1. 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

2. 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

3. General Population of SCI in UK
UK population totals – 58,789, (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

4. Mortality following SCI
3179 pts (2 centres Stoke and Southport)
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

5. 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

6. 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
Once stabilised in the field they are then transferred to Birmingham with rehab primarily Headley Court or referred to a SCIC.
Can go to any spinal unit across country – recent meetings with other nurses from different spinal units show there is some spread across them regarding how many they are seeing.

7. Headley Court
Recent refurbishment funded by
Help for Heroes Charity

8. Demographics of Fatalities Iraq and Afghanistan
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
Data from the UK Ministry of Defence Website (accessed 18/08/11)

9. Demographics of Injuries Iraq and Afghanistan
01/01/03 – 31/07/2009
Afghanistan
07/10/01 – 31/07/11
Casualites total
222
527
Very serious 73
259
Serious
149
269
Wounded in Action
315
1746
Non-battle
Injury/disease
3283
3367
Aeromedical
Evacuation
1971
4888
Data from the UK Ministry of Defence Website (accessed 18/08/11)

10. Published Papers UK 25 pts (448) = 5% Iraq and Afghanistan
USA 40 pts (513) = 9.8% Iraq only
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)

11. Armed forces discharges from service
Army
Navy
RAF
Medically discharged
4539
1474
1049
Musculoskeletal cause
2777
(63%)
875
(62%)
429
(49%)
Mental
Behavioural
590
(13%)
176
(12%)
231
(26%)
Data from the UK Ministry of Defence Website (accessed 18/08/11)

12. Pensions 141,715 war disablement pensioners (ongoing pension)
100% disablement rate = £ per week

13. Referrals to RNOHT between 1994 – Oct 2010 Total = 20
Navy = 1
Army = 9
Paratrooper = 2
RAF = 5
Marine = 1
Ex- SAS = 2
Rank
Officer = 6
Non-officer = 14
2009/2010 referrals = 8
Referrals from Headley Court = 14
Referrals direct to SCIC for rehab = 6

14. Place of Main Rehabilitation
40%
25%
20%
20%

15. Where injured? Iraq 4 Afghanistan 6 (one at sea) UK - peacetime 7
Abroad - peacetime 3

16. 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
Disectomy x1

17. Cause of injury – Iraq and Afghanistan
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

18. Other morbidities Iraq and Afghanistan
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

19. 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

20. Bladder Management

21. Upper Motor Neurone SCI
(T12 and above)
Loss of inhibitory impulses cause
neurogenic
detrusor overactivity
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
CC X
PMC X √ 
SMC √ √ √

22. Neurogenic detrusor overactivity
Detrusor Pressure
Diverticulum
Urine Flow
Intraurethral Pressure
Trabeculation
Sphincter EMG
Sphincter Dyssynergia
Fir tree
External Sphincter
dysnergia

23. What happens if we don’t treat it?
INFECTION
Neurogenic Detrusor Overactivity
REFLUX
Renal Failure
Detrusor Sphincter Dyssynergia

24. Lower Motor Neurone SCI
(L1 and below)
Under-active detrusor
acontractile detrusor
Under-active sphincter and urethra
sphincter incompetence
No sensation of bladder fullness
Flaccid bladder, no spontaneous voiding or voluntary control
CC X
PMC X
SMC X X X X

25. Diagnosis of Bladder Dysfunction
Cervical- 4
Thoracic- 7
Lumbar- 9
NDO 3 4
NDO + DSD 2 1
Acontractile
Acontractile + USI 5
Unknown
(not RNOHT)

26. Type of Bladder Management
Cervical patients all on anticholinergics
Thoracic patients 4 pts on anticholinergics, 1 pt acontractile, 1 pt old SARSI
Lumbar patients 1 pt on anticholinergics

27. Grips
Penis Holder

28. Bowel Management

30. Neurogenic Bowel Upper motor neurone T12 and above Reflex bowel
Tight anal sphincter
Lower motor neurone L1 and below
Flaccid bowel
Weak anal sphincter

31. Bowel Management Reflex – T12 and above Flaccid – L1 and below
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
Balanced high fibre diet
2000ml fluid per day
Abdominal massage/ straining
Gastro colic reflex
Manual evacuations
Positioning.
Regular exercise
Aperients

32. Bowel Management according to level of injury
Cervical
Thoracic
Lumbar
DS + ME 2 3
Anal Irrigation (Peristeen) 1
Spontaneous
evacuation
Colostomy
Unknown
Medication = Movicol, Docusate Sodium and Senna
Ano-physiology tests done in 3 patients

33. So what is the Stanmore hand shake?
It is a necessary procedure called a Digital Stimulation and then Manual Evacuation

34. Trans anal irrigation 25% of patients

35. Bladder and Bowel management has to fit into their life
– not lead it

36. Sexual Function and Disability
EAU (2010) Sexual Dysfunction: Erectile Dysfunction and Premature Ejaculation
Update on guidelines in sexual dysfunction assessment, treatment and management

37. Male SCI Upper motor neurone Reflex erections in 95%
Ejaculation possible in 5% complete and 32% incomplete
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

38. Cervical Level Injury Erectile and Fertility Function
Total pts = 4

39. Thoracic Level Injury Erectile and Fertility Function
Total pts = 7

40. Lumbar Injury Erectile and Fertility Function
Total pts = 9

41. 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

42. Fertility post SCI Semen quality reduces at approx 2 weeks post injury
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)

43. Marriage and relationships
Delvio and Richards 1996
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, pre-existing personality/behavioural difficulties
Pearcy et al 2007
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

44. 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

45. 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

46. 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

47. Neuropathic Pain
60%

48. Psychology
40%
20%

49. Change in patient’s status
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

50. Outcomes
Coping strategies (social reliance) has a direct impact on functional and rehabilitation outcomes
Kennedy et al (2011)
Functional outcome better and length of stay shorter if rehab is in a specialist SCIC
New et al (2011)