Effectiveness and safety of digital rectal stimulation and abdominal massage for neurogenic bowel dysfunction in stroke patients: a randomized controlled trial protocol.

BACKGROUND: Neurogenic bowel dysfunction (NBD) is a prevalent complication among stroke patients, significantly affecting their quality of life, duration of hospitalization, medical expenses, and even mortality. Although current guidelines suggest a conservative strategy for addressing bowel dysfunction, which includes techniques such as digital rectal stimulation (DRS) and abdominal massage, the availability of interventions remains limited in healthcare facilities. METHODS: This study follows a prospective randomized controlled parallel-group clinical trial design. The control group will receive standard care, while the intervention group will undergo a program that combines DRS and abdominal massage in addition to standard care. The duration of the intervention for both groups will be 6 weeks. The primary outcome measures will be the Wexner score. Furthermore, secondary outcomes measure will be assessed, including Bristol score, Patient Assessment of Constipation-Quality of Life (PAC-QoL), and Fecal Incontinence Quality of Life (FI-QoL). DISCUSSION: This study aims to evaluate the effectiveness and safety of a bowel rehabilitation program for stroke patients with NBD. The findings will provide information that can contribute to the formulation of bowel management strategies. TRIAL REGISTRATION: The study has been registered in the Chinese Clinical Registry under the number ChiCTR2300071709. This registration was completed on May 23, 2023. All items from the World Health Organization Trial Registration Data set are described in this manuscript.

Content, face, and construct validity of the Irritable Bowel Syndrome Quality of Life (IBS-QOL) as a measure of bowel-related quality of life in spinal cord injury.

INTRODUCTION: Neurogenic bowel dysfunction is commonly encountered after a spinal cord injury (SCI), leading to a tremendous impact on quality of life (QOL). The neurogenic bowel dysfunction score (NBDS) is commonly used to measure the severity of bowel dysfunction and predict QOL. However, there is no comprehensive instrument to assess bowel-specific QOL for SCI patients. Instead, the Irritable Bowel Syndrome-Quality of Life (IBS-QOL) questionnaire evaluates the impact of bowel dysfunction on several aspects of QOL, although this questionnaire has not been validated for the SCI population. Motivated by the compelling need of instruments to accurately evaluate the QOL in patients who develope NBD after SCI, we aimed to assess the construct, content, and face validity of IBS-QOL in this population. METHODS: Adult SCI patients with at least 3 months after their injury were recruited from the outpatient clinic of a national rehabilitation hospital. Patients completed the NBDS and IBS-QOL via telephone interview or paper survey in the clinic. Content and face validity were assessed via interviews with professionals with expertise in providing chronic care for SCI, as well as a subgroup of patients. Construct validity was assessed using the hypotheses testing method. Internal consistency was assessed using Cronbach's ⍺. Factor analysis was performed to assess the dimensionality of the IBS-QOL in the SCI population. RESULTS: A total of 106 patients with a median age of 45.5 years (interquartile range: 21-79) participated in the study. The majority of the sample were men (n = 82, 77%) and had endured thoracolumbar injuries (n = 74, 71.2%). Twelve patients (seven English- and five Spanish speakers) and six professionals took part in content/face validation interviews. The median IBS-QOL total score was 15.91/100 (interquartile range: 4.55-33.14). IBS-QOL differentiated the subgroups of patients with severe bowel symptoms in terms of uneasiness, sweating, or headaches during bowel emptying (p = 0.0003), time spent on bowel emptying (p = 0.0065), flatus incontinence (p = 0.0076), and overall satisfaction with bowel function (p < 0.001), demonstrating its adequate construct validity. Interviews with the patients and professionals supported the comprehensiveness, comprehensibility, and relevance of IBS-QOL for assessment of bowel-related QOL in the SCI population. Item-level analysis of professional responses showed that 97% of questions were relevant to the construct and population of interest. Internal consistency analysis yielded a Cronbach's ⍺ of 0.9684. Exploratory factor analysis yielded six underlying factors which cumulatively accounted for 72.21% of the total variance, reflecting the dimensionality of bowel-related QOL in SCI population. DISCUSSION: IBS-QOL questionnaire is a comprehensive measure of bowel-related QOL which encompasses the concerns of SCI patients. Our findings support the content, face and construct validity of IBS-QOL as a measure of bowel-related QOL in SCI. Further studies are warranted to assess the reliability and responsiveness of IBS-QOL, and to evaluate its performance across different patient populations.

Pediatric neurogenic bowel dysfunction: ICCS review document.

INTRODUCTION: The International Children's Continence Society (ICCS) aims to improve the quality of life in children with lower urinary tract dysfunction. A substantial portion of children also have problems with bowel dysfunction. There is a lack of evidence-based information on managing neurogenic bowel dysfunction (NBD) in children. OBJECTIVE/METHODS: The ICCS aimed to provide an up-to-date, selective, non-systematic review of NBD's definitions, assessment, and treatment. RESULTS: Specific definitions and terminology are defined within the document. Recommendations and considerations for physical assessment, history taking, and diagnostic studies are made. Management updates, both surgical and non-surgical, are provided as well as recommendations for follow-up and monitoring of individuals with NBD. CONCLUSION: This review of the current literature will help guide NBD management and research to improve NBD care.

The Neurogenic Bowel Dysfunction score (NBD) is not suitable for patients with multiple sclerosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Bowel and anorectal dysfunctions are common in patients with multiple sclerosis (pwMS). The use of validated questionnaires is recommended in the initial assessment and patient's follow-up. The Neurogenic Bowel Dysfunction (NBD) score is the most used questionnaire but has been developed in spinal cord injured patients and has never been validated in other neurological diseases. We aimed to assess NBD's relevance in pwMS. SETTINGS: Monocentric study in a tertiary neuro-urology department. METHODS: A retrospective study in pwMS consulting for the first time in our department, that fulfilled the NBD questionnaire between 2010 and 2021 was performed. Qualitative and quantitative answers for each question were analyzed. Content validity and internal consistency were evaluated. RESULTS: One hundred thirty-five pwMS (mean age 47.1, 58% of women) fulfilled the NBD questionnaire. Mean NBD score was 6.0 (SD 6.1) and 75% of patients had a score <9. Content validity analysis revealed 4 items not appropriate, 1 item with irrelevant calibration, and omission of some treatment widely used in pwMS. Internal consistency was appreciated with Cronbach's alpha = 0.48 IC 95% [0.31; 0.6]. CONCLUSION: NBD questionnaire lacks content validity and presents a weak internal consistency in pwMS. A specific questionnaire is therefore required in pwMS to optimize bowel management and follow-up.

Guideline for the management of neurogenic bowel dysfunction in spinal cord injury/disease.

INTRODUCTION: Almost all people with spinal cord injury/disease (SCI/D) suffer from neurogenic bowel dysfunction (NBD), with a considerable impact on quality of life. The Association of the Scientific Medical Societies in Germany (AWMF e.V.) guideline for NBD in SCI/D aims to provide practice-oriented support for the care of patients with NBD resulting from congenital or aquired SCI/D. The guideline describes the diagnosis and bowel management of NBD in people with SCI/D. Thus, treatment processes in acute medical care and rehabilitation as well as for lifelong aftercare are presented. METHODS: The present guideline was developed under the leadership of the German-speaking Medical Society for Paraplegiology in a multiprofessional interdisciplinary guideline team. To exceed the level of expert recommendations, consensus was reached within the framework of a structured nominal group process in defined steps under neutral moderation considering the criteria of the German guideline development instrument (DELBI). RESULTS: Individual bowel management must be developed on the basis of an adequate diagnosis and considering the different lesion types. Due to the multifactorial influenceability of the intestine and the individual neurological deficit, a simple to-do checklist is not effective. Various and complex bowel management programmes are the basis of the treatment of NBD. CONCLUSIONS: Guidelines can only be successful in so far as they are applied in everyday life. Of course, the selection and application of the measures described must always take into consideration the individual situation of the person concerned, and the correct application is always a prerequisite for success.

Neurogenic bowel dysfunction score in spinal cord-injured patients: translation and validation of the Dutch-language NBD score.

STUDY DESIGN: This is a prospective validation study. OBJECTIVES: The neurogenic bowel dysfunction (NBD) score is a widely used symptom-based questionnaire evaluating bowel dysfunction and its impact on quality of life (QoL) in spinal cord-injured patients. This study aimed to translate and validate a Dutch-language NBD score in patients with SCI. SETTING: Patients with SCI visiting the urology department or general practitioner (GP) in Rotterdam, the Netherlands. METHODS: Standardized guidelines were followed for the translation and validation process of the NBD score. Adult patients with SCI visiting our urology department were asked to participate by filling in a set of questionnaires: the NBD score, the Fecal Incontinence Quality of Life scale (FIQL), the Fecal Incontinence Severity Index (FISI), and the European Quality of life 5-Dimension 3-Level questionnaire (EQ-5D-3L) at baseline and 1-2 weeks afterward. A control group recruited at a GP office completed the questionnaires once. The following measurement properties were evaluated: content validity, internal consistency, reproducibility, criterion-, and construct validity. RESULTS: Fifty-eight patients and 50 references were included. Content validity was adequate, internal consistency was moderate (Cronbach's alpha 0.56 and 0.30) and reproducibility was adequate (ICC 0.87). Criterion validity was confirmed; NBD score correlated significantly with the FIQL, FISI, and EQ-5D-3L. NBD scores in the patient group were significantly higher than in references, demonstrating good construct validity. CONCLUSIONS: The Dutch-language version of the NBD score showed moderate to good measurement properties, and therefore is a reliable tool to measure bowel dysfunction in patients with SCI. We recommend standardized usage of this questionnaire for clinical evaluation and research purposes.

Validación al español de la versión en inglés del Neurogenic Bowel Dysfunction score (NBD score) en pacientes con lesión neurológica de origen central / Spanish validation of the Neurogenic Bowel Dysfunction score -NBD score- in patients with central neurological injury

Objetivo: validar al español el Neurogenic Bowel Dysfunction score (NBD score) que cuantifica la severidad de la disfunción intestinal en pacientes con discapacidad por lesión neurológica central y la satisfacción con el manejo intestinal.Material59 pacientes, 30 pacientes afectados de discapacidad intestinal por lesión medular y 29 pacientes afectados de discapacidad intestinal por accidente vascular cerebral.ResultadosEl resultado de la fiabilidad del constructo de la traducción al español del NBD Score para todo el grupo de pacientes muestra una α de Cronbach para todas las variables de 0,970 y el resultado de la fiabilidad del NBD score para todo el grupo en el test-retest, mediante el coeficiente de correlación interclase fue 0,970 (95% IC 0,954-0,980).ConclusionesLa versión traducida al español del NBD score es una herramienta válida para ser utilizada en nuestro medio, permitirá un acercamiento más real a la situación de discapacidad de cada paciente en relación con la disfunción intestinal neurógena y conocer la intensidad de la afectación y la eficacia en su manejo mediante las diferentes propuestas terapéuticas. (AU)

Objective: to validate into Spanish the Neurogenic Bowel Dysfunction score (NBD score) that quantifies intestinal dysfunction severity in patients with disabilities due to central neurological injury and satisfaction with bowel management.Material59 patients, 30 patients affected by intestinal disability due to spinal cord injury and 29 patients with intestinal disability due to stroke.ResultsThe result of the reliability of the construction of the Spanish translation of the NBD score for the whole group of patients shows a Cronbach's α for all the variables of 0.970 and the result of the reliability of the NBD score for the whole group in test-retest, using the interclass correlation coefficient, was 0.970 (95% CI 0.954-0.980).ConclusionsThe Spanish version of the NBD score is a valid tool for use in our environment; it will allow a more real approach to the disability situation of each patient in relation to neurogenic intestinal dysfunction and knowledge of the degree and the involvement and effectiveness of management through different therapeutic proposals. (AU)

Utility estimation for neurogenic bowel dysfunction in the general population.

BACKGROUND: Neurogenic bowel dysfunction (NBD) affects over 80% of individuals with spina bifida causing bowel incontinence and/or constipation. NBD is also associated with decreased quality of life, depression, anxiety, and decreased employment/educational attainment. Because NBD is a life-altering condition without a cure, understanding the utility of different health states related to NBD would aid clinicians as they try to counsel families regarding management options and to better understand the quality of life associated with disease management. OBJECTIVE: To elicit utility scores for NBD using an online community sample. STUDY DESIGN: A cross-sectional anonymous survey was completed by 1534 voluntary participants via an online platform (Amazon Mechanical Turk (MTurk, http://www.mturk.com/)), representing an 87% response rate. The survey presented hypothetical scenarios that asked respondents to imagine themselves as an individual living with NBD or as the caretaker of a child with NBD. The time trade-off (TTO) method was used to estimate a utility score, and outcomes for each scenario were calculated using median and IQR. Univariate comparisons of distributions of TTO for demographic data were made using Kruskal-Wallis tests. RESULTS: The median utility score for NBD was 0.84 [0.70-0.92]. Participants reported that they would give up a median of 5 years of their own life, to prevent NBD in themselves of their child. Utility values for child scenarios were significantly different when stratified by age, gender, race, parental status, marital status, and income. Stratification by current health status did not yield significantly different utility values. DISCUSSION: Study findings are comparable with other TTO-determined utility values of moderately severe disease states, including severe persistent asthma (0.83), moderate seizure disorder (0.84) and mild mental retardation (0.84). The significant variations in utility values based on age, gender, race, parent status, partner/marital status and income variables existed in our study, which is similar to findings in other health fields. Study limitations include lack of unanimous agreement about TTO's validity in measuring utility values, and MTurk participant reports can be generalized to greater population. CONCLUSION: NBD is perceived by the community as having a substantial impact on the lives of children with spina bifida, representing a 16% reduction from perfect health. In general, health state utilities have been increasingly used in healthcare systems to understand how burdensome a population perceives a disease is and to evaluate whether interventions improve quality of life years.

Spanish validation of the Neurogenic Bowel Dysfunction score -NBD score- in patients with central neurological injury. / Validación al español de la versión en inglés del Neurogenic Bowel Dysfunction score (NBD score) en pacientes con lesión neurológica de origen central.

OBJECTIVE: to validate into Spanish the Neurogenic Bowel Dysfunction score (NBD score) that quantifies intestinal dysfunction severity in patients with disabilities due to central neurological injury and satisfaction with bowel management. MATERIAL: 59 patients, 30 patients affected by intestinal disability due to spinal cord injury and 29 patients with intestinal disability due to stroke. RESULTS: The result of the reliability of the construction of the Spanish translation of the NBD score for the whole group of patients shows a Cronbach's α for all the variables of 0.970 and the result of the reliability of the NBD score for the whole group in test-retest, using the interclass correlation coefficient, was 0.970 (95% CI 0.954-0.980). CONCLUSIONS: The Spanish version of the NBD score is a valid tool for use in our environment; it will allow a more real approach to the disability situation of each patient in relation to neurogenic intestinal dysfunction and knowledge of the degree and the involvement and effectiveness of management through different therapeutic proposals.

Assessment of neurogenic bowel symptoms with the bowel dysfunction score in children with spina bifida: a prospective case-control study.

AIM: To compare the quality of life (QoL) in children with spina bifida with a control group of their peers using a validated questionnaire, the Neurogenic Bowel Dysfunction Score (NBDS). METHODS: The NBDS questionnaire was prospectively distributed to children attending a multi-disciplinary Spina Bifida clinic and healthy controls attending pediatric urology clinics. A score (out of 41) was assigned to each child based on their responses to the validated questionnaire. A lower score indicates better bowel function-related quality of life. SPSS software (v.25) was used for all statistical analysis. RESULTS: There were 98 respondents to the questionnaire, 48 children with spina bifida and 50 controls. The average age of respondents was 7.88 years (3-16 years). Of those with Spina Bifida, 33 (69%) were on retrograde rectal irrigations, [19 (58%) Peristeen® system, 11 (33%) tube rectal irrigations, and 3 (9%) Willis system], 6 (12%) were on laxatives, and 9 (19%) were on no treatment. The median NBDS for Spina Bifida patients was significantly higher 13.5 (2-32) compared to the control group 2 (0-26, p < 0.001). Amongst Spina Bifida patients, there was no difference in quality of life between the modalities of bowel management (p = 0.203). CONCLUSIONS: Despite active bowel management, children with spina bifida report a worse quality of life compared to the control group. In those with spina bifida, the lack of a difference between various bowel management strategies, including no treatment, indicates the need for a longitudinal study to evaluate the basis for this unexpected finding.

Development of a novel neurogenic bowel patient reported outcome measure: the Spinal Cord Injury Patient Reported Outcome Measure of Bowel Function & Evacuation (SCI-PROBE).

STUDY DESIGN: Outcome measure item generation and reduction. OBJECTIVES: To develop a patient reported outcome measure (PROM) addressing the impact of neurogenic bowel dysfunction (NBD) on individuals living with traumatic or nontraumatic spinal cord injury (SCI). SETTING: Tertiary rehabilitation center in Toronto, Canada. METHODS: A PROM based on the International Classification of Functioning, Disability and Health (ICF) framework was developed using the following steps: (a) item generation, (b) item refinement through iterative review, (c) completion of items by individuals living with SCI and NBD followed by cognitive interviewing, and (d) further item refinement, item reduction, and construction of the preliminary PROM. RESULTS: Following initial item generation and iterative review, the investigative team agreed on 55 initial items. Cognitive interviewing, additional revisions, and item reduction yielded an instrument comprised of 35 items; while ensuring at least two items were retained for each of the 16 previously identified challenges of living with NBD following the onset of a SCI. Scoring for the preliminary PROM ranges from 0 to 140. CONCLUSIONS: A preliminary PROM informed by the ICF for assessing the impact of NBD post-SCI has been devised, which can be used to inform clinicians and decision-makers on optimal ways to treat this serious secondary health complication. Future work will assess the validity and clinimetric properties of the PROM.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease.

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Creation and validation of a new tool for the monitoring efficacy of neurogenic bowel dysfunction treatment on response: the MENTOR tool.

STUDY DESIGN: Prospective observational study. OBJECTIVES: A tool to help decision-making tool for Neurogenic Bowel Dysfunction (NBD) in individuals with SCI is needed. We present a project to create and validate a new tool, the Monitoring Efficacy of NBD Treatment On Response (MENTOR), and to determine its level of concordance with decisions made by experienced clinicians in the field. SETTING: UK, Denmark, USA, Italy, The Netherlands, Germany. METHODS: The first phase was creation of the tool through a modified Delphi process. The second phase was the validation, wherein individuals with spinal cord injury with NBD were asked to complete the MENTOR tool immediately prior to clinic consultation. From the responses to the questionnaire of the tool, each participant was allocated into one of three categories reflecting the possible therapeutic recommendations ("recommend change", "further discussion" and "monitoring"). An expert clinician then assessed the participant, blinded to MENTOR results, and made an independent treatment decision. RESULTS: A total of 248 MENTOR forms were completed. Strong agreement was found when the MENTOR tool recommended monitoring (92%) or treatment change (83%); the lowest concordance when the decision was for the "further discussion" option (59%). Patient acceptability was reported by 97% of individuals. CONCLUSIONS: MENTOR is an easy to use tool to monitor the treatment of NBD and determinate progression through the clinical pathway. This validation study shows good correspondence between expert clinician opinion and MENTOR result. The tool has potential to be used in other patient groups, following further studies.

Anti-muscarinic drugs increase rectal compliance and exacerbate constipation in chronic spinal cord injury : Anti-muscarinic drug effect on neurogenic bowel.

STUDY DESIGN: Prospective cohort study OBJECTIVES: We hypothesized that anti-muscarinic agents alter rectal compliance in SCI patients and that altered rectal compliance relates to bowel symptomatology. Our primary aim was to compare rectal compliance before and after the institution of anti-muscarinics (solifenacin and tolterodine) and an adrenoceptor agonist (mirabegron) in these patients. Additionally, we wanted to evaluate if anorectal manometry differed before and after use of anti-muscarinic agents. SETTING: Tertiary neurogastroenterology clinic, London METHODS: Thirty-five patients with supraconal spinal cord injury (SCI) underwent anal manometry, assessment of rectoanal inhibitory reflex (RAIR) and rectal compliance before and after anti-muscarinic treatment (for overactive bladder) was started (mean follow-up 12 weeks). Patients were assessed identically, pre-and post-treatment (solifenacin n = 17, tolterodine n = 10, mirabegron n = 8). Doses used were as for non-SCI patients. RESULTS: Resting, squeeze and cough pressures were unchanged after anti-muscarinic treatment. Rectal compliance was significantly raised after anti-muscarinic treatment (p = 0.001). The percent amplitude of maximal sphincter relaxation of the RAIR was decreased (p < 0.001) and excitation latency was increased (p = 0.006). There was no significant change in the duration of recovery of the RAIR. There was a significant increase of the Wexner Constipation Score (p = 0.001) but no change in the Wexner Incontinence Score. There was a significant correlation between change in rectal compliance and change in Wexner Constipation Score (p = 0.001). Thus, increasing compliance of the rectum is associated with worsening of constipation after anti-muscarinic therapy. However, there were no changes in anorectal manometry or rectal compliance in those who received mirabegron. CONCLUSION: Anti-muscarinic therapy for overactive bladder increases compliance of the neurogenic rectum and alters anorectal reflex activity, with worsening of constipation.

Assessment of neurogenic bowel dysfunction impact after spinal cord injury using the International Classification of Functioning, Disability and Health.

BACKGROUND: Bowel function is frequently compromised after spinal cord injury (SCI). Regardless of this crucial importance in patients' lives, there is still scarce literature on the Neurogenic Bowel Dysfunction (NBD) deleterious impact on SCI patient's lives and only few studies correlating NBD severity with quality of life (QoL). To our knowledge there are no studies assessing the impact of NBD on the context of ICF domains. AIM: To assess NBD after SCI using ICF domains and to assess its impact in QoL. DESIGN: Retrospective data analysis and cross-sectional phone survey. SETTING: Outpatient spinal cord injury setting. POPULATION: Portuguese adult spinal cord injury patients. METHODS: Retrospective analysis of demographic data, lesion characteristics and bowel management methods at last inpatient discharge. Cross-sectional phone survey assessing current bowel management methods, the Neurogenic Bowel Dysfunction Score and a Likert Scale questionnaire about the impact on ICF domains and QoL. RESULTS: Sixty-four patients answered the questionnaire. The majority was male (65.6%), mean age 56.6±15.6 years, AIS A lesion (39.1%), with a traumatic cause (71.9%). The main bowel management methods were contact laxatives, suppositories and osmotic laxatives. 50.1% of patients scored moderate or severe NBD. Considering ICF domains, the greatest impact was in personal and environmental factors, with 39.1% reporting impact in financial costs, 45.3% in need of assistance, 45.3% in emotional health and 46.9% in loss of privacy. There was a significant association between severity of NBD and negative impact on QoL (P<0.05). CONCLUSIONS: The study confirms the major impact of NBD on personal and environmental factors of ICF and on the quality of life of SCI population. CLINICAL REHABILITATION IMPACT: These findings confirm that it is relevant to identify the main ICF domains affected by NBD after SCI in order to address targeted interventions, working toward changes in health policies and psychosocial aspects.

Neurogenic bowel dysfunction: Clinical management recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013.

BACKGROUND: Evidence-based guidelines for the management of neurological disease and lower bowel dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance. AIMS: To update clinical management of neurogenic bowel dysfunction from the recommendations of the 4th ICI, 2009. MATERIALS AND METHODS: A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and modifications applied to deliver evidence based conclusions and recommendations for the scientific report of the 5th edition of the ICI in 2013. RESULTS: The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic bowel dysfunction. The pathophysiology is described in terms of spinal cord injury, multiple sclerosis, and Parkinson's disease. Assessment requires detailed history and clinical assessment, general investigations, and specialized testing, if required. Treatment primarily focuses on optimizing stool consistency and regulating bowel evacuation to improve quality of life. Symptom management covers conservative and interventional measures to promote good habits and assist stool evacuation, along with prevention of incontinence. Education is essential to achieving optimal bowel management. DISCUSSION: The review offers a pragmatic approach to management in the context of complex pathophysiology and varied evidence base.

Reliability, validity and sensitivity to change of neurogenic bowel dysfunction score in patients with spinal cord injury.

STUDY DESIGN: Psychometrics study. OBJECTIVES: The aim of this study is to investigate the validity, reliability and sensitivity to change of neurogenic bowel dysfunction (NBD) score. SETTING: Dokuz Eylül University Faculty of Medicine, Turkey. METHODS: The study included 42 patients with spinal cord injury (SCI). The reliability of NBD score was assessed by test-retest reliability and internal consistency. Cronbach's alpha coefficient was calculated to determine internal consistency. The construct validity was evaluated by exploring correlations between the NBD score and SF-36 scales, patient assessment of impact of NBD on quality of life (QoL) and the physician global assessment (PGA). The Global Rating of Change (GRC) scale was used to assess the change of NBD to investigate the sensitivity of the score to change. RESULTS: Cronbach's alpha coefficient was 0.547. In test-retest reliability analysis, high correlations between total test-retest NBD score and answers of each question were found (r=1.000, P<0.001). NBD score had a strong and significant correlation with PGA (r=0.98, P<0.000) and the impact on QoL (r=0.92, P<0.001). There was a significant negative correlation between NBD score and subscales of SF-36 (P<0.05) except physical functioning, physical role functioning and physical component summary score. There was a significant improvement in NBD scores after treatment (P=0.011). A significant positive correlation was found between GRC scale and change in total NBD score (r=0.821, P=0.007). CONCLUSION: The Turkish version of the NBD score is a valid and reliable instrument and also sensitive to change in patients with SCI.

A Rare Intramedullary Spinal Cord Metastasis from a Retroperitoneal Leiomyosarcoma Presenting as a Non-Traumatic Spinal Cord Injury.

Leiomyosarcoma (LMS) is a rare but well-recognized malignant soft tissue sarcoma of smooth muscle origin. Metastases commonly occur in the lungs, liver, kidney, brain, and bone. Cases of metastatic osseous lesions or other extradural space-occupying masses secondary to LMS leading to neurologic compromise are relatively commonplace in the literature. Conversely, cases of intramedullary spinal cord metastasis (ISCM), an unusual entity as a sequela of any cancer, are exceedingly rare as a consequence of LMS. Only 2 cases of an ISCM from LMS are currently documented in the literature, and to the best of our knowledge, no case is described in the rehabilitation literature. This case report presents a patient with a history of longstanding metastatic LMS presenting with incomplete paraplegia, neurogenic bowel and bladder, and neuropathic pain. The patient was found to have an ISCM of the thoracic spinal cord. She made functional gains with concurrent inpatient rehabilitation and radiation but was unable to perform her own intermittent catheterization program, bowel program, or transfers and was unable to discharge home independently. Intramedullary spinal cord metastasis is a rare and potentially devastating consequence of LMS or any primary cancer, but can be amenable to common interventions in the acute inpatient rehabilitation setting.