| .
Contents . . . . . . . . .
|
The Unmentionable Symptoms of Arachnoiditis: Bowl, Bladder and Sexual Dysfunction; Pelvic Pain by Dr. Sarah Smith THE NEUROGENIC BOWEL: Longstanding spinal conditions can cause neurogenic bowel problems. The type of problem will depend on the location of the injury. Arachnoiditis tends to affect the nerve roots rather than the spinal cord itself , but can be considered to effectively cause a type of spinal injury; in some severe cases, this will effectively be a complete injury, although in the majority of cases, a partial injury is present. For example, a complete injury at the sacral level (the Cauda Equina)(LMN) results in an areflexic bowel in which no reflex peristalsis occurs. Nerves within the colon wall coordinate slow stool propulsion and the denervated external anal sphincter has low tone. This results in a sluggish stool movement, a dryer, rounder stool and a greater risk of faecal incontinence through the flaccid anal sphincter. A
reflexic bowel by contrast, resulting from an injury above the sacral
spinal segments (UMN), involves a sphincter which is spastic (increased
tone). Defaecation cannot be initiated by voluntary relaxation of the
sphincter. However, nerve connections between the spine and the gut are
intact and there remains reflexic coordination of stool propulsion. Gastrointestinal problems which may occur include:
* Irritable Bowel Syndrome # Inflammatory Bowel Disease (e.g. Crohn’s, Ulcerative colitis) Those with a lesser degree of nerve damage may find that they have some loss of rectal sensation, perhaps coupled with a visceral hyperpathia (heightened pain e.g. abdominal cramps with constipation) : this means that there is a delayed perception of the full rectum, and that once the threshold for perception of distension is reached, there is sudden, painful (often burning) urge to defaecate, which may result in incontinence. BOWEL CARE: In patients with neurogenic bowel, bowel care is best scheduled at the same time of day to develop a habitual, predictable response and eating or drinking about 30 minutes prior to bowel care may be needed to stimulate the gastrocolic reflex. Bowel care should be carried out at least once every 2 days in the long-term to avoid chronic colorectal distension. Reflexic
(UMN) bowel: Initially bowel care consists of placing a chemical stimulant into the rectum (suppository) and performing digital stimulation. The goal is soft-formed stool which can be readily evacuated. Areflexic
(LMN) bowel: The
bladder must first be emptied. Then an upright or side-lying position
adopted. Gentle Valsalva manoeuvres and/or manual evacuation are
performed. This may need to be done daily or sometimes twice daily.
The goal is firmly formed stool that can be retained between bowel care sessions and easily manually evacuated. Chemical stimulants include glycerin and bisacodyl. Hypertonic phosphate enemas should be used with caution, especially in patients with haemorrhoids. However, mini-enemas may be used to act as a trigger for reflex-mediated colonic peristalsis. Push-ups, abdominal massage and a forward-leaning position may aid evacuation by increasing abdominal pressure. Massaging the abdomen is best done in a clockwise motion up the ascending colon (on the right side of the abdomen), across the transverse colon and down the descending colon (left side of abdomen) leaning forward can be tried if balance is sufficient or movement not restricted. It is helpful to use high colonic motility periods such as after a meal (10-15 minutes) in which to perform bowel care. Valsalva manoeuvre (bearing down as if to empty the bowel) should not be performed with a full bladder. Attempts to increase intra-abdominal pressure and to strain do not in fact result in anal relaxation. High fibre diet may not have the same effect on SCI patients as on patients whose bowel functions normally. Individuals with SCI should not be uniformly placed on high fibre diets: the effects of current fibre intake on consistency of stool and frequency of evacuation should be assessed. It may in fact be necessary to decrease fibre in some cases. As to fluid intake, it is generally recommended that SCI patients aim to take in about 500ml/day over the standard recommended amount for healthy adult individuals. This works out at 1ml fluid/Kcal of energy needs or 40ml/kg body weights (both +500ml for SCI patient). Increased fluid helps to prevent the occurrence of hard, impacted stool and reduces the associated discomfort. However, if there are bladder problems in addition to neurogenic bowel (a fairly usual occurrence) then measures may need to be implemented to cope with the increased urine volume (see separate article on Genitourinary Problems). FAECAL
INCONTINENCE This
is an extremely distressing problem that remains pretty much a taboo
subject and thus many sufferers fail to seek help. It is, however, a problem for which there are a variety of measures that can be implemented to ameliorate the embarrassing and uncomfortable situation. Faecal incontinence means loss of control of the passage of faeces and/or wind from the rectum. There may be leakage of solid or liquid faeces or flatus (gas). The severity of the problem may range from inability to control passage of wind to total incontinence of solid stool. Although some patients are grossly incontinent, many will experience leakage, particularly if the stool is not formed (e.g. if there is diarrhoea for any reason). CAUSES OF FAECAL INCONTINENCE: § Constipation (including with ‘spurious’ i.e. overflow, diarrhoea) § Diarrhoea of any cause § Sphincter laxity (various causes) § Severe haemorrhoids § Rectal prolapse § Tumours Lower
motor neuron and/or sensory nerve lesions are
the most common problem in arachnoiditis e.g. Cauda Equina
lesions : this is known as : neuropathic incontinence Higher
spinal lesions may cause an upper motor neuron picture.(see above under
Neurogenic bowel) Causes
of Pelvic floor denervation: § Primary: pudendal nerve neuropathy, chronic straining at stool; childbirth § Secondary: injuries to spinal cord/Cauda Equina/pelvic floor nerves
As already stated, there is a spectrum of problems. Passage of flatus, with/without soiling of underwear may occur at any time of the day or soiling may happen after the bowels have already been opened, which tends to be unexpected and add to the difficulties of managing daily life. If there is a condition which causes diarrhoea (see above) then the problem may be exacerbated. Occasionally, the condition is so severe that the entire, formed stool is passed without warning. In people with spinal problems, it is possible that rectal sensation is diminished and this can combine with sphincter dysfunction, so that the incidence of incontinence comes on without warning. Alternatively, in some patients, there may be visceral hyperpathia, in which there is a delayed sensation threshold in the rectum, which means that rectal distension is not registered until it is at a greater pressure than normal people would sense; once the threshold is reached, there is a sudden and exaggerated sensation which may be very painful and the urge to defaecate comes on at the same time as the bowel begins to evacuate the stool: thereby again causing incontinence without any warning. These problems can cause a tendency to isolate oneself, rather than risk ‘accidents’ in public. ASSESSMENT: Although it is extremely embarrassing and distressing, it is vital for those who suffer from this problem to seek medical help. The doctor will need to know how long the problem has been going on, whether there were any factors in the period just before it began, and how often and in what way the problem is currently affecting the patient. He/she will also need to be aware of any other co-existing bowel problem, for example, Irritable Bowel Syndrome (IBS) which might cause altered stool consistency. If there has been blood in the stool, it is important to mention this. Examination will need to include a digital rectal examination. Tests: §
Colonoscopy:
to test for haemorrhoids, IBS,
inflammatory bowel disease, tumours etc. §
Anal
manometry: a balloon is inserted into the
anal canal and the pressure inside is measured: this allows assessment
of the function of the internal and external sphincters §
Recto-anal
reflex: when faeces enters the rectum, the
internal anal sphincter should relax; this reflex is lost in a condition
called Hirschsprung’s disease §
Rectal
sensation: a balloon is placed into the
rectum and inflated with air to detect at what pressure there is
‘onset of sensation’, then ‘a call to stool’ (desire to
evacuate) and ‘urgency of defaecation’ (need to urgently evacuate)
In some patients there may be diminished sensation (see above) and in
others there may be hypersensitivity, in which extreme urge is felt at
quite low levels of rectal distension. §
Pudendal
nerve latency: the external anal sphincter
is innervated by the pudendal nerve that arises from the S2-4 region of
the spine. An electrode is placed inside the rectum to stimulate the
nerve and another picks up a signal when the sphincter reacts to the
relayed impulse. Local damage to the nerve will lead to delayed or
interrupted transmission of the signal. Pudendal nerve function
(bilateral) can partially compensate for abnormal sphincter function §
Endoanal
ultrasound: this allows an image of the
anal canal and sphincters to be seen, and can detect visible anatomical
damage to any of the structures, that may have arisen through childbirth
or pelvic trauma. TREATMENT: As
there are various causes and types of problem, there must be an
individually based therapy. However, broad aims include: Modifying
bowel habit to fit a planned regime is
extremely helpful: measures such as diet(especially fibre content),
fluid intake, maximum maintenance of mobility, defaecation posture, drug
regimens (as discussed above) are all helpful in achieving a firm stool
at regular intervals The
aim is to avoid diarrhoea and
thus reduce leakage There
are numerous measures that can be employed: a Continence Advisor is the
best-placed professional to advise on the appropriate ones for the
individual. Examples include pads of various sizes and anal plugs. Biofeedback
using manometry or electromyography has been widely used but does not
appear to be particularly effective in individuals with neuropathic
incontinence. Electrical
stimulation: an electrical current
mimicking that sent naturally to the external anal sphincter may be
given via an electrode placed in the anal canal or skin electrodes
around the sphincter. Surgery: if clear damage to the external sphincter can be demonstrated on ultrasound, surgical repair can be successful in about 80% of patients*. Postanal repair aiming to restore the anorectal angle, tends to be less successful (about 30%) but might be of use in patients who have sustained injury due to childbirth. If there is extensive sphincter damage, a new one may be constructed surgically using a leg muscle, often combined with an electrical stimulator: this may be about 75% successful. Alternatively, a synthetic device, an inflatable cuff, may be used, but has yet to be tested on a large scale. (* Surgical repair if a damaged internal sphincter is most effective in severe cases, whereas in mild/moderate cases, there is a risk that the procedure may make matters worse.) BLADDER DYSFUNCTION Urgency:
the sudden
urge to empty the bladder; in arachnoiditis patients or those with chronic
pain syndromes which include an element of central pain, there may be
hyperaesthesia, in which the urge to urinate becomes acutely painful,
often with pain of a burning nature. Confusingly, urgency may arise when
there is somewhat (not complete) reduced sensation of the bladder
fullness. This is because there is a delay in the threshold of sensation
of fullness being reached, but once it is reached, there is an overblown
response, hence what would normally be a discomfort becomes pain,
sometimes quite severe. Frequency:
the
need to empty the bladder more often than usual, often only passing small
volumes; if due to an infection, it may be associated with pain on passing
urine. (usually if you pass urine more than 8 times in 24 hours this might
suggest a problem) Hesitancy:
this
is when the person knows they need to empty the bladder, but cannot
initiate urination, so has to wait for some minutes possibly, before urine
starts to be passed. This is more common in men, and tends to be
associated with prostate problems, but can also be due to spinal problems
and/or to medication such as antidepressants. Urinary
retention: is
when it is impossible to pass urine at all. Acute retention may occur in
prostate problems, for example, and if bladder sensation is intact, can be
exquisitely painful. It usually requires catheterisation to empty the
bladder. Retention may also
occur chronically in an underactive bladder and initially may not be
noticed by the patient if there is loss of bladder sensation.
Management of this problem, which can occur in spinal injuries,
necessitates regular self-catheterisation to empty the bladder or a
permanent in-dwelling catheter. Incomplete bladder emptying may occur if
the bladder muscle is not functioning well; residual volumes of urine
remain. This leads to increased susceptibility to infection. Dribbling:
this
is when the stream of urine does not cut off normally once the bladder is
empty, but continues to drip, or dribble. There may also be dribbling,
constant incontinence, if the bladder sphincter is damaged and unable to
hold the urine in the bladder. Dysuria:
pain
on passing urine; this may indicate an infection. It may be quite a sharp
pain which feels as if there are shards of glass being passed. Haematuria:
blood
in the urine: can seem very alarming! It may indicate an infection or
perhaps a kidney stone. Other more serious causes also need to be
excluded, so medical advice should always be sought if this occurs. Incontinence:
the
involuntary passing of urine. This may be constant dribbling, small
volumes lost on sudden movement, coughing or sneezing, urine leak with
urgency due to failure to reach the toilet in time or may be large volumes
without warning. Naturally, any of these problems can be a source of great
distress to the sufferer and may lead them to increasingly isolate themselves. (see below for more details). Nocturia:
the need to get up in the night to pass urine. Usually, the body is
programmed to concentrate urine overnight so that sleep is not
interrupted: which is why you may have noticed that early morning urine is
darker than at other times of the day (and why pregnancy tests tend to use
the first urine passed in the morning). However, it may be necessary to
pass urine at night, but if you have to get up more than twice, you might
be wise to seek medical advice. Nocturnal
enuresis: bedwetting, can be a real nuisance. TYPES
OF INCONTINENCE: 1)
Irritable/unstable
bladder: a
feeling of urgency may be accompanied by wetting. This can be due to an
over-active bladder muscle (detrusor) or else it may occur if an
overstretched bowel presses against the bladder. 2)
Reflex
incontinence: loss
of sensation of bladder fullness and interruption of the messages between
the brain and the bladder may cause it to empty by reflex activity which
occurs at a spinal level (as in babies) which is usually over-ruled by
messages from the brain. However, in spinal problems, these messages no
longer operate properly, so the bladder reverts to reflex emptying.
Without sensation to act as a warning, total bladder emptying may occur
suddenly and unexpectedly and can therefore be extremely embarrassing. 3)
Overflow/dribbling
incontinence:
if messages to the bladder muscle are disrupted, the muscle becomes weak
and unable to empty the bladder properly. This may lead to the bladder
becoming large and floppy, able to hold large amounts of urine but leaking
slightly. This is therefore known as overflow or dribbling incontinence. 4)
Stress
incontinence: if
muscles in the pelvic floor become weakened, commonly in women after
childbirth, the sling that they form, in which the bladder sits, is less
able to maintain the correct position of the bladder. The sphincters may
thus not stay closed during movements: sudden movements, coughing,
sneezing, may all trigger a small loss of urine. 5)
Combination
incontinence: although
this is not an ‘official’ urological term, I am using it to convey the
idea of more than one type of incontinence occurring: so, for example,
there may be some irritability coupled with stress incontinence. I am
including this category to make the important point that often urological
problems are not entirely straightforward. |
