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Spinal cord injury

Can cause lifelong urinary tract and sexual dysfunction, and at risk of urological infections, stones, renal failure and autonomic dysreflexia.

Spinal cord level is different to bony vertebral level:

Sacral spinal cord begins next to T12 / L1 – fractures of L1 and below tend to affect the sacral cord.

Conus medullaris and termination of the cord is around L1.

 

AIS classification

A – complete impairment, no motor or sensory function below level
B – incomplete, sensory function below level but no motor function
C – incomplete, more than half of key muscles below level not strong enough to move against gravity
D – incomplete, more than half of key muscles below level can move against gravity
E – unhindered motor function below level of injury

 

Spinal shock

Decreased excitability of spinal cord segments at or below the level of the lesion – absent somatic reflexes and flaccid muscle paralysis.

Urologically:

  • Acontractile areflexic bladder
  • Urinary retention with generally competent and closed bladder neck
  • Absent somatic reflexes (no bulbocavernosus reflex) – usually

Typically lasts 6 – 12 weeks but is variable.

Initially managed with catheter drainage, begin ISC when/if able.

Recovery will be noted with involuntary voiding between ISC, contractions and bypassing, return of sensation or reflexes.

During initial injury patients may have high flow (non-ischaemic) priapism due to abrupt loss of sympathetic tone – settles without intervention.

 

Early management of SCI:

  • Initial trauma management, stabilisation of everything else.
  • Management of bladder as above – IDC, transition to ISC or SPC
  • ?When to do first urodynamics – after spinal shock wears off and before discharge
  • Look out for autonomic dysreflexia if T6 or higher

Expected pattern of ongoing bladder function dependent on level of injury:

Suprasacral injury:

  • Detrusor overactivity
  • Dyssynergic striated sphincter (DSD)
    • Functional obstruction with high voiding pressures
  • Spasticity and hyperreflexia below level of lesion

Sacral injury:

  • Atonic bladder / detrusor areflexia
  • Competent non relaxing sphincter (may become fixed and open)
  • Flaccid paralysis with lack of reflexes below level of lesion

 

Management principles for spinal cord injury

The aim is to achieve low pressure storage and complete bladder emptying while promoting continence

Urodynamics at diagnosis and periodically if any changes in symptoms or clinical parameters.

Long term management is multidisciplinary, preferably in a specialist unit.

Goals:

  • Protect the upper tracts
  • Maximise continence and quality of life
  • Prevent or proactively treat complications – infections, stones etc
  • Optimise sexual function and fertility if important

 

Aim for a low pressure reservoir with normal compliance – treat overactivity with:

  • Anticholinergics
  • Botox
  • Augmentation

Aim for complete bladder emptying to prevent complications of retained urine:

  • Credé manoeuvre
  • ISC
  • IDC/SPC
  • Catheterisable channels

Identify and control DSD to reduce pressures and protect upper tracts:

  • ISC
  • IDC/SPC
  • Sphincterotomy

 

Long term urological complications of spinal cord injury:

  • Infections
    • Urinary stasis, foreign bodies/catheters, deconditioning, hospitalisation, stones all contribute to urine infections
    • Atypical signs and symptoms – look for fever, change in urinary symptoms or function including bypassing, malodourous cloudy urine, malaise/lethargy, autonomic dysreflexia, loin pain
    • Bacteriuria essentially the rule – treat only when symptomatic or around time of instrumentation
    • If new recurrent UTIs – needs re-assessment of LUT with urodynamics etc
  • Stones
    • Mainly struvite or calcium phosphate
    • Highest risk in first year
    • Multi-factorial – immobilisation, urinary stasis, hypercalciuria, catheters and foreign bodies, recurrent infections
  • Autonomic dysreflexia
    • Be aware of during urodynamics, catheter changes, any instrumentation, fertility procedures
  • Renal failure
    • Related to bladder pressures, recurrent infections, obstructions from stones, VUR
  • VUR
    • 17 – 25 %
    • Primary treatment is managing the lower tract and bladder pressures and ISC
  • Cancer risk
    • 25 x RR compared to non SCI population in some studies
    • Usually presents late/invasive
    • Mainly increase in SCC risk due to chronic inflammation, catheters
    • New onset haematuria must be fully investigated

 

Management of sexual function in SCI:

  • PDE5 inhibitors / ICI (be aware of potential AD)
  • Penile prosthesis – higher risk of infections
  • Often anejaculation – use penile vibratory stimulation or rectal probe electroejaculation
    • Watch for AD
    • Emission mediated by sympathetic T10 – L2, ejection/ejaculation mediated by pudendal nerve S2 – S4
    • Extract sperm from epididymis or testis if above methods unsuccessful

Non urological complications of SCI:

  • Bowels – constipation
  • Pressure injuries
  • Psychological complications
  • Mobility
  • Contractures (be aware of concomitant botox)

Surveillance and follow up:

  • Multidisciplinary with specialist spinal cord injuries unit preferred
  • At minimum if all stable:
    • Annual assessment with history and examination
    • Annual ultrasound of upper tracts and x-ray looking for stones
    • Renal function testing (Cr Cl may be more useful cf. serum creatinine due to muscle loss)
    • More often if very high risk
  • Patients must be educated to report changes in symptoms (haematuria, new UTIs, changes in continence, bypassing) which prompt re-assessment
  • Haematuria must be fully investigated – risk of cancers, stones
  • Any change in urinary tract function or symptoms
    • Reassessment with imaging, urodynamics