Bowel and Bladder Care in Patients With Spinal Cord Injury

Abstract

Complete and incomplete spinal cord injuries affect between 250,000 and 500,000 people on an annual basis worldwide. In addition to sensory and motor dysfunction, spinal cord injury patients also suffer from associated conditions such as neurogenic bowel and bladder dysfunction. The degree of dysfunction varies on the level, degree, and type of spinal cord injury that occurs. In addition to the acute surgical treatment of these patients, spine surgeons should understand how to manage neurogenic bowel and bladder care on both a short-and longterm basis to minimize the risk for complications and optimize potential for rehabilitation. Spinal cord injury (SCI) is a devastating incident that results from traumatic and nontraumatic events leading to spinal cord damage. 1 Leading causes include vehicular accidents, falls, violence (gun-shot injuries), sport-related, and medical or surgical complications. 2 The National Spinal Cord Injury Statistical Center indicates an incidence of 17,810 new cases each year in the United States, with a mean hospital stay length of 11 days. Worldwide, the incidence ranges from 250,000 to 500,000 persons per year.Since 2005, the average age at injury is 40.7 years. Although the life expectancy of SCI has improved dramatically since the 1950s, it remains below the cohort average. 3 After a SCI, the average life expectancy when compared with the general cohort ranges from 18.1% to 88.4% because of factors including age, sex, and the neurologic grouping of injury-with better prognosis in incomplete spinal cord lesions. 3 Incomplete quadriplegia is the most frequent form of SCI (47.2%), followed by complete paraplegia (20.2%), incomplete paraplegia (19.6%), and complete quadriplegia (12.3%). Under 1% of patients will experience complete neurologic recovery by the time of hospital discharge. 2 Bowel and bladder dysfunction have a devastating impact on the quality of life after SCI. Approximately 30% of patients recovering from a SCI are hospitalized on an annual basis, with genitourinary infections the most common cause of readmission (23.5 to 29.8%) and the fifth most common cause of death. Bowel dysfunction is the most reported report with an incidence between 20 and 60% and the ninth most common reason for rehospitalization. 4 The challenges of bowel and bladder dysfunction affect the daily

Principles of Rehabilitation Strategies in Spinal Cord Injury

“…Moreover, the fifth most common cause of mortality in SCI patients, is genitourinary infection. Bowel dysfunction is the fourth leading cause of re-hospitalization and the second most common complication according to SCI patients [114][115][116]. Therefore, bladder and bowel care comprise a notable part of the SCI rehabilitation program.…”

“…Based on a prior report, about 77% of SCI patients lack the ability to void voluntarily, which makes them dependent on assistance [117]. The most common bladder drainage method for neurogenic bladder management with the lowest risk of complications and urinary tract infection in SCI patients is clean intermittent catheterization [114,118]. Tetraplegic patients, however, might use indwelling or suprapubic catheters, which could increase the risk of complications, such as infection.…”

“…Pharmacological therapy using anticholinergics or beta-3-agonists is also effective in reducing the intravesical pressure in cases with hyperreflexic detrusor. In refractory cases or patients with renal impairment, a number of procedures, such as intravesical botulinum-A toxin injection, surgical interventions (e.g., bladder reconstruction and diversion procedures), and sacral neuromodulation, might also help in improving the symptoms [114].…”

Neurogenic Bladder Physiology, Pathogenesis, and Management after Spinal Cord Injury

“…In sacral injuries where the detrusor is areflexic, sacral anterior root stimulation (SARS) might be used to help stimulate the emptying of the bladder. A stimulator is placed intradurally at the sacral anterior root to stimulate the sacral pelvic nerve to cause detrusor contraction, and a posterior sacral root rhizotomy is also performed to prevent detrusor hyperreflexia by removing the sensory afferent pelvic nerves [ 55 ]. Sacral neuromodulation might be an option in patients who have failed all other management options, as it is a less-invasive approach than SARS, where the electrode is placed extradurally, and there is no need for posterior root rhizotomy [ 55 ].…”

“…A stimulator is placed intradurally at the sacral anterior root to stimulate the sacral pelvic nerve to cause detrusor contraction, and a posterior sacral root rhizotomy is also performed to prevent detrusor hyperreflexia by removing the sensory afferent pelvic nerves [ 55 ]. Sacral neuromodulation might be an option in patients who have failed all other management options, as it is a less-invasive approach than SARS, where the electrode is placed extradurally, and there is no need for posterior root rhizotomy [ 55 ]. Incomplete sacral spinal cord injuries result in a hypotonic detrusor muscle and subsequent incomplete bladder emptying.…”