Flashcards in SCI - Bowel & Bladder Deck (50)
What is the definition of neurogenic bladder?
"Dysfunction of the urinary system that is primarily due to a neurogenic cause (upper or lower motor neuron).
What are the 3 muscles important for maintaining fecal continence? PVA guidelines
"1. internal anal sphincter (IAS)
2. external anal sphincter (EAS)
3. puborectalis muscle"
Possible indications for suprapubic catheter?
"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)."
Indications or pre-requisites for bladder augmentation surgery?
"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."
What changes occur in the bladder after SCI?
"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)"
"Name the nerve and function of the system in bladder management:
Sympathetic nervous system, parasympathetic nervous system, motor NS."
1. Pelvic nerve
2. Function: Bladder emptying
2. Function: Storage of urine
3. alpha and beta receptors (IUS and detrusor respectively).
1. Pudendal nerve
2. Function: Motor control of external urethral sphincter. Voluntary storage and emptying."
What is the definition of a UTI? (SCIRE)
"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)
Cloudy urine with increased odour
Malaise, lethargy, or sense of unease.”"
Name 5 surgical interventions directed to improve bowel care/functioning
3. ACE procedure (aka MACE procedure): Malone anterograde continence enema
4. Muscle graft for puborectalis sling
5. Sphincter myotomy for dyssynergia
6. Sacral anterior root stimulation"
What is the MACE procedure?
"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.
"Name 5 non-surgical, non-pharmacological interventions that may improve bowel care.
"Electrical stimulation of abdominal wall muscles
Posterior tibial nerve stimulation (for fecal incontinence)
Pulsed water irrigation
Enema continence catheter
Digital rectal stimulation
Functional magnetic stimulation"
Name 8 long term GI issues with chronic SCI
3. Peptic ulcer disease
4. Colorectal CA (increased risk)
6. Pressure ulcers with tracking
7. Superior mesenteric artery syndrome
9. Rectal prolapse
Ref: Cuccurullo pg 585."
Name 3 clinical features of classic SMA syndrome
postpandal N&V/bloating/abdo pain
What is the definition of spinal shock?
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.
How long does spinal shock last usually?
Hours to weeks. PVA bowel document.
List 6 treatment recommendations for orthostatic hypotension.
"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."
List and describe 6 different types of wound debridement
"1. mechanical (hydrotherapy and irrigation, wet to dry)
2. biological (maggot therapy)
3. autolytic (using hydro colloids or hydrogels to keep the wound moist and allow body's own enzymes to remove devitalized tissue
4. enzymatic (streptokinase, Collagenase)
5. chemical (hypoChlorite)
6. surgical and sharp (scalpel and scissors)
List 8 reversible factors for incontinence and retention.
3. Atrophic vaginitis, urethritis ,BPH
6. Endocrine DM, ↓Na, ↑Ca, ↑Mg
7. Reduced mobility
8. Stool impaction
Outline a functional classification for the neurogenic bladder.
"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"
In detrusor areflexia (LMN bladder), why do some patients have difficulty emptying?
"Internal sphincter tone is usually flaccid with LMN lesion, but may be intact due to sympathetic innervation, causing difficulty with complete emptying.
What test can be employed to differentiate prostatitis from pyelonephritis?
"Cytology of expressed prostatic secretion for prostatitis,
BEST ANSWER - PSA would be elevated in prostatitis (Oostra 1998)"
What are some treatment options for neurogenic bladder in UMN (SCI, MS, etc)?
1. Post-void residuals.
2. ultrasound KUB (hydronephrosis, stones and bladder trabeculations).
3. urodynamics and cystoscopy at regular intervals
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.
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).
1. Indwelling catheters or condom catheterization
2. Intravesicular BoNT.
3. intravesical instillations (L4, oxybutynin, propantheline – SCIRE = not effective).
1. Suprapubic cather
2. Mitrofanoff (catherizable stoma).
3. Bladder Augmentation
6. Denervation procedures
8. intrathecal baclofen.
List 4 classes of treatment for enhancing bladder volumes in hyper-reflexic bladder in SCI.
"1. anti-cholinergics (propiverine, oxybutynin, tolterodine, trospium chloride).
2. denervation therapy (botulinum toxin into detrusor).
3. detrusor muscle therapy (topical vanillanoid compounds – capsaicin/resiniferatoxin).
4. intravesical instillations – oxybutinin (L4 evidence ineffective, SCIRE).
5. intrathecal baclofen/clonidine (secondary benefit of decreasing bladder spasticity).
List the SSx’s of a UTI. Post SCI:
"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
Indwelling catheters. Five complications.
"1. Bladder – UTI, cystitis
2. Bladder stones, kidney stones
4. Penile and scrotal fistulas
5. Vesicovaginal fistula
7. Urethral strictures,
8. Urethral diverticulum
9. Bladder carcinoma with long term use
10. Blocked indwelling catheter
Ref: Tan p 583
11. urethral erosions.
14. hydronephrosis (bladder wall thickening)
PVA Bladder guidelines pg 2."
Name four predisposing causes of urinary tract infections in spinal cord injured patients.
"1. bacterial colonization +/- resistance
2. DSD w/ assoc. ureteral reflux and hydronephrosis eventual areflexia (even in UMN lesion!!)
3. Catheterization – introduction of organisms
5. Stasis or insufficient ICs (i.e., < q6h)
Meds that cause retention e.g. TCA"
Is bowel wall compliance significantly altered after SCI? Explain.
"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.
Name 3 cutaneous reflexes that can be assessed in UMN bowel D/Os.
"1. Bulbocavernosus reflex (S2-4).
2. Anal wink/anocutaneous reflex (S2-4).
3. Plantar response (test of UMN).
4. Cremaster reflex (T12-L1-2; genitofemoral nerve).
5. abdominal reflex (Upper: T8-T10; Lower: T10-T12).
Ref: Neurology resident guide."
What are Rx options for UMN fecal incontinence?
"1. Environmental – having commode and toilet close by
2. Rule out causes of incontinence
3. 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
4. Skin Care
5. Odor control
6. 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
7. 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
8. 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
9. Surgical interventions – MAS procedure or colostomy
Ref: Tan p 602"
What are some clinico-anatomic changes assoc. w/ LMN bowel dysfunction?
"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).