The document discusses various conditions associated with spinal cord injury (SCI) including autonomic dysreflexia, orthostatic hypotension, neurogenic bladder, neurogenic bowel, sexual dysfunction, and pressure ulcers. It provides definitions and descriptions of each condition as well as information on signs, symptoms, causes, assessments, and management strategies. The conditions can affect people with SCI depending on the level and completeness of their spinal cord lesion.

1. SCI – Associated Conditions
NIN

2. Isi
• Autonomic Dysreflexia
• Orthostatic Hypotension
• Neurogenic Bladder
• Neurogenic Bowel
• Sexual Dysfunction
• Pressure Ulcer
• Lainnya

3. AUTONOMIC DYSREFLEXIA

4. Autonomic Dysreflexia
• Definisi
– Acute syndrome of excessive,
uncontrolled sympathetic output that
can occur in patients who have had an
injury to the spinal cord (generally at or
above T6 neurologic level)
• Why T6?
– Involvement of the splanchnic vascular
(critical mass of blood vessels)
• >> and >severe in complete lesion
• If left undetected and untreated, can lead to
stroke, intracranial or retinal hemorrhages,
seizures, myocardial infarction, and death.
Blackmer, 2003

5. Signs & Symptoms
- HT*
- Bradycardia (bs
jg tachy)
- Severe
headache
- Above the
level of the
lesion:
flushing,
sweating, nasal
congestion
-Below the level
of the lesion:
piloerection,
cool, pale skin
*) >>px SCI
baseline SBP 90-
110mmHg,
increase 20-40
mmHg may be
sign of AD
Blackmer, 2003; Kirshblum et al, 2007

6. • Identify and eliminate underlying cause
Blackmer, 2003

7. ORTHOSTATIC HYPOTENSION

8. Orthostatic Hypotension
• Definisi
– Sustained reduction of SBP > 20 mm Hg or DBP > 10
mm Hg within 3 minutes of standing or head-up tilt to
at least 60° on a tilt table
• Kausa
– Drug-induced: Antihypertensive agents,
antidepressants, and antiparkinsonian
– Depletion of intravascular volume
– Neurogenic: impaired ANS function  gagal
kompensasi dgn vasokonstriksi & peningkatan HR
Pada elderly  predisposisi OH multifaktorial
Magkas et al., 2019

10. Management OH in SCI
– Reposition—Trendelenburg/recliner WC.
– Gradual positional changes
– Accommodation (e.g., use of tilt table).
– Elastic stocking/ace wrap  venous return. Abdominal binder
 kurangin venous pooling ke abdomen
– Fluid resuscitation: Increase fluid intake.
– Pharmacologic agents
• Salt tablets 1 gram four times a day  increase circulating blood
volume.
• Midodrine (ProAmatine) (α-1 adrenergic agonist): 2.5 to 10 mg three
times a day (TID)
• Florinef® (mineralocorticoid): 0.05 to 0.1 mg daily  enhance
intravascular blood volume
• Caution: Once orthostasis improves, the patient may be at risk for
autonomic dysreflexia

11. NEUROGENIC BLADDER

12. Physiology
• Fungsi bladder =
menampung urin
sementara
• Produksi urin
+1cc/min
Fungsi Inervasi Detrussor Bladder neck/
internal sphincter
Filling/Storage Simpatis
T10-L2
Relaksasi
>> β-2 adrenergic
Kontraksi
>> α-1 adrenergic
Emptying Parasimpatis
S2-4
Kontraksi
cholinergic
Relaksasi
cholinergic
Voluntary control Somatic
Pudendal n. (S2-4)
m. sphincter ani externa  kontraksi

14. Physiology Control centers
• Cortex (Frontal lobe)
– Inhibit parasimpatis
SMC
• PMC
– Coordinating
detrussor & sphincter
• SMC
– Micturition reflex
center
• Motor cortex to
pudendal nucleus
– Voluntary control
(contract/inhibit
sphincter urethra ext)
v

15. Pathophysiology

16. (Dorsher & McIntosh, 2012)
Letak lesi Tipe Kondisi Efek
Di atas PMC
(stroke, brain tumor)
Uninhibited
bladder
• Reduced awareness of
bladder fullness and a low
• Capacity bladder
Urinary
incontinence
Antara PMC dan SMC UMN bladder • Detrusor-sphincter
dyssynergia
• Small, overactive, spastic
bladder
• Tight, spastic internal
sphincter
Urinary retention
Very high
pressures in the
bladder
Sacral
Damage detrussor but
not pudendal nucleus
Mixed Type A
bladder
• Detrusor areflexia
• Hypertonic external urinary
sphincter.
Urinary retention
Sacral
Damage pudendal but
not detrussor nucleus
Mixed Type B
bladder
• Flaccid external urinary
sphincter
• Disinhibited detrusor
Incontinence
SMC or nerve root LMN bladder • Detrusor areflexia
• Internal urinary sphincter
innervation is intact (TL)
Overflow
incontinence

17. Neurogenic Bladder Types
• Buku Ajar KFR & kuliah dr.BS
Type Detrussor Sphincter Konsekuensi Mx
A Hyperreflexive Spastic • Retensi
• High vesicular
pressure
• Reflux
• IC/ Indwelling
• Surgery:
sphincterotomy
B Hyperreflexive Areflexic • Inkontinensia • Drugs
• Surgery: artificial
sphincter
C Areflexic Spastic • Retensi
• Overdistended
bladder
• IC
• Ga boleh pake
Crede/valsava
D Areflexic Areflexic • Inkontinensia
(+overflow)
• IC
• Crede/valsava

18. Classification

19. Assessment: Anamnesis
• Chief complaint: Kelemahan dan tidak bisa buang air kecil
• Tanya onset: trauma? MOI trauma, klo low impact  kemungkinan fr patologis?
• Kelemahannya spt apa, apakah langsung tdk bs digerakkan sama sekali? Gradual? Masih bisa apa?
Kalau masih bisa gerak, pikirkan kemungkinan MMT masih ada, incomplete.
• BAK
– Sensasi penuh
– Sensasi ingin miksi (desire to void)
– Voiding spontan, terkontrol atau tidak
– Saat voiding ada urge tdk (tdk bisa menahan)
– Ada sensasi tuntas atau tidak
• BAB
– Sensasi ingin BAB
– BAB spontan, terkontrol atau tidak
– Saat BAB bagaimana, apakah ada cara khusus
• Ereksi ejakulasi
• Setelah KLL, diapakan
• Operasi, ada perbaikan tidak
• Bgmn activity nya sebelum dan setelah sakit
• Penyakit penyerta
• Psikososioekonomi dan lingkungan
– Harapan, hobi, kebiasaan harian, kondisi rumah
• Review of system

20. PF
• General status
• ASIA,
– Tanya sensorik dulu: light touch dan pin prick  sensor
level
– Motorik: key muscle  motor level
– VAC DAP
• Refleks: fisiologis, patologis, ACR, BCR
• Tonus: spastisitas
• MSK
– Look feel move. ROM, deformitas, kontraktur
– Decubitus: grade 2: sampai dermis.

21. Mx Neurogenic Bladder in SCI
• Long-term goals
– “Balanced bladder” with low bladder pressures
(<30-40 cmH2O)
– Urinary continence
– Minimizing risk of urinary tract infections (UTI)
– Minimizing risk of upper tract
deterioration/infection
• Bladder vol dipertahankan <500mL utk
menurunkan vesicoureteral reflux, overflow
incontinence, hydroureter

24. Strategies
• Indwelling catheter
– Fase spinal shock, trutama kalau infus (+)
– (+): easy
– (-): risiko UTI/stone, urethritis, cancer (>10y)
• Intermittent catheterization (IC)
– Bisa mulai 7-15d post injury, once patients can
tolerate a fluid restriction of 2 L/day
– Benefit: risiko UTI/stone lbh rendah, self image,
kondusif utk sexual activity. “best & safest long term
bladder method
– Vol urin 500ml/x, 4-5x/hr

25. Strategies
• Reflex voiding
– Male UMN bladder (with condom catheter)
– Manuver: suprapubic tapping, squeezing glans penis,
pulling pubic hair, anal manipulation
– Monitoring: urodynamic (pressure), PVR
• Bladder expression
– LMN bladder
– Kontraindikasi: DSD (krn makin ningkatin tek. bladder)
– Manuver: Crede (direct prssure at lower abdomen),
valsava (mengejan)

26. Strategies
• Electrical stimulation
– Parasacral dan n. tibialis
• Biofeedback
• Scheduled (timed) voiding
– Every 4 hours
• 24h voiding diary
– Fluid intake, time and quantity voided, PVR
• Medication

28. NEUROGENIC BOWEL

29. Physiology
• Parasimpatis
– increase upper GI
tract motility,
enhances colonic
motility
• Simpatis (storage)
– inhibit colonic
contraction, atur
sphincter ani int
• Somatik
– Pudendus s2-4:
sphincter ani ext
continence

31. Bowel Program
• Goal: consistent and complete evacuation of the bowel
at a specified time, in a relatively short time period,
without incontinence between programs
• Manfaatkan
– Gastrocolic reflex:
• Gastric distention  colon contraction
• Start bowel program dlm 30’ stlh makan/minum kopi
– Rectocolic reflex
• Stretch at bowel  sphincter ani int relaxed
• Suppositoria & digital stimulation (lubricated finger, slowly rotate
finger, clockwise, circular +1min/ sampe feces/flatus keluar)
• Dilakukan tiap hari atau /3hr

33. Bowel Program
• Fluid: 2-3L/d
• Diet: Adequate fiber (15-30g/d)
• Physical activity
• Consistent scheduling
• Positioning: sitting on padded
commode, left side lying
• Digital stimulation
• Assisstive technique
– Abdominal massage
– Valsava
– Deep breathing
– Ingestion of warm fluid
– Seated/forward leaning
position
• Stool softeners: Polyethylene
glycol (PEG) and Docusate
sodium , 1-2x/d
• Stimulant: Bisacodyl (Dulcolax),
15-30min before bowel program
• Areflexic Bowel :
Perform rectal checks and manual evacuation
2-3x/d
• Reflexic Bowel :

34. SEXUAL DYSFUNCTION

35. • Sexual excitation
– Psychogenic
– Physical stim: genital region  aff pudendal S-4 
eff parasimpatis  efektor
– Decreased libido: pyschological + physical changes
• Fertility
– Awal2 >>amenorrhea
– SCI does not not affect female fertility once menses
return  likelihood of pregnancy after SCI ~
– Labor  risk autonomic dysreflexia. Mx: spinal
anesthesia
Female

36. Male
• Erections (mainly parasimpatis, S2-4)
– Reflexogenic: can be unconciously/ secondary to manual
stim of genital region
– Psychogenic: erotic stim  cortical modulation of sacral
reflex arc
– Nocturnal: REM
• Ejaculation (simpatis, T11-L2)
– In SCI, the ability to ejaculate is less than the ability to
obtain an erection.
– Retrograde ejaculation
• Male Infertility after SCI
– Ejaculatory dysfx + poor semen quality

38. • Genital arousal requires dominance of parasympathetic output in
the terminal nerve endings in erectile tissue in men and women
over the tonic sympathetic tone (responsible for detumescence)
through the pelvic nerve, a final common pathway, that receives
inputs from the medial preoptic area and genitals.
• With parasympathetic stimulation, proerectile neurotransmitters,
particularly through the NO-cGMP pathway, promote smooth
muscle relaxation and tumescence.
• However, the sympathetic nervous system also has a proerectile
component, as demonstrated by lesions of the paravertebral
sympathetic chain in humans and stimulation of the hypogastric
nerve, and the sympathetic role may be “unmasked” following
sacral spinal injury

39. SCI
• Arousal triggered by sexual thoughts generated from the 5
senses or by sexual fantasy sends psychogenic impulses
down the spinal cord and modulates the spinal erection
centers of T11-L2 (psychogenic) and S2-S4 (reflexogenic).
• When the S2-S4 center is inaccessible following sacral SCI,
the T11-L2 thoracolumbar centre becomes the dominant
pathway for transmission of psychogenic signals of
erection.
• Psychogenic erections in men with lumbosacral lesions are
often of poorer quality, as these erections may result from
inhibition of the tonic sympathetic tone and/or from the
relaxation of the penile sinusoidal cavities, rather than true
vasodilation and penile rigidity.

40. Sexual Function Assessment &
Management
• Perineal reflexes (BCR and anal reflex)
– mediated by the sacral segments, also mediating reflex erection
• Cremasteric reflex
– mediated by the TL segments, also mediating emission and
psychogenic erection.
• Sacral reflexes (+)  use direct genital stimulation (e.g., masturbation,
intercourse, oral sex, and the like) to achieve erection.
• Cremasteric reflex (+)  attempt ejaculation, or to explore possible
retrograde ejaculation, or attempt vibrostimulation if natural ejaculation is
absent
• Sacral reflex (-), cremasteric reflex (+)  use psychogenic stimulation
(e.g., visual, auditory, olfactory, or verbal stimulation, fantasies, memories)
to achieve erection and ejaculation
(Courtois et al., 2009b, 2013b; Everaert et al., 2010).

41. Sexual function after SCI
(ISCOS textbook)
• Factors affect sexuality: impaired motor function, alters sensation,
impaired autonomic sexual function, incontinence (urinary & bowel),
spasticity, pain, depression
• Two pathways of genital arousal
– Psychogenic T11-L2 via hypogastric pathways to erectile tissue
– Sacral reflexogenic pathway mediated through S2-S4
• Neurogenic evaluation: pay attention to sensations in T11-L2 and
S2-S5, and abdominal and anal reflexes: specific importance in
judging future sex potential
– Abdominal reflex above umbilicus: T8-T10
– Abdominal reflex below umbilicus T10-T12
– Cremasteric reflex: L1-L2
– Bulbocavernosus reflex: S2-S4
– Anoanal reflex (“in and out”): S3-S4
– Anocutaneous reflex (anal wink): S4-S5
• Expected consequences of complete SCI : Lesi supraconal, conal,
infraconal

43. PRESSURE ULCER

44. Pressure ulcer
Patogenesis
• Ischaemia
• Pressure
• Friction
Prolonged pressure over bony
prominences (>70 mmHg)
continuously for 2 or more
hours  occlusion of the
microvessels of the dermis 
tissue ischemia.
Friction  Removes corpus
striatum of the skin.

45. NPUAP Pressure Ulcer Staging System
(Ip & Dicianno, 2015)

46. Treatment of Pressure Ulcers by
NPUAP Stage (Ip & Dicianno, 2015)

48. Prevention
• Regular pressure relief
– Bed: Turning/2 h
– Power WC: Tilting/reclining backward
– Manual WC: Weight shifting, lift buttock, leaning to one side 1-2min/x,
every 20-30 mins (sumber lain: 15dtk tiap 15mnt)
• Surface
– Proper mattress, seating, cushion, etc
• Skin care
– Keep skin dry and clean, baju nyaman adem
– Regular skin checks: report any areas of soreness, or reddening
• Healthy lifestyle
– Nutrition: drink plenty of fluids, varied and balanced diet, >>protein
– Avoid smoking
– Regular exercise  increase circulation, maintain muscle bulk
(padding)

49. Management
• Prevention!
• Cleansing
• Dressing : that promote a warm and moist wound healing
environment to treat grade 2, 3 and 4 pressure ulcers
• Debridement: autolytic, enzymatic, sharp, surgical
• Perbaikan kondisi. Target: Alb >3.5, Hb 12-14, treat infeksi
• Modalitas:
– ES  ↑ circulation, granulation, with ↓ bacterial count.
– hyperbaric oxygen; infrared, ultraviolet, laser  blm terbukti
• Lain2: flap, amputation, vacuum
• PDx: Xray  osteomyelitis? Konsul SpBP

50. LAIN2

51. • Heterotopic ossifification (HO) : >> hips, followed by the
knees, elbows, and shoulders.
• Spasticity: if painful, interfering with positioning, transfers,
or hygiene  kasi obat
– Baclofen
– Benzodiazepines
– Dantrolene sodium
– 2
– Tizanidine (A2 agonist)
– Botox/phenol utk local spasticity
• Psikologis: emotional adjustment. >>Depression, drug
addiction, divorce. Suicide rate >2-6x lipat
– Psychological support
– Medikamentosa

52. THANK YOU
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