1. Boman, Erika PhD, RNT
  2. Nylander, Malin BSc, RN
  3. Oja, Josefine BSc, RN
  4. Olofsson, Birgitta PhD, RN


Transanal irrigation has been introduced as a complement to standard bowel care for people with neurogenic bowel dysfunction. There is no contemporary integrative review of the effectiveness and feasibility of transanal irrigation from a holistic nursing perspective, only fragments of evidence to date. The aim was to investigate the effectiveness and feasibility of transanal irrigation for people with neurogenic bowel dysfunction. An integrative literature review was conducted. Nineteen studies were included. According to the results, transanal irrigation can reduce difficulties associated with defecation, episodes of incontinence, and the time needed for evacuation and bowel care. Transanal irrigation can increase general satisfaction with bowel habits and quality of life and decrease level of dependency. However, there are practical problems to overcome and adverse effects to manage. Discontinuation is relatively common. The results support the effectiveness of transanal irrigation, but feasibility is inconclusive. Users, including caregivers, report practical problems, and compliance was not always easy to achieve. It is important that users, including caregivers, are well informed and supported during transanal irrigation treatment, especially during introduction. The quality of the studies found was generally weak; therefore, high-quality quantitative and qualitative studies are needed on the topic.


Article Content

The majority of people with neurological disorders experience bowel problems, leading to what is called neurogenic bowel dysfunction (NBD) (Emmanuel, Collins, Henderson, Lewis, & Stackhouse, 2019). Reduced function and sensation are common, resulting in prolonged bowel transit time and impairment or loss of sphincter control. The severity of dysfunction depends on the location and extent of neurological disorder (Krogh & Christensen, 2009).


The physical consequences of NBD are extensive and can include constipation, fecal incontinence, and/or other potential problems such as hemorrhoids, abdominal pain, fecaloma, anal bleeding, rectal prolapse, anal fissures, bloating, and/or nausea (Adriaansen, van Asbeck, van Kuppevelt, Snoek, & Post, 2015; Coggrave, Norton, & Cody, 2014). There is also an increased risk of autonomic dysreflexia (i.e., an abnormal surge of the sympathetic nervous system as a response to painful stimuli below injury level). Problems with emptying the bladder can occur alongside NBD, and people with severe NBD often have problems with urinary incontinence and/or urinary tract infections (Cameron et al., 2015).


In addition to physical problems, NBD can have a negative impact on quality of life. People with NBD may fear having an accident in public or needing to spend hours on the toilet, which can have a major impact on quality of life and social integration. Problems associated with NBD tend to be unpredictable and may cause limitations in daily life: at work, in school, and/or participation in social contexts (Dibley, Coggrave, McClurg, Woodward, & Norton, 2017; Emmanuel, 2010a; Emmanuel et al., 2019; Nevedal, Kratz, & Tate, 2016). People with NBD often make involuntary changes based on what they perceive has a positive impact on their bowel function (Burns et al., 2015; Dibley et al., 2017). Furthermore, many with NBD need assistance with emptying the bowel, which can impact independence and lead to loss of dignity (Dibley et al., 2017; Emmanuel, 2010a; Emmanuel et al., 2019; Nevedal et al., 2016). It is important that healthcare staff understand that people with NBD do not suffer from a single occasion of constipation or fecal incontinence, but instead a life long problem that greatly impacts experienced quality of life (Coggrave, Norton, & Wilson-Barnett, 2009; Shaw, 2018).


The goal of NBD treatment is to experience control over bowel emptying. This includes for defecation becoming predictable and regular (Pardee, Bricker, Rundquist, MacRae, & Tebben, 2012), and regardless of injury level or underlying disease the treatment is the same (Krogh & Christensen, 2009). First-line treatment includes diet and fluid, lifestyle alterations, and laxatives or constipating drugs. The next step includes digital stimulation and suppositories, and biofeedback is recommended. The third step in the treatment pyramid is transanal irrigation (TAI) (Emmanuel et al., 2013).


TAI is a method of flushing out the lower part of the bowel using tap water and a closed system. A water-filled container is connected to a tubing system with a pump and a disposable rectal catheter (a review of different current systems can be found in Bardsley, 2020). TAI is performed while sitting on a toilet. A rectal catheter is inserted into the anus and a balloon inflated, which prevents the catheter from slipping out. Through the tubing system, water is flushed from the control unit/container into the colon. This flushes stool from the rectum, sigmoid colon, and parts of the descending colon. After completed irrigation, the container and tubing system are emptied of water and the rectal catheter is disposed of alongside other household waste (Emmanuel, 2010a).


There are previous reviews on the use of TAI for people with NBD. The focus of these reviews differs. Some include a focus on different treatment options, such as the comparison of TAI with surgical or pharmacological management (Gor, Katorski, & Elliott, 2016; Krassioukov, Eng, Claxton, Sakakibara, & Shum, 2010) or other enemas (Kelly, 2019). In others there is a focus on a specific medical condition, such as multiple sclerosis (Preziosi, Gordon-Dixon, & Emmanuel, 2018), or a specific age group, such as children and young people (Bray & Sanders, 2013). There are also some earlier reviews on the economics and feasibility of TAI (Christensen, Andreasen, & Ehlers, 2009; Emmanuel, 2010b). In a Cochrane review on the management of fecal incontinence and constipation in adults with NBD, evidence from one trial indicated positive results from TAI (Coggrave et al., 2014). Practical guidance for physicians has been presented in a consensus review, with a focus on a stepwise approach to assessments, interventions, and the monitoring of people with NBD (Emmanuel, 2019). There are even some commentary and discussion articles from a nursing perspective (e.g., Holroyd, 2017; Shaw, 2018; Wilson, 2017; Woodward, 2017; Yates, 2019). However, an overall systematic approach to the topic is lacking. To the best of our knowledge, there is no contemporary integrative review of the effectiveness and feasibility of TAI from a holistic nursing perspective-only fragments of evidence have been seen to date.



The aim of this review was to investigate the effectiveness and feasibility of TAI for people with NBD.



This is an integrative literature review (Whittemore & Knafl, 2005), a method which allows the simultaneous inclusion of studies with different research designs and was chosen to understand the phenomenon of concern more fully (Whittemore & Knafl, 2005). This review is reported in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) (Moher et al., 2009).


Search Strategy

The search strategy was designed in collaboration with a team of information specialists to find the optimal search strategies, including relevant databases and search terms. After discussion, the following databases were used: PubMed (Public/Publisher MEDLINE), CINAHL (the Cumulative Index to Nursing and Allied Health Literature), APA PsycInfo (American Psychological Association's Psychological Information Database), Scopus, and Web of Science Core Collection. Language was restricted to English, and year of publication from 2005 to 2020.


An initial search was undertaken in PubMed, using the terms "neurogenic bowel" and "transanal irrigation." We observed that the term "neurogenic bowel" was not entered into the database until 2009 and not all studies related to neurogenic bowel were indexed under the term, even after 2009. Therefore, a broader search was undertaken. This included synonyms/terms related to bowel dysfunction and diseases or injuries that may cause NBD and synonyms/terms related to the term "transanal irrigation."


In CINAHL, searches related to exact subject headings, title, and abstract were performed. In APA PsycInfo, titles and abstracts were searched. In Scopus, title, abstract, and keywords were searched. In Web of Science Core Collection, topic was searched.


The final search was performed at the beginning of December 2020 and resulted in 14,066 hits. The exact search queries are presented in Supplemental Digital Content Table A1 (available at:


Selection of Studies

All studies were imported into Endnote. Duplicates were excluded, resulting in 9,966 studies (a flowchart of the study selection process is presented in Figure 1). All titles were screened for relevance to the aim, resulting in 150 relevant titles. The abstracts of those studies were read and judged based on the inclusion criteria: (1) original research; (2) published in English; (3) published between 2005 and 2020; (4) includes people with NBD; and (5) TAI was implemented. Exclusion criteria were: (1) studies focusing on participants with nonneurogenic disorders, such as malformations, constipation, or fecal incontinence not related to NBD; (2) studies not specifically evaluating the effectiveness and feasibility of TAI; and (3) reviews, book chapters, editorial comments, and conference abstracts.

Figure 1 - Click to enlarge in new windowFIGURE 1. Flowchart over study selection process.

The 33 remaining studies were read in full. In some, people with other diagnoses alongside NBD were included. In others, treatment with TAI was used together with or compared with other treatment options. Studies were excluded if the results from TAI treatment could not be distinguished from other types of NBD treatment (n = 9). A cross-sectional study in which TAI was compared with another method was also excluded, because the effectiveness of TAI was considered unassessable due to the cross-sectional design.


Whittemore and Knafl (2005) emphasize that the evaluation of source quality in integrated reviews should be addressed in a meaningful way; traditional quality assessment methods may not be viable, because of the diversity of the primary sources. As a minimum criterion, we decided that all included studies must include a description of the design/method that made the study replicable. Four studies were excluded due to vague methodological descriptions. In total, 19 studies were included in this review.


Data Analysis

The first step in the analysis process was to classify included studies (Whittemore & Knafl, 2005). The characteristics of the included studies were analyzed: population (participant age and diagnosis), continent of origin, research design, study site (single or multisite), TAI system, and instruments/scales used for evaluation (Table 1).

Table 1 - Click to enlarge in new windowTABLE 1. Characteristics of the Included Studies (

The next step included coding, extracting, and displaying data (Whittemore & Knafl, 2005). The included studies were read thoroughly and data relevant to the aim were coded and extracted. In line with Whittemore and Knafl (2005), results from each primary source were reduced to a single page. One of the study authors extracted the data, whereas the others reviewed the correctness of the extracted data. To gain an overview of the data, a template was developed: first author, year of publication, country of origin; the participant age and diagnosis; study design and number of participants; TAI system and preparatory training; main findings; and strengths and limitations (Table 2).

Table 2 - Click to enlarge in new windowTABLE 2. Overview of Included Studies: Characteristics, Study Design, Transanal Irrigation System, Main Findings, Strengths, and Limitations

The subsequent step included data comparison to identify patterns and, in the final phase, to draw conclusions (Whittemore & Knafl, 2005). Similar variables were grouped and sorted to provide a categorization of the results (Table 3). Lastly, the results were abstracted and summarized.

Table 3 - Click to enlarge in new windowTABLE 3. Categorization of the Results


Study Characteristics

Study characteristics are summarized in Table 1. Eleven studies included young participants (<=18 years) whereas eight included adult participants (>=18 years). In those studies including young participants, caregivers were also included as participants. The studies included people with multiple sclerosis, myelomeningocele, spina bifida, or spinal cord injury. Five studies included people with mixed diagnoses.


The studies were mainly performed in Europe (Denmark, England, Germany, Italy, Sweden, or the United Kingdom). There were also studies from Asia (South Korea), North America (the United States [U.S.]), and Australia. The majority of studies were quantitative with varying designs: a randomized controlled trial, before-after studies (comparing outcomes before and after implementation of TAI at fixed point of time(s)), or follow-up studies (following users being introduced to TAI over time without fixed points of measure). In the quantitative studies, questionnaires, structured interviews, and/or review of medical records were used to collect data. Validated and nonvalidated scales were used to assess outcomes. Radiographic method (x-ray) was used in one study. Only one study had a qualitative design, and semistructured interviews were used to collect data.


Peristeen (Coloplast) was the most commonly used TAI system. Colotip (Coloplast) was used in one study. In most studies (n = 15), any eventual TAI preparatory training and/or support available for users, including caregivers, were described. The duration for which a TAI intervention was studied varied from 3 weeks to 4.1 years across the studies, with the exception of the radiographic method study, where the test period was 72 hours (Table 2).



To investigate the effectiveness of TAI, the following were assessed: difficulties associated with defecation; episodes of incontinence; and impact on other health concerns and healthcare needs. Also, time needed for evacuation and bowel care and general satisfaction with bowel habits and quality of life were studied. The measurements of effectiveness of TAI are presented in Supplemental Digital Content Table A2 (available at:


Difficulties Associated With Defecation

Constipation was assessed in 10 studies. In eight, reduced constipation was seen (Ausili et al., 2010, 2018; Christensen et al., 2006, 2008; Loftus, Wallace, McCaughey, & Smith, 2012; Midrio et al., 2016; Patel, Hopson, Bornstein & Safder, 2020; Preziosi et al., 2012). In one, no difference was seen between users and those no longer using TAI (King et al., 2017) and in another, no comparison was made (Hamonet-Torny et al., 2013). In two studies, significantly fewer participants had a feeling of incomplete evacuation after implementation of TAI (Del Popolo et al., 2008; Lopez Pereira et al., 2010). In two, a positive impact on fecal consistency was seen; that is, a larger number of people reported softer stool after the intervention (Ausili et al., 2018; Midrio et al., 2016).


In one study, a radiographic method (x-ray) was used to study intestinal transfer time, and significant improvement of the progression of intestinal bolus was found (Marte & Borrelli, 2013). In another, frequency of bowel movements was assessed, and a significant increase of movements was seen (Choi et al., 2015). In two, improvement in frequency (i.e., more regular defecation) was seen (Ausili et al., 2010; Midrio et al., 2016)


Laxatives and/or other enemas were assessed in four studies. In one, a significant reduction in laxatives was reported (Ausili et al., 2010), but Hamonet-Torny et al. (2013) found no significant difference in laxative consumption. In Midrio et al. (2016), a reduction in laxatives and enemas was indicated, but significance of the tests is not confirmed (Midrio et al., 2016).


Digital stimulation, evacuation of anorectum, and/or abdominal massage were investigated in four studies. Ausili et al. (2010) reported a significant decrease in digital stimulation or evacuation of anorectum. Midrio et al. (2016) indicated a reduction in manual extraction. Faaborg et al. (2009) found that 23% still required manual evacuation, and Hamonet-Torny et al. (2013) reported that two out of 10 required manual evacuation, with a similar percentage needing abdominal massages.


Episodes of Incontinence

Fecal incontinence was assessed in 14 studies. In 12, fecal incontinence was significantly reduced (Ausili et al., 2010, 2018; Christensen et al., 2006,2008; Del Popolo et al., 2008; Loftus et al., 2012; Lopez Pereira et al., 2010; Passananti, Wilton, Preziosi, Storrie, & Emmanuel, 2016; Patel et al., 2020; Preziosi et al., 2012). Results from two other studies also indicated improvement (Choi et al., 2015; Midrio et al., 2016). In one, no significant difference was found between users and those no longer using TAI (King et al., 2017). In another, fecal continence was assessed as being nearly normal (Hamonet-Torny et al., 2013).


Flatus incontinence was evaluated in five studies. In two, flatus incontinence was significantly reduced (Del Popolo et al., 2008, Loftus et al., 2012), and in another two studies improvement was indicated (Ausili et al., 2018; Midrio et al., 2016), whereas in one no difference was found (Ausili et al., 2010).


Impact on Other Health Concerns and Healthcare Needs

Abdominal pain and bloating were studied in four studies. A significant reduction of pain (Del Popolo et al., 2008, Loftus et al., 2012; Lopez Pereira et al., 2010; Patel et al., 2020) and bloating (Loftus et al., 2012) was shown. In a study on perianal skin problems, no difference was seen (Ausili et al., 2010).


Urinary tract infections were investigated in four studies. One showed a significant decrease in infections (Ausili et al., 2010), with improvement indicated in the other three (Christiansen et al. 2006; Del Popolo et al., 2008; Passananti et al., 2016). Passananti et al. (2016) indicated that the annual number of hospitalizations was reduced, and the proportion visiting a general practitioner, specialist, and/or dietician was reduced.


Time Needed for Evacuation and Bowel Care, General Satisfaction With Bowel Habits

Time needed for evacuation was evaluated in seven studies. In three, a significant decrease was seen (Ausili et al., 2018; Del Popolo et al., 2008; Kim, Lee, Lee, & Shin, 2013), and in two a reduction of time was indicated (Lopez Pereira et al., 2010; Midrio et al., 2016). Ausili et al. (2010) reported no significant change, and Christiansen (2006) saw no significant difference in time spent sitting on the toilet when compared with conventional bowel management.


Choi et al. (2015) showed that the time needed for bowel care decreased significantly. Christensen et al. (2006) showed significantly less time when compared with conventional bowel management. Hamonet-Torny et al. (2013) reported a more than 30-minute decrease for the majority (60%) of participants.


General satisfaction with bowel habits was assessed in four studies. In three, a significant increase in degree of general satisfaction was seen (Ausili et al., 2010; Del Popolo et al., 2008; Lopez Pereira et al., 2010). Hamonet-Torny et al. (2013) saw a high level of satisfaction (a mean score 9.1 out of 10).


Quality of Life

Quality of life, associated with bowel dysfunction, was evaluated in 12 studies. In eight, enhanced quality of life was seen (significant results) (Ausili et al., 2010; Choi et al., 2015; Christensen et al., 2006,2008; Del Popolo et al., 2008; Kelly, Dorgalli, McLorie, & Khoury, 2017; Kim et al., 2013; Loftus et al., 2012). However, King et al. (2017) reported no significant difference among users when compared with those no longer using TAI. Hamonet-Torny et al. (2013) and Passananti et al. (2016) presented no comparative (baseline) values but found that those still using TAI at follow-up experienced minor bowel dysfunction and found higher numbers of participants reporting mild or no problem, respectively.


General quality of life was assessed in four studies. In two, significantly higher overall quality of life was shown (Ausili et al., 2018; Midrio et al., 2016). In two studies, including participants with multiple sclerosis, no difference or even a decreased quality of life was seen (Passananti et al., 2016; Preziosi et al., 2012).


Lifestyle alterations related to bowel management were assessed in one study. Loftus et al. (2012) reported a significant decrease in the frequency of lifestyle alterations after the introduction of TAI.



To investigate the feasibility of TAI, the following were assessed: dependency, practical problems with the irrigation procedure, adverse effects, continuation and reasons for discontinuation, overall satisfaction with bowel regime/usefulness, and experiences.



Dependency was investigated in 12 studies, with change in dependency assessed in six studies. In five, a decrease was seen in the need for caregiver assistance (Ausili et al., 2018; Christensen et al., 2006; Lopez Pereira et al., 2010; Midrio et al., 2016; Passananti et al., 2016). Del Popolo et al. (2008) investigated dependence on caregiver and/or family and saw that the majority of study participants could be considered less dependent, two considered more dependent, and six saw no change.


Frequency of dependence was reported in four studies (Christensen et al., 2008; Faaborg et al., 2009; Hamonet-Torny et al., 2013; Patel et al., 2020). In a review of all included studies reporting numbers on dependency (needing practical help to carry out TAI), the frequency of dependency was seen to vary from 23% to 76%. Also, Kim et al. (2013) showed that a significantly higher proportion of noncompliant users needed assistance during bowel management when compared with compliant users.


Practical Problems With the Irrigation Procedure

Difficulties with catheter insertion was seen in five studies, with prevalence from 2% to 33.3% (Christensen et al., 2008; Del Popolo et al., 2008; Kim et al., 2013; King et al., 2017; Patel et al., 2020). Pain during catheter insertion was noted in two studies. Faaborg et al. (2009) found that 29% experienced pain, whereas Kim et al. saw that 1.9% experienced pain. Kim et al. also reported that 3.8% complained about the catheter being long and thick.


Technical problems with the equipment were reported in five studies (Ausili et al., 2018; Christiansen et al., 2006, 2008; Hamonet-Torny et al., 2013; Midrio et al., 2016). The frequency of technical problems varied between 5% (Ausili et al., 2018; Midrio et al., 2016) and almost 86% (Hamonet-Torny et al., 2013).


Leakage of irrigation fluid/fecal leakage was seen in seven studies, with prevalence from 3% to 64% (Ausili et al., 2018; Christensen et al., 2008; Del Popolo et al., 2008; Faaborg et al., 2009; Kim et al., 2013; Lopez Pereira et al., 2010; Midrio et al., 2016). Balloon/catheter expulsion was reported in eight studies (Ausili et al., 2018; Christensen et al., 2006,2008; Del Popolo et al., 2008; Faaborg et al., 2009; Kim et al., 2013; Lopez Pereira et al., 2010; Midrio et al., 2016, Patel et al., 2020). Kim et al. (2013) saw that up to 48.1% experienced balloon or catheter expulsion. Other studies reported lower frequencies. In Ausili et al. (2018), balloon expulsion had decreased to 3% at the end of the study.


Adverse Effects

The most commonly reported adverse effect when using TAI was abdominal pain/discomfort, seen in eight studies (Ausili et al., 2010; Choi et al., 2015; Christensen et al., 2006; Faaborg et al., 2009; Kim et al., 2013; King et al., 2017; Lopez Pereira et al., 2010; Patel et al., 2020). Other more common adverse effects were anorectal/perianal irritation/discomfort (Ausili et al., 2010; Christensen et al., 2006; Kim et al., 2013; Passananti et al., 2016; Patel et al., 2020), minor anal/rectal bleeding (Choi et al., 2015; Faaborg et al., 2009; Kim et al., 2013; Passananti et al., 2016), sweating (Ausili et al., 2010; Christiansen et al., 2006; Faaborg et al., 2009; Lopez Pereira et al., 2010), fatigue (Faaborg et al., 2009; Kim et al., 2013), and/or general discomfort (Ausili et al., 2010; Christensen et al., 2006; Faaborg et al., 2009).


Adverse events that required further care were reported in three studies. Christensen et al. (2006) reported four adverse events, but only two were related to TAI. Two participants experienced severe abdominal pain leading to hospitalization, but no serious conditions were found and they improved after the removal of constipated stool. Hamonet-Torny et al. (2013) also reported a subocclusive episode that required emergency consultation. Faaborg et al. (2009) reported a nonlethal bowel perforation (0.002% risk). No adverse events were reported in six studies (Ausili et al., 2010, 2018; Choi et al., 2015; Del Popolo et al., 2008; Loftus et al., 2012; Lopez Pereira et al., 2010).


Continuation and Reasons for Discontinuation

Frequency of continuation was investigated in three studies. Faaborg et al. (2009) found that 46% experienced a successful outcome at mean follow-up, decreasing to 35% after 3 years of using TAI. In that study, male gender, mixed symptoms, and prolonged colorectal transit time were associated with successful outcome, and a 20% dropout rate was seen in the first 3 months. Hamonet-Torny et al. (2013) reported that six out of 16 participants discontinued treatment (two thirds over 1 month). Passananti et al. (2016) reported a 55% rate of continuation at mean follow-up.


Reasons for discontinuation reported by users were addressed in nine studies (Table 4). In a comparison of compliant and noncompliant users, Kim et al. (2013) saw that the noncompliant group had a higher proportion of tetraplegia than paraplegia.

Table 4 - Click to enlarge in new windowTABLE 4. Reason for Discontinuation

Overall Satisfaction With Bowel Regimen/Usefulness

Satisfaction was assessed on a 10-graded scale (10 = perfect satisfaction) in four studies (Choi et al., 2015; Kim et al., 2013; Lopez Pereira et al., 2010; Patel et al., 2020). The mean grade of satisfaction varied from 7.3 to 8.75. Ineffectiveness was assessed in three studies and found to vary from about 3% (Ausili et al., 2018; Midrio et al., 2016) to 19.2% (Kim et al., 2013).



Only one qualitative study exploring experiences was found (Sanders, Bray, Driver, & Harris, 2014). The study was based on the experiences of caregivers (17 parents and one grandmother) to children aged 3-16 years. Before being introduced to TAI, the caregivers had struggled to find an optimal bowel regimen for their children, which they described as being emotionally draining. They had tried multiple different interventions. Although each new intervention offered hope for improvement, failures had a negative impact on their confidence to try new approaches. Confidence in the options professionals offered, such as TAI, was low.


The caregivers mentioned peer support systems, intended to build confidence, and that they were more confident about trying TAI if they considered the physicians and nurses to be competent. The caregivers also stated that receiving training for the home environment and support over time was empowering. After training, some even reported being proud of their new skills, linked to their child no longer being incontinent. Being continent was considered important, especially once a child started school. "Soiling in the classroom" and "still wearing nappy" were associated with social difficulty in a school environment. Being continent opened possibilities for participating in new activities, like swimming.


However, the caregivers struggled with the TAI bowel procedure. Some had to hold their child during irrigation, because the child found the procedure so distressing. Such challenges were perceived to be upsetting and could even strain the interparental relationship; parents could disagree on whether the treatment should be continued. The caregivers regularly re-evaluated the effectiveness of the treatment against the impact it had on their child, themselves and the rest of their family's busy social life.


Most were motivated to continue using TAI. Supporting their child in becoming independent was a strong driving force, in addition to "taking control" over bowel emptying. The achieved and prospective levels of independence were related to physical and cognitive disability. Some predicted that their child would never become fully independent.



TAI appears to be an effective method for people with NBD. TAI may have a positive effect on constipation and incontinence; reduces the time needed for evacuation and bowel management; and results in more regular defecation, less symptoms during evacuation, and a reduction in the use of other methods to support evacuation. Furthermore, other health concerns related to NBD may be eased, the need for healthcare services reduced, and quality of life enhanced. Regarding feasibility, the results are inconclusive. Users may become independent, but not all will. Practical problems were typical and a common reason for discontinuation, together with unsatisfactory effect, disliking treatment and side/adverse effects. Compliance was not always easy to achieve.


The results indicate that for people with neurogenic bowel TAI dysfunction might reduce difficulties associated with defecation, making it easier to empty the bowel more regularly and controlled. This is in line with previous reviews (Coggrave et al., 2014; Dale, Morgan, Carter, White, & Carolan-Rees, 2019) and a well-functioning bowel regimen (Pardee et al., 2012). Reducing constipation (including softening of stool, reducing intestinal transfer times and the need for laxatives and/or other support for emptying the bowel, and decreasing frequency of bowel movements and frequency of evacuation) is most relevant for people with NBD. In general, constipation can result in pain, loss of appetite, and lethargy (Cameron et al., 2015; Emmanuel, 2010b) and negatively affect quality of life (Belsey, Greenfield, Candy, & Geraint, 2010). For people with spastic tendencies, constipation even may aggravate spasticity or limit the person's mobility (Kheder & Nair, 2012). The results further suggested that TAI might reduce the time needed for evacuation. Reducing the time spent on the toilet is important, as prolonged toilet visits significantly increase the risk of pressure ulcers and also take time away from other, more enjoyable activities (Cameron et al., 2015).


The results even indicate that use of TAI can reduce fecal and flatus incontinence, which is in line with the results seen in other reviews (Bray & Sanders, 2013; Coggrave et al., 2014; Dale et al., 2019). Reducing incontinence is important, because incontinence is associated with negative self-affirmation, guilt, shame, and life limitations (Dibley et al., 2017; Olsson & Bertero, 2015). Not only the person with incontinence is affected, but also significant others. For example, parents worry about their child growing older, because soiling and nappies are socially unacceptable (Sanders et al., 2014).


NBD and its symptoms majorly impact the life of people with the condition and their significant others. People with NBD even perceive that their bowel is controlling them (Dibley et al., 2017; Nevedal et al., 2016). As seen in this review, TAI appears to be a means whereby control can be regained. Not only can TAI provide control over bowel emptying, it also has a positive impact on dependency, and both children and adults appear to become less dependent. However, level of dependency appears to be linked to overall functional and cognitive ability; severer degree of disability may hamper total independence. According to Wide, Mattsson, Drott, and Mattsson (2014), those who are independent in toilet procedures rate quality of life significantly higher than those who are fully dependent. From the results, TAI in general seems to have a positive impact on quality of life.


TAI appears to be effective and may increase independence, but the results are inconclusive regarding feasibility. Practical problems and adverse effects affect feasibility negatively. Yet severe adverse events such as bowel perforations were rare, which increase the benefit-risk ratio in support of the further use of TAI (Christensen et al., 2016). Practical problems were one of the most commonly reported reasons for discontinuation, mainly at the beginning of the treatment period. According to Bildstein et al. (2017), people who continue to use TAI seem to tolerate possible practical problems as their bowel function improves (Bildstein et al., 2017). TAI can be a well-functioning treatment for people with NBD (Dale et al., 2019), if users can persist through an initial period of practical problems, which according to Christensen et al. (2009) can be solved with adjustments.


To ensure compliance, training led by competent instructors alongside structured user support is essential (Adriaansen et al., 2015; Bildstein et al., 2017; Dale et al., 2019; Lallemant-Dudek et al., 2020; Sanders et al., 2014). The further development and use of new equipment is also needed. Passananti et al. (2016) found that problems with balloon bursts were reduced after catheter design was altered. Further, electronic systems with digital functions for TAI that improves user-friendliness (Passananti et al., 2016) and pumps that can increase feasibility (Charvier, Bonniaud, Waz, Desprez, & Leroi, 2020) have been developed none of the participants in the studies included in this review had access to such equipment.


One tendency that could be discerned was a difference in compliance between children and adolescents, and adults. Children and adolescents in general reported a high degree of compliance. This might be explained by the fact that many children and adolescents are supported by their parents. It has been suggested that parents of children with NBD often are driving forces in terms of improvement methods (Sanders et al., 2014), whereas an adult with NBD is more often "left on his/her own" (Burns et al., 2015). Children and their parents often receive information about TAI at an early stage, because it is an accepted treatment for those born with spinal cord injury. Adults who suffer from neurological diseases/injuries later in life tend to receive less information about TAI (Coggrave et al., 2009).


Cultural differences and differences in socioeconomic support systems also seem to affect level of compliance. In one of the included studies from Korea, parents were seen to take full responsibility for their child's care because there is a limited availability of support programs for children with chronic conditions (Choi et al., 2015). In the only study from Australia, there was a high rate of cessation with TAI, explained by a lack of outpatient support (King et al., 2017). In two studies, from Korea and the U.S., economic restrictions and/or insurance issues were reported as a reason for discontinuation (Choi et al., 2015; Patel et al., 2020). This indicates that TAI is not accessible for all, even if it is a cost-effective method in comparison to standard bowel care (Christensen et al., 2009; Emmanuel et al., 2016; Sengoku et al., 2018).


Implications for Nursing

For patients with NBD, the process of defecation is challenging causing symptoms of fecal incontinence and/or constipation known to be associated with a poorer quality of life. The results of this study show that TAI effectively reduces symptoms of NBD and thus nurses in clinical practice should inform potential uses on the method. However, it is important that nurses, as well as other healthcare staff, can offer a proper introduction Nurses guide and support the users and caregivers to pass the challenges that may follow the treatment of TAI. This is important for the treatment to be successful.



The aim of this integrative review was to investigate the effectiveness and feasibility of TAI for people with NBD. During quality appraisal it became clear that only one randomized control trial had been performed on the topic and several other studies had small participant numbers and/or were otherwise weak in quality (e.g., used nonstandardized measures, noncomparative, and/or short duration of treatment). This may affect reliability of the study. Also, the integrative design was chosen so that both quantitative and qualitative designs could be integrated. Yet only one qualitative study matched the inclusion criteria. Still, by summarizing the results from several studies tendencies can be found, and the results in this review are supported by previous, dated reviews.


When performing an integrative review, a broad approach should be used. To ensure high-quality search strategies, we consulted a team of information specialists who assisted with the searches. This led to a rich number of studies. Only one of the authors reviewed all of the included studies and withdrew data, which can be understood as a weakness. Nevertheless, the entire research team discussed any unclear cases and reviewed the correctness of the extracted data.



After completing this integrative review, we conclude that TAI seems to be an effective method for people with NBD. Regarding feasibility, the results are inconclusive but suggest that TAI can reduce dependency in bowel habits. However, users, including caregivers, report practical problems, and compliance was not always easy to achieve. It is important that users, including caregivers, are well informed and supported throughout treatment, especially by way of introduction. Also, there is a need for high-quality quantitative and qualitative studies on the topic to support our findings.



The authors thank Lillemor Lyren, Mattias Lennartsson, and their team at the Medical Library, Umea University.




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