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PMR Canadian Flash Cards > SCI - Bowel & Bladder > Flashcards

SCI - Bowel & Bladder Flashcards

1
Q

What is the definition of neurogenic bladder?

A

“Dysfunction of the urinary system that is primarily due to a neurogenic cause (upper or lower motor neuron).
GL definition.”

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2
Q

What are the 3 muscles important for maintaining fecal continence? PVA guidelines

A

“1. internal anal sphincter (IAS)

  1. external anal sphincter (EAS)
  2. puborectalis muscle”
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3
Q

Possible indications for suprapubic catheter?

A

“Urethral abnormalities (stricture, false passages, bladder neck obstruction).
Recurrent urethral catheter obstruction.
Difficulty with urethral catheter insertion.
Perineal skin breakdown from urine leakage due to urethral incompetence.
Psychological considerations (body image, personal preference).
Desire to improve sexual genital function.
Infections (prostatitis, urethritis, epididymo-orchitis).”

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4
Q

Indications or pre-requisites for bladder augmentation surgery?

A

“Intractable involuntary bladder contractions causing incontinence.
The ability and motivation to perform intermittent catheterizations.
The desire to convert from reflex voiding to an intermittent catheterization program.
High risk of upper tract deterioration due to hydronephrosis and/or ureterovesical reflux from high pressure detrusor-sphincter dyssnergia.”

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5
Q

What changes occur in the bladder after SCI?

A

“Activation of normally silent C fibers
Invagination of alpha adrenergic fibers of internal sphincter into skeletal muscle external sphincter
Change in location, number and density of receptors
Increased receptor sensitivity to circulating neurotransmitters (denervation super sensitivity)”

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6
Q

“Name the nerve and function of the system in bladder management:
Sympathetic nervous system, parasympathetic nervous system, motor NS.”

A

“PSNS (S2-4)

  1. Pelvic nerve
  2. Function: Bladder emptying

SNS (T11-L2)

  1. Hypogastric
  2. Function: Storage of urine
  3. alpha and beta receptors (IUS and detrusor respectively).

MOTOR (S2-4)

  1. Pudendal nerve
  2. Function: Motor control of external urethral sphincter. Voluntary storage and emptying.”
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7
Q

What is the definition of a UTI? (SCIRE)

A

“Consensus definition by NIDRR (National Institute on Disability Rehabilitation Research).

“A UTI is indicative of significant bactiuria with tissue invasion and resultant tissue response with signs and/or symptoms, including:
WBC in urine (from mucosal lining)
Discomfort/pain over kidneys/bladder, or during urination (dysuria)
Urinary incontinence (new)
Fever
Increased spasticity
Autonomic dysreflexia
Cloudy urine with increased odour
Malaise, lethargy, or sense of unease.””

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8
Q

Name 5 surgical interventions directed to improve bowel care/functioning

A

“1. Colostomy

  1. Ileostomy
  2. ACE procedure (aka MACE procedure): Malone anterograde continence enema
  3. Muscle graft for puborectalis sling
  4. Sphincter myotomy for dyssynergia
  5. Sacral anterior root stimulation”
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9
Q

What is the MACE procedure?

A

“Malone Antegrade continence enema:
1. Provides a catheterizable channel through which antegrade colonic washout can be performed.
2. Fluid is introduced in the RLQ, at the level of the ascending colon, to flush out large intestine.
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bowel/malone-antegrade-continence-enema-mace”

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10
Q

“Name 5 non-surgical, non-pharmacological interventions that may improve bowel care.

SCIRE”

A

“Electrical stimulation of abdominal wall muscles
Posterior tibial nerve stimulation (for fecal incontinence)
Pulsed water irrigation
Trans-anal irrigation
Enema continence catheter
Digital rectal stimulation
Functional magnetic stimulation”

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11
Q

Name 8 long term GI issues with chronic SCI

A 
"1. hemarroids 
2. Diverticuli
3. Peptic ulcer disease
4. Colorectal CA (increased risk)
5. Fissures
6. Pressure ulcers with tracking
7. Superior mesenteric artery syndrome
8. GERD
9. Rectal prolapse  
10. Pancreatitis
11. Cholecystitis
Ref: Cuccurullo pg 585."
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12
Q

Name 3 clinical features of classic SMA syndrome

A

postpandal N&V/bloating/abdo pain

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13
Q

What is the definition of spinal shock?

A

the phenomenon of temporary loss or depression of all or most reflex activity below the level of the spinal cord injury in the period following injury (Atkinson, 1996). PVA, bowel.

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14
Q

How long does spinal shock last usually?

A

Hours to weeks. PVA bowel document.

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15
Q

List 6 treatment recommendations for orthostatic hypotension.

A

“Memory aid: THINK – remove things that lower BP + artificially increasing BP.

Position changes: slowly rise from supine to sitting to standing.
Compression: abdominal binders, compression stockings for legs(after r/oPVD with ABI of <0.6).
PO intake: increase salt intake, increase fluid intake.
Medications: fluorinef, midodrine.
Remove medications that lower BP (eg. Tizanidine).
Small meals: limits post-prandial hypotension.”

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16
Q

List and describe 6 different types of wound debridement

A

“1. mechanical (hydrotherapy and irrigation, wet to dry)

  1. biological (maggot therapy)
  2. autolytic (using hydro colloids or hydrogels to keep the wound moist and allow body’s own enzymes to remove devitalized tissue
  3. enzymatic (streptokinase, Collagenase)
  4. chemical (hypoChlorite)
  5. surgical and sharp (scalpel and scissors)

Ref:”

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17
Q

List 8 reversible factors for incontinence and retention.

A

“DIAPPERS-Communication

  1. Delirium
  2. Infection
  3. Atrophic vaginitis, urethritis ,BPH
  4. Pharmaceuticals(diuretics)
  5. Psychological
  6. Endocrine DM, ↓Na, ↑Ca, ↑Mg
  7. Reduced mobility
  8. Stool impaction

Ref: ABC?”

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18
Q

Outline a functional classification for the neurogenic bladder.

A

“FAILURE TO STORE:
1. Neurogenic detrusor overactivity (eg supraponitne lesions such as stroke, TBI, MS, neoplasm, hydrocephalus, ParkinsonsDisease, Outlet or sphincter incompetence (eg myleodysplasia, stress incontinence)

FAILURE TO EMPTY:

  1. Bladder areflexia (eg spinal shock SCI, MS, peripheral neuropathies, sacral lesions, herniated lumbar disk, myelodysplasia, AVM, lumbar stenosis, arachnoiditis)
  2. Outlet or sphincter dyssynergia (eg suprasacral traumatic SCI)

Ref: Tan page 581”

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19
Q

In detrusor areflexia (LMN bladder), why do some patients have difficulty emptying?

A

“Internal sphincter tone is usually flaccid with LMN lesion, but may be intact due to sympathetic innervation, causing difficulty with complete emptying.
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bladder”

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20
Q

What test can be employed to differentiate prostatitis from pyelonephritis?

A

“Cytology of expressed prostatic secretion for prostatitis,

BEST ANSWER - PSA would be elevated in prostatitis (Oostra 1998)”

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21
Q

What are some treatment options for neurogenic bladder in UMN (SCI, MS, etc)?

A

“INVESTIGATIONS:

  1. Post-void residuals.
  2. ultrasound KUB (hydronephrosis, stones and bladder trabeculations).
  3. urodynamics and cystoscopy at regular intervals

CONSERVATIVE:

  1. Timed voids
  2. Kegel’s exercises
  3. fluid restriction (ie. At night).
  4. Incontinence products/pads
  5. Clean intermittent catheterization
  6. close to toilet.
  7. suprapubic tapping, biofeedback, etc.

MEDICAL:

  1. Anticholinergics: detrusor hyperreflexia (Oxybutinin, Tolteridine, Solifenacin – aka vesicare)
  2. Rare use of DDAVP (select patients – decrease urine output)
  3. Alpha blockers for obstructive symptoms (Tamsulosin).

INTERVENTIONAL:

  1. Indwelling catheters or condom catheterization
  2. Intravesicular BoNT.
  3. intravesical instillations (L4, oxybutynin, propantheline – SCIRE = not effective).
SURGICAL:
1. Suprapubic cather
2. Mitrofanoff (catherizable stoma).
3. Bladder Augmentation
6. Denervation procedures
7. sphincterotomy.
8. intrathecal baclofen.
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bladder/pharmacological-treatment"
22
Q

List 4 classes of treatment for enhancing bladder volumes in hyper-reflexic bladder in SCI.

A

“1. anti-cholinergics (propiverine, oxybutynin, tolterodine, trospium chloride).

  1. denervation therapy (botulinum toxin into detrusor).
  2. detrusor muscle therapy (topical vanillanoid compounds – capsaicin/resiniferatoxin).
  3. intravesical instillations – oxybutinin (L4 evidence ineffective, SCIRE).
  4. intrathecal baclofen/clonidine (secondary benefit of decreasing bladder spasticity).

Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bladder/pharmacological-treatment”

23
Q

List the SSx’s of a UTI. Post SCI:

A

“Systemic symptoms: fever, chills, increase spasticity, AD, malaise, dysuria, frequency, pain

Local symptoms: foul smelling urine, bloody urine, cloudy urine, leaking around the catheter, incontinence when previously not, local irritation

Ref:”

24
Q

Indwelling catheters. Five complications.

A

“1. Bladder – UTI, cystitis

  1. Bladder stones, kidney stones
  2. Hematuria
  3. Penile and scrotal fistulas
  4. Vesicovaginal fistula
  5. Epididymo-orchitis
  6. Urethral strictures,
  7. Urethral diverticulum
  8. Bladder carcinoma with long term use
  9. Blocked indwelling catheter

Ref: Tan p 583

  1. urethral erosions.
  2. incontinence.
  3. pyelonephritis.
  4. hydronephrosis (bladder wall thickening)

PVA Bladder guidelines pg 2.”

25
Q

Name four predisposing causes of urinary tract infections in spinal cord injured patients.

A

“1. bacterial colonization +/- resistance

  1. DSD w/ assoc. ureteral reflux and hydronephrosis  eventual areflexia (even in UMN lesion!!)
  2. Catheterization – introduction of organisms
  3. Dehydration
  4. Stasis or insufficient ICs (i.e., < q6h)

Ref:

Meds that cause retention e.g. TCA”

26
Q

Is bowel wall compliance significantly altered after SCI? Explain.

A

“Depends on the location of the lesion. If it is a upper motor neuron lesion, above the conus medullaris, then the enteric nervous system which regulates the bowel will continue with the input of the parasympathetics and sympathetic input. However, because the lesion is above the conus medullaris there may be autonomic dyssynergia, fecal distension of the colon and hypoactive peristalsis of the bowel, spastic EAS.

If it is a LMN neuron lesion below the conus medullaris then the ENS is intact and parastalsis will be intact. However, the bowel reflexes such as the anorectal reflex and the gastrocolic reflex will not be intact and incontinence is an issue.

Ref:”

27
Q

Name 3 cutaneous reflexes that can be assessed in UMN bowel D/Os.

A

“1. Bulbocavernosus reflex (S2-4).

  1. Anal wink/anocutaneous reflex (S2-4).
  2. Plantar response (test of UMN).
  3. Cremaster reflex (T12-L1-2; genitofemoral nerve).
  4. abdominal reflex (Upper: T8-T10; Lower: T10-T12).

Ref: Neurology resident guide.”

28
Q

What are Rx options for UMN fecal incontinence?

A

“1. Environmental – having commode and toilet close by

  1. Rule out causes of incontinence
  2. Behaviour management/patient management – timed bowel movements, anal sphincter retraining. Pelvic floor exercises, anorectal biofeedback, teaching patient bowel routine, and transfer and how to get clothes on and off
  3. Skin Care
  4. Odor control
  5. Stool Containment – provide skin protection, improve patient comfort and provide accurate measures of fluid loss
    a. External devices –external pouch
    b. Internal devices – internally placed catheter attached to a pouch
    c. Incontinence pants
    d. Anal plugs
  6. Dietary measures – constipating diet (rice, apples, bananas, yogurt cheese, marshmallows wheat products), high fiber diet, avoidance of diarrheic diet, fluid and electrolyte replacement, modification of enteral feeding, bacterial cultures
  7. Drug therapy –
    a. Antiperistaltic drugs – Imodium, lomotil, cholinergic blockers (atropine, belladonna), other opium derivatives (pragoric)
    b. Absorption agents (kaopectate, Donnagel, activate charcoal)
    c. Astringent and coating agents – Pepto-Bismal (Bismth subsalicylate), amphojel (aluminum hydroxide)
    d. Antibacterials – metronidazole and vancomycin
  8. Surgical interventions – MAS procedure or colostomy

Ref: Tan p 602”

29
Q

What are some clinico-anatomic changes assoc. w/ LMN bowel dysfunction?

A

“Failure to store – incontinence
LMN bowel syndrome, or areflexic bowel:

  1. loss of centrally-mediated (spinal cord) peristalsis and slow stool propulsion. A segmental colonic peristalsis occurs only due to the activity of the intrinsic myenteric plexus, resulting in the production of drier and round shaped stool.
  2. constipation and incontinence (atonic EAS and lack of control over the levator ani muscle that causes the lumen of the rectum to open).
  3. loss of anorectal reflex (ie. digital stimulation does not work. Need to do digital impaction).

Ref: ?”

30
Q

List all the reflexes that influence bowel function.

A

“1. Gastrocolic:

  1. Anorectal (rectocolic reflex):
  2. Colo-colonic:
  3. Rectoanal inhibitory reflex:
  4. holding (guarding) reflex:

Ref: delisa pg 1375.
“

31
Q

What is electrodefecation?

A

“The use of electrical or magnetic stimulation methods for bowel evacuation:

  1. abdominal belt stimulation (Korsten et al. 2004).
  2. superficial peripheral nerve stimulation (Mentes et al 2007).
  3. Praxis FES system (implantation of epineural electrodes for skeletal muscle activation) (Davis et al. 2001).
  4. implantation of epidural or anterior sacral root electrodes (S2-S4) (MacDonagh et al. 1990; Binnie et al. 1991; Chia et al. 1996; Kochourbos et al. 2000).
  5. magnetic stimulation techniques.

The Consortium of Spinal Cord Medicine (1998) acknowledges the use of electrical stimulation as a potential treatment modality, but recommends further research. A significant number of electrical or magnetic stimulation methods have been proposed and tested for their ability to improve bowel function in SCI individuals. These techniques are varied, from less expensive and non-invasive ones such as abdominal belt stimulation (Korsten et al. 2004) and superficial peripheral nerve stimulation (Mentes et al 2007), to more complex and invasive techniques including the Praxis FES system (implantation of epineural electrodes for skeletal muscle activation) (Davis et al. 2001) and the implantation of epidural or anterior sacral root electrodes (S2-S4) (MacDonagh et al. 1990; Binnie et al. 1991; Chia et al. 1996; Kochourbos et al. 2000). More recently, magnetic stimulation techniques have also been also used. This method, based on Faraday’s Law, uses devices to generate a magnetic field in order to induce an electric field, which then generates sufficient current to stimulate the peripheral nerves (Lin et al. 2002).
This methods make high pressure parastasis contractions stimulating for up to 10 seconds,”

32
Q

List the components of a bowel management program.

A

“1. diet, fluids, activity level modification.
2. rectal stimulation (mechanical or chemical).
3. scheduling of bowel program (based on pattern).
4. proper positioning for bowel routine.
5. appropriate assistive devices.
6. medication management.
7. individualized techniques (push ups, abdominal massage, valsalva, deep breathing, ingestion of warm fluids, etc).
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bowel/multi-faceted-bowel-management-program”

33
Q

Goals of bowel care program

A

“1. Minimize unplanned BM occurrence
2. Stool evacuation at regular, predictable time
3. Duration < 60 minutes
4. Minimize short-term and long-term GI complications
“

34
Q

Conservative measures for bowel management

A

“1. Adequate positioning (commode, sling)

  1. Maintain adequate fluid intake
  2. Minimize medications that decrease bowel motility e.g. narcotics, TCAs, anticholinergics
  3. Maintain high fiber diet
  4. Maintain physical activity levels
  5. Regular routine and schedule for bowel care
  6. Use padded seat for the commode
  7. Educate patient regarding gastrocolic reflex and anorectal reflex
  8. Digital stimulation
  9. Digital evacuation”
35
Q

List 5 potential complications of intermittent catherizations.

A

“1. UTI.

  1. bladder overdistention.
  2. urinary incontinence.
  3. urethral trauma with hematuria.
  4. urethral false passages.
  5. urethral stricture.
  6. autonomic dysreflexia (if level above T6).
  7. bladder stones.

PVA bladder guidelines, pg1.”

36
Q

In SCI, if bladder volumes consistently exceed 500 mL, what are 3 potential management options?

A

“1. increase frequency of IC.

  1. adjust fluid intake.
  2. consider alternative bladder management method.

PVA Guidelines – bladder, pg 1.”

37
Q

What are the 2 indications and 4 contraindications of crede and valsalva maneuver for bladder emptying?

A

“Indications:

  1. LMN bladder with low outlet resistance.
  2. sphincterotomy.

Contraindications:

  1. DESD (detrusor external sphincter dyssynergia).
  2. bladder outlet obstruction.
  3. vesicoureteral reflux.
  4. hydronephrosis.

PVA Guidelines, bladder, pg1.”

38
Q

List 6 indications for indwelling catheters in SCI.

A

“1. poor hand skills.

  1. high fluid intake.
  2. cognitive impairment
  3. substance abuse.
  4. elevated detrusor pressures.
  5. failure of other less invasive methods (eg. IC).
  6. temporary mgmt vesicoureteral reflux.
  7. limited assistance from cairegiver (making another type of bladder mgmt not feasible).

PVA Guidelines, bladder, pg2.”

39
Q

List 6 indications for suprapubic catheterization in SCI.

A

“1. urethral abnormalities (Stricture, false passages, bladder neck obstruction, fistula)

  1. urethral discomfort.
  2. recurrent urethral catheter obstruction.
  3. Difficulty with urethral catheter insertion.
  4. perineal skin breakdown from urine leakage from urethral incompetence.
  5. psychological considerations (body image, pt preference).
  6. desire to improve sexual genital fxn.
  7. prostatitis, urethritis, epidiymo-orchitis.

Ref: PVA bladder guidelines – pg 2 “

40
Q

Above what intravesicular pressure predisposes a patient to upper tract dysfunction (eg. Hydronephrosis)?

A

“40 mm H2O.
Hence, must determine LPP (leak point pressure) – if greater than 40 mm H2O, then problems will occur.

Ref: 1996 – Watanabe. Urodynamics of SCI. “

41
Q

“What are the phases in a urodynamic study?

What variables are measured/assessed during each phase?”

A

“FILLING PHASE:

  1. bladder sensation.
  2. bladder capacity.
  3. bladder wall compliance.
  4. bladder stability.

VOIDING PHASE (voluntary or involuntary):
1. LPP (leak point pressure).
2. maximum voiding pressure.
3. urethral sphincter activity.
4. flow rate.
5. voided value (post void residual – PVR).
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bladder/diagnosis-of-bladder-dysfunction”

42
Q

What time period after SCI should urodynamic testing be done?

A

“3-6 months post injury, or whenever bladder is out of spinal shock.
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bladder/diagnosis-of-bladder-dysfunction”

43
Q

“what is the magic bullet?

What is it indicated for?”

A

“1. water soluble (polyethel glycol) base suppository containing the active ingredient bisocodyl.
2. used in pts with prolonged bowel routines despite using standard, hydrogenated vegetable oil base bisocodyl suppository.
Ref: D Hill.”

44
Q

List two types of dietary fibre, and their effects on the GI system.

A

“SOLUBLE FIBRES:

  1. mix with water in intestine to form gel-like substance.
  2. traps certain body wastes to move them out of body.

INSOLUBLE FIBRES:

  1. absorb and hold water, producing uniform stool.
  2. helps push content through digestive system quickly.

NOTE: SCIRE – L4 evidence (small case series) high fibre diet may increase colonic transit time, not decrease – more research needed.
Ref: http://www.scireproject.com/rehabilitation-evidence/bowel-management/management/dietary-fibre”

45
Q

List 4 forms of rectal stimulation to promote bowel movements.

A

“1. digital rectal stimulation.
2. electrical stimulation (ie. Abdominal muscles).
3. functional magnetic stimulation.
4. sacral anterior root stimulation.
5. posterior tibial nerve stimulation.
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bowel/rectal-stimulation”

46
Q

what is rectal irrigation?

A

“Plused water irrigation into rectal region that removes stool.

L4 and L1b evidence that pulsed water irrigation helps decrease time spent on bowel management, and frequency of deficiation-related symptoms (eg. Headaches).
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bowel/colonic-irrigation”

47
Q 
"match the number with the letter:
LESION:
a. rostral to pons.
b. between pons and sacral spinal cord.
c. sacral spinal cord.
d. cauda equina or peripheral nerves.

URODYNAMIC STUDY PATTERN:

  1. detrusor hyperreflexia with sphincter dyssynergia.
  2. detrusor and sphincter areflexia.
  3. detrusor hyperreflexia with coordinated sphincters.
  4. detrusor and sphincter areflexia (normal detrusor function with areflexic sphincter).”
A

“A = 3 (recall: pons involved in coordinating detrusor and sphincters).
B = 1 (recall: reflexes intact, but not coordinated = dyssynergia).
C = 4.
D = 2 (recall: final pathway disruption leads to complete LMN).
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bladder/diagnosis-of-bladder-dysfunction”

48
Q

6 symptoms of fecal impaction in the elderly.

A

“1. abdominal bloating.

  1. anorexia.
  2. nausea/vomiting.
  3. fecal soiling/leakage.”
49
Q

List 4 causes of lower motor neuron bladder (ie. Sacral lesions)

A 
"1. spinal trauma (SCI).
2. herniated lumbar disk.
3. metastatic disease/tumours.
4. myelodysplasia.
5. AVM.
6. lumbar spinal stenosis.
7. inflammatory process (eg. Arachnoiditis).
Ref: Delisa pg 1353."
50
Q

List 4 causes of a suprasacral/infrapontine neurogenic bladder.

A

“1. demyelinating CNS (eg MS).

  1. trauma.
  2. vascular (AVM).
  3. cancer (primary or secondary).
  4. hereditary spastic paraparesis.
  5. infection (abcess, HTLV).
  6. degeneration (cervical spondylosis).”

PMR Canadian Flash Cards (9 decks)

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