Today is evident that  management of children with spina bifida (SB) or spinal cord injury(SCI) must be  a complete management of both neurogenic bladder and bowel dysfunction (NBBD). Transanal irrigation (TAI) has beeen succesfully reintroduced in the past years for the management of bowel dysfunction. Actually TAI is considered the first line treatment, before more invasive procedure as sacral neuromodulation or Malone either in patients with SB and SCI as in  operated for anorectal malformation (ARM). TAI effectiveness has been related to a correct training and a careful follow-up. Aim of our study is to investigate retrospectively how these aspects can improve the success of TAI on a long-term follow-up.

From January 2009 to december 2018, 82 patients, aged 3-18 years, have beeen treated with TAI , using  Peristeen system  ( Coloplast, Kokkedal, Denmark) or Navina Smart System ( Wellspect Molndal, Sweden). TAI has been performed in all , according a defined protocol approved by our Scientific/ethical Committee, after a written consent was signed. All patients presented a NBBD  due to: ARM in 23, SB in 35, SCI in 12. other causes of NBBD were present in the others  12, as cerebral palsy, brain injury, mielitis. TAI training have been performed in a 3 days module, where first irrigation have been always performed inside the Hospital by our specialist nurse team, while from  the second one by the caregiver , under control by  a specialist continence care. Patients have been evaluated  after a 1 year minimum follow-up using  a specific 10 domains questionnaire on bowel function, satisfaction,QoL . A score 0-10 was used , where 0 as reported as very poor results. Urine analysis have been evaluated during folllow-up.Data were evaluated by statistician, using SPMMS Microsoft excel program.

About 82  patients , 54  were in follow-up in our center , while 28 have  been only trained by us to a correct use of TAI in our Hospital , but are in follow-up in other centers.  6 patients refused to partecipate to the study, 4 patients have been lost at the follow-up. About 72 patients that answered to our questionnaire ( 51 in our center and 21 outside), TAI has been performed for 2,5- 9 years, mean 4 years. No serious adverse effects have been recorded. 30 patients reported to stop TAI because not satisfied about clinical results, or for problems related to irrigation. Drop out was of 16 patients in our group ( 31%) versus 14 ( 66%) outside. Up to now  35 patients are in treatment and follow-up in our center while 7 are still  in treatment in other Insititutions. Evaluating the questionnaries and the scores in our group 29/35 are higly satisfied (83%) and 27 reported an high effectiveness of bowel function (77%) comparing to  71% and 57% respectively in  patients only trained . Urinary tract frequency has been reported  reduced in all patients in treatment. Drop out rate seems reduced in our group as well as satisfaction increased , comparing to other patients in external follow-up .

The role of bowel management using TAI is well defined in a step pyramid of care, and the use of conservative medical treatment including dietary advice, laxatives, suppositories or enema are considered .  In paediatrics TAI is presenting an increasing use due to a high rate of success both in clinical as in QoL . Nevertheless the Centre were TAI is regularly used is still reduced as well as ther is a lacking number of HCP expert with a correct TAI use and patients training.The introduction of TAI should be individualized for each patient on the basis of clinical history, previous surgery, bowel diaries, type of stool (Bristol scale), frequency of stool, symptoms related, previous and presents therapy, diet, age, ability to walk or presence of wheelchair and quality of life. Faecal disimpaction is mandatory before.Is important to remember to the caregivers that a correct Bowel management is always multidimensional. There are documented risks associated with TAI, which include systemic reactions to irrigation solutions and rectal perforation, although these are very uncommon.Anyway in our opinion is very important to offer a careful follow-up to the patients and to the care giver in order to reduced dropout, that in many cases is related a no serious side effects or some technical problem during irrigation. In our experience the majority of data are related  a manual irrigation system , Peristeen, that has been the first one introduced. We have not investigated the effectiveness of different used system, because out of the aim of our study focused on the importance of training and follow-up.

TAI is co firming as a safe  and effective in the treatment of bowel dysfunction on long-term . A correct training and a careful follow-up seem to be important for increasing succes and reduce drop-out.
For this aspect a standardized protocol could be useful to use worldwide for a correct training of caregiver and patients  . Concern remains with the reduced number of well trained HCP , specialized courses could be useful in order to increase a correct practice of TAI in order to reduce migration from secondary Hospital to third and fourth level centers.

An evidence-based review of the use of transanal irrigation in children and young people with neurogenic bowel. Spinal Cord, 2013. 51(2): p. 88-93.
Consensus Review of Best Practice of Transanal Irrigation in Children. J Pediatr Gastroenterol Nutr, 2017. 64(3): p. 343-352.