Bladder and bowel problems in spina bifida
1. A person with spina bifida is usually born with an undamaged urinary system. Over time, paralysis leads to neurogenic bladder. It is caused by damage to the nerves in the sacral area:
- The bladder
- The urinary sphincter
- The muscular flap attached to the ureter.
2. Can be either flaccid or spastic:
- Flaccid - limp and cannot contract completely to force urine out. When the flaccid bladder becomes full, excess urine spills over and flows out of the body through the urethra. Urine dribbles out continually and when excess pressure is put on the bladder (laughing or crying), this dribbling becomes more severe. However, the bladder never empties completely and some (residual) urine always remains.
- Spastic - Does not store urine at all. The muscles that line this type of bladder are extremely sensitive and irritable. They contract and expel urine immediately after it enters the bladder.
3. Damage to the sphincter muscle can be either too tight or too loose. When the sphincter muscle is tight, urine becomes trapped in the bladder and is often forced back up the ureters to the kidney. If the sphincter muscle is too loose, however, urine continually leaks out of the body.
4. This backward flow of urine can be very damaging to the urinary system and especially the kidneys. Normally, a muscular flap on the ureters closes and once the urine flows out of the kidneys, it cannot flow back. However, the muscles that control this flap are often damaged and instead of following the path from the kidneys to the bladder and outside of the body, the urine flows back up the ureters to the kidney.
5. Urine infection - A person with spina bifida who has paralysis in the lower extremities should monitor the appearance of their urine carefully since they may not be able to feel the first warning signs — pain while urinating, for example — of a urinary tract infection.
Lack of sensation
For lower lesions, it is not so straightforward. Children who are able to walk fairly well seem only to lack some movement in the feet, but loss of sensation will usually be in some areas of the feet, right up the leg, and also the buttocks.
1. Possible problems
a. Burns
- Sunburn on legs and feet (especially if shoes and socks are usually worn).
- Wheelchair left in hot sun. The child transferring back into a hot wheelchair may burn buttocks, legs and feet.
- Hot drinks/chips held on lap.
- Hot car/bus seat.
b. Scrapes (Child crawling on rough ground (especially pool surrounds) may scrape knees, ankles and toes)
c. Pressure - Pressure areas are red areas of skin caused by prolonged pressure on one area. Any red area that disappears within 30 minutes is no problem, but one which persists from day to day needs attention. Pressure areas can develop into very nasty sores if they are not treated early and effectively. They can in some cases take months or years to heal.
Gait
General gait features include overall limb hypotonicity, flexed posturing of the lower limbs, decreased velocity in an attempt to conserve energy and significant foot deformities.
The following is the stem we were given for our end of year OSCE last year -
You are a doctor in a GP clinic. Arif Asri, a 36-year-old sales manager, has come to your clinic because he is very concerned about his health and wants to know what he can do to improve it. He has recently been diagnosed as having diabetes mellitus. Apart from this, he has gained a lot of weight in the past two years, and also smokes about 20 cigarettes a day. On examination his BP is 130/90 mm Hg and his BMI is 30.
Tasks:
You are required to:
a) Take a brief history of his lifestyle based on the ESSENCE model (4 mins.)
b) Suggest a plan for changing any one aspect of his lifestyle (diet, exercise, or smoking), using a behaviour change strategy e.g. Prochaska Diclemente cycle of behaviour change, and a model for target setting (4 mins).
Approaching this Station -
'Hi, my name is ______, how are you? I understand that you've come in today because you're concerned about your health?'
E – Education – 'what do you know about how your habits affect your health?'
S – Stress Management – 'do you ever feel stressed about work/relationships? How do you deal with this?'
S – Spirituality – 'do you get a sense of meaning from somewhere in particular? Do you attend church?'
E – Exercise – 'what sort of exercise do you do? How much would you do in a week?'
N – Nutrition – 'what would you eat for each meal in an average day?'
C – Connectedness – 'do you feel close to your friends or family? How much time do you spend with them/how often do you see them?'
E - Environment – 'who are you living with? Are you happy living with them? Do you think they would support your new lifestyle changes?'
BASK model for behavior change
Behaviors
Attitudes
Skills
Knowledge
SAME model for goal setting
Specific
Attainable
Measurable
Enjoyable
Prochaska DiClemente Cycle for change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse (relapse is not failure)
8. For this I would probably talk to patient through Prochaska (I find it easy to explain) – although stick with whichever you are most comfortable/familiar with.
Eg - “Are you familiar with the Prochaska DiClemente cycle? It's a system that is used for helping people initiate behaviour change. Most importantly, we need to identify the stage as which you are at. The first stage is Precontemplation, but by coming in to see me I recognise that you have already begun thinking about the changes we need to make. The next stage is contemplation, and this is where you begin to weigh up the benefits of embracing a healthier lifestyle, and it's great to see that you've done that. The next phase is Preparation, and this is what I'd like to work with you to do today... Proper preparation is very important etc... You've mentioned that you'd like to cut down on smoking -
- reduce number of cigarettes
- have you ever heard of nicotine patches?
- reward yourself when you resist a cigarette
- remove yourself from/reduce the number of situations where you want to smoke – high stress, 'smoko' at work etc
When you leave today I'd like you to begin to put this into Action... After this it is important to Maintain these changes... if you do move into Relapse, where the lifestyle changes we discuss are not upheld, remember that this is not a 'failure' as such... You can try again etc...
