Management of faecal incontinence and constipation in adults with central neurological diseases

  • Review
  • Intervention

Authors


Abstract

Background

People with neurological disease have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine line between the two conditions, with any management intended to ameliorate one risking precipitating the other. Bowel problems are observed to be the cause of much anxiety and may reduce quality of life in these people. Current bowel management is largely empirical with a limited research base.

Objectives

To determine the effects of management strategies for faecal incontinence and constipation in people with neurological diseases affecting the central nervous system.

Search methods

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 26 January 2005), the Cochrane Central Register of Controlled Trials (Issue 2, 2005), MEDLINE (January 1966 to May 2005), EMBASE (January 1998 to May 2005) and all reference lists of relevant articles.

Selection criteria

All randomised or quasi-randomised trials evaluating any types of conservative or surgical measure for the management of faecal incontinence and constipation in people with neurological diseases were selected. Specific therapies for the treatment of neurological diseases that indirectly affect bowel dysfunction were also considered.

Data collection and analysis

Two reviewers assessed the methodological quality of eligible trials and two reviewers independently extracted data from included trials using a range of pre-specified outcome measures.

Main results

Ten trials were identified by the search strategy, most were small and of poor quality. Oral medications for constipation were the subject of four trials. Cisapride does not seem to have clinically useful effects in people with spinal cord injuries (three trials). Psyllium was associated with increased stool frequency in people with Parkinson's disease but did not alter colonic transit time (one trial). Prucalopride, an enterokinetic did not demonstrate obvious benefits in this patient group (one study). Some rectal preparations to initiate defaecation produced faster results than others (one trial). Different time schedules for administration of rectal medication may produce different bowel responses (one trial). Mechanical evacuation may be more effective than oral or rectal medication (one trial). There appears to be a benefit to patients in one-off educational interventions from nurses. The clinical significance of any of these results is difficult to interpret.

Authors' conclusions

There is still remarkably little research on this common and, to patients, very significant condition. It is not possible to draw any recommendation for bowel care in people with neurological diseases from the trials included in this review. Bowel management for these people must remain empirical until well-designed controlled trials with adequate numbers and clinically relevant outcome measures become available.

摘要

背景

中樞神經疾病成年患者大便失禁及便秘的處置

神經系統疾病患者發生大便失禁及便秘的風險較一般民眾高很多。而兩種狀況之間常只有一線之隔,以任何處置改善其中一項則會增加另一項的風險。排便問題是造成這些病人焦慮和降低生活品質的原因。目前對腸道問題的處置方式大多是根據經驗而研究基礎有限。

目標

確認中樞神經疾病成年患者大便失禁及便秘處置策略的效果。

搜尋策略

我們搜尋Cochrane Incontinence Group Specialised Trials Register(搜尋日期為2005年1月26日)、Cochrane Central Register of Controlled Trials (2005年第2期)、MEDLINE(1966年1月至2005年5月)EMBASE(1998年1月至2005年5月)及所有相關論文的參考文獻列表。

選擇標準

所有評估中樞神經疾病患者大便失禁及便秘的任何保守或外科處置之隨機或半隨機試驗。間接影響腸道功能失調的神經疾病特定療法也列入考量。

資料收集與分析

兩位評論者評估合適論文的方法學品質及兩位評論者從涵蓋的試驗中以先行指定的結果評量範圍獨立地抽出的數據。

主要結論

基於搜尋策略選出十個試驗,大多數規模小而品質差。四項以口服藥物治療便秘為主題。Cisapride對脊髓損傷者似乎不具臨床效益(四項試驗)。Psyllium會增加帕金森氏病患者排便次數,但沒有改變結腸通過時間(一項試驗)。Prucalopride(一種促進腸道蠕動的藥物)對這類病人未呈現顯著效益(一項試驗)。某些引發排便的直腸製劑較其他製劑有較快的效果(一項試驗)。不同時程給予直腸製劑會產生不同的腸道反應(一項試驗)。機械式排空會較口服或直腸給藥更為有效(一項試驗)。護理人員的衛教介入對病人似有助益。上述結果的臨床意義仍難以評斷。

作者結論

對此常見而病人十分在意的狀況研究仍相當不足。就本評論所涵蓋的試驗,不可能對神經疾病患者的腸道照護作出任何建議。對這些病人的腸道處置,在得到足夠數目、採用臨床上相關結果評量及設計良好的對照試驗之前,仍應採用經驗性療法。

翻譯人

本摘要由中國醫藥大學附設醫院王弼慧翻譯

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

中樞神經疾病成年患者大便失禁及便秘的處置。本評論的目的,是要確認中樞神經疾病患者大便失禁及便秘處置策略的效果。神經系統疾病患者發生大便失禁及便秘的風險較一般民眾高很多。而兩種狀況之間常只有一線之隔,以任何處置改善其中一項則會增加另一項的風險。排便問題是造成這些病人焦慮和降低生活品質的原因。本評論乃納入任何直接且慢性地影響中樞神經系統的病理機制(創傷後、退化性、缺血性或腫瘤)的疾病患者,如多發性硬化症、脊髓損傷、腦血管疾病、帕金森氏病及阿茲海默氏病。儘管有頗多文獻論及神經性腸道機能障礙的原因,卻少有針對實際治療的研究。目前這些患者常被建議攝取大量水份、均勻飲食、充足的運動、固定排便時間及使用適量藥物。腸道問題是以嘗試?錯誤的方式發展出合併採用藥物(如容積性瀉劑、緩瀉劑、灌腸)及機械式排空(如以指刺激、以手挖出、腹部按摩、直腸沖洗)的處置。本評論包括十個隨機試驗,規模均小而大多數品質欠佳。四項以口服藥物治療便秘為主題。Cisapride對脊髓損傷者似乎不具臨床效益(四項試驗)。Psyllium會增加帕金森氏病患者排便次數,但沒有改變結腸通過時間(一項試驗)。Prucalopride對這類病人未呈現顯著效益(一項試驗)。某些引發排便的直腸製劑較其他製劑有較快的效果(一項試驗)。不同時程給予直腸製劑會產生不同的腸道反應(一項試驗)。機械式排空會較口服或直腸給藥更為有效(一項試驗)。護理人員的衛教介入對病人似有助益。 對此常見而病人十分在意的狀況研究仍相當不足。就本評論所涵蓋的試驗,不可能作出任何建議。在得到足夠數目、採用臨床上相關結果評量及設計良好的對照試驗之前,對這神經性腸道處置,仍應採用經驗性療法。

Plain language summary

Management of faecal incontinence and constipation in adults with central neurological diseases

The objective of this review was to determine the effects of management strategies for faecal incontinence and constipation in people with neurological diseases affecting the central nervous system.
Individuals with neurological disease have a much higher risk of both faecal incontinence and constipation than the general population. There is often a fine dividing line between the two conditions, with any management intended to ameliorate one risking precipitating the other. Bowel problems are the source of much anxiety and may reduce quality of life. This review is relevant to individuals with any disease with a pathological process directly and chronically affecting the central nervous system (post-traumatic, degenerative, ischaemic or neoplastic), such as multiple sclerosis, spinal cord injuries, cerebrovascular diseases, Parkinson's disease and Alzheimer's disease.

While there is considerable literature on the causes of neurogenic bowel dysfunction, there are few studies that focus on the practical management. Currently such individuals are commonly advised to have a good fluid intake, a balanced diet, sufficient physical exercise, scheduled bowel routine and moderate use of medications. Bowel management employs a combination of medications (e.g. bulking agents, laxatives, enemas) and mechanical interventions (e.g. digital stimulation, manual evacuation, abdominal massage, rectal irrigation) established on a trial and error basis.

The ten randomised studies included in this review reported small samples and were mostly of poor quality. Oral medications for constipation were the subject of four trials. Cisapride does not seem to have clinically useful effects in people with spinal cord injuries (three trials). Psyllium was associated with increased stool frequency in people with Parkinson's disease but not altered colonic transit time (one trial). Prucalopride did not demonstrate obvious benefits in this patient group (one study). Some rectal preparations to initiate defecation produced faster results than others (one trial). Different time schedules for administration of rectal medication may produce different bowel responses (one trial). Mechanical evacuation may be more effective than oral or rectal medication (one trial). Patients may benefit from even one-off educational interventions from nurses (one trial).

There is still remarkably little research on this common and, to patients, very significant condition. It is not possible to draw any recommendation from the trials included in this review. Neurogenic bowel management must remain empirical until well-designed controlled trials with adequate numbers and clinically relevant outcome measures become available.