Spinal Cord Injury: Bowel and Bladder Management

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Introduction   

Imagine one day you are able to walk and take care of your own needs. Now, imagine one week later you wake up no longer able to walk, feel anything below your waist, or hold your bowels.  

This is a reality for many people who sustain spinal cord injuries. Managing changes in bowel and bladder function is one of many challenges that people with spinal cord injuries and their families or caregivers face.  

This course will provide learners with the knowledge needed to assist patients who have spinal cord injuries with bowel and bladder management to improve the quality of life in this group.

Spinal Cord Injuries: The Basics

Spinal Cord Function 

Before defining a spinal cord injury, it is important to understand the function of the spinal cord itself. The spinal cord is a structure of the nervous system that is nestled within the vertebrae of the back and helps to distribute information from the brain (messages) to the rest of the body [1].  

These messages result in sensation and other neurological functions. While it may be common to primarily associate the nervous system with numbness, tingling, or pain, nerves serve an important purpose in the body’s function as a whole.

Spinal Cord Injury Definition 

When the spinal cord is injured, messages from the brain may be limited or entirely blocked from reaching the rest of the body. Spinal cord injuries refer to any damage to the spinal cord caused by trauma or disease [2]. Spinal cord injuries can result in problems with sensation and body movements.  

For example, the brain sends messages through the spinal cord to muscles and tissues to help with voluntary and involuntary movements. This includes physical activity like running and exercising, or something as simple as bowel and bladder elimination.  

Spinal Cord Injury Causes 

Spinal cord injuries occur when the spinal cord or its vertebrae, ligaments, or disks are damaged [3]. While trauma is the most common cause of spinal cord injuries in the U.S., medical conditions are the primary causes in low-income countries [4] [2]. 

Trauma 

• Vehicle accidents: Accounts for 40% of all cases [2] 
• Falls: Accounts for 32% of all cases [2] 
• Violence: Includes gun violence and assaults; accounts for 13% of all cases [2] [5] 
• Sport-related accidents: Accounts for 8% of all cases [2] 

Medical Conditions 

• Multiple Sclerosis (MS): Damage to the myelin (or insulating cover) of the nerve fibers [1] 
• Amyotrophic Lateral Sclerosis (ALS): Lou Gehrig’s disease, damage to the nerve cells that control voluntary muscle movements [1] 
• Post-Polio: Damage to the central nervous system caused by a virus [1] 
• Spina Bifida: Congenital defect of the neural tube (structure in utero that eventually forms the central nervous system) [1] 
• Transverse Myelitis (TM): Inflammation of the spinal cord caused by viruses and bacteria [1] 
• Syringomyelia: Cysts within the spinal cord often caused by a congenital brain abnormality [1] 
• Brown-Sequard Syndrome (BSS): Lesions in the spinal cord that causes weakness or paralysis on one side of the body and loss of sensation on the other [1] 
• Cauda Equina Syndrome: Compression of the nerves in the lower spinal region [1] 

Spinal Cord Injury Statistics 

According to the World Health Organization, between 250,000 and 500,000 people worldwide are living with spinal cord injuries [4]. In the U.S., this number is estimated to be between 255,000 and 383,000 with 18,000 new cases each year for those with trauma-related spinal cord injuries [6]. 

Age/Gender 

Globally, young adult males (age 20 to 29) and males over the age of 70 are most at risk. In the U.S., males are also at highest risk, and of this group, 43 is the average age [2].  

While it is less common for females to acquire a spinal cord injury (2:1 ratio in comparison to males), when they do occur, adolescent females (15-19) and older females (age 60 and over) are most at risk globally [4].  

Race/Ethnicity 

In the U.S. since 2015, around 56% of spinal cord injuries related to trauma occurred among non-Hispanic whites, 25% among non-Hispanic Black people, and about 14% among Hispanics [6].  

Mortality 

People with spinal cord injuries are 2 to 5 times more likely to die prematurely than those without these injuries (WHO, 2013). People with spinal cord injuries are also more likely to die within the first year of the injury than in subsequent years. In the U.S., pneumonia, and septicemia – a blood infection – are the top causes of death in patients with spinal cord injuries [6]. 

Financial Impact 

Spinal cord injuries cost the U.S. healthcare system billions each year [6]. Depending on the type, spinal cord injuries can cost from around $430,000 to $1,300,000 in the first year and between $52,000 and $228,000 each subsequent year [6].  

These numbers do not account for the extra costs associated with loss of wages and productivity which can reach approximately $89,000 each year [6]. 

Spinal Cord Injuries: Types and Complications

Four Levels of the Spinal Cord 

• Cervical (vertebrae C1 – C8): Neck; controls the back of the head down to the arms, hands, and diaphragm 
• Thoracic (vertebrae T1 – T12): Upper mid-back; controls the chest muscles, many organs, some back muscles, and parts of the abdomen 
• Lumbar (vertebrae L1 – L5): Lower back; controls parts of the lower abdomen, lower back, parts of the leg, buttocks, and some of the external genital organs 
• Sacral (vertebrae S1 – S5): Lower back; controls the thighs down to the feet, anus, and most of the external genital organs 

Types of Spinal Cord Injuries 

Spinal cord injuries may be classified by level and degree of impairment. There are four types of spinal cord injuries [5]. 

Injury Level 

• Tetraplegia or Quadriplegia: Injury at the cervical level; loss of feeling or movement to the head, neck, and down. People with this type of spinal cord injury have the most impairment. 
• Paraplegia: Injury at the thoracic level or below; limited or complete loss of feeling or movement to the lower part of the body.  

Impairment 

• Incomplete spinal cord injury: Some sensation and mobility below the level of injury as the spinal cord can still transmit some messages from the brain. 
• Complete spinal cord injury: Total loss of all sensation and mobility below the level of injury. Spinal cord injuries of this type have the greatest functional loss. 

Spinal Cord Injury Complications 

Complications from spinal cord injuries can be physical, mental, or social, and can impact overall quality of life. There are six common complications of spinal cord injuries [2]. 

Depression 

Studies show that 32.9% of adults with disabilities experience frequent mental distress [7]. Mental distress may be related to functional limitations, chronic disease, and the increased need for healthcare services.  Up to 37% of people with spinal cord injuries develop depression [2]. 

Pressure injuries 

People with spinal cord injuries may have problems with circulation and skin sensation– both risk factors for pressure injuries. Some may be bedridden or wheelchair-bound which also places them at risk for pressure injuries. Up to 80% of people with spinal cord injuries will have a pressure injury during their lifetime and 30% will have more than one [2].  

Spasticity 

Around 65% - 78% of people with spinal cord injuries have spasticity [2]. Spasticity is uncontrolled muscle tightening or contraction. The damage from spinal cord injuries causes misfires in the nervous system leading to twitching, jerking, or stiffening of muscles. 

Autonomic dysreflexia 

In some people with spinal cord injuries, a full bladder or bowel distention can cause a potentially dangerous condition called autonomic dysreflexia. The full bladder or bowel triggers a sudden exaggerated reflex that causes an increase in blood pressure. This condition is also associated with a severe headache, low heart rate, cold skin, and sweating in the lower body [8]. 

Respiratory problems 

If the diaphragm function is affected, as with cervical spinal cord injuries, there may be breathing difficulties. People with lumbar spinal cord injuries can even have respiratory problems as the abdominal muscles are used to breathe. 

Sexual problems 

Due to changes in muscle function and depending on the degree of damage, people with spinal cord injuries may have problems with arousal and climax due to altered sensations and changes in sexual reflexes.  

Changes in bowel and bladder function 

Many people with spinal cord injuries lose bowel control. Bowel problems can include constipation, impaction, and incontinence. They may also have problems with urination, for example, urinary retention. 

Bowel and Bladder Dysfunction in Spinal Cord Injuries 

This section will cover the normal function of the bowel and bladder, and the types of bowel and bladder dysfunction that occurs in patients with spinal cord injuries.

Normal Bowel and Bladder Function 

In normal bowel and bladder function, when the rectum or bladder fills with stool/urine and presses on area nerves (stimulation), the message is sent to the spinal cord which sends it to the brain. The brain gives the person the “urge” feeling, allowing an option to control the elimination or not.  

Whatever decision the person makes, the brain sends the message back to the spinal cord, which in turn sends a message to the elimination muscles (anal and bladder sphincters) to either relax or stay closed until the person is ready. In people with spinal cord injuries, the messages are limited or blocked, leading to problems with bowel and bladder control [9] [10].  

Bowel Dysfunction with Spinal Cord Injuries 

Reflex hypertonic neurogenic bowel occurs when a rectum full of stool presses against area nerves sending a message to the spinal cord, but it stops there. The message never makes it to the brain, so the person never gets the urge.  

As a result, a reflex is set off, prompting the spinal cord to send a message to the anal muscle (sphincter) instead, causing it to relax and release the stool. This condition leads to bowel incontinence and usually occurs in spinal injuries at the cervical and thoracic levels [9] [10]. 

Flaccid hypotonic bowel occurs when area nerves are also stimulated by a full rectum, but the message does not even reach the spinal cord, so there is no reflex. The anal sphincter is always in a relaxed state.  

As a result, the bowels simply empty when they are full, and this can occur at any time without the person having the ability to control it. This condition results in bowel incontinence and can lead to constipation as the patient does not have the urge and may not have the ability to push. This condition usually occurs in spinal injuries at the lumbar level [9] [10]. 

Bladder Dysfunction with Spinal Cord Injuries 

Reflex neurogenic bladder occurs when the bladder automatically starts to contract after filling with a certain amount of urine. The person has no urge to go as the messages are either limited or blocked from reaching the brain, therefore leading to loss of bladder control. Similar to reflex hypertonic neurogenic bowel, the full bladder triggers are nerves that set off a reflex, prompting the spinal cord to send messages to the bladder releasing urine outside of the person’s control [9] [10]. 

Acontractile bladder occurs when the bladder loses muscle tone after a spinal cord injury, lessening its ability to contract, leading to bladder distention, and dribbling of urine. People with this condition need to use urinary catheters to help empty the bladder [9]. 

The Nurse’s Role in Bowel and Bladder Management 

This section will cover how nurses can assess, intervene, and teach when caring for patients with spinal cord injuries who have bowel and bladder dysfunction.

Nurse Assessments 

When caring for patients with spinal cord injuries, nurses should obtain a detailed bowel and bladder history including diet, fluid intake, medications, and elimination patterns/habits [11]. Many of these patients may already manage their own bowel and bladder care at home.  

If so, the nurse should obtain the patient’s current regimen and communicate the information to the physician. The physician may choose to continue the regimen or adjust as needed based on the patient’s current illness/condition.  

Questions the nurse can ask the patient: 

• What does your typical diet consist of? 
• How much fluid do you drink on a daily basis? 
• How often do you have a bowel movement or urinate? 
• Do you schedule your bowel movements with assistance from medications? 
• Are there certain body positions or things you do to help you pass stool more easily?
• How often do you use an intermittent urinary catheter for bladder relief? 
• How much time do you spend on your bowel and bladder regimens? 
• Do you care for all of your elimination needs or does someone help you? 
• How does your bowel and bladder dysfunction affect your quality of life? 

Some assessments may be observed. For example, nurses may notice that the patient has a surgically placed permanent suprapubic urinary catheter or colostomy (when the bowel is cut somewhere above the level of the rectum and diverted to the outside of the abdomen). 

Nurse Interventions 

Since many patients with spinal cord injuries have problems with bowel and bladder function, elimination must be scheduled. Nurses can help by implementing bowel and bladder programs and providing education and support to patients, families, or caregivers.  

Regimens 

Follow the patient’s home bowel and bladder regimen (as ordered). This may include maintaining intermittent catheterization every few hours or administering suppositories daily.  

For patients who do not have a regimen already or wish to modify their current one, encourage them to pay attention to how often they urinate and pass stools, elimination problems, foods that alleviate or worsen the problem, and medications or other things that help. This can be done through a diary. 

Dietary Considerations 

Educate patients on the importance of a fiber-rich diet to avoid constipation. Patients should also be made aware that high-fat foods, spicy foods, and caffeine can alter gut dynamics and lead to bowel incontinence episodes [12]. 

Fluid Intake 

Some patients may avoid drinking enough water to avoid bladder complications (e.g., frequent incontinent episodes) [12]. However, nurses should educate patients on the importance of adequate fluid intake to prevent constipation. Patients should be made aware that bladder and bowel elimination regimens go hand in hand. 

Bladder Elimination 

For bladder dysfunction, help patients perform intermittent urinary catheterization as needed or place a temporary urinary catheter (as ordered). 

Bowel Elimination 

For bowel dysfunction, administer ordered suppositories and laxatives to help the bowels move (use suppositories in conjunction with the level of sensation the patient has near the anus/rectum) [9]. Changes in body position may help as well.  

While many of these interventions may not work in some patients with spinal cord injuries, bowel irrigation (water enemas) may be helpful [11]. Surgical placement of a colostomy may be indicated if all other measures have failed [11]. 

Emotional Support 

Ensure privacy and sensitivity during all elimination care as patients may experience embarrassment or frustration. 

Education for Families or Caregivers 

Provide education to families or caregivers on the importance of helping patients stay consistent with their elimination regimen, follow diet and fluid intake recommendations, and comply with medication orders.  

Referrals 

Inform the physician if interventions are not effective or if the patient, family, or caregiver has a special need (e.g., counselor or dietician). Refer patients and families or caregivers to support groups as needed.

Support Groups and Resources 

Christopher and Dana Reeve Foundation 

Christopher Reeve – an actor who was left paralyzed after an equestrian accident – and his wife Dana’s legacy lives on through their foundation, an organization that advocates for people living with paralysis [13].  

Miami Project to Cure Paralysis 

In response to his son, who acquired a spinal cord injury during college football, NFL Hall of Famer Nick Buoniconti and world-renowned neurosurgeon Barth A. Green, M.D. started a research program aimed at finding a cure for paralysis and discovering new treatments for many other neurological injuries and disorders [14]. 

National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) 

The National Institute on Disability, Independent Living, and Rehabilitation Research, a part of the U.S. Department of Health and Human Services’ Administration for Community Living, helps people with disabilities integrate into society, employment, and independent living [15].  

Paralyzed Veterans of America (PVA)  

A group of World War II veterans who returned home with spinal cord injuries, started this organization to support those with spinal cord injuries and dysfunction. Today, the organization focuses on quality health care, research and education, benefits, and civil rights to affected veterans [16].  

United Spinal Association 

The United Spinal Association supports people with spinal cord injuries and those in wheelchairs. The organization advocates for disability rights like access to healthcare, mobility equipment, public transportation, and community support. Support groups can be found on their website [17).  

Conclusion

Spinal cord injuries can have devastating effects on patients and their families. Management of basic bodily functions like bowel and bladder elimination should be made as easy as possible for these patients.

When nurses learn how to effectively help patients with spinal cord injuries better manage their own bowel and bladder regimens, quality of life and health outcomes may be improved for this group.

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