The goal of a neurogenic bowel continence program is to achieve timed elimination of stool through the use of oral laxatives, suppositories, and enemas [60]. These methods are used singly or in combination. Accomplishment of continence requires patience and motivation on the part of the family, physician, and nurse educator. A second goal is to avoid fecal impaction and the related liquid encopresis that occurs and is often mistaken by families as an episode of diarrhea. (See "Definition; clinical manifestations; and evaluation of encopresis").

].At the initiation of a bowel management program, bowel clean-out may be necessary. If the history of the patient reveals that there are several days without a bowel movement, or there is palpable stool on abdominal exam or rectal exam, then bowel clean out with a Fleet's enema should be initiated. The Pediatric Fleet's enema, which contains approximately 60 mL of solution should be used for children between 2 and 10 years of age. An abdominal radiograph should be ordered if confirmation of stool quantity is needed (eg, in an overweight patient). The assistance of a gastroenterologist may be needed if routine enemas do not produce acceptable results.

Once the bowel clean out has been accomplished, the patient may be placed on a regular program of a daily oral agent. Alternative regimens include:

Senokot: 0.5 to 1 tsp (2.5 to 5 mL) PO at bedtime in children 2 to 6 years of age and 1 to 2 tsp (5 to 10 mL) at bedtime in older children
Perdiem (100 percent psyllium): 1 to 2 tsp (5 to 10 mL) PO each day with 8 ounces (240 mL) of fluid per dose)
Lactulose (10 g/15 mL): 0.5 to 1 tsp (2.5 to 5.0 mL) PO each day
In addition, to the oral agent, a glycerin or bisacodyl suppository (10 mg) should be administered once per day 15 to 20 minutes after a meal to take advantage of the gastrocolic reflex. This is followed by placing the young child on the toilet and making sure his or her feet are well supported.

Some patients require daily evacuation of stool with the use of the visi-flow enema, which requires 20cc/kg of saline. This enema system comes with a water regulator so that the parent or the patient can control the speed of the water (or turn it off altogether for a rest) if he or she experiences abdominal cramping. Completing the enema takes usually 20 to 30 minutes. School-aged patients appreciate having the opportunity to have a nightly enema and avoid school accidents the following day.

If conservative medical management fails, then a surgical option is the antegrade continence enema [61-65].In this procedure, the appendix and cecum (or ileum if the appendix is not available) are used to create a catheterizable stoma. The patient is able to clean out the colon from the proximal end of the large intestine while sitting on the toilet, reducing the risk of fecal soiling and constipation. Fecal continence is achieved with this technique in approximately 85 percent of patients with spina bifida [65].

Skin integrity — Disruption of skin integrity is an important cause of morbidity in children with myelomeningocoele and often leads to hospitalization [66,67]. Decubiti often develop on the sacrum, buttocks, back, and feet. Other lesions include burns, abrasions, and ammoniacal dermatitis. Affected children are especially susceptible to burns because their lower extremities lack sensation and may not detect an elevated temperature. They should not be placed under running water without supervision because they may not detect exposure to very hot water. Similarly, they should avoid leaving hot food on the lap for a prolonged period which may lead to burns of the anterior thighs.

Patients with high level lesions may develop pressure decubiti with subcutaneous tissue necrosis. Patients with defects at the thoracic level are at risk for skin breakdown over the perineum and gibbus (bony angulation of collapsed vertebrae). The skin breakdown over the perineum is due to asymmetrical weight bearing and fecal and urinary incontinence. A commonly affected area is the ischial tuberosities, which should be inspected closely.

Ulceration over bony prominences and beneath orthotic devices can become very deep and involve muscle and/or bone. A chronic ulcer that does not improve with medical management should be evaluated for evidence of osteomyelitis. An abnormal radiograph or bone scan or an elevated sedimentation rate or C-reactive protein level may help distinguish an infected ulcer requiring long-term antibiotic therapy from a chronic ulcer that might benefit from consultation with a wound care specialist or plastic surgeon [68].

Neuropathic foot ulceration is common in patients who have low lumbar or sacral myelomeningocele. In one report, patients most likely to develop ulcers had foot rigidity, nonplantigrade position, and had undergone surgical arthrodesis [69