The bladder and intestines

Another aspect is the bladder. In normal circumstances, the bladder has two functions, namely storage and drainage of urine, which are controlled by both conscious as well as unconscious processes. When the bladder is getting fuller, the bladder muscle is unconsciously relaxed and both of the sphincters are contracted. Once the bladder content reaches a volume of around 500 ml, a signal is sent along the spinal cord towards the brain telling you that you have to make use of the bathroom. The internal sphincter already starts to relax, but due to the conscious muscle contraction of the external sphincter, you still retain the ability to hold the urine. Until you arrive at the toilet and decide to relax the external sphincter and contract the bladder muscle. That way the urine is released. This process is classified as the conscious contraction of the external sphincter. When you ignore the signal indicating the urge to use a bathroom, your bladder will become even fuller. Upon overloading of the bladder, you will no longer be able to hold your urine and the bladder will empty itself through unconscious relaxation of the muscles in the bladder wall. This unconscious control is called a reflex.

Paraplegia causes the entire or part of the sphincter and sometimes the bladder muscle to dysfunction. When the sphincter muscles disfunction, you are unable to hold urine and are subject to incontinence. On the other hand, when the bladder muscle dysfunctions or the sphincters experience spasms, small volumes of urine are always left behind in the bladder which gives rise to urinary infections. Usually, paraplegics experience a combination of these two complications. Bladder management is an important part of most rehabilitation programs, as it can give rise to many inconveniences.

The bladder is not the only affected organ, also the intestines are affected, mostly by reduced muscle activity. The gut still processes food, but at a slower speed than would ideally be the case, meaning that paraplegics often experience problems with their bowel movements. Good bowel management is essential and means that you keep your intestines under control as much as possible, thus reducing the incidence of incontinence. Bowel management means that the intestines are regularly emptied, at preset times. Usually, this comes down to either daily for some patients, or alternative at least twice a week for other patients. This is very personal and it is important that it fits with the daily schedule of patients. For people who can no longer empty their bowel in an ordinary manner, alternative methods exist such as anal stimulation or using of rectal laxatives. In some cases, more invasive approaches are needed, such as intestinal flushing or even the placement of a stoma.

The skin, spasticity, and sexuality

Looking at the skin, you already know that sensory inputs are no longer perceived and that this increases the chances to get your skin damaged. Due to the injury, your skin loses its most important function: all of the information regarding the state of your skin below the height of your injury is not transmitted to your brain. Sensory inputs such as light touches or tougher pressures are no longer noticeable. As a result, patients may not notice that their clothes are fitted too tightly or that they have been sitting in the same posture for too long. Consequently, tissues are experiencing the same pressure for extended periods of time and will not be able to receive a sufficient supply of oxygen. This is how pressure ulcers arise, that with time can turn into ugly wounds prone to infections. Those arise especially in areas where the bones are close to the skin’s surface as those are the places that are most heavily subjected to continuous pressure. For people who are wheelchair-bound, this means that the buttocks are particularly at risk of developing such pressure sores, and therefore should be checked upon regularly.

In addition, you do not feel when your skin is injured, for example by scratching something, skin burns, or freezing. Because the pain is not perceived, you are no longer receiving the warning signals that would normally call for action. You either do not pull back your hands or legs at all or only when it is already too late. Resulting in even more damage to the skin, which generally takes a long time to heal.

It was mentioned before that paraplegics can experience severe spasticity. Reflexes normally run along the spinal cord along a so-called reflex arc. Reflexes allow the body to quickly respond to stimuli, thereby protecting the body from external factors. Besides, reflexes allow you to maintain your posture, such as standing upright or sitting straight, by constantly evaluating and adjusting your current position. In paraplegia, the connections between reflex arches below the location of the injury and the brain are disrupted. When the reflex arc itself is not injured, the reflex ability will still remain intact. However, the reflex can no longer be suppressed by the brain if it is not needed. As a result, increased reflexes (or hyperreflexia) arises. Due to hyperreflexia, muscles can start to contract uncontrollably in response to a certain stimulus, which we call spasticity. Spasticity may be useful in some cases, but it can also significantly hinder daily life activities and/or give rise to severe pains.

Finally, an important complication of paraplegia is the effect it has on sexuality, though this is often viewed as a taboo to speak about. Sexuality comprises everything in the cycle of desire, arousal, orgasm, and relaxation. Paraplegia has an effect both on a physical as well as on an emotional level, though the exact effects are often difficult to predict and vary from person to person. One important thing to realize is that, besides affecting the biological processes, suffering an injury like this may seriously alter your mental state which in itself can put pressure on sexual experiences. Usually, consults regarding sexuality are taken very seriously during the rehabilitation process.

You have come to the end of this reading regarding the most important health aspects that should be considered in people with paraplegia. Besides these health aspects, there are also more specific medical complications that often make an appearance. These will not be covered in this course, but feel free to do some research on the web to find out more!

Source: DON