SPINAL CORD INJURY
A spinal cord injury may interrupt communication between the nerves in the spinal cord that control bladder and bowel function and the brain, causing incontinence. This results in bladder or bowel dysfunction that is termed "neurogenic bladder" or "neurogenic bowel."
If you have a spinal cord injury, look for these signs of a neurogenic bladder:
- Loss of bladder control (urinary incontinence)
- Inability to empty the bladder
- Urinary frequency
- Urinary tract infections.
Signs of neurogenic bowel include:
- Loss of bowel control (bowel incontinence)
- Bowel frequency
- Lack of bowel movements.
Before delving into causes and treatments, an understanding of spinal cord terms and injuries will be helpful.
The spinal cord has four areas. Going from top to bottom, the first and highest part of the spinal cord is known as the cervical spinal cord. The cervical region controls hand and arm sensation and function. Next is the thoracic spinal cord. The thoracic spinal cord controls the sensation and function of the muscles of the chest, back and abdomen. Next is the lumbar spinal cord. Lower back and leg activity is controlled here. The lowest part of the spinal cord is the sacral spinal cord. Bladder function, bladder and bowel external sphincters, sexual functions (including erections and ejaculation in men and responsiveness in women), and some leg muscles are the domain of the sacral spinal cord.
A very important part of voiding involves the sacral spinal cord. There is a part of the sacral spinal cord known as the sacral voiding, or micturition, center. This center receives and sends signals directly to and from the bladder. When the bladder becomes filled with urine, it sends signals to the sacral spinal cord. If this communication is disrupted, through disease or injury, the message is delayed or not received. The result is incontinence.
The position of the spinal cord injury has a lot to say in terms of what sort of incontinence may manifest. Above the sacral spinal cord (supra—sacral spinal cord injury) or at or below the sacral spinal cord.
Supra-Sacral Spinal Cord Injuries
Immediately after SCI, the bladder usually undergoes spinal shock. During spinal shock, the bladder does not contract. Spinal shock frequently lasts at least 2 to 3 months. However, it may last 6 months, and there are a few cases of it lasting up to 2 years. What happens after spinal shock depends in large part on the level and completeness of the spinal cord injury.
A spinal cord injury above the sacral center may prevent signals from going from the sacral voiding center up to the brain. The spinal cord injury may also block signals going from the brain back down the cord to the sacral voiding center. Since the brain is unable to have any control of the sacral center, the sacral center works on its own. A bladder that has involuntary or uninhibited contractions is known as an overactive bladder, or overactive detrusor (the bladder is also known as the detrusor). Since voiding occurs as a reflex, with signals coming in and out of the sacral voiding center, this is type of voiding is known as reflex voiding.
Between the brain and spinal cord is an area called the brainstem. Within the brainstem is the brain micturition, or “voiding”, center. This center is responsible for sending signals down the spinal cord to the sphincter to tell it to relax when a person’s bladder contracts. The spinal cord injury blocks signals from the brain micturition center to the sphincters. When the bladder, or detrusor, has an uninhibited (involuntary) contraction, the sphincters may not relax. This is known as detrusor sphincter dyssynergia (DSD).
DSD can cause high pressures to develop in the bladder. High bladder pressure over time can cause kidney damage.
Another problem that can occur in those with spinal cord injury at or above thoracic level 6 (T-6) is autonomic dysreflexia. The most dramatic effect is a sudden severe rise in blood pressure. One or more common symptoms that often occur with the high blood pressure are a severe headache, sweating, flushing, goose bumps, chills, a feeling of anxiety, and a slower pulse rate. However, about 30 to 40% of people have elevated blood pressures with few, if any, other symptoms (silent dysreflexia). Therefore, it is important to check your blood pressure when you have a full bladder or are voiding.
In addition to bladder issues, there are also two main types of neurogenic bowel, depending on level of injury: an injury above the conus medullaris (at L1) results in upper motor neuron (UMN) bowel syndrome; a lower motor neuron (LMN) bowel syndrome occurs in injuries below L1. The position and effect of the spinal cord injury are similar to those causing neurogenic bladder.
Bowel accidents happen. The best way to prevent them is to follow a schedule, to teach the bowel when to have a movement. Most people perform their bowel program at a time of day that fits with their lifestyle. The program usually begins with insertion of either a suppository or a mini-enema, followed by a waiting period of approximately 15–20 minutes to allow the stimulant to work. After the waiting period, digital stimulation is performed every 10–15 minutes until the rectum is empty. Those with a flaccid bowel frequently start their programs with digital stimulation or manual removal. Bowel programs typically require 30–60 minutes to complete. Preferably, a bowel program can be done on the commode. Two hours of sitting tolerance is usually sufficient. But those at high risk for skin breakdown need to weigh the value of bowel care in a seated position, versus a side-lying position in bed.
Talk to your doctor!! Incontinence is a normal part of life after a spinal cord injury but there are ways to manage it that can let you be comfortable and independent. Your doctor can discuss the detail of your particular injury and its impact on your bladder as well as suggesting potential management options.
- Anal irrigation. Anal irrigation is a new, conservative bowel management therapy to reduce constipation and assist in effective bowel movement and management.
- Clean technique intermittent catheterization. In clean technique intermittent catheterization (CIC), you or a healthcare professional inserts a thin tube (catheter) through the urethra and into your bladder several times during the day to empty your bladder.
- Continuous catheter drainage. A healthcare professional may insert a catheter through your urethra or abdominal wall and into your bladder to continuously empty your bladder.
Doctors trained in bladder management (urologists) may perform bladder reconstructive surgery that may resolve or improve bladder symptoms and management.
Your doctor may prescribe medications to improve bladder function, such as reduce bladder contractions, lower urinary frequency, improve loss of bladder control (incontinence), increase bladder storage, or empty the bladder. Your doctor may also prescribe medications to manage timing and consistency of bowel movements.
There are many medications that can help treat incontinence issues that arise with spinal cord injuries. Click here to learn about them.