Following Transverse Myelitis Janet Dean MS RN CRRN CRNP Pediatric Nurse Practitioner International Center for Spinal Cord Injury Department of Physical Medicine and Rehabilitation Johns Hopkins ID: 1007192
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1. Bowel and Bladder ManagementFollowing Transverse MyelitisJanet Dean, MS, RN, CRRN, CRNPPediatric Nurse PractitionerInternational Center for Spinal Cord InjuryDepartment of Physical Medicine and RehabilitationJohns Hopkins Hospital
2. Bowel and BladderFunctionsStore wasteRelease waste at the appropriate timesEach system hasMuscular storage areaOutlet valve or sphincterControlVoluntaryInvoluntary
3. Bladder FunctionStorage areaBladder or detrusorOutlet valveExternal urinary sphincterBladder distends Nerves send signals to cordSignals travel up to brainBrain decides what to do Sends signals down cordStore or release
4. Bowel FunctionStorage areaRectumOutlet valve External anal sphincterRectal distensionTriggers urge to defecateTriggers holding reflexNerves send signals to CordSignals travel to the brainBrain decides what to do Sends signals down the cord Hold or release
5. Neurogenic Bowel and BladderTransverse MyelitisChanges in your bladder and bowel functioningDisrupts sensation of having to urinate or have a bowel movementDisrupt the coordination between the brain and the bowel or bladderVoluntary control of sphincters is lostChanges how you go to the bathroom
6. Neurogenic Bowel and Bladder Higher level of Injury (T12 and above )Spastic or reflexic neurogenic BladderBladder is spastic and irritableUrinary sphincter is tight and does not relax voluntarilyDifficulty storing and releasing urineBowelDecreased GI motilityRectum holds stoolAnal sphincter tight and does not relax voluntarilyDifficulty releasing stoolLower Level of injury (T12 and below)Flaccid or areflexic neurogenic BladderBladder will not contract when it becomes fullUrinary sphincter is loose and fails to contractDifficulty storing urineBowelRectum holds stoolAnal sphincter fails to contractDifficulty holding stool
7. Spastic – ReflexicSpastic BladderProblemsBladder tries to distendBladder spasmsUrgency FrequencyIncontinenceBladder sphincter dyssynergiaDifficulty initiating and maintaining a stream of urineVesicoureteral refluxKidney damageSpastic BowelProblemsRectal distensionAnal sphincter tightensUnable to release stoolConstipationImpaction
8. Flaccid-AreflexicFlaccid BladderProblemsBladder very relaxedDoes not contract - overfillsSphincter outlet failsIncontinenceUrine leaks out Cough Sneeze or Activities that contract abdominal musclesFlaccid BowelProblemsRectum dilatesOutlet sphincter failsIncontinenceStool leaks outCoughSneezeActivities that contract abdominal muscles
9. How do I know Which Type I have?BladderUrology evaluationUrodynamic or Cystometric studies. VCUG – voiding cystourethrogramRenal UltrasoundBowelRectal examSensation Voluntary contractionOther GI exams are usually not necessaryWithout Formal EvaluationLevel of InjuryLower extremity muscle tone
10. How to Manage Bowel and BladderHealthy HabitsHealthy dietDrink, Drink, Drink spread fluids out over the dayFiber – help with stool constituencyActivityGood hygieneDo it yourselfAssistive devicesPositing equipmentDirect own careEstablish a good routine
11. Bowel and Bladder ProgramsGoalsPrevent incontinence and accidentsEmpty bowel and bladder at predictable timesMaintain health and prevent complicationsImpaction ConstipationDiarrhea Thick inelastic bladderFrequent urinary tract infectionsKidney damage
12. Bladder ManagementSpasticFrequent and urgent urinationMedications to relax the bladder Oxybutinin Intermittent CatheterizationEvery 4 hours (5x/day)FlaccidLeaking of urineMedications not effectiveIntermittent catheterizationEvery 3-4 hours Prior to doing activities that cause valsalva
13. Other Options for Bladder ManagementMen - Condom catheteroverflow Indwelling Foley catheterNot recommendedSuprapubic tubeReversible minor surgeryIncreased UTI and bladder bancerCatheterizable stoma placed in belly buttonPermanent, major surgeryless UTI and less bladder Cancer
14. Bowel ManagementSpasticUrgency and frequency May get to the toilet but have difficulty releasing stoolValsalva or contraction of the abdominal muscles pushing against an closed sphincterFlaccidRectal sphincter will not hold stoolFrequent leaking of small amounts of stoolActivities that cause valsalva will cause leaking of stool
15. Bowel ManagementBowel ProgramTakes planning and routineBest done every day to every other dayAdults in AM Kids in PMShould take 15 minutes to 1 hourSame time (after meal or snack is ideal)Generally a combinationMedicationsManual disimpactionDigital stimulationWork with you health professionals Guidelines and adviceCustomize what works for you
16. Bowel ManagementManage stool consistencyDietFiber (or supplement)Fluid Medications to soften stoolDocusate SodiumPEG (lower doses)Promote GI motilitySennaPEG (higher doses)
17. Bowel ManagementPositioningSit up on the toilet or bedside commodeLay on left side if you can not sit upChildrenBe sure feet are supported on a foot stool and they are comfortable
18. Bowel ManagementManual disimpactionUsing a gloved, well lubricated finger inserted into the rectum to break up and gently remove stool Remove stool that will be in the wayDigital stimulationInserting a gloved, well lubricated finger into the anal sphincter and gently rotating the finger around the anal sphincter in a circular directionTrigger reflex evacuationRectal MedicationBisacodyl suppository, Magic Bullet suppository. Enemeez mini enemaTrigger reflex evacuation
19. Bowel ProgramSpastic Routine Bowel ProgramEvery 1-3 daysSoft formed stoolTrigger reflex evacuationDigital stimulationSuppositoryFlaccidRoutine Bowel Program1-2 x/dayFirm formed stoolEasy to remove but does not leakSuppositories generally do not workManual disimpaction1-2 times per day prior to activities that cause valsalva
20. Bowel ProgramSpastic BowelManually remove stool from rectumInsert suppositoryDigital Stimulation after 5-15 minutesContinue digital stimulation every 5-10 minutes 3-4 timesFlaccid BowelManually remove stool from rectum. Can try digital stimulationValsalva or bearing down push ups, abdominal massageUse caution can cause hemorrhoids
21. How do I Know Program is Complete?SpasticNo stool in rectal vault after 2 digital stimulations 10” apartMucus and no stoolRectal sphincter becomes tightFlaccidRectal vault is empty
22. Other Options for Bowel ManagementFlaccid Bowel Cecostomy - reversible ACE procedure - permanent Allows you to do an enema from aboveSpastic Bowel Be cautions of above procedure with spastic rectal sphincter
23. Resourceshttp://www.pva.org/site/PageServer?pagename=pubs_main