Female Spinal Cord Injury Patients Research Articles

Knowledge Gaps in Urologic Care of Female Spinal Cord Injury Patients.

We highlight the substantial gaps in knowledge on urologic care of female spinal cord injury (SCI) patients. Males account for approximately 80% of people living with SCI in developed nations. Although there is a robust body of literature in some aspects of urologic care of individuals with SCI, such as treatments for neurogenic detrusor overactivity, there are relatively few studies focusing specifically on females. There are also few studies focusing on other aspects of urologic care of women with SCI such as sexual dysfunction, pelvic organ prolapse, and bladder cancer. Established guidelines for bladder management exist, generally recommending intermittent catheterization, but the fact remains that a substantial number of women with SCI utilize indwelling catheters for bladder management. There remains a paucity of literature using patient-reported measures regarding both outcomes and experiences of urologic management in the SCI population. Bladder management is challenging for many women with SCI. There are few studies on other urologic concerns in women with SCI.

Fertility and sexuality in the spinal cord injury patient.

After a spinal cord injury, patients have different perceptions of sexuality, sexual function, and potential for fertility. These changes can greatly impact quality of life over a lifetime. The purpose of this workgroup was to identify common evidence based or expert opinion themes and recommendations regarding treatment of sexuality, sexual function and fertility in the spinal cord injury population. As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury (SCI), a workgroup and comprehensive literature search of English language manuscripts regarding fertility and sexuality in the spinal cord injury patient were formed. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs). Genital arousal, ejaculation, and orgasm are significantly impacted after spinal cord injury in both male and female SCI patients. This may have a more significant impact on potential for fertility in male spinal cord injury patients, particularly regarding ability of generate erection, semen quantity and quality. Female patients should be consulted that pregnancy is still possible after injury and a woman should expect resumption of normal reproductive function. As a result, sexual health teaching should be continued in women despite injury. Pregnancy in a SCI may cause complications such as autonomic dysreflexia, so this group should be carefully followed during pregnancy. By understanding physiologic changes after injury, patients and care teams can work together to achieve goals and maximize sexual quality of life after the injury.

Sexual Function in Female Patients with Spinal Cord Injury

Objective: To determine the perception of sexuality, sexual function disorders and the effects of quality of life of sexual problems in female patients with spinal cord injury (SCI) in a Turkish population. Material and Methods: This study group was between the ages of 18-58 years; female SCI patients, sexually active before the spinal cord injury, were included. The control group consisted of healthy women. Neurological levels T10 and above, T11-L2, conus, and cauda were classified in three sub-groups. SCI and healthy women were evaluated with the TAF Rehabilitation Center Sexual Rehabilitation Evaluation Form in Women with SCI, Female Sexual Function Index, and Satisfaction With Life Scale. Results: Fifty SCI and 50 healthy women were included into the study; 46 patients before the injury and 40 patients after the injury had sexual intercourse experience, respectively. The decrease in sexual arousal and sexual intercourse was statistically significant (p=0.000) in the after-injury group than before the injury. Sexual interest and importance given to sexuality were significantly lower before the injury than in the control group (p<0.05). After SCI, based on the need to share intimacy, sexual activity ratio was 84%. In patients with a sense of the genitals, level of arousal was greater than those without (p=0.002). Lack of orgasm and sexual desire after the injury was the major problem experienced in sexual intercourse and was significantly increased after the SCI (p<0.05). Conslusion: In this study, we found that female SCI patients have a significant deterioration in sexual function, and it also impairs quality of life.

Temporal expression profile of CXC chemokines in serum of patients with spinal cord injury

Chemokines, a subclass of cytokine superfamily have both pro-inflammatory and migratory role and serve as chemoattractant of immune cells during the inflammatory responses ensuing spinal cord injury (SCI). The chemokines, especially CXCL-1, CXCL-9, CXCL-10 and CXCL-12 contribute significant part in the inflammatory secondary damage of SCI. Inhibiting chemokine’s activity and thereby the secondary damage cascades has been suggested as a chemokine-targeted therapeutic approach to SCI. To optimize the inhibition of secondary injury through targeted chemokine therapy, accurate knowledge about the temporal profile of these cytokines following SCI is required. Hence, the present study was planned to determine the serum levels of CXCL-1, CXCL-9, CXCL-10 and CXCL-12 at 3–6h, 7 and 28days and 3m after SCI in male and female SCI patients (n=78) and compare with age- and sex-matched patients with non-spinal cord injuries (NSCI, n=70) and healthy volunteers (n=100). ANOVA with Tukey post hoc analysis was used to determine the differences between the groups. The data from the present study show that the serum level of CXCL-1, CXCL-9 and CXCL-10 peaked on day 7 post-SCI and then declined to the control level. In contrast, significantly elevated level of CXCL-12 persisted for 28days post SCI. In addition, post-SCI expression of CXCL-12 was found to be sex-dependent. Male SCI patients expressed significantly higher CXCL-12 when compared to control and SCI female. We did not observe any change in chemokines level of NSCI. Further, the age of the patients did not influence chemokines expression after SCI. These observations along with SCI-induced CSF-chemokine level should contribute to the identification of selective and temporal chemokine targeted therapy after SCI.

Barriers to Implementing Intermittent Catheterisation in Spinal Cord Injury Patients in Northwest Regional Spinal Injuries Centre, Southport, U.K.

Intermittent catheterisation is the preferred method of managing the neurogenic bladder in patients with spinal cord injury. However, spinal cord physicians experienced problems when trying to implement an intermittent catheterisation regime in some spinal cord injury patients in the northwest of England. We present illustrative cases to describe practical difficulties encountered by patients while trying to adopt an intermittent catheterisation regime. Barriers to intermittent catheterisation are (1) caregivers or nurses are not available to carry out five or six catheterisations a day; (2) lack of time to perform intermittent catheterisations; (3) unavailability of suitable toilet facilities in public places, including restaurants and offices; (4) redundant prepuce in a male patient, which prevents ready access to urethral meatus; (5) urethral false passage; (6) urethral sphincter spasm requiring the use of flexible-tip catheters and α-drenoceptor–blocking drugs; (7) reluctance to perform intermittent catheterisation in patients >60 years by some health professionals; and (8) difficulty in accessing the urethral meatus for catheterisation while the patient is sitting up, especially in female patients. These cases demonstrate the urgent need for provision of trained caregivers who can perform intermittent catheterisation, and improvement in public facilities that are suitable for performing catheterisation in spinal cord injury patients. Further, vigilance should be exercised during each catheterisation in order to prevent complications, such as urethral trauma and consequent false passages. Health professionals should make additional efforts to implement intermittent catheterisation in female spinal cord injury patients and in those >60 years.

Limited value of bladder sensation as a trigger for conditional neurostimulation in spinal cord injury patients

Conditional stimulation of dorsal genital nerves suppresses undesired detrusor contractions (UDC) and consequently increases bladder capacity and prevents incontinence. No clinically applicable sensor exists for reliable bladder activity monitoring as a trigger for conditional stimulation. Primary objective of this study was to determine whether bladder sensation concomitant with UDC may be used for spinal cord injury (SCI) patients to trigger neurostimulation in daily life. Nineteen male and 7 female SCI patients suspected of detrusor overactivity (DO) underwent conventional and 6-hr ambulatory urodynamics. Patients were instructed to do normal daily activities and to activate event buttons of the ambulatory recorder to mark events: physical activity, bladder sensation, micturition or intermittent catheterization, and urinary incontinence. Detection rate was defined as the number of recorded bladder sensation divided by the total number of recorded UDC during ambulatory urodynamics. Bladder sensation was reported by 73% of patients in daily life. Only 41% of patients had analyzable bladder sensation concomitant with UDC during ambulatory urodynamics. For ambulatory and conventional urodynamics, mean detection rates were 23% and 72%, respectively, with mean recording delays of 57 and 16 sec after UDC onset, respectively. Bladder sensation only occurs in a small group of SCI patients combined with a rather low detection rate and long reaction time. Therefore, bladder sensation as a trigger for conditional stimulation does not seem to be suitable for SCI patients with DO. Reliable techniques for chronic bladder activity monitoring are a prerequisite for successful clinical application of conditional stimulation.

Serum amino acids as indicators of cerebrospinal neuronal activity in patients with micturition disorders

Our previous study showed that the spinal glycine level in rats was changed by spinal injury or bladder outlet obstruction, and this change was reflected by serum glycine levels. Therefore, we measured the serum glutamate and glycine levels in healthy volunteers and patients with cerebrospinal damage or benign prostatic hyperplasia (BPH) to confirm whether the change of serum amino acid levels was obtained from these patients as well as the animal experiment. We measured the serum glutamate and glycine levels in 170 healthy controls, 57 patients with cerebrovascular disease (CVD), 68 patients with spinal cord injury (SCI), and 70 patients with BPH. Amino acid levels were compared between the controls and patients, according to gender, level of spinal injury and the type of bladder activity. In the healthy controls, glutamate levels were higher and glycine levels were lower in men than in women. On group comparison of each gender, there were no differences of glutamate levels. However, glycine levels were lower in male and female SCI patients and BPH patients than in controls. According to the level of spinal injury or the pattern of bladder activity and amino acid levels, there were no relationships among them. Serum glutamate and glycine levels were not related to the spinal injury level or bladder activity. However, serum glycine levels changed in patients with SCI or BPH patients, so it may be possible to use it as an indicator of spinal glycinergic neuronal activity.

Comparison of Bladder Management Complication Outcomes in Female Spinal Cord Injury Patients

A total of 70 female spinal cord injury patients was retrospectively analyzed for outcomes of long-term bladder management. Three groups were defined: 1) 23 patients on intermittent catheterization, 2) 25 treated by reflex voiding and incontinence padding, and 3) 22 with an indwelling catheter. Mean years of using the specific bladder management technique were 8.5 plus/minus 4.7, 15.8 plus/minus 7.3 and 16.7 plus/minus 9.0 for the 3 groups, respectively. All patients were evaluated for long-term complications. There were 4 major complications (17 percent) in the intermittent catheterization group, 10 (40 percent) in the padding group and 58 (greater than 200 percent) in the indwelling catheter group. The aggregate difference in complication rates among the 3 group was highly significant (p less than 0.00001). Of comparable long-term patients (11 to 23 years) there were no major complications among 6 on intermittent catheterization, 8 among 14 who use padding and 21 among 9 with an indwelling catheter. The differences among the groups remained significant (p less than 0.00001). Additional analyses showed highly significant differences between the catheter group and the other 2 groups (intermittent catheterization p = 0.0009 and padding p = 0.0005), and a difference that approached significance between the intermittent catheterization and padding groups (p = 0.085). The results strongly support intermittent catheterization as the optimal management of female patients following spinal cord injury given that other factors, in particular independent hand function or the need for appropriate assistance, are considered.

Comparison of Bladder Management Complication Outcomes in Female Spinal Cord Injury Patients

Comparison of Bladder Management Complication Outcomes in Female Spinal Cord Injury Patients

Differences in urinary tract infections in male and female spinal cord injury patients on intermittent catheterization.

Intermittent catheterization has gained wide acceptance for use in hospitalized patients following spinal cord injury. Most studies evaluating this procedure, however, look only at the infection rate in the male SCI population. In this study the rate and type of infection encountered in the male and female SCI population were evaluated in an inpatient hospital environment. Fifty four patients who were undergoing intermittent catheterization with the MMG/O'Neil catheter system were evaluated. All patients were similar with regard to level of injury and bladder management. There were 45 males and nine females in our study group (n = 45). A total of 10,945 catheterizations were performed with 75 infections indentified. The overall infection rate was 0.68% or one infection for every 146 catheterizations. Of the 45 males there were 58 infections of which 11 (18%) were E. coli. This contrasts with the female population (9) in which there were 17 infections with nine (53%) being E. coli. While a variety of infecting organisms were present in males, females were colonized with either E. coli, enterococcus or Klebsiella. While hospital based intermittent catheterization would appear to be associated with an acceptable low incidence of urinary tract infections (0.68%), infected females have a higher incidence of E. coli (53%) compared to the male population (18%). This study also demonstrated that female patients had a significantly higher infection rate than males (nine females with 17 infections compared to 45 males with 58 infections over the same time period). The higher incidence of urinary tract infections in females with E. coli perhaps is related to the proximity of bowel/stool contamination.

Creatinine Clearance Prediction in Spinal Cord Injury Patients: Comparison of 6 Prediction Equations

The renal function of spinal cord injury patients frequently is overestimated by 3 commonly used equations to predict creatinine clearance. Overestimation of creatinine clearance may result in aminoglycoside overdosage and resultant nephrotoxicity. Three newer prediction equations have been developed from creatinine clearances measured in neurologically abnormal patients. These 6 equations were tested in 77 male and 9 female spinal cord injury patients (48 quadriplegics and 38 paraplegics, including 38 with acute and 48 with chronic injuries). The equation developed by Sawyer and Hutchins was superior to 2 other equations developed in spinal cord injury patients and 3 equations developed in neurologically normal patients. However, creatinine clearances predicted by this equation were within 30ml. per minute of measured creatinine clearances in only two-thirds of the spinal cord injury patients. Errors ranged from overestimation by 95ml. per minute (151 per cent) to underestimation by 106ml. per minute (45 per cent). The potential for large errors in creatinine clearance prediction necessitates measurement of creatinine clearance as soon as possible when renal excreted and toxic pharmaceuticals are administered to spinal cord injury patients.

Management of neurogenic bladder in female spinal cord injury patients.

Twenty-two female spinal cord injury patients were admitted to the Spinal Cord Injury Service at the West Roxbury VAMC during a period of 17 years (1965-1982). Bladder status and means of drainage were evaluated. Twelve patients (55%) required no means of drainage, nine of them were dry all the time, while the other three needed pamper support to counteract occasional wetness. Seven were on constant indwelling catheters, two were on self-catheterization, while one had an intestinal loop diversion. It appears that female spinal cord injury patients depend more on constant indwelling catheters than their male counterparts. In some instances, female paraplegics do well on self-catheterization. Catheter complications in female spinal cord injury patients appear to be less than in males.

The urological status of 86 females following spinal cord injury.

A review of the urological problems in 86 female spinal cord injury patients is presented. There were no urological or renal deaths. Three urinary diversions were performed. Fifty-five patients are catheter-free and 28 are managed with permanent catheter drainage. The problems of "bladder training" are presented.

Observations on menstruation and pregnancy among female spinal cord injury patients.

Twenty-five female patients with spinal cord injury were interrogated about their menstrual periods. The following observations were noted: the majority of females had a return of their menses within the first six months after injury; 50 per cent, have not missed a single period; in this series, one patient had a return of menstruation after 16 months and another after 30 months; level and extent of the lesion did not appear to play a role; presence or absence of sacral reflex arcs did not play a role; females who are in or near the climacteric period of life will probably lose their menses; dysmenorrhea ceased to be a painful experience after injury. Four patients were pregnant at time of injury, and five patients were pregnant after injury. The following observations were noted: none of the patients pregnant at time of injury aborted their pregnancies; all babies were delivered vaginally except one by caesarean section; there were far less renal complications associated with pregnancy among those patients who had children prior to injury; the obstetrician must be aware of autonomic dysreflexia and its management in order to differentiate it from a pre-eclampsia.