Bowel/Bladder And Sexual Dysfunction After SCI Flashcards
(47 cards)
1
Q
Spastic or hyperreflexice bladder
A
Associated with UMN injuries
- Lesions above the conus medullaris
2
Q
Flaccid or areflexive bladder
A
Associated with LMN injuries
- cauda equina/conus medullaris, sacral segment
3
Q
Bladder impairment after SCI
A
60% of pts will have UTI within one year of injury
- a leading cause of mortality and morbidity
- use of catheter to drain bladder -> increased risk of infection
4
Q
Spastic bladder/UMN qualities
A
- Injuries above L1
- sensation lost
- voiding reflex is intact between bladder and SC; detrusor mm reflexively contracts
- increased bladder mm, detrusor and sphincter tone
- lack of coordination between detrusor and sphincter (dyssynergia) -> detrusor can contract w/ small amount of urine but sphincter wont release b/c of increased tone
- messages blocked to brain resulting in frequent, involuntary bladder emptying
- may have incomplete bladder emptying
5
Q
Flaccid bladder/LMN qualities
A
- Injuries below L2
- sensation lost
- voiding reflex is NOT intact between bladder and SC -> no signal sent to detrusor
- decreased/loss of bladder mm and sphincter tone
- bladder will continue to fill and may leak when full
- unable to empty bladder voluntarily
6
Q
Urinary tract infection
A
- Not all bacteria is bad -> get culture to treat specific infection, if no sx, may not treat
When to treat: - fever
- pyuria: pus in urine
- symptomatic; increased spasticity
- could lead to sepsis if not treated *
7
Q
Goals of bladder management
A
- minimize urinary tract complications
- prevent/control infection and other complications; bladder stones, urethral erosion, higher risk for bladder cancer
- preserve function of upper urinary tract
- maintain low pressure system
- help pt be independent
- maintain continence
- maintain skin integrity
- understand need for lifelong urologic follow-up (yearly to test kidney function)
8
Q
Bladder hypertonicity
A
Can cause back pressure into kidneys
9
Q
Hydronephrosis
A
Swelling of kidney due to backup of urine
10
Q
Vasicoureteral reflux
A
Backward flow of urine up the ureter
11
Q
Intermittent or straight catheterization
A
- preferred method
- performed by self or caregiver
- sterile technique (new) vs clean technique (boil)
-recommend one catheter one time throw it out; depends on insurance, done 3-6x/day
12
Q
External catheter
A
- condom catheter for males
- purewick for females; used in hospital setting, includes suction
For spastic or UMN bladder only; when bladder reflexively empties when it gets full enough
13
Q
Indwelling catheters
A
- urethral aka foley
- convenient to capture and measure urine in hospital
- high incidence of UTI; typically within 48 hours will develop bacteria
- convenient for females with caregiving or functional limitations
- may cause urethral trauma or urethral incompetence
- kinks common**
14
Q
Supra-pubic catheter
A
- surgically places tunnel from abdomen to bladder
- drains into bag directly
- more common for higher level SCI
- increased risk for obstruction, bladder stones
15
Q
Urostomy
A
- surgical procedure where opening created between urinary bladder or lower ureters and skin on the lower abdomen
- can use part of ileum or colon to create a stoma and guide urine directly into bag
16
Q
Catheterizable stoma
A
- one way valve and place catheter inside stoma
- can use appendix or piece of colon to connect bladder to abdominal wall
- used more commonly with women with tetraplegia; easier to empty bladder and do not need to transfer
17
Q
Fluid intake balance
A
2L/day
Less at night
18
Q
Valsalva maneuver
A
Can be used to void
19
Q
Crede
A
- put strong external pressure on lower abdomen
- not recommended; could cause reflux back into kidneys
20
Q
Pharmacologic therapies for bladder control
A
- promote bladder emptying
- decrease bladder pressure/spasticity (UMN)
21
Q
BOTOX
A
- injected into bladder itself (spastic bladder)
- or into urinary sphincter; hold a bit more urine and decrease incontinence
22
Q
Tens and epidural stim
A
Newer, lots of benefits with bladder regulation
23
Q
Urinary drainage bags
A
- overnight drainage bad
- leg bag; can wear under clothing
- be sure bag is lower than level of bladder
- avoid kinks
24
Q
Securing catheter
A
- avoid tension or tug -> damage to urethra
- close catheter line
25
Normal bowel function
- stool propels through colon via peristaltic waves
- dedication begins w/ spontaneous involuntary advancement of stool into rectum
- urge to deface comes from rectal stretch
- valsalva maneuver and voluntary control of abdominal muscles increases intra-abdominal pressure
- defecation occurs by relaxation of external anal sphincter via voluntary control
26
Spastic/UMN bowel
- Injury is above defecation reflex center
- loss of rectal sensation
- loss of voluntary control
- reflex intact; rectal stretch receptors activate, rectal muscle contraction occurs -> defecation
- hypertonic sphincter may not release feces
27
Flaccid/LMN bowel
- Injury below L1
- loss of rectal sensation
- loss of voluntary control
- loss of reflex -> stool collects in rectum -> sluggish movement -> bowel stretches to accommodate
- hypotonic external anal sphincter may leak when becomes too full
28
Bowel program
- planned set of activities that produce a bowel movement in a controlled manner
- timing
- stool consistency
- perform daily or every other day
29
Goals of bowel program
- evacuate stools at a regular, predictable time within 60 min
- minimize GI symptoms/complications
- consider quality of life issues
- minimize or eliminate occurrence of unplanned bowel movements
30
Neurogenic bowel management
- fluid intake; balance with bladder management
- fiber; dietary, supplemental
- activity; no longer walking
- trouble shooting; change one aspect of program at a time, wait 2-3 cycles
- screening for colo-rectal cancer
31
Digital stimulation
- manual disimpaction
- stimulate peristalsis
32
Chemical rectal agents
- suppository
- enema
33
Oral agents
- use at least 8 hours prior to planned bowel program
- laxatives
- stool softeners
34
Functional assessment for bowel program
- sitting tolerance and angle; left sidelying in bed with or without caregiver assist
- sitting balance and transfer ability
- upper extremity function; adaptive equipment, commodes
- skin breakdown risks; bed pan contraindicated for home use
- anthropometric characteristics
- home accessibility
35
Complications associated with neurogenic bowel
- constipation
- fecal impaction
- bowel obstruction
- hemorrhoids
- autonomic dysreflexia
- unplanned bowel movements
- psychological/social distress
- aging: bowel program no longer works
36
Reflexive arousal
- local genital stimulation occurring without though process
Reflex arc of pudendal nerve and S2-4 parasympathetically mediated
- could happen with catheterization
37
Psychogenic arousal
- occurs with mental stimuli
- sympathetic activation of fibers at the T10-L3 levels
- available in LMN but not UMN
38
Sexual response in SCI
- Incomplete > complete
UMN > LMN; reflexive sexual response intact
Psychogenic response more likely in lower level injuries that maintain some T10-L2 innervation
39
Erectile dysfunction tx
75% report ability to obtain but not reliable and short duration
- meds; viagra
- vacuum erection device
- penile implants
- intracavernosal injections; vaso active drugs
- urethral suppository
40
Fertility in males after SCI
- ejaculation not same as orgasm
- SCI can affect nerve pathways responsible for ejaculation (S2,3,4) impaired
- require assisted ejaculation in complete injuries; retrograde ejaculation can occur - semen into bladder
- sperm and semen continue to be produced at poor viability and low motility
- semen muscle be artificially inseminated into partner
41
Female vaginal lubrication treatment
- use of water-soluble lubricant may be used to assist
- longer and more intense genital stimulation often required
42
Fertility in females after SCI
- not affected
- menses may cease for a few months due to spinal shock and initial trauma
- consider management of menstrual fluid; tampon vs pads
43
Pregnancy in SCI
Skin; weight changed
Bladder; pressure, may need indwelling catheter for some time
Mobility; COG changes, balance and transfers affected
Safety issues
44
Labor and delivery in SCI
- vaginal delivery possible but challenging additional support needed
- uterus is an involuntary muscle
- unable to assist with voluntary abdominal pushing and bearing down; may need forceps
- autonomic dysreflexia potential with lesions above T6
45
Orgasm and SCI
Males; orgasm w/o ejaculation in complete injuries, 50% report being able to have an orgasm
Females: achieve orgasm based on cervical stimulation or long more intense clitoral stimulation -> regardless of intact vs impaired sensation, report lower sexual desire, activity, and ability to acheived orgasm than men
* Higher levels of orgasm in context of trust and emotional safety and connectedness *
46
Where PTs can help w/ sexual function
- offer positional tips; props, pillows, straps, toys, positioning and location may change
- consider experimentation
- reject idea of only ableist sexual expression
- masturbation may be first step
* Limited info levels *
47
Comfort level in discussion sexual function with patients
Improve personal comfort level; acknowledge anxieties, self exam of our own background and experience, identify personal values, maintain professional boundaries, clarify relationship
Improve patient comfort level; use open ended questions in neutral tones, progress from general to specific topics, use validating statements, readiness, privacy, respect, educate on resources
