Management of Neurogenic Bowel Dysfunction

January 2022

Guidelines: Bowel Management for Patients with

Neurogenic Bowel Dysfunction

‘Neurogenic bowel’ is the term used to describe dysfunction of the colon due to loss of

normal sensory and/or motor control or both, as a result of central neurological disease or

damage (trauma). Damage to the spinal cord and brain interrupts the neural pathways and

the outcome will vary depending on the location and severity of the damage.

Neurogenic bowel dysfunction (NBD) is a temporary or permanent disruption of bowel

function. NBD can be life altering, affecting all aspects of a patient’s social, physical and

emotional wellbeing. Patients likely to present with NBD are patients with Spinal Cord Injury

(SCI), Cauda Equina Syndrome, Multiple Sclerosis, Guillain Barre Syndrome, and some

patients with Stroke. NBD can present in any situation where there is interruption of the

normal innervation of the bowel.

Purpose of Guidelines:

The purpose of this document is to provide front line health care providers and physicians with

guidance to assist and support (empower) patients and their care providers to develop and /

maintain a bowel management routine. The goal of the bowel routine is to minimize or eliminate

the occurrence of unplanned or difficult evacuations; to evacuate stool at a regular, predictable

time within 60 minutes of bowel care; and to minimize gastrointestinal (GI) complications.

Key Messages:

1. Bowel movements are usually a personal and private function. Loss of independence

and control of something so private may cause the patient to feel vulnerable. It can be

very stressful and elicit a range of emotions including anxiety and grief.

2. The goal of a bowel routine is to minimize or eliminate the occurrence of unplanned or

difficult evacuations.

3. It is important to plan a consistent, regularly scheduled bowel routine in collaboration

with the patient, as well as their possible caregivers.

4. If a patient with an SCI at T6 (or occasionally T7-8) or above begins to experience signs

and symptoms of Autonomic Dysreflexia (AD) during the bowel routine, bowel care

should be stopped, and AD resolved before resuming.

5. Bowel routine should be initiated as early as possible in the acute phase of injury to help

establish the bowel routine and to prevent complications.

6. An effective bowel routine will need trial and evaluation, close monitoring, and careful

adjustments that can take up to months to establish.

7. Bowel management and education is important in supporting the patient in rehabilitation

and empowering their independence over time.

Types of NBD: Reflexic (spastic) vs Areflexic (flaccid)

Nearly everyone who experiences a spinal cord injury (SCI) will have some level of NBD.

NBD can be classified into two types: reflexic (spastic) neurogenic bowel and areflexic

(flaccid) neurogenic bowel.

Reflexic (spastic) NBD is seen with injuries above approximately vertebral level T12. It

results in a hypertonic and spastic bowel because the defecation reflex centre, which causes

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the involuntary contraction of muscles of the rectum and anus, remains intact. However, the

nerve damage results in disruption to the nerve signals and therefore there is an inability to

relax the anal sphincters and defecate, often leading to constipation.

Areflexic (flaccid) NBD is typically seen with injuries below approximately vertebral level

T12. There is damage to the defecation reflex. There is a significant risk of incontinence due

to the atonic or flaccid external anal sphincter and lack of control over the muscle that

causes the lumen of the rectum to open. The patient cannot feel the need to have a bowel

movement, and the rectum can’t easily empty by itself. There is a significant risk of

incontinence due to the atonic or flaccid external anal sphincter and lack of control over the

muscle that causes the lumen of the rectum to open.

Note: The commonly used terminology upper motor neuron versus lower motor neuron has

generally been abandoned for NBD. (PVA 2020 guidelines)

After an acute SCI, a patient may initially have an areflexic bowel. Once reflexes return, the

bowel may become reflexic. Management of NBD may be required for a short time in

reversible syndromes, or may be a permanent part of life going forward for patients with SCI

and other irreversible neurological disorders. Bowel symptoms are more severe in patients

with complete SCI than in those with incomplete SCI.

Principle of Care

A comprehensive evaluation of bowel function, impairment, and possible problems should

be completed by the most responsible health practitioner (MRHP), often a Physiatrist, at the

onset of NBD and at least annually throughout the continuum of care.

Starting early bowel management and education is important in supporting the patient in

rehabilitation and regaining their independence. A basic bowel management routine should be

used in individuals with both reflexic and areflexic NBD during the acute phase of care. It is a

treatment plan designed to eventually minimize or eliminate the occurrence of unplanned or

difficult bowel evacuations.

Each cycle of bowel care should be scheduled at the same time of day to facilitate habituation.

This is important to support the patient in resuming activities such as school, work, leisure and

recreation on discharge and transition back to community. Build the plan with the patient. An

effective bowel routine will need trial and evaluation, close monitoring, and careful adjustments

that can take up to months to establish.

For most individuals with a reflexic (spastic) NBD, a minimum of 3 adequate bowel movements

per week is recommended to avoid constipation. For persons with areflexic (flaccid) NBD, a

minimum of daily bowel care is typically needed in order to minimize the risk of unplanned bowel

evacuations. The ideal frequency of bowel movements per week should factor in an individual’s

lifestyle and bowel history prior to their SCI.

Patient and Family Education and Engagement

Education for patients with NBD and/or caregivers should be provided and tailored to their level

of understanding. It is important to understand what education the patient / family has, and what

additional information they need to become confident with managing their bowel routine.

It is important to plan the bowel routine with the patient with NBD, as well as their possible

caregivers.

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If a patient with an SCI at T6 or above begins to experience signs and symptoms of Autonomic

Dysreflexia (AD), the bowel routine should be stopped and AD resolved before resuming.

Persons who live with chronic neurological disorders (including SCI), and have managed their

neurogenic bowel are usually the experts in their own bowel care. It is important to consider this

expertise when changes are required to their bowel plan. Situations like admission to hospital,

health changes, illness, or even normal aging may affect the bowel function or patterns of a

person with a neurological disorder (including SCI). Collaborative problem solving between care

providers and patients is recommended to find bowel management solutions that work for the

patient and their family.

As the patient and care providers learn more about the patient’s bowel habits and patient-

centered needs and concerns, the bowel routine is expected to be adjusted and adapted over

time.

Table 1: Summary of Care: Reflexic (Spastic) vs. Arreflexic (Flaccid) Bowel

Reflexic (Spastic) Bowel

(previously referred to as

upper motor neuron lesion)

Areflexic (Flaccid) Bowel

(previously referred to as

lower motor neuron lesion)

Patho-

physiology

• More common in spinal cord injuries

or lesions above T12

• Lesion allows for impulses to get to

and from the spinal cord, resulting in

the presence of bowel reflexes

• Patients with reflexic NBD benefit

from mechanical and chemical rectal

stimulation because the defecation

reflex is intact.

• More common in spinal cord injuries or

lesions below T12 (cauda equina

syndrome)

• Lesions in the peripheral nerves block

impulses from getting to and from the

spinal cord, resulting in the absence of

reflexes

• Patients with areflexic NBD require

manual evacuation of stool because of

the absence of the defecation reflex.

• May occur in some lesions above T12

during the first days to months after

injury, resolving to reflexic bowel with the

return of reflex activity.

Characteristics

• Patient does not feel the need to

have a bowel movement, but the

reflex to have a movement is still

intact.

• The rectum may evacuate more

stool after a bowel movement when

the anus is stimulated (ie with

cleaning/peri-care)

• The rectum empties at irregular times,

especially when the patient is upright

(due to gravity) or on movement

transitioning from bed to chair, and

laying to sitting

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Management

start as early as

possible

Including in

acute care

• This type of bowel can be “trained”

to respond to stimulus, although the

training can take a long time to

develop.

• It is recommended that the bowel

care occur daily in the acute phase

of injury and during the

establishment of a bowel routine. As

the bowel routine becomes more

established and efficient, individuals

may choose to decrease their bowel

care to a minimum of 3 times a

week because of different life

considerations. (This usually does

not occur until several weeks or

months after injury.)

• Mechanical rectal stimulation is

used to trigger anorectal reflexes to

increase motility and relax

sphincters. (This stimulation can be

done with a finger or with an

adaptive device.)

• Digital rectal stimulation is a form

of mechanical rectal stimulation that

is most commonly used. This

procedure may be performed side

lying or over a commode.

• Digital rectal stimulation is

performed by the affected individual

or caregiver by placing a gloved,

lubricated finger into the rectum and

performing slow rotation in a circular

movement for no longer than 10 to

20 seconds at a time. Repeat the

rectal stimulation sequence every 5

to 10 minutes until evacuation of the

stool is achieved. Using additional

fingers or excessive dilation has

shown no benefit and can contribute

to complications.

• Having the patient consume food or

a beverage 30 minutes prior to

bowel care, can stimulate the

• This type of bowel requires more

frequent manual evacuation of stool and

may not be successful in bowel training.

Digital inspection and evacuation of

bowels will likely be required two or

more times per day, especially in the

initial stages.

• Manual evacuation of stool is indicated

as treatment and is performed with the

affected individual side-lying in bed or

positioned on a padded commode if

prescribed to be performed in an upright

position. The individual with SCI or

caregiver inserts a single, gloved,

lubricated finger into the rectum to

disimpact and remove stool that is

present in the rectal vault.

• Manual rectal disimpaction /removal of

stool – minimum daily, up to TID after

meals

• Care note: If there is stool in the rectum

when a patient with an areflexic bowel

sits upright, gravity may cause that stool

to be expelled. If this happens at an

unplanned time, it is likely to impact the

patient’s schedule and rehab, requiring

care and cleanup. The rectum should be

inspected for stool before the patient is

moved to an upright position.

• Goal is for stool to be firm (Bristol Type

3). See Appendix C

• Once a routine has been established

manual evacuation may only need to be

performed daily (but may be more often

depending on the patient’s individual

needs)

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gastrocolic reflex, and help facilitate

a bowel movement.

• Goal is for stool to be soft and

formed (Bristol Type 4). See

Appendix C.

Typical routine

see Appendix A

Complications

• Complications associated with

mechanical rectal stimulation

include potential for AD (for those at

risk), hemorrhoids, abdominal

distension, and anal fissures.

• If during mechanical rectal

stimulation an individual has signs

and symptoms of AD, such as

bradycardia, cardiac arrhythmia,

pounding headache, anxiety,

sweating above the level of their

SCI, flushing, blurry vision, nasal

congestion, and/or piloerection,

rectal stimulation should be

discontinued immediately.

(Lidocaine gel for lubrication is

commonly used to reduce the risk of

AD episodes caused by mechanical

rectal stimulation.)

• Complications associated with manual

evacuation of the bowel include: AD (for

those at risk), hemorrhoids, and anal

fissures.

Changes over

time

• Bowel routines will require customization for each patient. The initial plan

described above will likely change over the months and years following acquired

spinal cord injury according to patient response.

Medication

management

Medications

commonly

prescribed to

facilitate bowel

routine (as per

SCI order set)

Bowel will respond to peristaltic

stimulants.

Bowel training:

1. Daily polyethylene glycol (PEG)

3350 17g packet* daily or QHS

2. Sennosides (Senna)* 1-2 tablets PO

daily or QHS

Bowel Routine:

1. PEG based Bisacodyl* suppository

10mg 10-15 minutes before planned

evacuation (some stool may

Bowel will not respond to peristaltic

stimulants. Osmotics or lubricant

medications to make stool pass more

easily through the intestine may be

prescribed.

1. Psyllium mucilloid powder 1 packet daily

up to TID (Each packet to provide 3.4 g

psyllium)

Caution: patients will need appropriate

fluid intake to prevent constipation while

taking psyllium

2. Lidocaine 2% gel 5 to 10 mL rectally

PRN prior to disimpaction

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evacuate when suppository is

inserted.)

2. Lidocaine gel 2% prn for lubrication

is commonly used to reduce the risk

of AD episodes caused by

mechanical rectal stimulation.

3. If bleeding or uncomfortable

hemorrhoids with digital stimulation,

add Anusol-HC 2.5% cream after

bowel movement for 14 days

3. If bleeding or uncomfortable

hemorrhoids with manual dis-impaction,

add Anusol-HC 2.5% cream after bowel

movement for 14 days

Dietary

Consideratio

• Water and other healthy fluids: Fluids are crucial to maintaining a healthy

bowel routine. Many other factors will not be effective without taking in enough

fluids. Healthy fluids should not include caffeine or alcohol beverages, as these

will cause dehydration (unless there are intake restrictions). Patients should be

encouraged to avoid dehydration to reduce the tendency to experience

constipation.

• Diet: Fibre plays a key role in establishing a successful bowel routine. A person

with a SCI must learn how fibre impacts their bowel routine as well as which

foods affect their bowel routine.

• Consult a registered dietitian if the patient has poor appetite, poor oral intake, or

significant weight changes, or if guidance is required for fluid and fibre intake.

• Patients with SCI should not be routinely placed on high-fibre diets. Increases in

fibre intake should be done gradually to assess tolerance.

* medications require an order from an authorized prescriber.

** patients with spinal cord injury and/or at risk of pressure ulcers should never be seated on a

commode without appropriate padding or pressure redistribution material between the patient

and the seat.

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Appendix A: Typical Routine for Management of NBD

Reflexic (Spastic) Bowel

Areflexic (Flaccid) Bowel

• Bowel care is best performed approximately 30

minutes after eating

• Bisacodyl suppository (if ordered) 10-15

minutes before planned evacuation

• Bowel care is best performed approximately 30-

60 minutes after eating

• Psyllium mucilloid powder 1 packet daily up to

TID (Each packet to provide 3.4 g psyllium)

• Caution, patients will need appropriate fluid

intake to prevent constipation while taking

psyllium

• If occurrence of pain or history of autonomic

dysreflexia (AD) with bowel evacuation, follow

AHS AD protocol or obtain an order for

application of topical lidocaine 2%* to anus.

• Explain procedure and get permission to

proceed

• Daily AM or PM routine (depending on

patient’s’ schedule):

1. Have patient sitting on padded

commode**, in sling of mechanical lift, or

lying on left side

2. Digital rectal stimulation (for no longer than

10 to 20 seconds at a time); allow stool to

evacuate unassisted; repeat every 5-10

minutes X 2 until evacuation of the stool is

achieved.

3. Digital disimpaction may be required for any

stool that does not evacuate with

stimulation alone.

4. Perform this routine even if the bowels have

emptied spontaneously earlier in the day

• NOTE: simply inserting a suppository and

waiting for results without stimulation and

manual disimpaction will not likely be effective,

and can cause impaction of stool in the rectum

• If patients displays signs and symptoms of

AD, stop bowel care. AD is a medical

emergency. Manage AD (See AD protocol)

Caution: vagal response (syncope) may

occur with bowel routine

• Explain procedure and get permission to

proceed

• Routine should be performed twice per day and

prn (eg. prior to getting the patient up in their

wheelchair).

• If patient having more incontinence—may need

to increase frequency of routine.

1. Have patient sitting on padded commode, in

sling of mechanical lift, or lying on left side

2. Digitally inspect the rectum for stool

3. If stool is present, remove it by performing

digital disimpaction

4. If stool is too hard to remove, consider

administering a glycerin suppository* (as per

prescriber’s orders) into the bulk of stool,

then trying to remove stool after 30 minutes.

NOTE: Incontinence may be more frequent due to

areflexic bowel, therefore nursing may need to

assess more frequently for incontinence, and

provide assistance as required.

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Appendix B: Glossary

Autonomic Dysreflexia: Autonomic Dysreflexia (AD) is a potentially life-threatening

condition that most commonly occurs in patients with a SCI at or above the T6 neurological

level; and sometimes in patients with a SCI at level T7-8. AD is a medical emergency that

causes a sudden rise in the patient’s blood pressure. AD is a usually the result of a noxious

stimuli below the level of the spinal cord injury, that the patient with SCI may not be able to

feel or is unaware of. Early management includes recognition and removal of the cause of

the noxious stimuli. If conservative management is unsuccessful, medical management with

anti-hypertensive medication may be required to prevent serious complications. If left

untreated, AD may result in serious complications (e.g., stroke, seizure, cardiac arrest, and

death).

Bowel Care: is the process of assisted defecation, typically at a scheduled interval, which

can include rectal stimulation (chemical, mechanical, or both), manual evacuation of stool,

positioning, and adaptive equipment. Mechanical rectal stimulation should be used for

individuals with reflexic NBD. Manual evacuation of stool should be used for individuals with

areflexic NBD.

Manual Evacuation or Digital Disimpaction: is indicated as treatment for areflexic bowel

management and fecal impaction. Performed with the affected individual side-lying in bed or

positioned on a padded commode if prescribed to be performed in an upright position. Insert

a single, gloved, lubricated finger into the rectum to disimpact and remove stool that is

present in the rectal vault.

Mechanical Rectal Stimulation: manual procedures to stimulate bowel evacuation in the

setting of reflexic neurogenic bowel dysfunction.

Digital Rectal Stimulation: is a form of mechanical

rectal stimulation that is most commonly used for

those with reflexic NBD. Insert a gloved, lubricated

finger into the rectum and perform slow rotation in a

circular movement for no longer than 10 to 20

seconds at a time. Repeat the rectal stimulation

sequence every 5 to 10 minutes until evacuation of

the stool is achieved. Using additional fingers or

excessive dilation has shown no benefit and can contribute to complications.

Assistive Device (adaptive digital stimulator): Any device that increases the

independence of a person with a disability. An example is a digital stimulator, which

helps a person with limited hand function to be more independent with bowel care.

Also called adaptive device.

My Shepherd Connection

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Appendix C: Bristol Stool Chart

The Bristol Stool Scale (Heaton et al 1992)

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Appendix D: Bowel Management Medications: Tips and Tricks

Medication

Mechanism

of Action

Ideal for

Purpose

(Prevention,

Rescue or

Management)

Tips

Bulk Forming Agents

Psyllium

(Metamucil®)

Increases physical bulk

of feces, which

stimulates peristalsis in

normal bowel; promotes

growth of health gut

flora. Acts within 12- 72

hours.

Patients with loose

or liquid stools, or

fibre deficit in diet;

may be helpful in

preventing

accidents in

patients with

flaccid bowel;

patients whose

stools are difficult

to pass

Prevention;

Chronic

Management

Not appropriate

for acute bowel

impaction

Can cause

distention and gas.

Can be taken up to

TID. Take with a full

glass of water; avoid

with enteral

administration –

likely to clog tubing.

Fruit Lax

(contains soluble

and insoluble fruit

fibre)

Osmotic and bulking

agent

Patients with fibre

poor diets

Prevention;

Chronic

Management

Take with meals

and lots of water,

consult a dietitian

for frequency. Too

much fibre too

quickly can cause

bloating and

cramping

Osmotics and Hyperosmotics

Polyethylene

Glycol (PEG)

3350 (Colyte®)

with electrolytes

Draws water into the

lumen of the gut,

distending the colon

with promotes

peristalsis; causes

abdominal distention

and subsequent

evacuation of the bowel.

Acts within 48 hours.

Patients preparing

for bowel

procedures

Bowel prep

Reconstitute with

water. Makes 4

liters of solution.

Lactulose

Oral

Draws water into the

lumen of the gut,

distending the colon

with promotes

peristalsis; causes

abdominal distention

and subsequent

evacuation of the bowel.

Acts within 24-48 hours.

Chronic or

subacute

constipation

Prevention or

Chronic

Management

Max 60 mL per day

May cause gas,

distension, belching

and discomfort in

the first week. May

take up to 48 hours

for results.

Glycerin

Suppository

Rectal

Osmotic and softens,

lubricates. May also

stimulate. Acts within

15-60 minutes.

Acute constipation

with rectal

impaction of stool

that is too hard and

Treatment of

Constipation

Usually works 15-60

minutes. Patient to

stay in side-lying

position while

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Medication

Mechanism

of Action

Ideal for

Purpose

(Prevention,

Rescue or

Management)

Tips

bulky to pass.

suppository is in

place. Try to insert

suppository directly

into stool.

Tap water enema

Rectal

Adds water to stool;

causes bowel

distention, stimulating

peristalsis and

expulsion of stool

Only to be used as

last resort as bowel

prep prior to

endoscopy or

rectal procedures/

diagnostics.

Not

recommended

except in bowel

prep

Can cause fluid and

electrolyte

imbalance with

repeated

administration.

Uses 500-1000 mL

warm water.

Sorbitol 70%

Oral

Adds water to stool;

causes bowel

distention, stimulating

peristalsis and

expulsion of stool.

Onset of action: 24-48

hours.

Less sweet than

lactulose, may

cause less nausea.

Saline Laxatives (Osmotics and Hyper-Osmotics containing magnesium or phosphates)

Sodium

phosphate enema

(Fleet®)

Rectal only

Draws water into the

lumen of the gut,

creating softer stools,

potentially affecting

systemic fluid and

electrolyte balance. Acts

quickly with results

usually within 3 to 5

minutes.

Acute constipation

Rescue (Use

with caution)

Rectal

administration will

increase serum

phosphorus levels.

Don’t give more

than once in 24 h

period. May result

in acute kidney

injury.

Magnesium

hydroxide

(Milk of

Magnesia®)

Oral

Draws water into the

lumen of the gut,

distending the colon

which promotes

peristalsis; causes

abdominal distention

and subsequent

evacuation of the bowel

Acts in 30 minutes to 3

hours.

Chronic or

subacute

constipation; only

for patients with

GFR > 30 mL/min

Management

Max dose 60 mL in

24 h; one 30 mL

dose contains 2400

mg of elemental

magnesium;

magnesium toxicity

can occur with

excessive oral

doses. Also helps

with symptoms of

indigestion/reflux

Magnesium

Citrate

(Citromag®)

Draws water into the

lumen of the gut,

distending the colon

which promotes

peristalsis; causes

abdominal distention

Acute Constipation

Rescue

Results within 3

hours. May cause

electrolyte

imbalance,

especially in young

children or patients

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Medication

Mechanism

of Action

Ideal for

Purpose

(Prevention,

Rescue or

Management)

Tips

and subsequent

evacuation of the bowel.

Acts within 30 minutes

to 3 hours.

with renal

insufficiency.

Peristaltic Stimulants

(Give for spastic or non-neurogenic bowel. Will not be effective for flaccid bowel.)

Bisacodyl

(Dulcolax®) oral

Directly stimulates the

colonic mucosa to

produce peristalsis.

Tablets act in 6 to 12

hours.

Suppositories act in 15

minutes to 1 hour.

Give for spastic or

non-neurogenic

bowel. Will not be

effective for flaccid

bowel.

Prevention and

treatment

Given in the evening

to produce a bowel

movement in the

morning.

Bisacodyl

suppository

Routine

Maintenance of

neurogenic

bowel;

Rescue for non-

neurogenic

bowel

Give in the evening

to avoid lengthy AM

bowel management.

Ensure suppository

is placed in contact

with the rectal wall.

Cascara oral

Irritates the intestinal

mucosa; increases

motility and alters fluid/

electrolyte secretion.

Management

May cause

cramping

Senna oral

(Senokot®)

Stimulates neuro-

peristaltic response.

Acts in 6 to 10 hours.

Prevention and

Management

Take with a large

glass of water, or

large enteral flush.

Soap and water

enema

Distends the bowel,

increasing peristalsis;

irritates/stimulates the

mucous membranes of

the bowel.

Only to be used as

a last resort as

bowel prep prior to

endoscopy or

rectal procedures /

diagnostics.

Not

recommended

except in bowel

prep as may

cause colonic

mucosa irritation

Use the pre-

prepared kit/

package or, if no kit

available, mix 5 mL

mild liquid soap in

1000 mL warm

water. Can causes

fluid and electrolyte

imbalance with

repeated

administration.

Lubricants

Mineral Oil

Enema

Lubricates stool for

easier passing. Acts

within 2-15 minutes.

When straining

may be painful or

dangerous; difficult

to pass or very

hard stools

Management,

Rescue

Usually works within

2-15 minutes.

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Medication

Mechanism

of Action

Ideal for

Purpose

(Prevention,

Rescue or

Management)

Tips

Medications with a unique mechanism of action to treat constipation

Methylnaltrexone

(Relistor®)

injectable

Opioid receptor

antagonist that acts

upon GI tract to prevent

opioid induced

decreased GI motility

and delay in GI transit

time. Acts within 30-60

minutes.

Opioid induced

constipation

Rescue (only in

those with

opioid induced

constipation)

Should not be used

with other laxatives;

Monitor for opioid

withdrawal.

Naloxegol

(Movantik®) oral

Opioid receptor

antagonist that acts

upon GI tract to prevent

opioid induced

decreased GI motility

and delay in GI transit

time. Acts within 6 to 12

hours.

Prucalopride

(Resotran®)

Serotonin agonist

whose action at the

receptor site promotes

stimulation of peristaltic

reflex, intestinal

secretions and GI

motility. Acts within 2-3

hours

Chronic idiopathic

constipation

Management of

chronic

idiopathic

constipation

refractory to a 4-

week trial of

osmotic

laxatives;

Management of

chronic

intestinal

pseudo-

obstruction

refractory to

other laxatives.

Only indicated for

females in Canada

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References

Basson, M.D. (2014, October 1). Constipation Medication. Medscape. Retrieved from

http://emedicine.medscape.com

Canadian Pharmacists Association. (n.d.) Retrieved April 1, 2015, from http://www.e-cps.ca.

Ottawa, ON.

Consortium for Spinal Cord Medicine. (2020). Management of Neurogenic Bowel

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