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Bladder dysfunction after Spinal cord injury

The biggest problem with people who have spinal cord injury is the dysfunction of the bladder. The nerves controlling the bladder and the related muscles are situated at the end of the spinal cord, and when it gets damaged, the signals from the bladder are not able to reach the brain, resulting in physical complications.

Anatomy

Kidneys and ureters keep on doing their work as it is an involuntary process that does not need messages from the brain. To allow the urine to pass smoothly, there should be a coordinated action of ureters, bladders, and related muscle groups. However, post Spinal cord injury, this coordinated action is disturbed.

Due to the lack of brain control, the sphincter and detrusor muscles become overactive, leading to high bladder pressure resulting in incontinence and infections in the bladder. Detrusor gives sphincter the message to pass the urine. In spinal cord injury, the message cannot pass properly. The bladder after Spinal Cord Injury is called the Neurogenic bladder. There can be two types of bladders after spinal cord injury:

A. Spastic bladder – Spastic bladder occurs after cervical, thoracic, or lumbar spinal cord injuries. It is a dysfunction of the bladder which causes the patient to not know when it may get empty.

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The condition can result in urge incontinence, and the patient may not be able to control the functions of the bladder. The stretch receptors in the wall of the bladder are triggered, causing the motor nerves to get stimulated, resulting in the emptying of the bladder.

B. Flaccid bladder – Flaccid bladder occurs when the injury is in the sacral region, which denervates the sphincter. A flaccid bladder often holds the urine more than usual and can cause stretching of the bladder wall. It may damage the detrusor wall and may also increase the infection chances.

Complications of Neurogenic Bladder:

1. UTI (Taweel et al.,2015)

2. Kidney stones (Chen et al., 2002)

3. Cancer of bladder

4. Hydronephrosis

Management for bladder control after Spinal Cord injury

Not all spinal cord injuries are the same. Some have spared neural pathways, which makes achieving bladder control easier. Spared neural pathways are the connections that are not damaged at the site of injury. These spared neural pathways allow communication between the areas below the injury and the brain. By utilizing neuroplasticity, the CNS can rewire itself post-injury.

 

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To ensure the quality of life, proper management of the neurogenic bladder is a must. The main aim of the management is to empty the bladder before it is too full. However, the intervention program mainly depends on the site of the injury. The most popular way form of bladder management is catheterization which are of two types:

a. Intermittent catheterization – It requires catheterizing an individual every 4-6 hours to empty the bladder. This is the ideal method for individuals who don’t want to stay connected with the catheter all the time.

b. Indwelling catheterization – In this type of catheterization, an individual is connected to a catheter all the time. However, the method can cause UTI, so it is only done for individuals who are not suitable for intermittent catheterization.

Other bladder management techniques used post spinal cord injury are:

a. Timed voiding – This is a behavioral exercise that is done in combination with taking note of one’s fluid intake. The recommended fluid intake is 6-8 water glasses per day. The patient is asked to avoid caffeinated beverages. The training also includes fluid limitation after 6 pm to avoid night accidents.

b. Valsalva and Crede Manoeuvres – In this method, the patient is taught to push a closed fist inwards over the bladder to empty it. Valsalva is a process where you tighten the abdominal muscles to empty your bladder.

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The amount of bladder emptying depends on the force that you apply and how much your sphincter can get relaxed. However, the process is not recommended for the long term as it increases the intravesical pressures and causes rectogenital prolapse, hernia, hemorrhoids, etc. (Chang et al., 2000).

c. Pelvic floor muscle exercises- Kegel or pelvic floor muscle exercises strengthen the muscles that support the pelvic organs. With regular practice, the patient may learn to relax and contract the muscles that control urine voluntarily. These exercises help in reducing the chances of leakages and enable the patient to empty his bladder completely.

d. Education – The patient should be educated about bladder management after Spinal cord injury to prevent further complications (Thietje et al., 2011). Good communication between health professionals, patients, and care givers can significantly improve the quality of life of the patient (Vaidyanathan et al., 2004)

Bowel dysfunction after Spinal Cord injury

There is an upper and lower part of the digestive tract in our digestive system. The upper digestive tract is where the food breaks down in different nutrients that fuel our body. The waste removal takes place in the lower part of the digestive tract through the wave-like action called peristalsis. A bowel movement is initiated when sufficient stool is accumulated in the rectum. When the rectum is full of stool, the urge to defecate increases. When we go to the bathroom, the brain signals the anal sphincter to release, and through the action of muscle, the stool moves out through the anus. The frequency of bowel movements varies from person to person. Similarly, the consistency of the stool also differs from individual to individual.

Spinal cord injury

After the injury of the spinal cord, the message from the body doesn’t reach the brain. This means that the sensation when the bowel is full and the urge to defecate is lost. There is also a loss of control of anal sphincter muscle function. When normal bowel function is lost due to injury to spinal nerves, this is called neurogenic bowel. There can be two types of neurogenic bowel after SCI depending on the level of injury. In injury to above T12 levels, a reflex bowel occurs where the anal sphincter remains closed. In injuries above T12, flaccid bowel occurs where there is loss of reflex response. Though there is a loss of anal sphincter muscle tone and reduced peristalsis, the bowel usually cannot clear itself. Due to flaccid sphincter, fluid and mucus can leak out of the anus.

Bowel Management

It doesn’t matter what the level of injury is; stool must be removed, so a bowel program is necessary based on the condition of an individual. Most patients with Spinal cord injury use bowel programs which vary from patient to patient on the basis of their SCI level.

Reflex Bowel program – It can be done once a day or every alternate day or three times a week, depending on the need of an individual. In this program, you need gloves, lubricants, and enemas. Wear gloves and insert the lubricated enema in the rectum of the patient. Place it as high as possible, but it shouldn’t touch the wall of the rectum. Enemas usually start to work in 15-25 minutes. You can also insert a lubricated finger in the rectum and move it in a circular pattern for a few seconds to start bowel movement (Korsten et al., 2007). Once the rectum is tightly closed, and no stool is coming out, you will know that there is Bowel movement is over.

Flaccid bowel program – Flaccid Bowel program is done a few times a day. As stimulants are not effective in the Flaccid bowel, manual removal of stool needs to be done. To promote stool movement, your therapist may suggest you utilize common body actions like leaning forward and side to side, abdominal tightening, and Valsalva maneuver. Once bowel movement is over, you can clean and dry the area.

Bowel management means the ability to retrain the bowel to empty at a scheduled time in order to prevent accidents and avoid leakages. It also includes that you should feel secure about yourself and participate in the tasks that you like. Electrical stimulation of the abdominal wall is another technique that may be used. Wearing abdominal belts with electrodes reduces the colonic transit time and bowel care time in patients (Korsten et al., 2004).

A well-devised bowel program is one part of bowel management; other important components of bowel management are:

a. Timing – Before spinal cord injury, a person must be having a predictable bowel movement which means bowel movement each morning at the same time. After the injury, an individual must retrain his body to respond to the bowel movement only when stimulated during bowel programs. The patient must select the best time of the day for the Bowel movement, and he should follow the same schedule every day until they are accident-free between the programs.

b. Nutrition – What you eat greatly affects your bowel program. Drinking hot beverages, eating food rich in fibers, etc., starts peristalsis in a reflex bowel. You can have effective results if you drink something warm thirty minutes before the program.

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Vegetables, fruits, and whole-grain foods have high fiber content, which can maintain the health of your digestive system. However, you should maintain the quantity of fibers as high fiber content can result in diarrhea.

c. Water intake – Water plays a key role in regulating your digestive system, and it keeps your stool from getting hard, preventing impaction and constipation.

d. Physical activity – Getting involved in physical activities also make it easier for the stool to pass.

An unplanned bowel movement is something that is most embarrassing, so no matter what, you should always continue the bowel program when it is scheduled. You should always consult your health care provider if you want to make adjustments to your bowel programs.

Life after Spinal cord injury is not easy, you have to deal with many complications, but with proper family support and the expertise of health care professionals, you can lead a normal life. Contact Progressive Care to know more about post spinal cord injury rehabilitation.

References:

1. Taweel, W. A., & Seyam, R. (2015). Neurogenic bladder in spinal cord injury patients. Research and reports in urology, 7, 85–99. https://doi.org/10.2147/RRU.S29644

2. Chen, Y., DeVivo, M. J., Stover, S. L., & Lloyd, L. K. (2002). Recurrent kidney stone: a 25-year follow-up study in persons with spinal cord injury. Urology, 60(2), 228–232. https://doi.org/10.1016/s0090-4295(02)01734-x

3. Thietje, R., Giese, R., Pouw, M., Kaphengst, C., Hosman, A., Kienast, B., van de Meent, H., & Hirschfeld, S. (2011). How does knowledge about spinal cord injury-related complications develop in subjects with spinal cord injury? A descriptive analysis in 214 patients. Spinal cord, 49(1), 43–48. https://doi.org/10.1038/sc.2010.96

4. Vaidyanathan, S., Singh, G., Soni, B. M., Hughes, P. L., Mansour, P., Oo, T., Bingley, J., & Sett, P. (2004). Do spinal cord injury patients always get the best treatment for neuropathic bladder after discharge from regional spinal injuries centre?. Spinal cord, 42(8), 438–442. https://doi.org/10.1038/sj.sc.3101576

5. Chang, S. M., Hou, C. L., Dong, D. Q., & Zhang, H. (2000). Urologic status of 74 spinal cord injury patients from the 1976 Tangshan earthquake, and managed for over 20 years using the Credé maneuver. Spinal cord, 38(9), 552–554. https://doi.org/10.1038/sj.sc.3101060

6. Korsten, M. A., Singal, A. K., Monga, A., Chaparala, G., Khan, A. M., Palmon, R., Mendoza, J. R., Lirio, J. P., Rosman, A. S., Spungen, A., & Bauman, W. A. (2007). Anorectal stimulation causes increased colonic motor activity in subjects with spinal cord injury. The journal of spinal cord medicine, 30(1), 31–35. https://doi.org/10.1080/10790268.2007.11753911

7. Korsten, M. A., Fajardo, N. R., Rosman, A. S., Creasey, G. H., Spungen, A. M., & Bauman, W. A. (2004). Difficulty with evacuation after spinal cord injury: colonic motility during sleep and effects of abdominal wall stimulation. Journal of rehabilitation research and development, 41(1), 95–100. https://doi.org/10.1682/jrrd.2004.01.009h