life threatening nature of gastrointestinal motility symp-
toms and bowel dysfunction, since SCI patients have
symptoms of the neurogenic bladder, common urinary
complication, and respiratory problems too [3538]. Ano-
rectal dyssynergy demonstrates similarities in symptomatic
phase to those seen in the bladder following SCI.
Why is important to deal with this issue? In long-term
management of patients with SCI, one of the most
important problems that reduce the quality of life (QOL)
and delays social adjustment is bowel dysfunction [3942].
Furthermore, GI symptoms are more often associated with
depression, anxiety, and significant impairments in QOL in
a significant portion of persons with SCI [43, 44].
In conclusion, the long-term follow-up of patients post-
SCI needs the specialized management which includes
patient education, an adequate fiber diet-oriented dietary
adjustments, concomitant use of oral laxatives, supposito-
ries, and other conservative treatment modalities [45].
Further studies with clear management protocols are nee-
ded to evaluate their utility. In periods of symptom pro-
gression and more severe symptoms, the trans-anal
irrigation, the Malone appendicostomy, or a colostomy
could be recommended [46]. To sustain patients QOL, an
individually tailored approach modified from current-vali-
dated protocols should be applied taking into consideration
whenever possible patients personal differences.
387
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