Chapter 14: Bowel and Bladder Management

Chapter 14 presents information on bladder and bowel function and management practices after spinal cord injury.

INTRODUCTION

Most people with spinal cord injuries (SCIs) lose volitional control of their bladders and bowels; because the bladder and lower bowel are innervated by sacral cord segments, all complete lesions and many incomplete lesions result in urinary and fecal incontinence. Due to the profound impact that incontinence can have on a person's health and lifestyle, bladder and bowel management are critical concerns following spinal cord injury.

COMPLICATIONS RELATED TO BLADDER AND BOWEL DYSFUNCTION

Bladder and bowel dysfunction following spinal cord injury can cause life-threatening complications if not managed appropriately. Kidney damage can occur when excessive pressure in the bladder (high intravesical pressure) causes urine to reflux into the ureters (vesicoureteral reflux).^1,2 Hydronephrosis and eventual renal failure can result. Kidney function is also threatened by urinary tract infection (UTI), a common sequela of bladder dysfunction after spinal cord injury.^1,3-5 Factors that contribute to UTIs include high intravesical pressures, large volumes of urine left in the bladder after emptying (high residual volumes), vesicoureteral reflux, prolonged intervals between emptying, and contamination from catheters.^1,6 Spinal cord injury is also associated with a high incidence of kidney and bladder stones and an elevated risk of bladder cancer.^1,7,8

Altered bowel function can also lead to serious complications. For example, decreased bowel motility and impaired evacuation can lead to colonic stasis, constipation, fecal impaction, and megacolon.^9-12 Additional common complications include ileus, abdominal pain, appetite loss, diarrhea, hemorrhoids, and diverticulosis.^3,10-12

Impaired bladder and bowel function can pose a more immediate threat to people with cervical or high thoracic lesions. Bladder distention or fecal impaction can trigger autonomic dysreflexia, a heightened autonomic response that can progress rapidly to death.^a

Incontinence can also cause skin breakdown. Feces or urine that remains in contact with the skin for prolonged periods can damage the skin. Once breakdown occurs, the person may have to restrict their activities while the skin heals; the healed area will remain vulnerable to subsequent pressure injuries. The person may face prolonged hospitalization, sepsis, amputations, and even death.^b

In addition to the impact on physical health, bladder and bowel dysfunction can have profound psychosocial consequences. For example, involuntary voiding and bowel movements (bowel and bladder accidents) can cause embarrassment and social isolation. They also can hinder return to home after rehabilitation and interfere with participation in social activities, employment, sexual relationships, and other life situations.^13-16 Incontinence may be associated with lower quality of life and life satisfaction,¹⁷ as well as a higher prevalence of depression.¹⁸