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Spinal Cord Injury: Progress, Promise, and Priorities
is to prevent incontinence. Treatment of detrusor-sphincter dyssynergia is aimed at ensuring adequate drainage, low-pressure storage, and low-pressure voiding. Both of these bladder conditions can be treated with anticholinergic or other types of medications that suppress contraction of the detrusor muscles. However, in many cases these medications do not suppress contractions. Bladder augmentation (augmentation cystoplasty) is often recommended for patients who have destrusor hyperreflexia or reduced compliance that fails to respond to anticholinergics (Sidi et al., 1990). New treatments have been introduced for these conditions, including pharmacological therapies to reduce the hyperactivity of the detrusor muscle (such as botulinum toxin or capsaicin) and functional electrical stimulation (see below). For example, a Food and Drug Administration (FDA)-approved device, known as the Vocare bladder system, uses surgically implanted electrodes to stimulate the sacral nerves controlling bladder function. The patient manually controls the stimulator using an external transmitting device. The benefits of these therapies have yet to be fully investigated (Burns et al., 2001). In another strategy, male patients may undergo sphincterotomy or stent placement to use the hyperreflexia to empty the bladder. The Consortium for Spinal Cord Medicine will soon be describing the strength of the evidence in a clinical practice guideline under development.
Neurogenic Bowel Treatment
Neurogenic bowel, the absence of voluntary control over stool elimination, affects the vast majority of individuals with spinal cord injuries. Some studies have found that as many as 95 percent of individuals with spinal cord injuries require at least one therapeutic procedure so that they can defecate (Glickman and Kamm, 1996). The majority of individuals with spinal cord injuries rate bowel dysfunction as a major life-limiting problem (Kirk et al., 1997). Before they leave the hospital, most patients are taught how to care for neurogenic bowel. Care is designed to regularize bowel movements and prevent constipation, incontinence, other gastrointestinal symptoms, and serious complications from impacted bowels (see the section on autonomic dysreflexia below). It consists of a program with several components that are individualized to patients with one of two types of neurogenic bowel: reflexic bowel and areflexic bowel. Both types require dietary fiber and fluid intake, oral medications, and rectal suppositories. Treatments help to stimulate the transport of stool through the bowels and hold moisture within the stool. Key differences in treating reflexive bowel versus areflexic bowel include the type of rectal stimulant, the consistency of the stool, and the frequency of bowel care. Clinical practice guidelines for the management of neurogenic bowel were developed in 1998 (Spinal Cord Medicine Consortium, 1998).