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clinical practice
James W middleton
Grace leong
linda mann
MBBS, PhD, FAFRM(RACP), is Director, Statewide Spinal Cord Injury Service, and Associate Rehabilitation Specialist, Statewide Spinal Professor, Rehabilitation Studies Unit, Faculty of Medicine, The University of Sydney, New South Specialist, Spinal Cord Injuries Unit, Royal management of spinal cord injury
in general practice – part 1
the general practitioner plays a vital role in the primary care
Background
of people with spinal cord injury. in a previous article we
Spinal cord injury (SCI) is a complex disability, often requiring illustrated how practice structures can accommodate people
specialised knowledge and expertise to manage multisystem with disabilities, allowing health surveillance/promotion and
impairments. This topic is often not included in undergraduate disease prevention activities through a comprehensive,
medical education and the general practitioner may understandably systematic approach.1
feel underprepared for managing a patient with SCI. Objective
Bladder function
This two part article provides an overview of common complications Spinal cord injury (SCI) disrupts bladder control, affecting reciprocal coordination between detrusor and bladder neck, proximal urethra and Discussion
pelvic floor muscles. Bladder management methods include: Common management issues in SCI include neurogenic bladder and • clean intermittent self catheterisation (CISC) with an anticholinergic bowel dysfunction, autonomic dysreflexia, sexuality, fertility, pressure areas, pain, spasticity, musculoskeletal disorders, neurological medication such as oxybutynin hydrochloride (preferred method complications, general health and psychological wellbeing. Armed with key information, management of the patient with SCI can be • drainage by permanent indwelling urethral or suprapubic catheter, or systematically addressed in the general practice setting.
• reflex voiding with an external collecting device.2Urological complications are common after SCI, including urinary tract infection (UTI), nephrolithiasis, epididymo-orchitis, urethral stricture/false passage, and rarely, bladder cancer in those with a permanent catheter for more than 15–20 years.3 Conditions affecting the general population should not be forgotten (eg. benign prostatic hypertrophy). Sustained high bladder fil ing pressures from poorly controlled detrusor hyperactivity and/or reduced bladder compliance may cause upper tract deterioration, hydronephrosis and renal failure. Renal function should therefore be routinely monitored. Urea, electrolytes, creatinine, estimated glomerular filtration rate (eGFR) are recommended annual y, with renal tract imaging (ie. ultrasound or intravenous pyelogram) performed every 2 years. Symptoms listed in Table 1 should alert the GP of underlying pathology requiring expedient action.
Urinary tract infection is very common but symptoms may be altered or absent in a person with SCI. Colonisation and asymptomatic bacteriuria occurs frequently in populations with permanent catheters in situ, particularly with low pathogenic organisms such as Pseudomonas aeruginosa or mixed growth. Treatment (when symptomatic) should be based on microurine examination, culture and reprinted from australian Family physician Vol. 37, No. 4, April 2008 229
clinical practice management of spinal cord injury in general practice – part 1
sensitivity in a fresh urine specimen taken at new catheter change. Table 1. Urological symptoms that should alert the GP to action Inappropriate, frequent or prolonged antibiotic therapy can predispose to development of antibiotic resistant strains over time. Criteria to assist clinical decision making are shown in Table 2. Recurrent UTIs • Increased or new episodes of incontinence call for review of patient hygiene and catheterisation techniques • Obstructive symptoms – hesitancy, poor stream, frequency and consideration of further investigation to exclude bladder calculi, diverticulum or catheter cystitis. Antiseptic medications (eg. Hiprex or • Lower abdominal discomfort or bladder spasms cranberry juice/tablets) are not effective.4 • Passing ‘grit' or 'stones’ in urine• Difficulty passing an intermittent self catheter Gastrointestinal system and bowel management
Bowel dysfunction is common fol owing SCI, secondary to impaired • Increased spasticity or episodes of autonomic dysreflexia triggered by bladder fullness or pathology colonic transit time, altered compliance, immobility and medication • Blood in urine, weight loss (especially if the patient is a side effects (eg. anticholinergics, antidepressants, narcotic smoker or has had an indwelling catheter for more than analgesics).5 Problems such as constipation, faecal incontinence or bowel accidents, abdominal distension and pain can significantly impact on social and emotional wel being, participation and quality • Worsening renal blood tests if results known of life.6 Diseases such as reflux oesophagitis and gallstones causing • Lost to follow up with no recent (within 5 years) urological repeated complaints of abdominal bloating or nausea are also more prevalent in SCI population, but may be misdiagnosed due to altered sensation. The prevalence of chronic gastrointestinal symptoms Table 2. Guidelines for antibiotic treatment of UTIs4 • Antibiotics are indicated if:
– microscopy showing WCC >100 associated with a pure growth of organisms, OR
– leucocyte esterase of +++ to ++++ on urine dip stick, AND
– at least one ‘category 1’ OR at least 2 ‘category 2’ symptoms, as defined below:
category 1 symptoms
• Elevated temperature (>38º core or 37.5º per axilla)
• New or worsening symptoms of autonomic dysreflexia
category 2 symptoms
• Increased frequency or strength of muscle spasms
• Onset of urinary incontinence (eg. leaking around catheter or in between self catheterisation) despite taking usual anticholinergic
medications to control detrusor overactivity • New abdominal discomfort, unexplained by other pathology Table 3. Key principles in management of neurogenic bowel • Determine type of bowel impairment by doing a rectal examination. Patients often have loss of voluntary control over defecation and external anal sphincter (EAS). There are generally 2 types of bowel impairment: – upper motor neuron (UMN) or reflexic bowel (usually with lesions above T12). There is intact defecation and anocutaneous reflexes and hypertonic EAS with anorectal dyssynergia – lower motor neuron (LMN) or areflexic bowel. Patient often has loss of sacral reflexes including defecation and anocutaneous reflex • Develop individualised regular bowel routine (daily or every second day for UMN, or twice per day or daily for LMN). Bowel care should be done at the same time every day with: – bowel emptying timed 20–30 minutes after a meal (to utilise gastrocolic reflex)– rectal emptying achieved using an enema, suppositories, anal digital stimulation and/or manual evacuation (latter being particularly – positioning over toilet can assist with stool emptying eprinted from
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increases with time after injury, suggesting that these problems are with rectal bleeding, autonomic dysreflexia, diarrhoea (spurious), and bowel accidents. A systematic approach begins with consideration Bowel regimens should be individualised, taking into consideration of the patient’s premorbid GI function, concurrent conditions, current the level and extent of neurological impairment, functional status, skin bowel regimen, medication use and defaecation procedure (time taken integrity, diet and nutritional factors, the individual’s problem solving for evacuation, frequency, amount and stool consistency, eg. using skills, social situation and lifestyle goals. Principles for establishing Bristol Stool Chart). Fundamentals of treatment are adequate hydration, or adjusting a bowel program appear in Table 3. Bowel function and a high fibre diet, regular bowel care, minimisation of constipating program should be reviewed regularly as part of an annual cycle of care medications and appropriate aperients when required (Table 4). using a structured questionnaire.1 Modifications to management are Haemorrhoids with per rectal (PR) bleeding are also common,8 often worsened by manual procedures, enemas and constipation. Constipation is common and can present with a range of symptoms Minor symptomatic cases can often be managed with topical such as abdominal distension, pain, early satiety, nausea, respiratory therapy or banding. In some, haemorrhoids can act as a trigger for compromise from diaphragmatic ‘splinting’, worsening haemorrhoids autonomic dysreflexia and can cause recurrent major bleeding, Table 4. Advice for management of common bowel problems possible causes
recommended action/s
and minimal on alternate days, bowel pattern may be changing and may be If using physical interventions, review technique. If not, consider Patient may require disimpaction if hard mass is found on PRReview bowel regimen and change lifestyle factors Abdominal X-ray may help to confirm If abdominal X-ray reveals proximal GI Soft, poorly formed stool Excessive laxative use and/or Unbalanced diet (insufficient insoluble Clostridium difficile toxin if recently fibres) or residue later in the dayChange in dietGastrointestinal illness reprinted from australian F
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clinical practice management of spinal cord injury in general practice – part 1
which should prompt consideration of haemorrhoidectomy. The Table 6 lists common signs and symptoms of AD. Individuals may presence of haemorrhoids and rectal trauma in SCI can give a high experience combinations of symptoms peculiar to them, without false positive rate on faecal occult blood testing and this test should all of the typical symptoms of the condition. If the condition is not be relied on for screening of colorectal cancer (CRC). There is no unrecognised or not treated promptly, intracranial haemorrhage, definitive evidence to date to suggest that there is an increased risk encephalopathy and seizures or a cardiac arrhythmia may occur, of CRC in SCI and screening should fol ow that recommended for which can result in death. Remember that BP for people with high paraplegia or tetraplegia is typical y low (~90–100/60 mmHg lying down and possibly lower while sitting). Autonomic dysreflexia autonomic dysreflexia
symptoms may occur within the normal BP range for the general Autonomic dysreflexia (AD) is a potentially life threatening condition population (ie. 20–40 mmHg above resting systolic level).10 affecting persons with a SCI lesion at or above T6 level.9 In these Autonomic dysreflexia is most commonly related to bladder/ individuals, a nociceptive stimulus (Table 5) below SCI level triggers urinary tract problems such as distended or severely spastic bladder, excessive reflex activity of sympathetic nervous system (major urinary tract infection, bladder or renal stones, and epididymo- splanchnic outflow) causing severe vasoconstriction with rapidly orchitis; followed by bowel problems such as constipation, rectal rising, uncontrol ed blood pressure (BP). Secondary parasympathetic distension, enlarged haemorrhoids, and irritation by enema. Other activity (elevated BP sensed by aortic/carotid baroreceptors) produces causes may relate to skin (eg. pressure sores, burns, ingrown vagal activation with bradycardia and blood vessel dilatation above toenails) or other systems (eg. fracture, distended stomach, labour, the injury level, insufficient to lower BP. severe menstrual cramping, sexual stimulation).
case study
Bob, 42 years of age, with C5 incomplete tetraplegia from a motor vehicle accident 5 years ago, presents to his GP
complaining of an intermittent pounding headache with flushing over his face, sweating and feeling anxious. He also mentions having experienced abdominal cramps. Using the SOS Health questionnaire,1 the GP elicits the following history. Bob’s bladder is managed by suprapubic catheter on free drainage. He reports taking oxybutynin (Ditropan) 2.5 mg twice per day, which he had reduced from 5 mg three times per day due to a dry mouth. He drinks about 2 L/day and a carer changes his catheter every month. He has had three UTIs in the past 6 months (with Klebsiella grown on several previous cultures). Over the past 3 weeks Bob has noticed large amounts of urinary debris and occasional blood clots with frequent catheter blockages and some leaking of urine around his SPC site and per urethra. He has abdominal distension and a feeling of fullness and discomfort in his abdomen and is spending up to 2 hours on the toilet for bowel care, with his stool ‘dribbling out’. He has a second daily bowel regimen, taking Coloxyl two 120 mg tablets per day as well as 60 mL of pear juice twice per day. He uses Bisalax enemas to initiate evacuation, describing sweating during emptying and prolonged rectal discharge. Bob denies any changes in his medications or dietary intake. He reports that his skin is intact.
On examination, Bob’s BP is 139/86 mmHg sitting in wheelchair, HR 90 bpm and temperature 37.6°C. He has mild abdominal distension with no tenderness or rigidity on palpation. A PR reveals an empty rectum and prolapsed haemorrhoids which bleed on contact. The SPC site looks moist but there is no skin breakdown or purulent discharge. Urine in the catheter appears cloudy and urine analysis reveals positive leucocytes and nitrites.
The GP’s provisional diagnosis is AD precipitated by bladder distension caused by intermittent catheter blockages related to recurrent UTIs, as well as possible bowel impaction. The GP also considers reduced bladder compliance and/or detrusor hyper-reflexia following reduction of anticholinergic medication.
The GP discusses a management plan with Bob. He changes the suprapubic catheter and sends a fresh urine specimen for culture before starting appropriate antibiotic treatment (considering Klebsiella pneumoniae to be the most likely organism). He advises Bob to increase his fluid intake to 3 L/day, drinking consistently throughout the day. The GP gives him a prescription for Nitrolingual Spray and an Autonomic Dysreflexia Emergency Treatment Card. He also arranges for the community or practice nurse to educate Bob and his carers further on what to do in case another episode occurs. The GP suggests that Bob reduce current ‘softeners’ and increase the fibre in his diet or add a bulking agent such as Metamucil or Normafibre to firm the consistency of his stools (checking abdominal X-ray first to exclude faecal impaction with overflow). The GP recommends a bowel chart to monitor stool consistency changes making further necessary adjustments after 3–5 bowel cycles. Bisalax can cause local irritation to the rectum and may be the cause of the discharge. Microlax enemas or glycerine suppositories are a gentler alternative in combination with digital stimulation and abdominal massage techniques to assist with facilitating the defecation reflex. Results of investigations (catheter specimen of urine [CSU], blood tests, renal tract ultrasound and abdominal X-ray) reveal Klebsiella pneumoniae and a 1 cm bladder calculus. The GP refers Bob to an urologist for a cystoscopy and opinion about performing a videourodynamic study. The urologist performs a cystoscopy, removing the stone, and finds areas of reactive catheter cystitis requiring diathermy. Videourodynamics on oxybutynin 2.5 mg twice per day reveals high detrusor pressures with detrusor hyper-reflexia. The GP suggests oxybutynin be increased to 5 mg three times per day, but reminds Bob that this may cause constipation and increased aperients may be needed.
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Table 5. Common precipiants of autonomic dysreflexia Warning: do not use GTN spray/tablets if phophodiesterase (PDE5) inhibitors such as sildenafil (Viagra), vardenafil (Levitra) have • Bladder – urinary tract infection, epididymo-orchitis, been taken in the previous 24 hours or tadalafil (Cialis) within last bladder distension, renal tract calculus, urological • Bowel – constipation, rectal irritation, haemorrhoids conclusion
• Skin – pressure area, burn, ingrown toenail, tight clothing Secondary prevention and management of conditions arising from SCI require specialised knowledge. Common diseases also occur, but may • Gastrointestinal – biliary colic, appendicitis, other causes of not present typical y because of altered sensation, therefore cal ing for a high degree of suspicion. The GP is ideally placed to deliver first • Obstetric and gynaecological – onset of labour, severe line care and support for people with SCI. resources
• Clinical information booklets, listed below, are available at www.ciap.health.
nsw.gov.au by fol owing the specialties link: – Middleton J. Management of the neurogenic bladder for adults with Table 6. Common symptoms and signs of autonomic dysreflexia – Stolzenhein G. Management of the neuropathic bowel for adults with – Middleton J. Treatment of autonomic dysreflexia for adults with spinal • Jannings W, Temblett J, Cairns G, Pryor J. Solving common bowel prob- • Flushing/blotching of skin above spinal injury level lems. A resource tool for persons with spinal cord injury. Rehabilitation • Profuse sweating above spinal injury level Nursing Research & Development Unit 2002. Available from the Continence • Skin pallor and piloerection below spinal injury level • Autonomic Dysreflexia Medical Emergency Card. Telephone SSCIS • Blurred vision (dilatation of pupils) • Shortness of breath, sense of apprehension or anxiety references
1. Mann L, Middleton JW, Leong G. Fitting disability into practice: focus on spinal cord If AD is suspected, get help and do not leave the patient alone. injury. Aust Fam Physician 2007;36:1039–42.
2. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Bladder manage- Sit the person upright (to buffer rise in BP), loosen tight clothing, ment in adults with spinal cord injury: a clinical practice guideline for heathccare compression stockings and abdominal binders. Ask if they suspect providers. Paralyzed Veterans of America, 2006. a cause (usually due to bladder or bowel problems). Identify the 3. Groah SL, Weitzenkamp D, Lammertse DP, et al. Excess risk of bladder cancer in cause (eg. check bladder drainage equipment for kinks, obstruction spinal cord injury: Evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med Rehabil 2002;83:346–57.
to flow of urine into bag). Monitor BP every 2–5 minutes. Gentle 4. Lee BB, Haran MJ, Hunt LM, et al. Spinal-injured neuropathic bladder antisepsis irrigation (with ~30 mL saline) can be tried to unblock a nondraining (SINBA) trial. Spinal Cord 2007;45:542–50.
catheter.2 If unsuccessful or bladder is managed by CISC or reflex 5. Lynch AC, Antony A, Dobbs BR, Frizelle FA. Bowel dysfunction following spinal cord injury. Spinal Cord 2001;39:193–203.
voiding, catheterise the patient using a generous amount of lubricant 6. Rajendran SK, Reiser JR, Bauman W, Zhang RL, Gordon SK, Korsten MA. containing local anaesthetic gel (eg. 2% lignocaine jel y). Similarly, if Gastrointestinal transit after spinal cord injury: effect of cisapride. Am J constipation is suspected, check the rectum for faecal material and 7. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Neurogenic bowel evacuate the contents after anaesthetic gel is inserted for several management in adults with spinal cord injury. Paralyzed Veterans of America, 1998.
minutes.7 If BP is >150 mmHg, drug treatment should be commenced.
8. Stone JM, Nino-Murcia M, Wolfe VA, et al. Chronic gastrointestinal prob- Glyceryl trinitrate (GTN) can be given sublingually as a spray lems in spinal cord injury patients: a prospective analysis. Am J Gastroenterol (Nitrolingual) or half to one tablet (Anginine) or transdermally (5 mg 9. Cole TM, Kottke FJ, Olson M, et al. Alterations of cardiovascular control in high patch), repeated every 5–10 minutes up to three times. If GTN is spinal myelomalacia. Arch Phys Med Rehabil 1967;48:359–68. unavailable or contraindicated, give nifedipine (10 mg tablet crushed, 10. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Acute manage- mixed with water and swallowed).11 In severe cases with a persisting ment of autonomic dysreflexia: individuals with spinal cord injury presenting to healthcare facilities. 2nd edn. Paralyzed Veterans of America, 2001.
noxious stimulus, parenteral treatment or epidural anaesthesia may 11. Braddom RL, Rocco JF. Autonomic dysreflexia: a survey of current treatment. Am J be necessary. Close monitoring after the episode is recommended. A MedicAlert bracelet may be considered along with carrying GTN and an Autonomic Dysreflexia Medical Emergency Card to alert medical personnel of this condition. reprinted from australian F
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