A single-unit survey of bowel washout practice in children with neuropathic bowel

Background

The majority of children with spina bifida require medical assistance to eliminate socially disabling faecal incontinence. Having recently surveyed units across the UK and Ireland on their practice of bowel washouts (see abstract S30), we wished to evaluate our own (largely traditional) programme in more detail.

Materials and methods

Patients receiving bowel washouts were captured from the regional departmental database of 165 children (aged 0 - 18 years) with spina bifida, and a database of others attending the Continence Nurse Specialists. Parents were then contacted by telephone, and/or the child's records reviewed, to complete a questionnaire on their individual practice.

Results

Ten patients with spina bifida, and six with other "neuropathic" conditions (anorectal malformation, Hirschsprung's disease and chronic constipation) were identified. The mean age at which bowel washouts were instituted was 11.0 (range 4 - 18) years, and the mean interval since was 3.1 (range 0.3 - 8) years.

An initial washout volume of 500 ml was prescribed for all children and, in some cases this was titrated according to effect. Salt was added to tap-water to approximate an isotonic solution for all washouts. In the washout solution twelve children required a laxative (sodium citrate in 11, and bisacodyl in one), while four did not. Rectal washouts were all administered via a balloon-catheter (Coloplast's Peristeen system in 7 children), and most ACE washouts via a "gastrostomy" button-device (7 children).

The most common side-effect was abdominal cramping, particularly with bisacodyl or if the previous washout had been omitted. The time spent on the toilet after administration of the washout varied from 30 - 90 (mean = 53) minutes, with a tendency to be longer in those with larger washout volumes. All children were established on a daily washout, and then the interval between washouts was gradually increased, unless incontinence returned: 13 children still required once-daily washouts, but three other children remained socially clean with a washout every other day, three-times per week, and twice per week respectively (the latter on bisacodyl).

The chief difficulty for both children and parents was the time commitment, although this was more than offset by the improved quality of life.

Conclusion

Bowel washouts are a very effective treatment for neuropathic bowel. Although our numbers are small, the increased tendency to abdominal cramps seen with bisacodyl appears to be justified if it reduces the weekly-time spent on the toilet, which is the main complaint by users.