Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury

Abstract

Study design: Randomized, controlled clinical trial. Objectives: Bladder and bowel management may cause serious autonomic dysreflexia (AD) in subjects with high spinal cord injury (SCI). We aimed at investigating autonomic responses to digital rectal evacuation (DE), transanal irrigation (TAI) with 500 ml and filling cystometry (FC) in SCI. Setting: Aarhus University Hospital, Denmark. Methods: Eight subjects with SCI (AIS A) at or above T6 (high SCI) and a previous history of AD were compared with three subjects with SCI (AIS A) between T10 and L2 (low SCI). In randomized order, DE, TAI and FC were performed. AD was defined as an acute rise in systolic blood pressure (sBP) of X30 mm Hg above baseline. Blood levels of norepinephrine and epinephrine were determined before and shortly after the procedures. Results: During all three procedures, AD occurred in all patients with high SCI but not in those with low SCI. In high SCI subjects, DE increased median sBP from 127 (range: 86-154) to 188 (range: 140-206) mm Hg (Po0.02), TAI from 126 (range: 91-146) to 163 (range: 130-188) mm Hg (Po0.02) and FC from 125 (range: 106-149) to 200 (range: 179-220) mm Hg (Po0.01). The sBP increase was lower during TAI than during DE (Po0.05) or FC (Po0.02). In high SCI subjects, the blood levels of norepinephrine, but not those of epinephrine, increased significantly during all three stimuli (all Po0.05). Conclusion: Bowel and bladder management caused AD in high SCI. The response is less severe during TAI than during FC or DE.

Iatrogenic urological triggers of autonomic dysreflexia: a systematic review

“…Of the studies reviewed, the majority were preinterventionpostintervention comparisons or were of limited sample size (n = 8-26). [37][38][39][40][41]43,44 In an effort to increase evidence-based practice in this area, it is suggested in future studies to perform randomized controlled trials with an appropriate sample size and include cervical/thoracic, complete/incomplete SCI individuals. Although a variety of medications were used in the treatment of hypertension or during a hypertensive crisis, nifedipine in particular was shown to be the most effective during urodynamics, 39 cystoscopy 47 and ESWL 58 both for relief of acute AD and for the prevention of AD.…”

“…Liu et al 34 reported that during cystoscopy SCI individuals developed greater changes in SBP than urodynamics (67.1 ± 33.8 vs 51.8 ± 21.8 mm Hg), indicating that stimulation of the urethra/prostate/internal sphincter region probably is a more potent stimulus of AD than just the filling of the bladder. Faaborg et al 44 showed that SBP increased less during transanal irrigation (36 mm Hg, range 30-63) than during digital evacuation (57 mm Hg, range 41-75) or filling cystometry (61 mm Hg, range 55-100)-the SBP response between digital evacuation and filling cystometry was insignificant.…”

“…Most studies 17,21,[23][24][25]33,34,41,44 used BP changes as the criteria, whereas some studies 15,16,39 used maximal BP as the criteria. One study 26 used both of these indicators.…”

International spinal cord injury bowel function basic data set (Version 2.0)

“…Digital anorectal stimulation, rectal evacuation or transanal irrigation may cause autonomic dysreflexia either with symptoms or as silent autonomic dysreflexia. 17 For children, fussiness and irritability are common signs that autonomic dysreflexia may be present. 18 This variable is new in the data set but part of the NBD score.…”

Translating promising strategies for bowel and bladder management in spinal cord injury

“…There was agreement early in the discussion that many serious health issues and potential incontinence "accidents" could be avoided if sensory information, such as bladder fullness, pain due to impaction or urinary tract infection (UTI) was available. For example, it is well documented that autonomic dysreflexia can be triggered by activation of the sensory afferents due to an over-filled bladder or colon, routine bladder emptying, digital stimulation or the process of manual evacuation (Faaborg et al, 2014;Lee et al, 2017;Vaidyanathan et al, 2017Vaidyanathan et al, , 2018. Dysfunction in sensory feedback varies based on each injury; while some individuals with SCI retain some sensation, others have little or no sensory warning before a bowel or bladder movement.…”