Bowel, Bladder, and Sexual Dysfunction After SCI

Question 1

What level of the spinal cord contains the sacral micturition center?

Answer 1

S2-S4 Level

Question 2

“Spastic” or “Reflexive” Bladder

Answer 2

• Usually at level T12 injury and above
• The sacral micturition center may start sending signals on its own to tell the bladder to squeeze or relax, causing incontinence
• The bladder might try to squeeze, but the external sphincter muscle may tighten at the same time, causing inability to urinate and high pressure build up in the bladder. This can also over stretch the bladder and cause bladder infections, kidney infections, and kidney stones.

Question 3

Is a spastic bladder/ reflexive bladder an UMN or LMN Neurogenic bladder presentation.

Answer 3

UMN Neurogenic Bladder Presentation

Question 4

Is a Flaccid/Areflexive bladder an UMN or LMN Neurogenic bladder presentation.

Answer 4

LMN Neurogenic Bladder Presentation

Question 5

“Flaccid” or “ Areflexive ” Bladder

Answer 5

• Usually L1 or below
• Occurs when the reflexes are sluggish or absent due to the injury occurring below the sacral micturition center.
• The patient will not feel when his/her bladder is full, nor be able to squeeze the bladder, causing:
  ◦ Over distention of the bladder
  ◦ Bladder overflow if the urinary sphincter is weak
  ◦ Inability to release urine, causing back up into kidneys if a strong urinary sphincter is still present.

Question 6

What is a Bladder program?

Answer 6

An ongoing set of treatments and practices that maintains the health of the patient’s
bladder and kidneys.
◦ Empty the bladder to avoid accidents and prevent infections
◦ Does not fix the dysfunction caused by the SCI
◦ Increases patient’s health and quality of life
Most common methods are
◦ Intermittent catheterization (IC)
◦ Indwelling catheter (Foley)
◦ Indwelling suprapubic catheter
◦ An external condom catheter for men

Question 7

Intermittent Catheterization

Answer 7

• Most common: done on an “as needed” basis so you do not have to wear a catheter and urine bag all the time.
• Perform every 4 6 hours, 4 6 times/day
• Maintain volumes less than 500 ml
  ◦ We want to prevent bladder distension (over
  stretching of the detrusor muscle)

Question 8

C4-C6 Functional Expectations for Bladder
Management

Answer 8

• Patient should be able to independently verbally direct their bladder program to a caregiver

Question 9

C7-C8 Functional Expectations for Bladder
Management

Answer 9

• Patient may be able to assist with clothing management and catherization with assistive devices

Question 10

T1-L5 Functional Expectations for Bladder
Management

Answer 10

*Full hand function is present, but trunk control and balance will be impaired in higher thoracic level injuries.

• Males: should be able to learn and complete bladder management from wheelchair level
• Females: initiate from bed level using mirror and positioning strategies, then progress to over toilet using mirror or touch technique to locate anatomy (work closely with O.T.).
• A supportive padded commode seat may be recommended to provide trunk support when cathing over
  the toilet.

Question 11

Is a UMN Neurogenic Bowel a reflexive bowel or Areflexive bowel

Answer 11

Reflexive bowel

Question 12

Is a LMN Neurogenic Bowel a reflexive bowel or Areflexive bowel

Answer 12

Areflexive bowel

Question 13

Reflexive Bowel

Answer 13

• Usually at level T12 injury and above
• The sensation that the rectum is full of stool may be lost.
  ◦ The voluntary control of anal sphincter muscles may be absent and the muscles remain tight.
  ◦ Once the rectum becomes too full of stool, a defecation reflex is elicited and the stool can be released without conscious control.
  ◦ Anal sphincter responds to digital stimulation to trigger bowel movement

Question 14

Areflexive Bowel

Answer 14

• Usually below T12
• Results in slowed stool movement through the digestion tract (this occurs with neurogenic bowels both reflexic and areflexic)
  ◦ The defecation reflex is interrupted and the muscles of the anal sphincter remain relaxed
  ◦ This results in frequent involuntary accidents at inappropriate times
  ◦ Patients with this type of injury may not respond to digital stimulation or suppositories because the reflex arc is not intact

Question 15

What is a Bowel Program?

Answer 15

• Evacuates stool to avoid accidents, bowel impactions, or other complications.
• Performed at a time that fits with the person’s lifestyle (either morning or evening)
• A successful bowel program usually takes 30
  60 minutes (but may take several hours at first while training the body)
• Many things can affect the success of the program

Question 16

Anocutaneous reflex

Answer 16

contraction of external sphincter when touched or provided with pin prick

Question 17

Bulbocavernosus reflex

Answer 17

performed by pinching dorsal glans penis or pressing clitoris while assessing for bulbocavernosus reflex and external anal sphincter contraction in anal canal.

Question 18

If reflex is present

Answer 18

◦ Patient presents with an UMN injury and proceed with reflexic /UMN bowel program

Question 19

If reflex is not present

Answer 19

◦ Patient presents with a LMN injury and proceed with areflexic/LMN bowel program

Question 20

C4-C6 Functional Expectations for Bowel Program

Answer 20

◦ Patient should be able to independently verbally direct their bowel program to
a caregiver Use of a padded tilting shower commode chair with chest strap.
◦ Clothing management dependently performed in bed. Use of mechanical lift
transfer to commode chair.

Question 21

C7-C8 Functional Expectations for Bowel Program

Answer 21

◦ Use of a padded tilting shower commode chair with chest strap.
◦ Patient may use mechanical lift or transfer board depending on their abilities.
◦ Patient may be able to assist with clothing management and bowel program
with adaptive equipment (work with O.T.)

***Use of a padded tilting shower commode chair with chest strap

Question 22

T1-L5 Functional Expectations for Bowel Program

Answer 22

◦ Use of padded commode (higher injuries will need back support)
◦ Independent with clothing management either in or out of bed.
◦ Use of transfer board or sit pivot transfer technique.
◦ Patient should be independent with all portions of bowel program.

Question 23

What is Sexuality?

Answer 23

Natural desire to bond through love, affection, and intimacy
◦ Emotional connections
◦ Physical contact
◦ Sexual identity
◦ Gender identity

Question 24

How Does SCI Affect Sex?

Answer 24

◦ Loss of movement
◦ Altered sensation
◦ Sexual reflexes
◦ Arousal
◦ Orgasm
◦ Fertility
◦ Desire
◦ Self confidence

Question 25

Arousal

Answer 25

Arousal is a normal part of sexual function that results increases in heart rate, blood pressure, respiratory rate, and blood flow to genitals
◦ Women have an increase in vaginal lubrication
◦ Men have an erection

Question 26

Two pathways for normal arousal

Answer 26

◦ Reflex pathway response to touch
◦ Psychogenic pathway response to thoughts, sights, sounds

Question 27

Sex After Injury

Answer 27

After SCI, one or both pathways may be blocked
◦ UMN: may be stimulated through touch (reflexive)
◦ LMN: may be stimulated through thoughts/sounds/sight (psychogenic)

Question 28

Can women still get pregnant after sustaining SCI? (Yes/No)

Answer 28

Yes

Question 29

Are men able to get partners pregnant?

Answer 29

◦ Men may not be able to get partners pregnant
◦ May be unable to ejaculate
◦ Poor sperm motility
◦ Recommend urologist for treatment strategies