Hypothesis / aims of study
Neurogenic bowel dysfunction (NBD) affects quality of life: lots of aspects, such as job, hobbies, daily activities, can be conditioned by symptoms related to NBD. Through the establishment of specific bowel program it is possible to mitigate these problems.
Retrograde Trans-Anal Irrigation (TAI) has become an established treatment for neurogenic bowel dysfunction (NBD) which does not respond to conservative management (1). The impact of TAI in NBD is considerable and it improves quality of life by reducing constipation and faecal incontinence.
Moreover through complete emptying of the descending colon, sigmoid colon and rectal ampulla, obtained by TAI, it is possible to carry out more control on the incidence of urinary tract infections (UTIs) (1, 2), because TAI can remove residual stool, the main source of infection
However, some long-term studies have shown a reasonable rate of non-adherence to treatment due to compromised effectiveness and difficulty to use. The percentage of drop out varies from 54% in a series of 19 months follow-up (1), to 14% in a series of children (3). Nevertheless there are only a few studies that investigate adherence to TAI in long term period: long term follow-up of TAI use is not clearly known and the percentage of infections reduction is not clearly demonstrated.
Study design, materials and methods
From July 2008 to February 2020, 88 patients have been trained in our centre to perform TAI using a system called Peristeen (Coloplast A/S). It is an integrated system consisting of a coated rectal balloon catheter, a control unit including a manual pump, and a water container. The catheter was inserted into the rectum and the balloon inflated to hold the catheter in the rectum while a tap water enema was slowly administered with the manual pump, keeping a stable pressure in the bowel. Subsequently, the balloon was deflated and the catheter removed, followed by bowel emptying of the enema and other bowel contents.
In 2013 we established a “TAI unit” made up of a dedicated team (1 doctor and 3 nurses): before 2013 38 patients were trained, from 2013 50 patients were trained.
We performed a prospective study with the last 50 patients trained to TAI in our centre: we administrated a questionnaire about bowel function (NBD score before and after TAI) ; we asked them the frequency (episodes per year) of urinary tract infections before and after TAI. With the term “infection” we mean symptomatic infection that lead to prescription of antibiotic therapy. Moreover, we asked patients if they follow an antimicrobial prophylaxis, with antibiotics or supplements. We followed the patients by visit or phone interview or e-mail, asking them if they still use TAI; if they do not use TAI yet, we asked them the reason that had determinate the abandonment of the treatment.
Results
From September 2013 to February 2020 we teached TAI technique to 50 patients.
From the 50 patients trained in TAI in our centre, none of the patients is lost at follow up.
Mean follow-up is 40 months (min 2 months, max 77 months).
21 patients are male, 29 patients are female. 20 patients had a spinal cord injury, 6 patients spina bifida, 9 multiple sclerosis, 15 suffered from other pathologies. All of them were adults patients (more than 18 years old).
Currently 40 patients still use Peristeen (80%, group A) and 10 patients (20%, group B) interrupted the treatment. Among group B, the reasons for discontinuing TAI were: unsatisfactory effect in 4 patients (40%), troublesome in using Peristeen in 2 patients (20%), difficulty to source the TAI system (contract health business) in 2 patients (20 %), other reasons in 2 patients (20% - bowel ischemia in 1 patient, worsing of the multiple sclerosis in the other patient).
We evalued NBD score and UTI’s frequency in group A before TAI training and after TAI training.
We recorded that mean NBD in group A before TAI is 18 (min 2 – max 32) which corresponds to severe level of bowel dysfunction, after TAI mean NBD score is 6 (minimum score 2 – maximum score 10), which corresponds to very low level of bowel dysfunction. Best benefits are related to decrease of digital stimulation or evacuation, decrease of faecal incontinence and decrease of discomfort during defecation.
As far as UTIs frequency is concerned, in group A patients meanly reported 7 episodes of UTI per year (min 2 – max 15 episodes per year) before TAI use; after TAI training, patients report meanly 2 episodes of UTI per year (min 0 – max 6 episodes per year). Moreover, 1 patient had a urinary sepsis that required hospitalization before starting TAI; this never happened after the beginning of TAI. As far as antimicrobial prophylaxis is concerned, 16 patients took prophylaxis before starting Peristeen system: among them, 12 patients used supplements, while 4 patients used antibiotics (nitrofurantoin); at the present day, 8 patients take prophylaxis: among them, 7 use supplements and only 1 patient still uses nitrofurantoin.
Interpretation of results
First of all, our follow-up is among the longest ones reported in literature.
In our centre the percentage of drop out (20%) is lower than in other series of adult patients.
The reasons for discontinuing TAI were: unsatisfactory effect in 4 patients (40%), troublesome in using Peristeen in 2 patients (20%), difficulty to source the TAI system (contract health business) in 2 patients (20 %), other reasons in 2 patients (20% - bowel ischemia in 1 patient, worsing of the multiple sclerosis in the other patient). The reason of a high retention rate is the creation of a “TAI unit” with a dedicated team, which can adequately study, train and follow the patients.
The level of bowel dysfunction recorded in patients still using TAI is highly decreased (NBD score from 18 before TAI to 6 after TAI), showing that TAI improves QOL.
As reported in literature, TAI reduces UTIs: in our records UTI’s episodes per year have been significantly decreased and even the use of prophylaxis had also decreased. However, UTIs meanly did not zero: this is probably related to patient’s features and intermittent cateterization; moreover the antibiotics prescription is usually made by physicians that wrongly treat asymptomatic batteriuria.
Concluding message
As reported in literature, patients that perform colonic irrigation feel improvements on NBD, that is demonstrated by the decreasing of NBD score. Best results are obtained for digital stimulation, faecal incontinence and discomfort during defecation. TAI has a good impact on urinary tract infection on long term: this study demonstrates that TAI can reduce (and sometimes can zero) the incidence of urinary tract infection straight related to neurogenic bowel dysfunction; TAI can also decrease the use of antimicrobial prophylaxis. Reduction of urinary tract infections produces less hospitalization, decrease of health costs and prevention of bacterial resistance to antibiotics.
The better result is adherence to TAI: in our centre only 20% of patients have stopped TAI treatment, which is one of the best retention rate reported in literature. The recurrent reasons for discontinuing TAI were unsatisfactory effect, troublesome in using the system and difficulty to source the irrigation system. The drop out rate can be reduced by establishing a “TAI unit” to better follow the patients. However, the problem of sourcing the irrigation system remains.