Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2

Published: 2021-07-05

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Amanda Jensen — host
Jason Fisher — guest
Mark Levitt — guest
Speaker 4 — guest
Speaker 5 — guest
Speaker 6 — guest

Chapters

0:04Introduction and Episode Context — Host introduces the episode as part 2 of spinal patients and bowel management, recapping part 1 topics including MiraLax, Senna, and urological considerations for Malone procedures.
1:09Appendix Sharing and Channel Lengthening Techniques — Discussion of unequal appendix division between urology and colorectal teams, with technical strategies to extend short appendiceal stumps using suturing or non-cutting staplers to create longer channels and reduce leakage.
3:02Alternative Approaches: Unplicated Malones and Rectal Irrigation — Indications for unplicated Malones in rural or behavioral patients, and introduction of rectal irrigation devices as non-surgical alternatives for families hesitant about stomas.
4:42Ambulatory Status and Management Choice — How patient mobility, wheelchair dependence, and anatomic factors like absent coccyx influence the choice between rectal enemas, Malone, or cecostomy for bowel management.
6:13Coordinating Colorectal and Urologic Surgery — The critical importance of establishing bowel management before urologic procedures, including using sigmoid colon for bladder augmentation and how successful bowel management can eliminate vesicoureteral reflux and avoid reimplantation.
8:33Orifice Placement Strategies — Institutional variations in placing Malone and Mitrofanoff orifices, with discussion of umbilical versus right lower quadrant positioning based on anatomy, blood supply, and surgical sequencing.
10:51Managing Poor Pelvic Floor Tone — Practical techniques for retrograde enema administration in spina bifida patients with lax pelvic floors, including balloon volume adjustments, bisacodyl addition, volume modifications, and mobilization strategies.
13:08Closing and Case Summary — Episode conclusion with recap of the 5-month-old spina bifida case and key teaching points on multidisciplinary collaboration and enema techniques.

Key claims

1:38When urologists and colorectal surgeons split an appendix, the division is typically 70/30 in favor of urology, not equal sharing — Mark Levitt
1:55The colorectal team benefits from using the portion of appendix closer to the cecum because it has a stronger blood supply — Jason Fisher
2:11A 1-2 centimeter appendiceal stump can be extended 2-3 more centimeters by suturing or using a non-cutting laparoscopic stapler along the cecal wall — Jason Fisher
2:34One of the main problems with Malone appendicostomy is leakage — Jason Fisher
2:47The longer the Malone channel, the less likely it is to leak — Jason Fisher
2:55Extending the channel 2-3 centimeters by suturing or stapling can be extremely helpful in preventing leakage — Jason Fisher
3:07Children in rural locations or with behavioral issues who pull at tubes are good candidates for unplicated Malones — Speaker 4
4:00Rectal irrigation devices made by companies like Coloplast can be used by patients with hand difficulties to self-administer enemas — Jason Fisher
4:57Spina bifida patients with absent coccyx have difficulty retaining enema fluid even for the short time needed to transfer to toilet — Speaker 5
5:53Most spinal patients prefer not to have a bag and would prefer transferring to a commode and doing an antegrade flush — Mark Levitt
6:48If a colon is very difficult to empty (requiring voluminous or concentrated enemas) and the urologist needs to do an augment, the sigmoid can be removed from colonic transit to make bowel management easier and used for bladder augmentation — Mark Levitt
7:24If a patient has an easy-to-empty colon and needs bladder augmentation, the urologist can use small bowel instead — Mark Levitt
7:39A careful assessment of existing bowel management (sit time, ingredients, flush volume) must be done before the next surgical intervention — Speaker 4
7:52A good bowel management plan can influence the urologic plan; patients who are empty regularly for stool may have improved bladder function — Mark Levitt
8:07Vesicoureteral reflux might resolve with successful bowel management, potentially saving a patient from ureteral reimplantation — Mark Levitt
8:45Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux — Jason Fisher
9:19In Kansas City, the Mitrofanoff goes at the umbilicus and the MACE or appendicostomy goes in the right lower quadrant — Speaker 4
9:29Anatomically, the bladder is a midline structure and access through the umbilicus makes sense; the cecum is right lower quadrant and placement there makes sense — Mark Levitt
9:44At Cincinnati, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage — Jason Fisher
10:21Blood supply is the ultimate driving factor for orifice placement; Malones not in the umbilicus are typically due to blood supply issues — Jason Fisher
10:42Orifices should not be matured until everyone has a plan in the OR to avoid one team pulling on the other's mesentery — Mark Levitt
10:51The last steps of combined procedures should be: mature the Mitrofanoff, mature the Malone, then close the abdomen — Jason Fisher
11:09The laxity of pelvic floor and anal canal in spinal patients makes them different, especially when doing retrograde enemas — Jason Fisher
11:31Adding bisacodyl to the flush has shown good success in spina bifida patients — Speaker 5
11:35Spina bifida patients sometimes do better with smaller enema volumes because their colons empty at different rates — Speaker 5
11:54Having patients stand up at the end of their flush, move around, and sit back down can help evacuate more stool because things move through their colon differently — Speaker 5
12:16Putting additional water volume into the enema balloon helps hold it in place so fluid doesn't go around it in patients who cannot hold like other children — Speaker 6
12:58Using MiraLax helps with stool on the right side of the colon to aid complete evacuation in spinal patients — Amanda Jensen

Cases discussed

0:265-month-old with spina bifida since birth presenting with constipation, discussed across two episodes
3:19Younger child in rural location with behavioral issues and cecostomy tube

Points of disagreement

9:00Orifice placement for Malone and Mitrofanoff procedures
- Speaker 4: In Kansas City, Mitrofanoff goes at umbilicus and MACE/appendicostomy in right lower quadrant
- Mark Levitt: Has done both approaches; anatomically bladder is midline (favoring umbilical Mitrofanoff) and cecum is right lower quadrant (favoring RLQ Malone)
- Jason Fisher: At Cincinnati for two decades, 99% of Malones are umbilical and almost all Mitrofanoffs are right lower quadrant with rectus tunnel; acknowledges need to compare outcomes

Open questions

Which orifice placement strategy (umbilical Malone vs umbilical Mitrofanoff) produces better patient satisfaction outcomes - requires comparative study between institutions
What is the optimal balloon volume or catheter type for enema retention in spina bifida patients with absent coccyx
At what threshold of bowel management difficulty should sigmoid diversion for augmentation be considered versus keeping colon in continuity

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Umbilicus or Right Lower Quadrant: Where to Place Malone and Mitrofanoff Orifices

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Question

When a spina bifida patient requires both a Malone appendicostomy for antegrade continence enemas and a Mitrofanoff channel for bladder catheterization, where should each orifice be placed 9:19 9:44? The umbilicus offers cosmetic advantage and midline access 9:29. The right lower quadrant follows anatomic logic 9:29. Both positions work, but centers have adopted opposite conventions 9:19 9:44.

Umbilical Mitrofanoff, Right Lower Quadrant Malone

In Kansas City, the Mitrofanoff goes at the umbilicus and the MACE or appendicostomy goes in the right lower quadrant 9:19. Mark Levitt has done both approaches and notes the anatomic rationale: the bladder is a midline structure, and access through the umbilicus makes sense; the cecum is right lower quadrant and placement there makes sense 9:29. This arrangement follows the native anatomy of the organs being accessed 9:29.

Umbilical Malone, Right Lower Quadrant Mitrofanoff

Cincinnati has practiced the opposite configuration for two decades 9:44. Jason Fisher reports that 99% of their Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage 9:44. The few Malones not placed in the umbilicus are typically due to blood supply issues 10:21. Fisher acknowledges the difference: "At one point, we'll compare our outcomes and see from a patient satisfaction, which may or may not be better or they may be equal" 9:44.

The Driving Factor

Both sides agree on what ultimately determines placement: blood supply is the ultimate driving factor for orifice placement 10:21. The mesenteric reach and vascular anatomy constrain the decision more than any theoretical preference 10:21. Fisher emphasizes this point explicitly — blood supply issues account for the exceptions to Cincinnati's usual pattern 10:21.

Both also agree on surgical sequencing 10:42 10:51. Orifices should not be matured until everyone has a plan in the OR to avoid one team pulling on the other's mesentery 10:42. The last steps of combined procedures should be: mature the Mitrofanoff, mature the Malone, then close the abdomen 10:51. This prevents one team's orifice placement from compromising the other's vascular supply 10:42 10:51.

What Would Resolve It

Fisher stated the resolution criterion directly: compare outcomes between centers 9:44. Patient satisfaction, leak rates, ease of catheterization, and long-term function would settle whether one configuration offers clinical advantage or whether both work equally well 9:44. The discussants did not cite existing comparative data, leaving this an empirical question awaiting systematic comparison 9:44. Until then, both approaches remain defensible, and the choice reflects institutional practice pattern rather than evidence-based superiority 9:19 9:44.

Takeaways from this story

Blood supply, not anatomic theory, ultimately determines where Malone and Mitrofanoff orifices can be safely placed
Cincinnati places 99% of Malones umbilically with RLQ Mitrofanoffs; Kansas City does the opposite—both work
Never mature orifices until both teams finalize their plans to avoid compromising each other's mesenteric blood supply

Coordinating Bowel and Bladder Management in Spina Bifida: When Two Surgical Teams Share One Patient

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Discipline

Children with spina bifida face dual neurogenic dysfunction: their bowels don't propel stool effectively, and their bladders don't store or empty reliably. Both problems stem from the same spinal lesion, but they require different surgical specialists — colorectal surgeons for the bowel, urologists for the bladder. The challenge is that these systems are anatomically adjacent and physiologically intertwined. A full rectum compresses the bladder; chronic constipation changes ureteral angles and can cause reflux 8:45. Effective management requires not just technical skill from each team, but deliberate coordination of timing, tissue allocation, and surgical sequencing.

The Core Clinical Problem

Most spina bifida patients cannot achieve social continence through conservative measures alone. They need surgical access ports: a Malone appendicostomy (antegrade continence enema, or MACE) for bowel irrigation from above, and often a Mitrofanoff channel for clean intermittent catheterization of the bladder. Both procedures commonly use the appendix. When one patient needs both channels, the appendix must be divided between the two teams — and as one discussant notes, urologists are reluctant to share the appendix 1:38. The split is typically 70/30 in favor of urology, leaving the colorectal surgeon with a short stump 1:38.

Beyond the mechanics of channel construction, there is a deeper strategic question: the state of the bowel directly affects bladder function. Fecal impaction pushes on the bladder and alters the angle at which the ureters enter, potentially causing vesicoureteral reflux 8:45. Establishing effective bowel management first may improve bladder dynamics enough to change the urologic plan entirely — possibly eliminating the need for ureteral reimplantation 8:07.

How the Approach Works

Appendix sharing and channel construction. When the appendix is divided, the colorectal team receives the portion closer to the cecum, which has a stronger blood supply 1:55. If the stump is only 1-2 centimeters, it can be extended by suturing or using a non-cutting laparoscopic stapler along the cecal wall, adding 2-3 centimeters of effective channel length 2:11. This matters because leakage is one of the main complications of Malone appendicostomy 2:34, and longer channels leak less 2:47 2:55.

Bowel management before bladder surgery. A careful assessment of the existing bowel regimen — sit time, flush volume, enema ingredients — must precede any urologic intervention 7:39. If the colon is difficult to empty, requiring large or concentrated enemas, and the patient needs bladder augmentation, the sigmoid can be removed from colonic transit (simplifying bowel management) and used by the urologist for the augment rather than discarded 6:48. If the colon empties easily, the urologist can use small bowel for augmentation and leave the colon intact 7:24. Successful bowel management may resolve reflux and spare the patient a reimplantation procedure 7:52 8:07.

Orifice placement. Institutional practice varies. At one center, the Mitrofanoff is placed at the umbilicus and the MACE in the right lower quadrant, following anatomic logic: the bladder is midline, the cecum is right-sided 9:19 9:29. At another, 99% of Malones go to the umbilicus and most Mitrofanoffs to the right lower quadrant with a tunneled channel through the rectus to prevent leakage 9:44. Blood supply is the ultimate determinant 10:21. Critically, orifices should not be matured until both teams have completed their work — augments, reimplants, channel construction — to avoid one team pulling on the other's mesentery 10:42. The final steps are: mature the Mitrofanoff, mature the Malone, then close 10:51.

Managing poor pelvic floor tone. Spina bifida patients with lax pelvic floors and absent coccyx cannot retain enema fluid the way other children can 4:57 11:09. Practical adjustments include adding bisacodyl to the flush 11:31, using smaller enema volumes because their colons empty at different rates 11:35, having patients stand and move around mid-flush to promote evacuation 11:54, and increasing the water volume in the balloon catheter to create weight that holds it in place and prevents fluid from leaking around it 12:16. MiraLax helps with right-sided stool to aid complete evacuation 12:58.

Where Practice Is Contested

There is no consensus on orifice placement — umbilical versus right lower quadrant for each channel — and outcomes data comparing the two strategies are lacking. The choice of antegrade versus retrograde enema administration depends on ambulatory status, transfer ability, and family preference; most spinal patients prefer not to have a stoma and would rather transfer to a commode for antegrade irrigation 5:53, but this is not universal. Rectal irrigation devices offer a non-surgical alternative for some families hesitant about stomas 4:00, though patient selection criteria remain institution-dependent.

When to Involve This Team

Refer to a combined colorectal-urology clinic when a spina bifida patient is not achieving social continence with conservative bowel management and has urologic issues requiring surgical intervention. Refer before the urologist operates if possible — the bowel management plan must be established first, as it may fundamentally alter the bladder surgery 7:52 8:07. If a patient already has a Malone or cecostomy and is being considered for bladder augmentation, ensure the colorectal team is involved in preoperative planning so tissue can be allocated efficiently 6:48.

Takeaways from this story

Establish bowel management before bladder surgery — successful bowel emptying may resolve reflux and change the urologic plan.
Short appendiceal stumps can be extended 2-3 cm by suturing or stapling along the cecal wall to reduce Malone leakage.
When colon is hard to empty and augment is needed, use sigmoid for both: remove it to simplify bowel management, roll it for bladder.
In spina bifida patients with lax pelvic floors, increase balloon water volume to hold retrograde enemas in place during administration.
Mature orifices last in combined procedures — after all augments and reimplants — to avoid pulling on shared mesentery.

Topic overview

A multidisciplinary discussion on bowel management in pediatric spina bifida patients, focusing on surgical collaboration between colorectal and urology teams. The speakers address technical considerations for Malone appendicostomy and Mitrofanoff procedures, including appendix-sharing strategies, channel lengthening techniques to reduce leakage, and orifice placement decisions. They emphasize the importance of optimizing bowel management before urologic interventions, as successful fecal management can improve bladder function and potentially eliminate the need for procedures like ureteral reimplantation. The discussion includes practical strategies for retrograde enema administration in patients with poor pelvic floor tone.

Key takeaways

Urologists typically claim 70-80% of appendix length in shared procedures; colorectal surgeons can extend remaining stump 2-3cm via suturing/stapling.
Longer Malone channel length significantly reduces leakage risk; consider cecal wall extension techniques when appendix is short.
Rectal irrigation devices (e.g., Coloplast) offer non-surgical alternative for families hesitant about Malone/Mitrofanoff procedures.
Spina bifida patients with absent coccyx struggle to retain enemas; antegrade continence enema via Malone may improve compliance.
Patient mobility and transfer ability should guide bowel management choice: ambulatory patients often prefer toilet-based regimens over stomas.

Keywords

spina bifida constipation urinary incontinence stool incontinence vesicoureteral reflux fecal impaction Malone appendicostomy MACE Mitrofanoff cecostomy bladder augmentation bladder neck tightening ureteral reimplantation rectal irrigation retrograde enema

Hashtags

#SpinaBifida #PediatricSurgery #BowelManagement #NeurogenicBowel #ColorectalSurgery

Transcript

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Hey there listeners, it's Amanda Jensen from Cincinnati Children's. Have you downloaded the new version of the stay current pediatric surgery app? It's in the Google Play Store and in the Apple App Store. So download the app so you are able to see those pictures in real time as we discuss them. Alright, today's episode is spinal patients and bowel management needed for a urologist, part two. If you remember from last week, we discussed a 5 month old with a history of spina bifida since birth who presented with constipation. We discussed bowel management with use of MiraLax as our musher and use of Senna and Bisciotal as our pushers. We discussed Senna rashes and how to reduce the risk of them. We additionally discussed Uh, management of urinary and stool incontinence in the older child and need for a malone. In regards to urological considerations, sometimes we need a temporizing way to forward flush such as a sycostomy tube or a non-placated, non-trimmed malone, and this decision making with collaboration with urology is key as they tend to want to use the appendix for their metrofenoff. All right. Now, back to our colorectal quiz. Today I have with me Doctor Jason Fisher from Cincinnati Children's. When you get that really short stumpy appendix, whether it be from splitting it, and the urologist, if I have a 7 centimeter appendix, the urologist takes 6.25 centimeters and I get 0.75. Um, by the way, just so you know, urologists are not very good shares. That's Doctor Mark Levitt from Children's National. You know, when you have two kids, two kids on a playground, and they're splitting a cookie, usually you split it, and the person who split it isn't the one who uses it. But when it comes to urology, a split is about 70/30. That's what I've seen. That, that's a good day, absolutely. But there are tricks. We, we are in the benefit, right, because we're you. Using the appendix that's closer to the cecum, that portion of the appendix, so we're gonna have a stronger blood supply. Also, there are tricks to extend the appendix or fake how long that appendiceal channel could be. And you could either do it by suturing, or there's a laparoscopic version of a TA or linear stapler that doesn't cut. And you could use either of those to sort of lengthen the channel along the wall, the edge of the cecum, so that you could take your 1 or 2 centimeter appendiceal stump and extend it 2 or 3 more centimeters. And the reason for that is we know that one of the problems with the alone is leakage. And we do have some tricks for leakage, right? We do, we sometimes do application that's been mentioned a couple of times here already. But the other thing that I think is important about Malone's is the actual length of the channel. The longer the channel, the less likely that Malone's going to leak. Extending the channel 23 centimeters either by suturing or stapling can be extremely helpful. Another important, you know, both to Mark, um, and Jason's point. Uh, the first one is a great reason why a child would need an unplacated malone would be they live in a rural location, they are behavioral and they kind of pull at all the tubes. We had a sycostomy that we placed in a younger child, um, for a similar situation, and within a day, they had managed. In this rural location to pull that tube out and because we'd sutured it in place, they were able to get it back in and the child didn't need additional surgery, but it was a real nail biter and so that would be a great reason to keep that, to, to, to do that approach. I also wanna mention one thing that Um, and there are all different reasons, but one of the options I give to my patients and their families when deciding about Malone's, Metrofanoffs, and bowel management, etc. is the use of rectal irrigation. And I carefully use the term rectal irrigation in that there are some devices out there that are made specifically for patients to sort of wash their colons. With a pressurized water system that is made to be used by patients that have maybe some difficulties using their, all their hands or, and can self-administer an enema that way. I know coloplast makes one. And there are a few other options out there as well. That's always an option that I give to the families if they are hesitant about the loans and Metronas, etc. uh, is one of the options out there. I just wanna make sure we mention it. Wendy, can you just comment on that? I think that's a really important point is the ambulatory status of the spinal patient and how that might influence your choice of their bowel management, be it enemas, Alone or in fact a stoma. And some of these spinal kids, you know, if they have an absent coccyx, it's really hard for them to get a good clean with the rectal enemas of the balloon because they have a really challenging time retaining any fluid, even for the short amount of time from standing up to get on the toilet. Or these kids are wheelchair bound, to your point, but at 2, expecting a kid like that to stay there to empty, it's really challenging for families. Another reason that we've chosen the ecostomy route, or if we're able to use the appendix, doing the Malone route in this, these spinal kids, is that we can usually get them a small potty on the floor or allow them to not have to, with their mobility, you know, compromise, do something rectally, and then figure out a way for them to empty. Yeah, I think that's right, and I think you have to take into consideration the um transfer. Uh, to the commode issue. Although I will say most spinal patients that I've taken care of would prefer not to have a bag and would prefer transferring to a commode and doing an anti-grade flush. There is the occasional patient that Uh, again, this is all about quality of life, so we need to talk about that with the family and make, and make the right decision. I do wanna, uh, bring up one other point to consider before, if we are in this collaborative mode and we have a nice plan with urology and urology has made a decision. And the issues for urology are, does the bladder neck need to be tightened, does the bladder need to be augmented? Does the patient need a metrofenoff? And it could be all of the above, or 1 or 2 or uh of the above. If there is an augment possibility, it's vitally important that the colorectal team has figured out what is the bowel management plan for that patient. Because you may very well have a case where the colon is very difficult to empty, and you know that because the enema is very voluminous or very concentrated, and then the urologists say, I need to do an augment. What an opportunity for sharing. Take the sigmoid out of the transit of the colon, which will make the bowel management that much easier, and instead of throwing it away or giving it to the pathologist, roll it over on its mesentery, and then the urologist can use that. As an augmentation. So just have that in mind, if that's a possibility. If the patient has an easy to empty colon, then obviously that colon can stay in, and the urologist need to do a And augment, they can use small bowel. And then, of course, there's the splitting of the appendix opportunity that we've already discussed. Go ahead. You're really saying is that you have to do a really careful assessment of the existing bowel management plan before the next surgical intervention to understand the amount of sit time, ingredients and the flush that's going in. If you have a good bowel management plan, you actually might influence the urologic plan. There are plenty of patients out there that once they're empty regularly for stool, and are never having impactions, their bladder works a lot better. Their reflux might go away. You might save a patient from a ureter reimplantation with successful bowel management. So I think it's really important that the two teams, as is really nicely demonstrated, all three of our centers, work closely together in formulating these plans, because many times the urologist will say, I need the, uh, I need the bowel work to happen first before I really know what's happening with this bladder. Great point. I, I, it's so key to understand what, exactly what Rebecca said. Understand the bowel management needs before going in there and just doing an operation. Changing the potential surgical plan of the urologist because fecal impaction is pushing up on the bladder and changing the angle of the ureter entering the bladder and causing reflux, etc. The key point being from this collaboration is key. Where do you Guys, when you do a shared, uh, Malone Merofanoff experience, whether it's a shared appendix or independent neo appendix, etc. where do you put the orifices? What goes in the umbilicus and what goes in the right or left lower quadrant? What happens in, uh, Kansas City? In Kansas City, the metrofeoff goes at the umbilicus, and the mace or appendicostomy goes in the right lower quadrant. I can tell you I've done both. Anatomically, the bladder is a midline structure, and access to the bladder going through the umbilicus makes a lot of sense. And the cecum is a right lower quadrant and popping it to the right lower quadrant makes a lot of sense. Uh, Mark, you know what I do. We've been doing it here for two decades now, is that 99% of our malones are in our umbilicus, and a few random malones are in the right lower quadrant. And almost all of our metrofinoffs are in the right lower quadrant with a, with a tunnel channel through the rectus, helping to prevent leakage from the metrofenoff. So, we do it the opposite way, I guess that At one point, we'll compare our outcomes and see from a patient satisfaction, which may or may not be better or they may be equal. Obviously, the number one driving point is where does it reach and the blood supply. So that, the few that we have that aren't in Malone's, that aren't in the umbilicus are typically due to blood supply, at least from our standpoint. So that has to be the ultimate driving point. What else do we have to consider? Make sure they're properly separated. And don't uh do your orifices until everyone has a plan in the OR. So that one team is not pulling on the other's mesentery. So what do you mean by that, Mark, is don't mature your orifice until everything's sort of been built and done, what augments, reimplants, etc. So the, the last steps of the procedure are mature the metrofenoff, mature the malone, and then close the abdomen. I would love to ask definitely this patients with spinal problems, the laxity of their pelvic floor and their Anal canal is a huge issue in many of these patients and sort of makes them a little different, especially when doing retrograde enemas. Any tricks, tips, things that you have found and learned along your careers that you could share with everyone? We have found really good success adding visacodyl to their flesh. Sometimes they do better with the smaller volumes because they dump out at different rates, you know, they, their colons. Just move different than other kids. So, um, it's one extreme or the other, you know, we, we see them in bowel management boot camp and we either have them on low rates or completely maxed out to clean out their colon. And then the other thing that, um, you know, that Doctor Rent has recommended a lot that I think has been really helpful is she asks the families or the kids, depending on their ambulation, to kind of stand up at the end of their flesh and move around and then sit back down again. And, and try to have a little bit more stool because of the fact that we know things just move through their colon differently. Any other tips or tricks? Um, one thing that we've noticed, and this is in regard to enemas through the rectum rather than through an anti-grade port, would be to put a volume of water into the balloon, and we've kind of found that that really helps to hold it into the. so that the fluid doesn't go around it. Just because they don't have the ability to hold like our other kids do, and having that little bit of heavy fluid in there really helps when we don't have integrade access for those kids to be able to hold on to that liquid volume as long as possible. So to summarize, in spinal patients with poor pelvic floor muscles, adding additional water to the balloon using a larger balloon size or a different shape, such as a cone. Really helps with administration of enemas and additionally using MiraLax for stool on the right side of the colon to help them evacuate all of their stool. Mark, I think it's that time. Yeah, you know, I, uh, I thought you were gonna say that, and I was realizing, did you, did you guys hear that there were, um, 22 red blood cells that fell in love. It's true. Sadly, though. Their love was in vain. Terrible, terrible. All right, that wraps up part two of the colorectal quiz, bowel management and spinal patients and the need for a urologist. Let's summarize the case. This was a 5 month old with a history of spina bifida since birth, who presented with constipation. In this episode, we specifically discussed tips and tricks in the OR with collaboration with urology. And specifically in patients with spinal differences, how to use different enema recipes and Foley tricks to help them evacuate. Thank you for joining us for the colorectal quiz. Download the Stay Current app if you have not already, and remember, knowledge should be free. Until next time. This is Amanda Jensen with Cincinnati Children's.

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