We searched the Cochrane Incontinence Group Trials Register (searched 8 June 2012), which includes searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process as well as handsearching of journals and conference proceedings; and all reference lists of relevant articles.
SELECTION CRITERIA: Two review authors independently assessed the risk of bias of eligible trials and independently extracted data from the included trials using a range of pre-specified outcome measures.
MAIN RESULTS: Twenty trials involving 902 people were included.Oral medicationsThere was evidence from individual small trials that people with
Parkinson's disease had a statistically significant improvement in the number of bowel motions or successful bowel care routines per week when fibre (
psyllium) (mean difference (MD) -2.2 bowel motions, 95% confidence interval (CI) -3.3 to -1.4) or oral
laxative (isosmotic
macrogol electrolyte solution) (MD 2.9 bowel motions per week, 95% CI 1.48 to 4.32) are used compared with placebo. One trial in people with
spinal cord injury showed statistically significant improvement in total bowel care time comparing intramuscular
neostigmine-
glycopyrrolate (
anticholinesterase plus an
anticholinergic drug) with placebo (MD 23.3 minutes, 95% CI 4.68 to 41.92).Five studies reported the use of
cisapride and
tegaserod in people with
spinal cord injuries or
Parkinson's disease. These drugs have since been withdrawn from the market due to adverse effects; as they are no longer available they have been removed from this review.Rectal stimulantsOne small trial in people with
spinal cord injuries compared two
bisacodyl suppositories, one
polyethylene glycol-based (
PGB) and one hydrogenated
vegetable oil-based (HVB). The trial found that the
PGB bisacodyl suppository significantly reduced the mean defaecation period (
PGB 20 minutes versus HVB 36 minutes, P < 0.03) and mean total time for bowel care (
PGB 43 minutes versus HVB 74.5 minutes, P < 0.01) compared with the HVB
bisacodyl suppository.Physical interventionsThere was evidence from one small trial with 31 participants that abdominal
massage statistically improved the number of bowel motions in people who had a
stroke compared with no
massage (MD 1.7 bowel motions per week, 95% CI 2.22 to 1.18). A small feasibility trial including 30 individuals with
multiple sclerosis also found evidence to support the use of abdominal
massage.
Constipation scores were statistically better with the abdominal
massage during treatment although this was not supported by a change in outcome measures (for example the
neurogenic bowel dysfunction score).One small trial in people with
spinal cord injury showed statistically significant improvement in total bowel care time using electrical stimulation of abdominal muscles compared with no electrical stimulation (MD 29.3 minutes, 95% CI 7.35 to 51.25).There was evidence from one trial with a low risk of bias that for people with
spinal cord injury transanal irrigation, compared against conservative bowel care, statistically improved
constipation scores,
neurogenic bowel dysfunction score, faecal incontinence score and total time for bowel care (MD 27.4 minutes, 95% CI 7.96 to 46.84). Patients were also more satisfied with this method.Other interventionsIn one trial in
stroke patients, there appeared to be a short term benefit (less than six months) to patients in terms of the number of bowel motions per week with a one-off educational intervention from nurses (a structured nurse assessment leading to targeted education versus routine care), but this did not persist at 12 months. A trial in individuals with
spinal cord injury found that a stepwise protocol did not reduce the need for oral laxatives and manual evacuation of stool.Finally, one further trial reported in abstract form showed that oral
carbonated water (rather than tap water) improved
constipation scores in people who had had a
stroke.
AUTHORS' CONCLUSIONS: There is still remarkably little research on this common and, to patients, very significant issue of bowel management. The available evidence is almost uniformly of low methodological quality. The clinical significance of some of the research findings presented here is difficult to interpret, not least because each intervention has only been addressed in individual trials, against control rather than compared against each other, and the interventions are very different from each other.There was very limited evidence from individual trials in favour of a bulk-forming
laxative (
psyllium), an isosmotic
macrogol laxative, abdominal
massage, electrical stimulation and an
anticholinesterase-
anticholinergic drug combination (
neostigmine-
glycopyrrolate) compared to no treatment or controls. There was also evidence in favour of transanal irrigation (compared to
conservative management), oral carbonated (rather than tap) water and abdominal
massage with lifestyle advice (compared to lifestyle advice alone). However, these findings need to be confirmed by larger well-designed controlled trials which should include evaluation of the acceptability of the intervention to patients and the effect on their quality of life.