Overview
Definition:
Spinal cord injury (SCI) in children involves damage to the spinal cord, leading to temporary or permanent loss of function, sensation, and autonomic activity below the level of injury
Bowel and bladder dysfunction, termed neurogenic bowel and neurogenic bladder, are common and significant sequelae requiring structured management programs for optimal quality of life and to prevent secondary complications.
Epidemiology:
In pediatric SCI, the incidence varies by region and cause, with falls, motor vehicle accidents, and sports injuries being common
Autonomic dysreflexia, though less frequent in complete spinal cord transections below T6, can occur
Neurological and functional deficits are often more severe due to the developing nature of the pediatric nervous system.
Clinical Significance:
Effective bowel and bladder management programs are crucial to prevent serious complications such as urinary tract infections (UTIs), kidney damage, constipation, fecal impaction, autonomic dysreflexia, and skin breakdown
These programs significantly impact a child's social participation, self-esteem, and overall well-being.
Clinical Presentation
Symptoms:
Inability to voluntarily control bowel or bladder function
Urinary incontinence or retention
Fecal incontinence or constipation
Recurrent UTIs
Abdominal distension
Pain with defecation
Signs of autonomic dysreflexia (hypertension, bradycardia, sweating above lesion level) in higher SCI.
Signs:
Variable anal tone
Presence of stool in rectum on digital exam
Distended bladder
Perineal sensory deficits
Weakness or paralysis below the level of injury
Reflexive bowel or bladder activity depending on the level and completeness of SCI.
Diagnostic Criteria:
Diagnosis is based on clinical history of trauma or neurological insult, presence of neurological deficits below the level of injury, and objective evidence of bladder and bowel dysfunction confirmed by urodynamic studies and bowel care assessments
Absence of voluntary control and presence of spasticity or flaccidity are key indicators.
Diagnostic Approach
History Taking:
Detailed history of the injury (mechanism, time of onset)
Neurological status (level of injury, completeness)
Previous bowel and bladder habits
Current management strategies and their effectiveness
History of UTIs, kidney stones, constipation, or fecal impaction
Family history of neurological or urological conditions
Nutritional status.
Physical Examination:
Complete neurological examination (motor, sensory, reflexes)
Examination of the perineal area for sensation and reflexes
Digital rectal examination to assess anal tone and presence of stool
Abdominal examination for distension and tenderness
Assessment for signs of autonomic dysreflexia.
Investigations:
Urodynamic studies (cystometry, pressure-flow studies) to assess bladder function and capacity
Renal ultrasound to evaluate for hydronephrosis or stones
Voiding cystourethrogram (VCUG) to assess for vesicoureteral reflux
Uroflowmetry to measure urine flow rate
Stool culture and analysis
Kidney function tests (creatinine, BUN).
Differential Diagnosis:
Congenital anomalies (spina bifida occulta, myelomeningocele)
Spinal cord tumors
Spinal cord infections (abscess, arachnoiditis)
Traumatic vertebral injuries without direct spinal cord involvement
Neuropathies affecting the autonomic nervous system.
Management Bowel
Initial Management:
Establish a consistent bowel program based on the level of injury and residual function
Aim for predictable bowel movements to prevent accidents and complications
Initial management may involve manual evacuation or suppositories.
Bowel Program Components:
Timed defecation (e.g., daily or every other day)
Dietary modifications (adequate fiber and fluid intake)
Stool softeners and laxatives (e.g., polyethylene glycol, senna)
Suppositories (bisacodyl) to stimulate defecation
Digital stimulation or manual evacuation
Enemas (less frequent).
Medical Management:
Laxatives: Polyethylene glycol (PEG) 3350 (adult doses adjusted for age/weight, e.g., 0.5-1.5 g/kg/day)
Stimulant laxatives: Senna (child dose 5 mg/kg/day)
Stool softeners: Docusate sodium (child dose 5 mg/kg/day).
Surgical Management:
Rarely indicated for bowel management in children
May include colostomy or appendiceal orifice creation in severe, intractable cases that do not respond to conservative measures, and significantly impact quality of life
Sacral nerve stimulation has limited evidence in pediatric SCI.
Supportive Care:
Adequate hydration
Regular monitoring of bowel movements and stool consistency
Skin care around the perianal area
Education for the child and family on the bowel program
Nutritional counseling for fiber intake.
Management Bladder
Initial Management:
Achieve adequate bladder emptying to prevent urinary retention, overdistension, and UTIs
The primary goal is to protect renal function and maintain continence
Bladder management strategy depends on the SCI level and urodynamic findings.
Bladder Program Components:
Clean Intermittent Catheterization (CIC) is the gold standard for emptying the bladder
Timed voiding attempts (if residual sphincter control or sensation exists)
Use of anticholinergic medications to reduce bladder spasms and improve capacity
Suprapubic catheterization or urinary diversion in select cases.
Medical Management:
Anticholinergics: Oxybutynin (usual pediatric dose 0.2-0.4 mg/kg/day divided q6-8h
max 5 mg/dose)
Tolterodine ( pediatric dose 0.8-1.2 mg/kg/day divided q12h
max 2 mg/dose)
Antibiotics for active UTIs
Prophylactic antibiotics are generally discouraged unless recurrent, complicated UTIs are present and an underlying cause is identified.
Surgical Management:
Indications include refractory detrusor sphincter dyssynergia, severe bladder dysfunction, recurrent UTIs or renal damage, and failure of conservative management
Procedures may include bladder augmentation, creation of Mitrofanoff channel for easier CIC, sphincterotomy, or urinary diversion.
Supportive Care:
Regular fluid intake
Monitor for signs and symptoms of UTIs (fever, dysuria, cloudy urine)
Prompt treatment of UTIs
Regular renal ultrasound follow-up
Education for child and family on CIC technique and hygiene
Skin assessment for pressure areas, especially with mobility issues.
Complications
Early Complications:
Urinary retention
Urinary tract infections (UTIs)
Constipation and fecal impaction
Autonomic dysreflexia
Deep vein thrombosis (DVT) and pulmonary embolism (PE) in immobility
Pressure sores.
Late Complications:
Renal damage secondary to recurrent UTIs or vesicoureteral reflux
Bladder stones
Urethral strictures
Chronic constipation
Autonomic dysreflexia episodes
Osteoporosis
Spasticity and contractures.
Prevention Strategies:
Consistent adherence to bowel and bladder programs
Adequate hydration
Prompt treatment of UTIs
Regular renal surveillance
Skin integrity checks
Mobility and range of motion exercises
Prophylaxis for DVT if indicated
Education on recognizing and managing autonomic dysreflexia triggers.
Prognosis
Factors Affecting Prognosis:
Level and completeness of the spinal cord injury
Age at injury
Promptness and effectiveness of initial management
Adherence to long-term management programs
Development of complications
Presence of co-morbidities.
Outcomes:
With comprehensive and consistent bowel and bladder programs, children with SCI can achieve good continence, prevent serious complications, and maintain a good quality of life
Long-term renal function preservation is a key outcome
Social integration and independence are significantly enhanced.
Follow Up:
Regular follow-up with a multidisciplinary team including pediatric neurologists, urologists, rehabilitation specialists, and nurses
Urodynamic reassessments, renal ultrasound, and screening for complications as per age and injury status
Ongoing education and support for the child and family are vital.
Key Points
Exam Focus:
The core of management lies in establishing individualized, consistent bowel and bladder programs
Clean Intermittent Catheterization (CIC) is the cornerstone of bladder management
Dietary modifications and regular stimulation form the basis of bowel management
Understanding autonomic dysreflexia and its management is critical.
Clinical Pearls:
Empower the child and family with knowledge and skills for self-management
Early and consistent intervention leads to better long-term outcomes
Regular multidisciplinary team input is invaluable
Always consider renal protection as a primary goal in bladder management.
Common Mistakes:
Inadequate fluid intake
Infrequent or inconsistent CIC
Ignoring early signs of UTI
Over-reliance on laxatives without dietary management
Lack of regular follow-up and reassessment
Failure to educate family adequately on management protocols.