The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury: a randomized controlled trial of a stepwise protocol

Study design: Randomised controlled trial. Objectives: High-quality evidence for interventions in bowel management (BM) after spinal cord injury (SCI) is lacking and BM programs are developed empirically. This randomized, controlled trial compared usual care with a stepwise protocol based on earlier published work to examine whether systematic use of less invasive interventions could reduce the need for oral laxatives and invasive interventions such as manual evacuation, and improve BM outcomes in individuals with chronic SCI. Setting: United Kingdom. Methods: In all, 68 individuals were recruited (35 in intervention group), median age 47 years (range 24-73 years), median duration of injury 16 years (range 1-47 years). Bowel diaries were maintained for a maximum of 6 weeks while the intervention group followed a stepwise protocol designed to test interventions singly and in combination. Measures of quality of life and preferences for different bowel care interventions were recorded. Results: The stepwise protocol did not improve BM outcomes; fecal incontinence was more frequent (P=0.04); the need for oral laxatives and invasive interventions was not reduced (P=0.4). Bowel care took consistently longer in the intervention group. Conclusions: The study findings support the need for manual evacuation in BM and provide evidence of acceptability of the technique to SCI individuals. For some individuals oral laxatives are an essential part of management. The results are in contrast with previous studies in younger samples with shorter duration of injury. Spinal Cord (2010) 48, 504-510; doi: 10.1038/sc.2009.166; published online 1 December 2009