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- 1. Study Notes Neurogenic Bowel & Bladder Dr Mrinal Joshi Director, Rehabilitation Research Centre Professor & Unit Head, Dept. of PMR SMS Medical College & Associated Hospitals Jaipur
- 2. Neurogenic Bowel • Dysfunction from trauma & disease within the spinal cord • Mainly affects the colorectum & the anal canal • Peristalsis & secretion primarily controlled by enteric nervous system • Submucosa (Meissner’s plexus) & gut muscle (Auerbach’s plexus) • Vagus innervates below the splenic flexure of colon • Distal colon parasympathetic from S2-S4 • Sympathetic to colon & rectum from T9-T12 • Parasympathetic enhances secretion & peristalsis; relaxing sphincter • Sympathetics reduce secretion & peristalsis; contracting sphincters
- 3. Anal canal • Anal canal surrounded by striated ext. & smooth internal sphincters • Upper part surrounded by puborectalis muscle • Int. sphincter under reflex control of enteric & sacral nerves • Ext. sphincter under voluntary control of pudendal S3-5 • Puborectalis creates an anorectal angle • Prohibiting the content in the anal canal
- 4. Defecation • Preceded by mass movement of stool • Rectal wall stretch initiates defecation reflex • Stimulates contraction of rectal wall through sacral reflex arc • Rectoanal inhibitory reflex (RAIR) causes relaxation of int. sphincter • Mediated by parasympathetics • Voluntary contraction of ext. sphincter inhibits
- 5. Continence depends on Consistency of stools Colorectal transit time Rectal tone Anorectal sensibility Tone of puborectalis muscle Voluntary contraction of ext. anal sphincter
- 6. Neurogenic bowel Sympa. & Parasymp. act through stimulation or inhibition No direct innervation of smooth muscles Parasymp. Innervation through vagus nerve To stomach, small intestine & proximal colon unaffected by SCI No UMN or LMN gut Lesions above S2 have increased tone & contractility of rectum Causing reflex defecation Lesions at or below S2 have reduced tone & contractility Causing faecal impaction & incontinence
- 7. SCI Acute phase gut is hypotonic & unresponsive to stimulus Severely prolonged colonic transit time during first week after injury Pattern of prolonged transit time varies in individuals Reflexic NBD have prolonged transit time in colon but not in rectum Long transit time in descending colon & rectosigmoid in areflexic Emptying of rectosigmoid is significantly delayed in both
- 8. SCI defecatory disorders Impaired rectal emptying • Poor rectal muscle propulsion • Increased resistance to evacuation Obstructed defecation • High anal resting pressure • Incomplete relaxation • Dyssynergia – pelvic floor & external sphincter Decreased / absent anal sensations & voluntary contraction
- 9. NBD Reflexic NBD Increased tone and contractility of rectum Areflexic NBD Poor emptying of rectum Hypotonic rectum Poor sphincter function Incontinence & impaction Commonly reported symptoms Constipation Fecal incontinence Need for digital evacuation Abdominal discomfort Hemorrhoids
- 10. Assessment • International Standard for Neurological Classification for SCI • Sacral reflexes & pelvic floor tone • Bristol stool for scale • Bowel management subscale (26 items) SCI-QOL (SCI-QOL@udel.edu) • International SCI bowel function basic data set (16 items) • Detailed GI history
- 15. GI history Occurrence of incontinence Associated symptoms Frequency of defecation Consistency of stool Approximate volume of stool per evacuation Presence of urge / urgency Ability to control defecation Stress incontinence
- 16. Current bowel care Use of oral & rectal medications Facilitative techniques Schedule of medications and methods Duration of bowel care Functional level and need for assistance Premorbid condition Type and amount of fibre consumed Amount of fluid intake List of activities
- 17. Evaluation • Quantifies amount of faeces • Ascending colon, transverse colon, descending colon & recto-sigmoid • Scored as • No faeces – 1 • Small amount of facecs – 2 • Moderate faecal stasis – 3 • Severe faecal stasis – 4 • Minimum score is 4 and maximum is 16 Starreveld score on abdominal x-ray CT abdomen
- 18. Evaluation • Colonic transit time • Radio-opaque markers • Distribution of markers in right, transverse and recto-sigmoid • Scintigraphy with 99m-Tc-sulfur colloid • Every 30 minutes for 2 hrs for gastric emptying • 24, 48, 72 after the meals • Wireless motility capsule • Information on pH, gastric emptying, colonic and whole gut transit time
- 19. Evaluation • Anorectal manometry • Pelvic floor dyssynergia / obstructive defecation • Deficient propulsive force with increased resistance • High rectal pressure / paradoxical contraction of pelvic floor • Sensor probe can measure • Puborectalis and anal sphincter pressure at rest / squeeze / cough • Rectal sensation & compliance • Presence of recto-anal inhibitory reflex (RAIR) • Pelvic electromyography • Pudendal nerve latency • Rectal tone is higher in supraconal lesions than conal/cauda equina lesions • Pudandal neuropathy and impaired RAIR is common
- 21. Common complications Constipation Incontinence Abdominal pain Anorectal pain • Mechanical rectal stimulation can induce • Bradycardia / arrythmia / pounding headache / anxiety / sweating above level /flushing / blurry vision / nasal congestion / piloerection • Discontinue rectal stimulation • Use lidocaine lubricating gel / slow rotation /10-20 seconds / every 5-10 minutes • Use gastrocolic reflex Autonomic dysreflexia – T6 level or above
- 22. Manual manoeuvre • Lower right abdomen with heel of hand in clockwise manner • In some likely to give abdominal pain / haemorrhoids • Increase risk / unclear benefit Abdominal massage • Performed gently • Excessive force can lead to contraction of pelvic floor • Avoid in reflexic NBD Valsalva manoeuvre
- 23. Adaptive equipment • Suppository insertor or digital stimulator
- 24. Adaptive commode
- 25. Daily fiber recommendations • SCI consortium recommends 15 gm fibre per day – adjust gradually • Asso. Rehab Nurses recommend 20-35 gm of fibre per day • Inst. Of Medicine recommends 14 gm per 1000 calories • Adequate intake 25 gm for women • 38 gm for men below 50 yrs. • 30 gm for men above 50 yrs. • 21 gm for women above 50 yrs.
- 26. Fibres • Fibre containing foods have soluble as as insoluble fibres • Coarse and insoluble fibre such as wheat bran, irritates large bowel mucosa, stimulate water & mucosa secretion, leading to soft stools • Coarser particle can produce constipation • Psyllium is a gel forming soluble fibre, high water holding capacity and resist dehydration • Fermentable oligosaccharides disaccharides monosaccharides & polyols (FODMAPS)
- 28. Maintaining hydration • Rehab Nurses suggest 2L / day to avoid constipation • Can also be estimated by one of the following • 1ml/ kcal energy consumed • 30ml/ Kg body weight • 100ml/ kg for first 10 kg, 50ml/kg for next 10 kg and 15ml for each additional kg of body weight (Fluid consumption = 1,500 + ((weight in kg-20) X 15)
- 29. Oral medications • Normal or slow transit constipation • Minimise constipating drugs (anticholinergics, opiates etc.) • Gradually increase fibre intake • Osmotic agent (milk of magnesia (Megalax) / polyethylene glycol –PEG(Pegmove)) • Supplement with osmotic agent (senna/ bisacodyl (cremaffin fresh tab)) • Lubiprostone (Lubowel) or linaclotide if no response • Prucalopride – enterokinetic (serotonin4 receptor agonist) (Pruwel) • Neostigmine with glycopyrrolate in severe cases in closely monitoring setting in hospital
- 31. Rectal agents • Bisacodyl suppository (Dulcolax) • Contact irritant, enhances motility, increases water content, reduce transit • Glycerine suppository (Neotomic enema) • Lubricant and stimulates rectal contractions • PEG based bisacodyl suppository • Docusate mini enema • Soapsuds or milk & molasses enema is not routinely recommended
- 32. Rectal agents • Trans-anal irrigation • 20-30 minutes after meals • Clean water at 36 to 38 deg.C pumped at 200 to 300ml/min • 500ml to start , saline can be used • If fail second session with 10-15 minutes break • Contraindications • Rectal / anal stenosis • Inflammatory bowel disease • Diverticulitis • Ischemic colitis • Colorectal cancer • Rectal surgery in last 3 months
- 33. Pulsed irrigation device • Widening of anus with a lubricated speculum • Application of 5mll/second pulses of tap water with a cuffed tube • Used for one minute
- 34. Functional Electrical Stimulation • Sacral Anterior Root Stimulation • Posterior laminectomy is performed • Sleeves electrode are placed on S2-4 anterior roots • Bilateral posterior rhizotomy is performed • Electrodes connected to transmitter box • Increases frequency of defecation • Reduces time spent
- 35. Functional Electrical Stimulation • Sacral Nerve Stimulation • Electrode placed through posterior foramina of sacral bone usually S3 • If symptoms reduce in next 3 weeks • A permanent electrode is placed • Minor surgical method with few complications • But lack of trials
- 36. Functional Electrical Stimulation Posterior tibial nerve stimulation • Temporary electrode placed close to posterior tibial nerve • Afferent stimulation to sacral spinal cord • Reduces faecal incontinence • Evidence is limited Dorsal genital nerve stimulation • Plaster electrode placed over genital nerve of the penis or clitoris • Causes minor contractions of rectum • But more studies needed
- 37. Functional Electrical Stimulation Electrical stimulation of abdominal muscle • Surface electrode over the external oblique & rectus • May aid in defecation by stimulation • Small study showed reduction in bowel care time Perianal electrical stimulation • Caused acute anal contraction in couple of patients Epidural electrical stimulation • Currently being explored
- 38. Malone antegrade continence enema (MACE) • Safe & effective when conservative management fails • Surgical creation of an entry with appendix connected to abd. wall • Through appendicostomy catheter is introduced • To administer an enema to irrigate the colon and rectum • Valve mechanism is created • No leakage of stools • Does not require external device
- 39. Malone antegrade continence enema (MACE) • Potential complications • Stomal stenosis • Stomal site infection • Leakage through stoma • Difficulty in catheterisation • Among different surgical procedures, had highest quality-adjusted life expectancy • Best long term outcomes
- 40. Colostomy • Recommended for severe NBD • Decreases and bowel care time improves independence • Left sided / Sigmoid colostomy is best maximizing water absorption & prevents dehydration • Right sided colostomy results in more watery stools, required more care and risk of left sided colonic diversion colitis
- 41. Medical complications Abdominal pain Anorexia Autonomic dysreflexia Severe constipation Bowel obstruction Ileus Small intestine bacterial overgrowth Ischemic bowel syndrome Abdominal distension Dilated colon Intestinal perforation
- 42. Education
- 43. Education
- 49. Evaluation of Neurogenic Bladder History Physical examination • Complete neurological status • Sensations and reflexes • Anal sphincter and pelvic floor functions • Bladder Diary • Urinalysis, blood chemistry, USG, IVP, X-Ray KUB, Urodynamic study
- 54. Association between SCI & Bladder • Seong Jin Jeong 2010, Kyle J. Weld, Wyndaele JJ, Kaplan SA, Blaivas, J.G.
- 55. Mismatch • Degeneration or reorganization of neural pathway • Incomplete lesions • Combined lesions • Extension of cord injuries with cord fibrosis • Aberrant healing process • Vascular extensions • UDS is an important tool for management
- 58. Treatment Goal • Protection of upper urinary tracts • Improvement of urinary tracts • Improvement of patients QOL • Restoration of (part of) the normal LUT function • Cost effectiveness • Technical intricacy • Possible complications • Individualized strategies
- 59. Intermittent Catheterization • Consider when sufficient hand skill or willing caregiver • Avoid • Inability for SCIC • Unwilling caregiver • Abnormal urethral anatomy • Poor cognition & motivation • High fluid intake • AD despite treatment
- 61. CIC Complication UTI Bladder over-distension Incontinence (fluid management) Urethral trauma Urethral false passage Urethral strictures AD Bladder stones
- 62. Indwelling Catheter • Poor hand skills • High fluid intake • Cognitive impairment or substance abuse • Elevated detrusor pressure • Temporary management of VUR • Limited assistance of caregiver
- 63. IDC Complications Bladder stones Kidney stones Urethral erosions Epididymitis Recurrent UTI Incontinence Pyelonephritis Hydronephrosis Bladder Cancer
- 64. Suprapubic Catheterization Urethral abnormalities Recurrent catheter obstructions Difficulty in urethral catheter insertion Perineal skin breakdown Psychological considerations Improve sexual genital functions Prostatitis, urethritis or epididymoorchitis
- 65. Crede’s & Valsalva • LMN with low outlet resistance or sphincterotomy • Avoid as primary method • Avoid • DSD • Bladder outlet obstruction • VUR • Hydronephrosis
- 66. Complications Incomplete bladder emptying High intravesical pressure Developing VUR Developing hydronephrosis Abdominal bruising Possible hernia
- 67. Reflex voiding • Bladder contractions present • Sufficient hand skills • Poor compliance with fluid restrictions • Small bladder capacity • Small PVR • Ability to maintain condom catheter • Avoid • Females • High pressure voiding • AD
- 68. Enhancing Volume
- 69. Enhancing Volume Pharmacologically Anticholinergic Therapy • Propeverine, Oxybutynin & Trospium • Non responders, two medications • Transdermal patch has less dry mouth Toxin therapy • BTX-A is effective in reducing incontinence & excessive bladder pressure while improving capacity Capsaicin & Resiniferon toxin, promising
- 70. Enhancing Volume Non-Pharmacologically • Electrical Stimulation • Surgical Augmentation
- 72. Enhancing Bladder Emptying • Moxicylyte • Tamsulosin • Terazocin Alpha adrenergic Blockers BTX-A injected in sphincter
- 73. Enhancing Bladder Emptying Valsalva & Crede’s maneuver IDC with diligent care & follow up may be effective & satisfactory Condom catheter be monitored for low pressure drainage & complete emptying Portable ultrasound, handy tool
- 74. Other Methods Intranasal DDAVP reduces nocturnal urine emission T11, L5 or S1 to the S2-S3 anastomosis of nerve roots may result in improved function
- 76. Detrusor Areflexia • Stopping leakage • Improving storage • Improve empting • CIC
- 77. UTI - NIDDR • Significant bacteriuria with tissue invasion • Leukocytes in urine • Discomfort or pain over KUB or urination • Onset of urinary incontinence • Fever • Increase spasticity • Autonomic dysreflexia • Cloudy urine with increase odor • Malaise, lethargy, or sense of unease
- 78. Significant Bacteriuria • IDC & SPC should be changed before collection • Intermittent Catheterization • ≥ 102 cfu • Catheter free on condom drainage • ≥ 104 cfu • Suprapubic or Indwelling catheters • any detectable concentration • Spontaneous management • ≥ 105 cfu
- 79. Preventing UTI • Sterile & clean intermittent catheterization • Prelubricated non-hyrophilic catheter are better than PVC • Securing with StatLock device • Long term TMP-SMX is not recommended • Weekly oral cyclic antibiotic customized to individual may benefit • Periurethral cleaning
- 80. StatLock
- 81. Autonomic Dysreflexia • Spinal cord injury at or above T6 • Results from noxious stimuli • Most common cause is bladder distension • Sudden & severe elevation in blood pressure • SBP 10-20mm above baseline • Severe headache, sweating, flushing, goose bumps, chills, feeling of anxiety or slow pulse • Silent dysreflexia