urological system and continence control issues in spina bifida
6: Controlling faecal incontinence (including constipation
and bowel dysfunction)
Spina bifida may affect
faecal continence in many ways. An understanding of the issues can
assist general practitioners in supporting their patients through
the process of learning to effectively manage faecal incontinence
in conjunction with specialist centres.
Key issues for clinicians
Faecal incontinence is a major source
of poor quality of life for young people and adults with spina
An understanding of the special faecal incontinence issues
for people with spina bifida is necessary for successful incontinence
Faecal incontinence control is best managed in conjunction
with a specialist spina bifida clinic.
Dietary management can help some people successfully manage
diarrhoea, constipation and incontinence.
Constipation should never be left untreated for longer
than two days
Medication is useful for softening and loosening stools.
Clinicians need to familiarise themselves with incontinence
appliances such as anal plugs.
Surgical procedures are an important method of incontinence
Faecal incontinence - a major barrier to
independence Achieving and maintaining bowel continence is
one of the most difficult challenges for people with spina bifida.
Successful control of faecal incontinence is a key barrier that
needs to be overcome in order to achieve full independence and free
participation in activities of daily living. In addition, faecal
incontinence has a major impact on issues of self esteem. Reviewing bowel training and timing Young people and adults with spina bifida visiting
their GP will have already established their bowel habits, although
some may not be benefiting from more recent developments in surgery
The GPs role will then be to review bowel training and timing
techniques, and to ensure that the patient has full access to the
latest management developments. Special issues - physical and behavioural Bowel training is usually started in childhood,
but may become more difficult in the adolescent years. Growth may
affect the nerves to the anus and rectum, causing a change in bowel
habits and an increased risk of incontinence.
In addition, as adolescence marks a time of increasing independence,
sense of invulnerability, experimentation and rebellion, many young
people may pay less attention to health maintenance issues. The role of GPs and specialist clinics General practitioners managing adults and young
people with spina bifida should assess faecal continence as part
of any routine review. An awareness of factors that can cause intermittent
problems may help the GP manage simple continence problems, but
continuing incontinence should be referred to specialist clinics.
In addition, many adult patients may have lost ongoing contact with
specialist treatment clinics and may not be aware of advances in
the treatment of faecal incontinence. By referring to specialist
clinics, GPs can ensure that patients can benefit from latest management
techniques. Faecal incontinence control Spina bifida related nerve damage has a major
impact on the ability to maintain faecal continence. While clinicians
will be familiar with the general principles of incontinence management,
the presence of spina bifida adds another set of issues that need
to be addressed. The following is a list of areas that clinicians
need to consider when assessing faecal incontinence. Level of lesion The presence of thoracic level spina bifida involvement
may increase the difficulty in bearing down during defaecation,
while patients with sacral lesions may have more difficulty obtaining
appropriate and dependable stool consistency. Stool consistency and frequency Assessing the consistency and frequency of stools
allows the clinician to formulate an appropriate management plan.
Constipation can occur very quickly in spina bifida, which can exacerbate
incontinence. Poor diet and lack of exercise are common contributory
factors. While young children may not eat foods that promote stool
formation, dietary intervention can help some young people and adults
prevent constipation. Medications to assist bladder relaxation may
cause constipation. Constipation can also increase the risk of urinary
Long term constipation requires long term treatment. When the bowel
is overstretched from chronic constipation, faeces will reaccumulate
quickly after treatment. Untreated constipation can lead to a toxic
megacolon. After continuous treatment, the bowel may return to its
normal size and if diet is adequate, the stool will return to its
normal consistency. The length of treatment time depends upon how
long the constipation has been present.
Constipation should never be
left untreated for longer than two days.
Diarrhoea can make the practical management
of incontinence difficult, as well as increasing the risk of soiling. Diet and meal times Fluid and fibre intake influence stool consistency
and frequency. In addition, eating can stimulate bowel function
and timing bowel emptying after meals can facilitate incontinence
control. Anal and rectal canal Moderate to severe neurological involvement in
spina bifida can prevent the anus from fully closing. Nerve damage
may cause a very lax anus resulting in a loss of ability to retain
stools, especially during periods of heavy physical activity, such
The presence of redundant tissue in the rectal canal may make correct
insertion of a suppository more difficult.
Altered sensation from nerve damage
There may also be a reduced or absent rectal sensation, causing
difficulty in recognising when the rectum is full or when bearing
down occurs. This difficulty in detecting sensation changes may
be greater when the person is busy or distracted, increasing the
risk of soiling. Patients need to be encouraged to go to the toilet
as soon as they feel the need, before any distraction can occur. Difficulty detecting soiling Some people will also have difficulties with
genital skin sensation that may affect their ability to feel when
their skin is wet after soiling. In addition, altered smell sensation
may make it difficult to detect when soiling has occurred. Slower bowel development The bowels of children with spina bifida can
be slow to develop. Some children may be as old as nine years before
the bowel is mature. This may mean many years of faecal incontinence. Mobility, activity and temperature changes Increased physical activity and changes in temperature
can cause the bowels to relax and empty, such as when having a bath
or when swimming. Medications Anaesthesia and medications can cause constipation.
Anticholinergic medications used for bladder incontinence control
can also cause constipation. Antibiotics, often for urinary tract
infections, may cause diarrhoea and increase the risk of faecal
incontinence. Where indicated, the prophylactic use of probiotic
yoghurt and increasing fibre intake may help to minimise these effects. Intercurrent exacerbating factors Lifestyle factors and life events may also cause
changes in bowel habits. Common exacerbating factors include:
disruption in usual daily routines
a change in water, such as when travelling
intercurrent illness, especially febrile illness
anxiety, especially at school or at work
hospital procedures or operations
changes to family structure such as a new birth, separation,
death of a relative, or
starting a new school or job.
Effective continence control is best achieved
within the context of a specialist clinic.
Access to facilities and aids Difficulty in access to bathrooms, toilets at
home, in educational institutions and the workplace can increase
incontinence control problems. In addition, there may be difficulty
in transferring to toilets if the person is in a wheelchair.
Table 8. Foods frequently associated
with causing loose stools and faecal incontinence
Citrus fruit, fruit juice, passionfruit,
Corn (fresh or tinned)
Chocolate/malt/chocolate powders used to flavour
Table 9. Dietary control of stool
consistency - foods that soften stools
Highly refined (white) breads, biscuits
High fibre breads and natural whole grain
cereal, eg. bran, oatmeal, rice, muesli
fruits, juice with high sugar content
raw vegetables, raw fruit, sugar free juices
and spices, nuts, pizza, muesli bars, chocolate
Overview of conservative management of faecal
incontinence Finding the balance - the role of the specialist
clinic As every patient is different, effective bowel
control regimens need to be tailored to the needs of each individual.
Effective continence control is best achieved within the context
of a specialist clinic. However, clinicians need to be aware of
the general management principles and interventions used for faecal
incontinence control. Diet, fluids, diarrhoea and constipation While a healthy diet for people of all ages is
a general health principle, diet can be used effectively by some
people to alter stool consistency and frequency in order to facilitate
Dietary control of stool consistency is not achievable by everyone,
but some patients can benefit significantly if given appropriate
information. Carers involved in food preparation may also benefit
from dietary information.
Certain foods can cause diarrhoea, which may exacerbate soiling
(Table 8). Also, stools can be softened by increasing foods high
in fat, fibre and moderate in sugar intake (Table 9). Water intake
should also be increased. Conversely, these foods should be decreased
when trying to harden stools (Table 10). Drug control of stool consistency Drugs can be used to control stool consistency,
but should only be used for a limited period of time, as long term
use of some drugs may have a deleterious effect on bowel function
and increase the risk of drug interactions. Bulk forming agents,
however, are not associated with long term adverse effects.
In general, expert advice should be consulted prior to initiating
drugs to control stool consistency, especially in children. Also,
some drugs, especially adsorbents, may interfere with the absorption
of other drugs. Commonly used drugs are listed in Table 11. Bowel emptying - overview of methods and
techniques There are many techniques and methods for emptying
bowels ranging from normal toileting to sophisticated surgical techniques.
Most young people and adults with spina bifida presenting to their
GP will have had extensive toileting program experience. The aim
of the following overview is to familiarise clinicians with the
principles of commonly used techniques in controlling faecal incontinence.
The prescription of individual bowel programs is best done within
the context of a specialist spina bifida clinic. General practitioners
should not hesitate to refer patients to these clinics if they detect
continuing problems with incontinence. Behavioural training Effective bowel control involves creating a system
for bowel emptying at regular intervals, at least every 24 hours.
Due to the lack of rectal sensation common in spina bifida, developing
a daily routine ensures regular evacuation. For example, associating
the timing of bowel emptying with meals, baths, physical activities,
particular times of day, helps establish predictable continence
patterns. This will depend upon the persons physical, cognitive
and functional level. Behavioural training will be more successful
if lower motor function is intact.
When establishing new bowel emptying patterns, daily reinforcement
of any bowel procedures with the assistance of regular home nursing
visits, where available, can greatly expedite the adoption of new
interventions. Anal/rectal stimulation Weakened nerves can sometimes be stimulated by
wiping the anus firmly with toilet paper as soon as the person sits.
If the stool is not being expelled, slight pressure can be applied
with fingers to each side of the anus to replace the natural lift
of the anus, lost due to neurological damage. Similarly, there are
other techniques that can be learned to improve bowel emptying.
Digital stimulation involves inserting a gloved finger into the
anal canal and internal sphincter, and massaging the mucosal wall
to stimulate a contraction to eliminate a stool. This is more effective
in the presence of lower motor neurons. Suppositories and microenemas Microenemas and suppositories can be used to
establish timed bowel actions and treat constipation. Microenemas
and suppositories can also fully empty the bowel, allowing a longer
period between evacuation.
Patients and carers need to learn correct techniques, which can
be taught in the specialist treatment clinic. Large volume fluid enemas If other methods have failed, large volume enemas
also called colonic washouts, may be required to treat constipation.
The amount and type of fluid is determined by the specialist clinic,
but may include solutions of saline; water; soap and water; or other
solutions. The enema is administered by using a 30 mL balloon catheter
and a large syringe. These are available in specially designed colonic
washout sets such as the Willis Washout System. Care must be taken
not to use rubber catheters in those with latex allergies.
The volume of fluid required for the enema may increase the pressure
on an already overstretched bowel, and there is an increased risk
Enemas will clean the bowel for 23 days. While many patients
find enemas a manageable way to control bowel emptying, large volume
enemas may be difficult or virtually impossible for a person with
limited mobility and can contribute to dependency. Buttock strapping This method can be used when prevention of soiling
is important, but will not work when the stools are soft, or when
there is diarrhoea. Strapping can be used when swimming, on special
outings or as a regular approach to faecal incontinence (Figure
6). Strapping should be removed from the buttocks
when it is the regular time to empty the bowels or when the person
feels the need to empty their bowels.
Try different types of tapes to ensure they are waterproof or that
no adverse reactions occur. Typically used tapes include elastic
adhesive tapes, nonallergenic tapes, waterproof adhesive tape and
Strapping buttocks: procedure
The tape is applied low on the buttocks
to be under the person when they sit down.
Cut the appropriate length of tape
Look for the position of the anus
Attach tape to one buttock. While holding buttocks
together, attach the other end of the tape to the other
buttock, ensuring that the tape passes over the anus.
If the skin is sensitive, place some nonallergenic
tape on each buttock. Stronger tape can then be applied
on top of the nonallergenic tape.
If the anus is very lax, a small piece of paper,
such as half a piece of toilet paper, can be folded and
placed over the anus. Females should check that the tape
has not slipped down into the vagina
Anal plugs Anal plugs are an important continence management
tool and offer real independence for some people with spina bifida.
The anal plug, made from foam, is lubricated with Vaseline and inserted
into the anus. After coming into contact with the moisture of the
bowel, it expands in about 30 seconds to form a mushroom like shape
that prevents rectal leakage. The anal plug is made from slightly
porous material so that air can pass through the plug. The plug
is removed with an attached string, and is changed after each toilet
visit. Removal of the plug does not stimulate the rectal muscles,
and thus the plug may be removed slowly. The anal plug can be worn
safely for up to 12 hours. Combined with diet and bowel regimens,
anal plugs have significantly changed the lives of many people with
spina bifida by increasing their independence.
Table 10. Dietary control of stool
consistency - foods that harden stools
High fibre breads and natural whole grain
cereal, eg. bran, oatmeal, rice, muesli
Highly refined (white) breads, biscuits
fruits and vegetables, fruit juice.
vegetables with low fibre such as potatoes, pumpkins,
carrots. Tinned fruits in small amounts
spices, pizza; minimise oil, butter and margarine
Table 11. Commonly used drugs to control
Bulk forming agents
that harden stools
Milk of magnesia
Parrafin (Paralax, Methylcellulose)
or ispaghula husk
Na sulphosuccinate (Coloxyl tablets)
Agents altering motility
Surgical procedures When bowel emptying and faecal incontinence is
not successfully controlled with the aforementioned methods, surgical
procedures may be indicated. These procedures are only used after
other more conservative methods have failed. Many patients express
high degrees of satisfaction after this procedure is performed.
These procedures are sometimes performed concomitantly with other
urological surgical procedures. Malone procedure and antegrade colonic enemas The Malone procedure - also called continent
appendicostomy - is used for the management of faecal incontinence
and involves bringing the appendix to the surface of the skin and
creating a stoma. Like similar procedures, the Malone procedure
provides access to the proximal colon for the administration of
enemas called antegrade colonic enemas (ACE). There is no unpleasant
smell as the bowel contents are sterile at the level of the appendix.
The stoma can be left in place longterm if necessary.
A major advantage of the Malone procedure is the ease of self administration,
especially in people with poor mobility when compared to the more
usual retrograde washouts.
One potential disadvantage of the Malone procedure is that the appendix
is then unavailable to use when constructing catheterisable stomas,
such as in the Mitrofanoff procedure (see Chapter 5 Controlling
urinary incontinence). Caecostomy catheters A caecostomy catheter is a nonlatex, flexible
tube that is inserted into the patients caecum through the
skin in the right iliac fossa, providing a comfortable, convenient
way to irrigate and empty the bowels with an enema solution. The
enema is given through the tube and the faeces exits through the
Caecostomy tubes can improve independence in those who experience
faecal incontinence with troublesome soiling and in those patients
that do not respond well to rectal enemas or other methods. For
example, they may be unable to perform retrograde bowel washouts.
Caecostomy tubes offer a chance for independence in patients who
may have previously run out of treatment options.
The caecostomy tube is placed in a two part process. Firstly, a
temporary tube is inserted into the caecum, which is followed about
six weeks later by a long term tube, which is much less visible
than the temporary tube.
There is a choice of washout fluids and many patients find that
optimal function is achieved by varying the composition of these
fluids. This is best discussed with a specialist continence clinic.
The caecostomy catheter provides a regular, predictable method for
defaecation and, due to its position, can be used independently
by wheelchair dependent people. Many people who previously wore
pads are able to wear regular underwear after a caecostomy tube.
Caecostomy catheters may not be suitable in people who have had
previous abdominal procedures.
Case study: Peter is 21 years and
has faecal incontinence Peter has ongoing faecal incontinence.
He is a community walker with anklefoot orthosis and
the incontinence interferes significantly with his active
The problem has also caused a lack of confidence, causing
him to quit two jobs and he remains housebound because of
frequent bowel accidents. Microenemas, routine training and
diet management have not been fully successful. Anal plugs
He uses large volume washouts every two days or so and manual
evacuation, both of which he needs assistance with. After
a Malone procedure he is able to much more confidently self
administer the enema, which seems to be working reliably.
As a result, Peter is slowly becoming more outward looking.