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
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
General Population of SCI in UK
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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
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
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

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
Headley Court
Recent refurbishment funded by
Help for Heroes Charity
Demographics of Fatalities
Iraq 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)
Demographics of Injuries
Iraq and Afghanistan
Iraq
01/01/03 – 31/07/2009
Afghanistan
07/10/01 – 31/07/11
222
527
73
259
Serious
149
269
Wounded in
Action
315
1746
Non-battle
Injury/disease
3283
3367
Aeromedical
Evacuation
1971
4888
Casualites
total
Very serious
Data from the UK Ministry of Defence Website (accessed 18/08/11)
Published Papers

USA 40 pts (513) = 9.8%
Iraq only
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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)
Armed forces discharges from service
2005-2010
Army
Navy
RAF
Medically
discharged
4539
1474
1049
Musculoskeletal
cause
2777
(63%)
590
(13%)
875
(62%)
176
(12%)
429
(49%)
231
(26%)
Mental
Behavioural
Data from the UK Ministry of Defence Website (accessed 18/08/11)
Pensions

141,715 war disablement pensioners (ongoing
pension)

100% disablement rate = £327.72 per week
Referrals to RNOHT
between 1994 – Oct 2010
Total = 20
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Rank
Navy = 1
 Officer = 6
Army = 9
 Non-officer = 14
Paratrooper = 2
RAF = 5
Marine = 1
Ex- SAS = 2
2009/2010 referrals = 8
Referrals from Headley Court = 14
Referrals direct to SCIC for rehab = 6
Place of Main Rehabilitation
8
40%
7
6
5
25%
4
20%
3
2
1
0
20%
RNOHT
Headley Court
No rehab
Outpatients only
Where injured?
Iraq
Afghanistan
UK - peacetime
Abroad - peacetime
4
6
(one at sea)
7
3
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
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
Other morbidities
Iraq and Afghanistan
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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
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
Bladder Management
Upper Motor Neurone SCI
(T12 and above)
Loss of inhibitory impulses cause
neurogenic
detrusor overactivity
CC X
PMC X
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
√
√

SMC √
Neurogenic Detrusor Overactivity
Neurogenic detrusor
overactivity
Detrusor Pressure
Diverticulum
Urine Flow
Trabeculation
Intraurethral Pressure
Sphincter EMG
Fir tree
External Sphincter
dysnergia
Sphincter Dyssynergia
What happens if we don’t treat it?
INFECTION
Neurogenic
Detrusor
Overactivity
Detrusor
Sphincter
Dyssynergia
REFLUX
Renal
Failure
Lower Motor Neurone SCI
(L1 and below)
Under-active detrusor
acontractile detrusor
CC X
PMC X
Under-active sphincter and urethra
sphincter incompetence
No sensation of bladder fullness
SMC X
X
Flaccid bladder, no spontaneous
voiding or voluntary control
X
X
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
1
(not RNOHT)
0
1
(not RNOHT)
Unknown
Type of Bladder Management
5
4.5
4
3.5
ISC
ISC + AUS
SPC
Voids on urge
Unknown
3
2.5
2
1.5
1
0.5
0
Cervical
Thoracic
Lumbar
Cervical patients all on anticholinergics
Thoracic patients 4 pts on anticholinergics, 1 pt acontractile, 1 pt old SARSI
Lumbar patients 1 pt on anticholinergics
Grips
Penis Holder
Bowel Management
Neurogenic Bowel
Upper motor neurone T12 and above
Reflex bowel
Tight anal sphincter
Lower motor neurone L1 and below
Flaccid bowel
Weak anal sphincter
Bowel Management
Reflex – T12 and above
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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
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Balanced high fibre diet
2000ml fluid per day
Abdominal massage/ straining
Gastro colic reflex
Manual evacuations
Positioning.
Regular exercise
Aperients
Bowel Management according
to level of injury
Cervical
Thoracic
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
Lumbar
So what is the Stanmore hand
shake?
It is a necessary procedure called a Digital
Stimulation and then Manual Evacuation
Trans anal irrigation
25% of patients
Bladder and Bowel management
has to fit into their life
– not lead it
Sexual Function and Disability
EAU (2010) Sexual Dysfunction: Erectile Dysfunction and Premature Ejaculation
Update on guidelines in sexual dysfunction assessment, treatment and management
Male SCI

Upper motor neurone
 Reflex erections in 95%
 Ejaculation possible in 5% complete and 32% incomplete
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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

Cervical Level Injury
Erectile and Fertility Function
4
3.5
3
Relex erections
PDE5 only
Vacum device
Caverject
Can Ejaculate
No Ejaculate
2.5
2
1.5
1
0.5
0
Total pts = 4
Thoracic Level Injury
Erectile and Fertility Function
12
10
PDE5 only
PDE5 + Vacuum
Caverject only
Not known
Unreliable ejaculation
Can ejaculate
No ejaculate
Unknown
8
6
4
2
0
Total pts = 7
Lumbar Injury
Erectile and Fertility Function
4
3.5
PDE5 only
Caverject
MUSE
Not needed
Unknown
Refused referral
No ejaculate
Can ejaculate
Unknown
3
2.5
2
1.5
1
0.5
0
Total pts = 9
Incidence of SD
General Population
Men
1
in 10 adult males experience sexual dysfunction
Important that my patients know
that it isn’t always a disabled
person’s problem
Fertility post SCI
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Semen quality reduces at approx 2 weeks post injury
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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)
Marriage and relationships
Delvio and Richards 1996
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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, preexisting personality/behavioural difficulties
Pearcy et al 2007
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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
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
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
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
Neuropathic Pain
12
10
60%
8
6
4
2
0
Huge Problem
No Problem
Not Documented
Psychology
8
40%
7
6
5
4
3
2
1
0
20%
PTSD
Low mood
Not documented
'Making of him'
Change in patient’s status
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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
Outcomes

Coping strategies (social reliance) has a
direct impact on functional and
rehabilitation outcomes
Kennedy et al (2011)
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Functional outcome better and length of
stay shorter if rehab is in a specialist SCIC
New et al (2011)