Patients with spinal cord injury face a number of challenges, with continence being a top priority. For those affected by neurogenic bladder and bowel, there are various management options available. To help understand these options, study notes in this area can be useful. These notes, which are similar to index cards, can highlight key information related to the management of neurogenic bladder and bowel in spinal cord injury patients.
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1. Study Notes
Neurogenic Bowel &
Bladder
Dr Mrinal Joshi
Director, Rehabilitation Research Centre
Professor & Unit Head, Dept. of PMR
SMS Medical College & Associated Hospitals
Jaipur
2. Neurogenic Bowel
• Dysfunction from trauma & disease within the spinal cord
• Mainly affects the colorectum & the anal canal
• Peristalsis & secretion primarily controlled by enteric nervous system
• Submucosa (Meissner’s plexus) & gut muscle (Auerbach’s plexus)
• Vagus innervates below the splenic flexure of colon
• Distal colon parasympathetic from S2-S4
• Sympathetic to colon & rectum from T9-T12
• Parasympathetic enhances secretion & peristalsis; relaxing sphincter
• Sympathetics reduce secretion & peristalsis; contracting sphincters
3. Anal canal
• Anal canal surrounded by striated ext. & smooth internal sphincters
• Upper part surrounded by puborectalis muscle
• Int. sphincter under reflex control of enteric & sacral nerves
• Ext. sphincter under voluntary control of pudendal S3-5
• Puborectalis creates an anorectal angle
• Prohibiting the content in the anal canal
4. Defecation
• Preceded by mass movement of stool
• Rectal wall stretch initiates defecation reflex
• Stimulates contraction of rectal wall through sacral reflex arc
• Rectoanal inhibitory reflex (RAIR) causes relaxation of int. sphincter
• Mediated by parasympathetics
• Voluntary contraction of ext. sphincter inhibits
5. Continence
depends on Consistency of
stools
Colorectal
transit time
Rectal tone
Anorectal
sensibility
Tone of
puborectalis
muscle
Voluntary
contraction of
ext. anal
sphincter
6. Neurogenic bowel
Sympa. & Parasymp. act through stimulation or inhibition
No direct innervation of smooth muscles
Parasymp. Innervation through vagus nerve
To stomach, small intestine & proximal colon unaffected by SCI
No UMN or LMN gut
Lesions above S2 have increased tone & contractility of rectum
Causing reflex defecation
Lesions at or below S2 have reduced tone & contractility
Causing faecal impaction & incontinence
7. SCI
Acute phase gut is hypotonic &
unresponsive to stimulus
Severely prolonged colonic transit time
during first week after injury
Pattern of prolonged transit time varies in
individuals
Reflexic NBD have prolonged transit time
in colon but not in rectum
Long transit time in descending colon &
rectosigmoid in areflexic
Emptying of rectosigmoid is significantly
delayed in both
9. NBD
Reflexic
NBD
Increased tone and contractility of rectum
Areflexic
NBD
Poor emptying of rectum
Hypotonic rectum
Poor sphincter function
Incontinence & impaction
Commonly
reported
symptoms
Constipation
Fecal incontinence
Need for digital evacuation
Abdominal discomfort
Hemorrhoids
10. Assessment
• International Standard for Neurological
Classification for SCI
• Sacral reflexes & pelvic floor tone
• Bristol stool for scale
• Bowel management subscale (26 items) SCI-QOL
(SCI-QOL@udel.edu)
• International SCI bowel function basic data set
(16 items)
• Detailed GI history
11.
12.
13.
14.
15. GI history
Occurrence of incontinence
Associated symptoms
Frequency of defecation
Consistency of stool
Approximate volume of stool per evacuation
Presence of urge / urgency
Ability to control defecation
Stress incontinence
16. Current bowel care
Use of oral & rectal medications
Facilitative techniques
Schedule of medications and methods
Duration of bowel care
Functional level and need for assistance
Premorbid condition
Type and amount of fibre consumed
Amount of fluid intake
List of activities
17. Evaluation
• Quantifies amount of faeces
• Ascending colon, transverse colon, descending
colon & recto-sigmoid
• Scored as
• No faeces – 1
• Small amount of facecs – 2
• Moderate faecal stasis – 3
• Severe faecal stasis – 4
• Minimum score is 4 and maximum is 16
Starreveld score on abdominal x-ray
CT abdomen
18. Evaluation
• Colonic transit time
• Radio-opaque markers
• Distribution of markers in right, transverse and recto-sigmoid
• Scintigraphy with 99m-Tc-sulfur colloid
• Every 30 minutes for 2 hrs for gastric emptying
• 24, 48, 72 after the meals
• Wireless motility capsule
• Information on pH, gastric emptying, colonic and whole gut transit time
19. Evaluation
• Anorectal manometry
• Pelvic floor dyssynergia / obstructive defecation
• Deficient propulsive force with increased resistance
• High rectal pressure / paradoxical contraction of pelvic floor
• Sensor probe can measure
• Puborectalis and anal sphincter pressure at rest / squeeze / cough
• Rectal sensation & compliance
• Presence of recto-anal inhibitory reflex (RAIR)
• Pelvic electromyography
• Pudendal nerve latency
• Rectal tone is higher in supraconal lesions than conal/cauda equina lesions
• Pudandal neuropathy and impaired RAIR is common
21. Common complications
Constipation
Incontinence
Abdominal pain
Anorectal pain
• Mechanical rectal stimulation can induce
• Bradycardia / arrythmia / pounding headache / anxiety / sweating above level /flushing / blurry vision / nasal congestion /
piloerection
• Discontinue rectal stimulation
• Use lidocaine lubricating gel / slow rotation /10-20 seconds / every 5-10 minutes
• Use gastrocolic reflex
Autonomic dysreflexia – T6 level or above
22. Manual manoeuvre
• Lower right abdomen with heel of hand in clockwise
manner
• In some likely to give abdominal pain / haemorrhoids
• Increase risk / unclear benefit
Abdominal
massage
• Performed gently
• Excessive force can lead to contraction of pelvic floor
• Avoid in reflexic NBD
Valsalva
manoeuvre
25. Daily fiber
recommendations
• SCI consortium recommends 15 gm fibre per day – adjust
gradually
• Asso. Rehab Nurses recommend 20-35 gm of fibre per day
• Inst. Of Medicine recommends 14 gm per 1000 calories
• Adequate intake 25 gm for women
• 38 gm for men below 50 yrs.
• 30 gm for men above 50 yrs.
• 21 gm for women above 50 yrs.
26. Fibres
• Fibre containing foods have soluble as as
insoluble fibres
• Coarse and insoluble fibre such as wheat
bran, irritates large bowel mucosa, stimulate
water & mucosa secretion, leading to soft
stools
• Coarser particle can produce constipation
• Psyllium is a gel forming soluble fibre, high
water holding capacity and resist
dehydration
• Fermentable oligosaccharides disaccharides
monosaccharides & polyols (FODMAPS)
27.
28. Maintaining
hydration
• Rehab Nurses suggest 2L / day to avoid
constipation
• Can also be estimated by one of the
following
• 1ml/ kcal energy consumed
• 30ml/ Kg body weight
• 100ml/ kg for first 10 kg, 50ml/kg
for next 10 kg and 15ml for each
additional kg of body weight (Fluid
consumption = 1,500 + ((weight in
kg-20) X 15)
29. Oral medications
• Normal or slow transit constipation
• Minimise constipating drugs (anticholinergics, opiates etc.)
• Gradually increase fibre intake
• Osmotic agent (milk of magnesia (Megalax) / polyethylene glycol –PEG(Pegmove))
• Supplement with osmotic agent (senna/ bisacodyl (cremaffin fresh tab))
• Lubiprostone (Lubowel) or linaclotide if no response
• Prucalopride – enterokinetic (serotonin4 receptor agonist) (Pruwel)
• Neostigmine with glycopyrrolate in severe cases in closely monitoring setting in
hospital
30.
31. Rectal agents
• Bisacodyl suppository (Dulcolax)
• Contact irritant, enhances motility, increases water content, reduce transit
• Glycerine suppository (Neotomic enema)
• Lubricant and stimulates rectal contractions
• PEG based bisacodyl suppository
• Docusate mini enema
• Soapsuds or milk & molasses enema is not routinely recommended
32. Rectal agents
• Trans-anal irrigation
• 20-30 minutes after meals
• Clean water at 36 to 38 deg.C pumped at 200 to
300ml/min
• 500ml to start , saline can be used
• If fail second session with 10-15 minutes break
• Contraindications
• Rectal / anal stenosis
• Inflammatory bowel disease
• Diverticulitis
• Ischemic colitis
• Colorectal cancer
• Rectal surgery in last 3 months
33. Pulsed irrigation
device
• Widening of anus with a lubricated speculum
• Application of 5mll/second pulses of tap water with a cuffed
tube
• Used for one minute
34. Functional Electrical
Stimulation
• Sacral Anterior Root Stimulation
• Posterior laminectomy is performed
• Sleeves electrode are placed on S2-4
anterior roots
• Bilateral posterior rhizotomy is
performed
• Electrodes connected to transmitter
box
• Increases frequency of defecation
• Reduces time spent
35. Functional Electrical
Stimulation
• Sacral Nerve Stimulation
• Electrode placed through
posterior foramina of sacral bone
usually S3
• If symptoms reduce in next 3
weeks
• A permanent electrode is placed
• Minor surgical method with few
complications
• But lack of trials
36. Functional Electrical Stimulation
Posterior tibial nerve stimulation
• Temporary electrode placed close to posterior tibial nerve
• Afferent stimulation to sacral spinal cord
• Reduces faecal incontinence
• Evidence is limited
Dorsal genital nerve stimulation
• Plaster electrode placed over genital nerve of the penis or clitoris
• Causes minor contractions of rectum
• But more studies needed
37. Functional Electrical Stimulation
Electrical stimulation of
abdominal muscle
• Surface electrode over
the external oblique &
rectus
• May aid in defecation by
stimulation
• Small study showed
reduction in bowel care
time
Perianal electrical
stimulation
• Caused acute anal
contraction in couple of
patients
Epidural electrical
stimulation
• Currently being
explored
38. Malone antegrade continence enema (MACE)
• Safe & effective when conservative management fails
• Surgical creation of an entry with appendix connected to abd. wall
• Through appendicostomy catheter is introduced
• To administer an enema to irrigate the colon and rectum
• Valve mechanism is created
• No leakage of stools
• Does not require external device
39. Malone antegrade
continence enema (MACE)
• Potential complications
• Stomal stenosis
• Stomal site infection
• Leakage through stoma
• Difficulty in catheterisation
• Among different surgical procedures,
had highest quality-adjusted life
expectancy
• Best long term outcomes
40. Colostomy
• Recommended for severe NBD
• Decreases and bowel care time improves
independence
• Left sided / Sigmoid colostomy is best
maximizing water absorption & prevents
dehydration
• Right sided colostomy results in more watery
stools, required more care and risk of left sided
colonic diversion colitis
55. Mismatch
• Degeneration or reorganization of neural pathway
• Incomplete lesions
• Combined lesions
• Extension of cord injuries with cord fibrosis
• Aberrant healing process
• Vascular extensions
• UDS is an important tool for management
58. Treatment Goal
• Protection of upper urinary tracts
• Improvement of urinary tracts
• Improvement of patients QOL
• Restoration of (part of) the normal LUT function
• Cost effectiveness
• Technical intricacy
• Possible complications
• Individualized strategies
59. Intermittent Catheterization
• Consider when sufficient hand skill or willing caregiver
• Avoid
• Inability for SCIC
• Unwilling caregiver
• Abnormal urethral anatomy
• Poor cognition & motivation
• High fluid intake
• AD despite treatment
73. Enhancing
Bladder
Emptying
Valsalva & Crede’s maneuver
IDC with diligent care & follow up may
be effective & satisfactory
Condom catheter be monitored for low
pressure drainage & complete emptying
Portable ultrasound, handy tool
77. UTI - NIDDR
• Significant bacteriuria with tissue invasion
• Leukocytes in urine
• Discomfort or pain over KUB or urination
• Onset of urinary incontinence
• Fever
• Increase spasticity
• Autonomic dysreflexia
• Cloudy urine with increase odor
• Malaise, lethargy, or sense of unease
78. Significant Bacteriuria
• IDC & SPC should be changed before collection
• Intermittent Catheterization
• ≥ 102 cfu
• Catheter free on condom drainage
• ≥ 104 cfu
• Suprapubic or Indwelling catheters
• any detectable concentration
• Spontaneous management
• ≥ 105 cfu
79. Preventing UTI
• Sterile & clean intermittent catheterization
• Prelubricated non-hyrophilic catheter are better than PVC
• Securing with StatLock device
• Long term TMP-SMX is not recommended
• Weekly oral cyclic antibiotic customized to individual may benefit
• Periurethral cleaning
81. Autonomic Dysreflexia
• Spinal cord injury at or above T6
• Results from noxious stimuli
• Most common cause is bladder distension
• Sudden & severe elevation in blood pressure
• SBP 10-20mm above baseline
• Severe headache, sweating, flushing, goose bumps, chills, feeling of anxiety or slow pulse
• Silent dysreflexia