Everybody has to go. For those of us with neurological conditions like spinal cord injury, multiple sclerosis, or even complications from a stroke, you can often feel tethered to the toilet. In fact, bladder and bowel control consistently rank among the most important functions to regain among people living with spinal cord injury, according to a study led by Dr. Kim Anderson-Erisman of the Miami Project that surveyed nearly 700 cohorts.
Understanding bladder and bowel options starts with knowing how the systems work. The urinary system consists of an upper tract and a lower tract. The upper tract includes the kidneys and ureters — the ducts that drain urine from the kidneys. The lower tract consists of the bladder, sphincter and urethra. Think of the bladder as the body’s holding tank for urine, while the sphincter is the door and the urethra is the pathway. In a normal functioning system, when the bladder is full, a sensory signal sent to the brain says, “Hey, you need to go.” Once you are in an appropriate position to release, a signal is sent from the brain through the spinal cord telling the sphincter to relax and open the door, allowing urine to pass through the urethra. But for those of us with neurological conditions, the process doesn’t work like that.
For spinal cord injury, neurogenic bladder dysfunction is dependent on the level of injury. Those with lower level injuries can have a flaccid bladder, meaning the bladder does not contract when it is full. High level injuries tend to have a hyperactive bladder (the bladder is overactive with contractions, while the sphincter is underactive). Complications from not managing a neurogenic bladder can lead to frequent urinary tract infections or damage, renal injury or failure, autonomic dysreflexia or simply a stinky mess. These complications are nothing to brush off. They can lead to serious health complications and even death.
Coming up with a way to manage your unique bladder management method means focusing on preserving the system, minimizing complications and matching your lifestyle. Conventional methods of emptying the bladder are intermittent catheterization, credé (pushing manually on bladder), valsalva maneuver (straining), indwelling catheters and external or condom catheters. Oral or patch medications such as alpha blockers or anticholinergics — like Ditropan, Detrol or Vesicare — can help. (For more on the benefits and risks associated with anticholinergics, see “Anticholinergic Medications and Dementia: Clarification, Perspective, Options,” August 2016.) Reflex voiding can be an option, or even surgical procedures like bladder augmentation or continent urinary diversion.
For the bowel system, food is digested through the intestines and makes its way to the colon. Nerve signals are sent to the brain, alerting when evacuation is necessary, and the process begins voluntarily involving the rectum. For those with neurological injuries, it is not so easy. For T12 injuries or above, reflexic bowel dysfunction is common. However, since anal reflexes stay intact, defecation can be triggered by stimulating the rectum (using a finger or device) to open the anal sphincter so stool comes out. For those with T12 injuries or below, an areflexic bowel is common. In this case, the rectum loses its reflexes and stool can leak out.
Similar to the bladder system, the bowel system has no singular approach that is adequate; a combination solution is usually needed. Finding the right evacuation method — such as manual removal or digital stimulation — and keeping on a schedule are first steps for a bowel care program. Also finding the right medication and/or device can help make the program less burdensome and reduce the overall program time.
Medications can be in the form of oral medications, like stool softeners (Colace or Docusate), bulking agents (Metamucil or Benefiber) or hyperosmolar agents (Milk of Magnesia or Miralax). There are also suppository medications like colonic stimulants or bisacodyl (Magic Bullet or Dulcolax) or mini-enemas (Enemeez). There are full enema or flushing systems to help get the job done, too — like Peristeen transanal evacuation system or the PIE pulsed irrigation system — that use water to help clean out the pipes.
Keep in mind one of your best means to keep bladder and bowel systems healthy is a good routine and proper nutrition. Authors Kylie James and Joanne Smith offer some great advice in their book, Eat Well, Live Well with Spinal Cord Injury. For example, good bowel nutrition requires not only plenty of fluids, but also gearing your diet toward high fiber foods like whole grains, oatmeal, beans, legumes, nuts and fiber-friendly fruits and vegetables (apples, berries, apricots, spinach, broccoli or sweet potatoes.) These options have been around for a long time.
In 2013, the FDA approved the use of onabotulinumtoxinA, otherwise known as Botox, for the treatment of overactive bladder. Injections are made directly into the bladder to relax the bladder muscle. A study published in 2015 showed that those with thoracic or lumbar injuries responded better than those with cervical level injures. The typical effective time between needed injections was eight months, and some people were able to discontinue their oral bladder medication completely.
Implanted electrical stimulation that directly activates the bladder is another option that is currently on the market for people living with spinal cord injury. The system is surgically implanted with an external control unit for the user to select options for voiding the bladder, evacuating the bowels, or for males, getting an erection. The down side of this device is not only the surgical risk, but also that it requires a dorsal rhizotomy, or cutting the sensory nerves of the sacral spinal cord. In Europe, the device is sold by Finetech Medical as the Brindley device. In the United States, it is no longer available. Other neuromodulation devices are available on the market in the United States and can be considered under the advisement of a trained urologist.
Sacral nerve stimulation requires an implanted device that sends electrical pulses to the sacral nerve and is offered by Medtronics (InterStim) or Axonics (SNM systems). Both devices have an option to test the system on a trial basis before getting the full system implanted, giving you the ability to see if the device will work for your particular situation.
Tibial nerve stimulation (a method of modulating bladder reflex pathways) is a conditional treatment that typically delivers around 30 minutes of stimulation to the tibial nerve in the lower leg. Systems like Cogentix Urgent PC or Medtronic NURO system use percutaneous electrodes to control the bladder. Home-use implanted tibial nerve stimulation systems are currently in development by Nuviant Medical, StimGuard and BlueWind Medical.
There are also pelvic floor stimulators (external devices that provide stimulation to the pelvic floor muscle to improve the voluntary opening and closing of the urethra). With these devices there has been expanded use specifically for neurogenic bladder dysfunction, and there are active clinical trials exploring more qualification data as well. When choosing any option that is currently on the market or in trials, Dr. Graham Creasey, surgeon at the Palo Alto VA Medical Center and Stanford University, advises, “Leave your options open, think long term and be aware that things can change.”
On the Research Front
With all these options, there is still much activity on the research front to find better solutions, particularly in the medical device realm. The Craig H. Neilsen Foundation has put efforts toward further research, and the National Institutes of Health specifically identified bladder and bowel control as a key area for development in their five-year research plan. So, what is actually happening on this front? A list of human clinical trials can be found through clinicaltrials.gov, but here are a few highlights:
A company called Spinal Singularity is developing the Connected Catheter. Led by Derek Herrera, who lives with paraplegia, the company is working on a device that is an extended use, internally inserted, smart catheter. It has a pressure sensor to notify the user when the bladder is full and needs to be drained. The device has a valve to open and close the urethra upon command by the user. It is designed to minimize unexpected leakage and the need for an external leg bag. It is currently under development with clinical trials in the United States projected later in 2017.
Other ongoing trials are looking at the impact of gait training on bladder function, and also epidural stimulation or even electromagnetic stimulation. Then there are mechanical interventions. Magnetic valves, such as the FENIX system, are being developed to go around the urethra or colon to maintain urinary or fecal continence. Women may benefit from devices such as the Eclipse system, which involves a vaginally-inserted pressure balloon that pushes up against the rectum to maintain fecal continence. These systems may be more appropriate for individuals who do not have intact pelvic reflexes on which electrical stimulation devices act.
Another encouraging and related area of development in technology is dorsal genital nerve stimulation, which stimulates the dorsal penile nerve in males or the dorsal clitoral nerve in females. There have been some small studies conducted in Europe. One study conducted by a team at the Institut Guttmann Neurorehabilitation Hospital in Spain found that 10 out of the 12 participants used DGN stimulation to decrease undesirable bladder contractions and in turn increase bladder capacity. Another small study at Radboud University Nijmegen Medical Centre in the Netherlands demonstrated in seven of the eight participants with SCI that DGN stimulation suppressed involuntary contractions.
At Case Western Reserve University in Cleveland, Ohio, researchers are developing a device in clinical trials using external surface electrical stimulation to block the reflexes of voiding contractions. Drs. Dennis Bourbeau, Kenneth Gustafson and Steven Brose recently completed a short-term chronic test of genital nerve stimulation in study participants with SCI. This particular study enrolled 24 participants with neurogenic overactivity, spinal cord injury and pelvic sensation. The results showed that 23 of 24 individuals tolerated the stimulation at levels needed to block reflexive bladder contractions or increase capacity of the bladder. Plus, the stimulation did not cause autonomic dysreflexia or intolerable spasticity.
In another study conducted by the same research team, participants (also with neurogenic overactivity and SCI) used the external GNS device in their home settings with the option of continuous stimulation throughout the day or on demand stimulation. After one month of use, they reported a significant reduction in leakage events throughout the day. Although reporting to be satisfied, participants also reported a primary concern was the bulkiness of the system. With these results, researchers are now looking to develop an implanted device to stimulate the same nerves and hope to not only reduce urinary and bowel incontinence but improve sexual function.
The ultimate goal of research is to improve quality of life for people with SCI or other neurological disorders. “If our approaches are successful, we hope to improve confidence, independence, and dignity for these individuals as well as significantly reduce costs and burdens related to care,” says Bourbeau.
Finding the right options for managing bladder or bowels is not just a health issue but a lifestyle one, too. Sometimes the right solution for you may be a combination of treatments. It is really important to find a doctor who is willing to work with you to help you find that right fit — so you can break that tether to your toilet.
• Bladder and Bowel Articles (archived columns and features from New Mobility): search “bladder” or “bowel” along with other keywords on newmobility.com
• Bladder and Bowel Foundation: www.bladderandbowelfoundation.org
• BOTOX: www.botoxforincontinence.com/botox-can-help/patient-stories.aspx
• Eat Well, Live Well with SCI: www.eatwelllivewellwithsci.com
• National Foundation for Continence: www.nafc.org
• Neurotech Network Bladder Management Fact Sheet: www.neurotechnetwork.org/factsheets/factsheet_urinary.html
• Options for Bladder Management: www.msktc.org/lib/docs/Factsheets/SCI_Bladder_Health.pdf
• Research and Reports from the NIH: Neurogenic bladder in spinal cord injury patients: www.ncbi.nlm.nih.gov/pmc/articles/PMC4467746/
• United Spinal Association (archived webinar and resources):
– Bowel Management: www.spinalcord.org/video-solutions-bowel-management/
– Bladder Management: www.spinalcord.org/video-solutions-bladder-management/
• Urinary anatomy: www.niddk.nih.gov/health-information/health-topics/urologic-disease/nerve-disease-and-bladder-control/Pages/facts.aspx
• Uro Today: www.urotoday.com
• Axonics SNM: www.axonicsmodulation.com
• Congentix, Urgent PC: www.cogentixmedical.com/
• Fenix: Torax Medical: www.toraxmedical.com
• Finetech Medical: http://finetech-medical.co.uk
• Medtronic Interstim: www.medtronic.com/patients/overactive-bladder/index.htm
• Medtronic, NURO system: www.medtronic.com
• Peristeen: www.coloplast.co.uk/peristeen-anal-irrigation-system-en-gb.aspx
• PIE Medical: piemed.com
• Spinal Singularity: www.spinalsingularity.com