Bladder, Bowel and Sexual Function Needs of our Spinal Cord Injured Armed Forces

1
Bladder, Bowel and Sexual Function Needs of our
Spinal Cord Injured Armed Forces

• Sharon Wood
• Clinical Nurse Specialist
• Neuro-Urology and Sexual Function
• Royal National Orthopaedic Hospital

2
Why Neuro-Urology at an Orthopaedic Hospital

• The London Spinal Cord Injury Unit
• 12 acute beds
• 12 rehab beds
• 5 tissue viability beds
• 2 paediatric beds
• One of the 11 SCIC in the UK

3
General Population of SCI in UK

• UK population totals 58,789,194
  (2001 Census)
• Est 40,000 SCI in UK (BASCIP 2001)
• Est 1200 new injuries each year
• In UK x 1 person paralysed every 8hrs, average
  age 32.6yrs
• Cost annually 500 million
• Not a reportable condition so data is incomplete
• BASCIP 2001
• www.apparelyzed.com/statistics

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Mortality following SCI

• 3179 pts (2 centres Stoke and Southport)
• 1943-1990
• 1st Respiratory
• 2nd Ischaemic heart disease
• 3rd Injuries (including suicide)
• 4th Urinary system (was 1st pre 1972)
• 9th Septicaemia
• Frankel et al (1998)

Life expectancy tetraplegic post WW1 1
month Now 5yrs of normal life expectancy
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General SCI Population Discharge

• 36.8 of patients leave a SCIC clinically
  depressed
• 21 of patients discharged from SCIC go to
  interim placements such as nursing homes or other
  institutions and not to their own property.
• Can take years to get an adapted property

6
Armed forces

• Majority of patients will be transferred to Queen
  Elizabeth Hospital in Birmingham
• Headley Court, Epsom Downs, Surrey
• 20 Neurology inpatient beds (inc brain injury and
  SCI)
• 46 beds polytrauma and medical conditions

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Headley Court
Recent refurbishment funded by Help for Heroes
Charity
8
Demographics of FatalitiesIraq and Afghanistan
Iraq 01/01/03 31/07/2009 Afghanistan 07/10/01 31/07/11
Total Killed 179 377 (379)
Killed in Action 111 299
Died of Wounds 25 39
Other 43 39
Data from the UK Ministry of Defence Website
(accessed 18/08/11)
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Demographics of InjuriesIraq and Afghanistan
Iraq 01/01/03 31/07/2009 Afghanistan 07/10/01 31/07/11
Casualites total 222 527
Very serious 73 259
Serious 149 269
Wounded in Action 315 1746
Non-battle Injury/disease 3283 3367
Aeromedical Evacuation 1971 4888
Data from the UK Ministry of Defence Website
(accessed 18/08/11)
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Published Papers

• USA 40 pts (513) 9.8 Iraq only
• Head injury and Spinal Cord Injury
• Navy (Bethesda) and Army (Washington)
• Predominately blast injuries
• More than the Vietnam War
• Bell et al (2009)

• UK 25 pts (448) 5 Iraq and Afghanistan
• Only cervical level
• Breeze et al (2011)

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Armed forces discharges from service
2005-2010 Army Navy RAF
Medically discharged 4539 1474 1049
Musculoskeletal cause 2777 (63) 875 (62) 429 (49)
Mental Behavioural 590 (13) 176 (12) 231 (26)
Data from the UK Ministry of Defence Website
(accessed 18/08/11)
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Pensions

• 141,715 war disablement pensioners (ongoing
  pension)
• 100 disablement rate 327.72 per week

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Referrals to RNOHT between 1994 Oct 2010Total
20

• Navy 1
• Army 9
• Paratrooper 2
• RAF 5
• Marine 1
• Ex- SAS 2

• Rank
• Officer 6
• Non-officer 14

2009/2010 referrals 8 Referrals from Headley
Court 14 Referrals direct to SCIC for rehab 6
14
Place of Main Rehabilitation
40
25
20
20
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Where injured?
Iraq 4
Afghanistan 6 (one at sea)
UK - peacetime 7
Abroad - peacetime 3
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Level and cause of injury
Cervical 4 Fall (Disectomy) RTA Bullet Skiing
Thoracic 7 Crush injury from vehicle x1 Fall x1 Diving x1 Helicopter crash x1 RTA x3
Lumbar 9 Epidural x1 IED x3 RTA x1 Bullet x1 Helicopter crash x1 Disectomy x1
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Cause of injury Iraq and Afghanistan

• Iraq (4)
• Crush injury from jeep under fire 1
• RTA 1
• Bullet 1
• Helicopter crash 1

• Afghanistan (6)
• Fall (at sea) 1
• Bullet 1
• Fall from back of helicopter under fire 1
• Improvised explosive device 3

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Other morbiditiesIraq and Afghanistan

• Head injury 1
• Shoulder injury 2
• Fractured ankle 1
• Fractured ribs 1
• Dislocated hip 1
• Knee injury 1
• Limb amputations 1
• Blast/skin injuries 1
• Hand injury 1
• Internal abdominal bleeding 1

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Philosophy of Bladder and Bowel Management
Preservation of Renal Function Promotion of
Continence Abrams et al (2008) A Proposed
Guideline for the Urological Management of
Patients with Spinal Cord Injury EAU (2011)
Neurogenic Lower Urinary Tract Dysfunction NICE
guidelines LUTS for men 2010 and urinary
incontinence in women 2006 NICE due to publish
Oct 2012 Incontinence in Neurological
Disease Guidelines for the Management of the
Neuropathic Bowel in Spinal Cord Injury (2009)

• Patients Perspective
• Socially acceptable
• Simple
• Avoids drainage device
• Personal control

• Medical Perspective
• Low pressure storage
• Complete efficient emptying
• Preservation of renal function

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Bladder Management
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Upper Motor Neurone SCI (T12 and above)
Loss of inhibitory impulses cause
neurogenic detrusor overactivity Urethra and
sphincters also overactive unco-ordinated
Detrusor sphincter dyssynergia (DSD) High
pressure voiding which may cause kidney
damage Incontinence due to uncontrolled
emptying Loss of bladder sensation and voluntary
control
CC X
PMC X
?
v
SMC v
v
v
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Neurogenic Detrusor Overactivity
Neurogenic detrusor overactivity

Detrusor Pressure
Diverticulum
Urine Flow
Intraurethral Pressure
Trabeculation
Sphincter Dyssynergia
Sphincter EMG
Fir tree
External Sphincter dysnergia
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What happens if we dont treat it?
INFECTION
Neurogenic Detrusor Overactivity
REFLUX
Renal Failure
Detrusor Sphincter Dyssynergia
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Lower Motor Neurone SCI (L1 and below)
Under-active detrusor acontractile detrusor
Under-active sphincter and urethra sphincter
incompetence No sensation of bladder
fullness Flaccid bladder, no spontaneous voiding
or voluntary control
CC X
PMC X
SMC X
X
X
X
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Diagnosis of Bladder Dysfunction
Cervical- 4 Thoracic- 7 Lumbar- 9
NDO 3 4 0
NDO DSD 0 2 1
Acontractile 0 1 2
Acontractile USI 0 0 5
Unknown 1 (not RNOHT) 0 1 (not RNOHT)
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Type of Bladder Management
Cervical patients all on anticholinergics Thoraci
c patients 4 pts on anticholinergics, 1 pt
acontractile, 1 pt old SARSI Lumbar patients 1 pt
on anticholinergics
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Penis Holder
Grips
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Bowel Management
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Neurogenic Bowel

• Upper motor neurone T12 and above
• Reflex bowel
• Tight anal sphincter
• Lower motor neurone L1 and below
• Flaccid bowel
• Weak anal sphincter

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Bowel Management

• Reflex T12 and above
• Balanced high fibre diet
• 2000ml fluid per day
• Suppositories, DRE and Manual evacuations (DRF)
• Gastro colic reflex
• Abdominal massage
• Positioning
• Regular exercise

• Flaccid L1 and below
• Balanced high fibre diet
• 2000ml fluid per day
• Abdominal massage/ straining
• Gastro colic reflex
• Manual evacuations
• Positioning.
• Regular exercise
• Aperients

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Bowel Management according to level of injury
Cervical Thoracic Lumbar
DS ME 2 3
Anal Irrigation (Peristeen) 1 2 2
Spontaneous evacuation 1 1 3
Colostomy 0 0 1
Unknown 0 1 3
Medication Movicol, Docusate Sodium and Senna
Ano-physiology tests done in 3 patients
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So what is the Stanmore hand shake?

• It is a necessary procedure called a
  Digital Stimulation and then Manual Evacuation

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Trans anal irrigation25 of patients
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Bladder and Bowel management has to fit into
their life not lead it
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Sexual Function and Disability
EAU (2010) Sexual Dysfunction Erectile
Dysfunction and Premature Ejaculation Update on
guidelines in sexual dysfunction assessment,
treatment and management
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Male SCI

• Upper motor neurone
• Reflex erections in 95
• Ejaculation possible in 5 complete and 32
  incomplete
• Lower motor neurone
• 25 able to have some type of erection
• Ejaculation possible in 18 complete and 70 in
  complete
• (Fazio and Brock 2004)
• Cauda equina injuries
• No erectile activity

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Cervical Level InjuryErectile and Fertility
Function
Total pts 4
39
Thoracic Level Injury Erectile and Fertility
Function
Total pts 7
40
Lumbar Injury Erectile and Fertility Function
Total pts 9
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Incidence of SD

• General Population
• Men
• 1 in 10 adult males experience sexual dysfunction
• Important that my patients know that it isnt
  always a disabled persons problem

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Fertility post SCI

• Semen quality reduces at approx 2 weeks post
  injury
• Abnormal sperm motility and viability not sperm
  count
• Related to at least one abnormal hormonal level
  (51) and hypothalamic-pituitary axis abnormality
  (86)
• Better bladder management and less infections
  help.
• Repeated ejaculation with Ferticare vibrator or
  electroejaculation can improve semen quality
• Ultimately, best to take samples for fertility
  treatment from testicular biopsies
• Patki et al (2008)

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Marriage and relationships

• Delvio and Richards 1996
• Marriage more sustainable if higher education
• If divorced pre/peri injury then more likely to
  have a successful post injury marriage
• Women less likely to marry than men and divorce
  and separation is higher in women with SCI
• Lack of social exposure/accessible buildings,
  social skills, pre-existing personality/behavioura
  l difficulties
• Pearcy et al 2007
• Relationships are more likely to fail in acute
  rather than rehab stage
• Disempowerment, over assistance, family and
  friends are motivators though
• Information/education of activities

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SCI perceptions of themselves sexually

• Anderson et al 2007
• Direct link between sexual function and quality
  of life.
• 87.9 sexually active post SCI increased with age
  of injury
• 83.2 altered sense of themselves as a sexual
  person
• Intimacy, sexual need, self-esteem, to keep a
  partner
• Fear of bladder and bowel accidents
• Autonomic dysreflexia directly related to
  bladder/bowel management and sensitivity.
• Can be sexually stimulating

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Body image

• of all the symptoms associated with physical
  disability, the most oppressive and destructive
  is the radical loss of self-esteem
  
• Barbin and Ninot 2008

Skiing increased perception of an attractive
body. Athletic identity, increased
confidence BACKUP
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Important message
You can still have an active sex life You can
still have children if you want to You still
have the same modes of arousal Brain,Tactile and
Orgasm It may not be exactly the same as before
but can be just as good
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Neuropathic Pain
60
48
Psychology
40
20
49
Change in patients status

• From independent to dependent directing own
  care
• Partners should not be carers
• Financial pressures
• Compensation claims can go on for years
• Ego
• Patient not a sexual person
• Rehabilitation encourages empowerment,
  independence and
• re-integration back into society

50
Outcomes

• Coping strategies (social reliance) has a direct
  impact on functional and rehabilitation outcomes
• Kennedy et al (2011)
• Functional outcome better and length of stay
  shorter if rehab is in a specialist SCIC
• New et al (2011)