Aging

Genitourinary and Gastrointestinal Systems

There are several normative age-related changes of the genitourinary and gastrointestinal systems that can lead to serious health problems for the elderly. With regard to the genitourinary system, there is a progressive and structural breakdown of the kidneys with age, and problems with urinary continence that results from decreased bladder capacity and compliance, and an increase in involuntary bladder contractions (Aldwin & Gilmer 2004). In males, enlargement of the prostate also contributes to incontinence (Dubeau 1997), and prostate cancer is one of the primary causes of death (McClain & Gray 2000). Although urinary tract infections (UTIs) increase with age, women are at greater risk, with the incidence in males only approaching that of women when they are 60 years or older (Foxman 2002). Unlike the genitourinary system, the gastrointestinal system retains much of its regular function, and it is unclear whether the few normal changes do affect the health of the older population. Some potential issues include slowing in large intestine motility, and diminished gut motility, with an increase in water resorption in the colon, which contributes to hard stool and increased risk of constipation, rectal fissures, hemorrhoids, and diverticular diseases (Wilson et al. 1997).

In persons with SCI, the effects of neurogenic bladder may compound the effects of aging in persons with SCI (Madersbacher & Oberwalder 1987) since bladder management techniques, such as the use of indwelling catheters, may contribute to the occurrence of common complications such as UTIs (Charlifue et al. 1999) and for a higher risk of developing bladder cancer (Groah et al. 2002). Similarly, neurogenic bowel may also compound aging after SCI given that persons with SCI often have higher rates of bowel-related complications compared to the general population (Cosman et al. 1993).

In this section, 9 longitudinal studies and 13 cross-sectional studies on the genitourinary and gastrointestinal systems after SCI are reviewed.

Author Year; Country
Score
Research Design
Total Sample Size		 Methods Outcome

Elmelund et al. 2014; Denmark
Retrospective Chart Review
Level 4
N=119

 Population: 119 people with SCI (103 M, 16 F);
Mean age of injury (y)= 21 (range 18-25);
Mean follow up YPI= 40 (range 36-44);
Level of injury: Cervical (47%), thoracic (40%), lumbar (13%)
Death during follow up: n=43
Methodology: A total of 119 individuals sustaining traumatic SCI during the years 1944–1975 from an SCI clinic in Denmark were included in the study to investigate the role of plasma creatinine (p-creatinine) in monitoring renal deterioration in patients up to 50 years after SCI.
Outcome Measures: P-creatinine measurements, renography and glomerular filtration rate (GFR) measured with Cr-EDTA clearance.
  1. When compared with median p-creatinine level in the first 5-year period after injury, the level of p-creatinine was stable throughout the first 30 years and decreased significantly after the 30th until 45th year post injury.
  2. Only patients with a functional distribution outside the 30-70% limits on renography or a relative GFR ≤51% of that expected had a significantly elevated level of p-creatinine. Significance was not found for patients with a distribution outside the 40-60% limits on renography or relative GFR ≤75%.
  3. P-creatinine decreased over time in patients with SCI with a level below the upper reference limit and was a poor detector of early renal deterioration in patients with SCI.
Gao et al. 2017; USA
Retrospective chart study
Level 4
N=43		 Population: 43 persons with SCI (28 M, 15 F); mean age of injury (y) = 20.6 (range 1-43); median follow-up (YPI) = 45 (range 40-50); Cervical (44%), thoracic (53%), lumbar (3%); AIS A (56%), AIS B (7%), AIS C (21%), AIS D (16%)
Methodology: A retrospective chart review of patients with SCI who received long-term urologic care at a urology clinic was completed. Urologic complications and bladder management were evaluated in 5-year intervals to assess and analyze the management and types of urologic complications in people with SCI.
Outcome Measures: Urologic complications and bladder management methods.
  1. All suffered from at least one UTI, averaging 48.6 episodes over 40 YPI, and 6.1 cases per 5 years per person.
  2. UTI episode peaks occurred in the 1st and 10th 5-year intervals, with an average incidence of 7.8 and 10.0 cases per 5 years per person, respectively
  3. Besides UTI, the most common complications were bladder stone (49%), hydronephrosis (47%), and vesicoureteral reflux (33%).
  4. The bladder managements used for the longest period were condom catheter in men (79%) and clean intermittent catheterization in women (33%), with an average maintenance of 23.6 and 38.0 years, respectively.
  5. Male gender, cervical injury, and condom catheter use were closely related to UTI and renal insufficiency.
Hwang et al. 2017; USA
Longitudinal
Level 2
N=131		 Population: 131 persons with SCI (84 M, 47 F) at first interview: mean age (y)= 33.4±6.1 (range 25-48); mean age at injury (y)=13.4±4.6 (range 0-18); Duration of SCI (y)=19.5±7 (range 8-41); Tetraplegia (58.8%)
Interval between first and last interviews (y)=3.2±1.3 (range 1-5)
Methodology: Participants were given a questionnaire and a follow-up annually between 2010-2015 (participants completed at least 2) to describe the long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and to determine changes in psychosocial outcomes associated with NBD-related factors in adults with sustaining a SCI before 19 years of age.
Outcome Measures: Type and evacuation time of bowel management programs; Generalized estimating equations were formulated to determine odds of change in outcomes over time.
  1. The odds of using manual evacuation, oral LAX, and colostomy increased 7.7%, 5.2%, and 7.1%, respectively, while the odds of using rectal suppositories/enemas decreased 6.7% with each passing year
  2. Over time, individuals with paraplegia were 5 times more likely to use manual evacuation and 90% and 65% less likely to continue using rectal suppositories/enemas and oral LAX, respectively, compared with those with tetraplegia.
  3. Individuals with complete injuries were 3 times more likely to use oral LAX over time compared with those with incomplete injuries.
  4. Participants using manual evacuation and DS were less likely to experience prolongation of bowel program duration over time; for those using rectal suppositories/enemas, the likelihood of increasing duration nearly doubled with each passing year.
  5. Participants using oral LAX had 3.9 times increased likelihood of having abdominal pain with each passing year.
Nielsen et al. 2017; Denmark
Longitudinal
Level 2
N=109		 Population: 109 participants with SCI (76% M. 26% F), median age (y)=55 (IQR 49-63), median TSI (y)=28 (IQR 24-34); cervical (9%), thoracic (30%), lumbar (61%); complete lesion (66%), incomplete lesion (34%)
Methodology: A questionnaire on bowel function was sent to members of the Danish SCI association in 1996, and was sent again to surviving members in 2006 and in 2015 to describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with SCI followed for two decades.
Outcome Measures: Questionnaire describing age, gender, time since lesion, constipation, obstructed defecation, fecal incontinence, QoL, and abdominal pain and discomfort.
  1. The proportion of respondents using more than 30min to defecate increased significantly from 1996 (21%) to 2015 (39%). Accordingly, more considered themselves to be constipated and more took oral laxatives
  2. No significant change in frequency of defecation, use of digital evacuation, help needed for bowel management or use of enemas. No change in constipation as a cause of some or major restrictions on daily life.
  3. No significant change in fecal incontinence
  4. 22/109 respondents had undergone surgery related to NBD (20%). Eleven (10%) had a stoma, including 5 (5%) with colostomy, 3 (3%) with appendicostomy, 1 (1%) with iliostomy and 2 (2%) with unspecified stomas.
Elmelund et al. 2016; Denmark
Retrospective		 Population: 116 people with SCI (100 M, 16 F);
Mean age at injury (y)= 22±8
Mean follow-up YPI= 39±7
Level of injury: Cervical (46.6%), thoracic (41.4%), lumbar (12.0%)
Death during follow-up: n=42
Methodology: 116 people admitted to a clinic in Denmark with traumatic SCI sustained between 1956-1969 and 1970-1975 were included in the study to investigate the extent of renal deterioration and risk indicators in patients with SCI up to 45 years after SCI. Cr-EDTA plasma clearances were collected from medical records from time of injury until 2012, and the occurrence of renal deterioration was analyzed by cumulative incidence curves. Glomerular filtration rate (GFR) results were converted to an age- and gender-adjusted relative GFR (r-GFR).
Outcome Measures: Renal deterioration using GFR results; urinary tract stones, dilatation of the upper urinary tract (UUT) and bladder-emptying methods
  1. The cumulative incidence of moderate renal deterioration increased with a constant rate after 15 YPI and was 58% after 45 YPI. Severe renal deterioration occurred primarily after 23 YPI, and the cumulative incidence was 29% after 45 YPI.
  2. UUT dilation and a history of renal/ureter stones requiring removal were significant risk indicators of renal deterioration in all analyses.
  3. Patients who had sustained a SCI in the period 1970−1975 had a significantly higher risk of moderate renal deterioration than patients who had sustained an SCI in 1956–1969, but no difference was found between the groups in terms of severe renal deterioration or the level of r-GFR.
  4. The bladder-emptying methods used for the longest period were reflex triggering (63%), bladder expression (22%), indwelling catheter (5%), normal voiding (4%), ileal conduit (3%) and clean intermittent catheterisation (2%).
Nielsen et al. 2016; Denmark
Longitudinal survey
Level 2
N=130		 Population: 130 persons with SCI (72% M, 28% F); mean age (y)=56.0±9.8 (range 35-82); mean TSI=30.5±9.8 (range 20-69); 125 participants answered the questions about abdominal pain where n=41 experienced abdominal pain and discomfort in the past week and n=84 did not.
Methodology: A questionnaire on chronic abdominal pain and discomfort was sent to participants who had been members of the Danish SCI association for 10 years twice: in 2006 and in 2015—to evaluate the prevalence of abdominal pain in long-term SCI.
Outcome Measures: abdominal pain and discomfort with an intensity scale (1-10 NRS)
  1. The percentage of responders with abdominal pain in 2015 (32.8%) was almost identical to the percentage in 2006 (34.2%), and the median pain intensity was the same (6.0)
  2. 28 individuals (24%) had abdominal pain or discomfort at both time points, and 48 (42%) did not have abdominal pain or discomfort at either time point. Nine (8%) individuals had developed pain in 2015 that was not present in 2006, and 30 (26%) individuals with abdominal pain in 2006 no longer reported abdominal pain in 2015
  3. Among those responding to both the questionnaires, the proportion who used more than 15 min to defecate and the proportion who reported that constipation had an effect on their quality of life also had not changed from 2006 to 2015 but the use of laxatives increased from 32% in 2006 to 52% in 2015
Adriaansen et al. 2017; The Netherlands
Cross-sectional
Level 5
N=282		 Population: 282 participants with SCI acquired between 18-35 years of age and ≥10 YPI, current age 28-65 years; 74% male, 26% female; 3 groups: Time since injury (TSI) 10-19 years N=107, TSI 20-29 years N=96, TSI ≥30 years N=79 Age (years), mean (SD): 48.3 (8.9); mean TSI (years): 22.0 (range 16.8-30.3) Cervical 41%, thoracic 53%, lumbar 6%; AIS A 69%, AIS B 14%, AIS C 10%, AIS D 8%
Methodology: Random samples of eligible participants were drawn from 8 Dutch rehabilitation centers. Participants completed a self-report questionnaire about their bladder management methods to study the relationship between neurogenic lower urinary tract dysfunction (NLUTD), bladder management methods, and quality of life (QoL).
Outcome Measures: The International Lower Urinary Tract Function Basic SCI Data Set and the Short-Form Qualiveen (SF-Qualiveen).
  1. The most common bladder emptying method in people with long-term SCI was clean intermittent catheterization (CIC) (42.6%), followed by condom catheter drainage (11.3%), indwelling suprapubic catheterization (11.3%), and voluntary bladder reflex triggering (11.0%)
  2. The TSI 10-19 group had more participants with a continent urinary diversion compared to the other two TSI groups. More participants in the TSI ≥30 group had a transurethral catheter compared to the other two groups. No significant associations were found between other bladder-emptying methods and TSI
  3. Participants using a transurethral catheter reported the highest impact of NLUTD. Participants with a continent urinary diversion reported the lowest impact of NLUTD on QoL.
  4. Higher age and indwelling catheter use were independently associated with a higher impact of NLUTD on QoL
Adriaansen et al. 2015; The Netherlands
Cross-sectional
Level 5
N=258		 Population: 258 participants with SCI (73% M); mean age (y)=48 (range 29-65); mean TSI (y)= 24±9 (range 10-47); tetraplegia (40%), paraplegia (60%)
Methodology: TSI was stratified among participants into 10-19, 20-29, and ≥30 years after SCI to describe long-term bowel management and neurogenic bowel dysfunction (NBD) in individuals who have been living with SCI for ≥10 years.
Outcome Measures: International SCI Bowel Function Basic Data Set, neurogenic bowel dysfunction (NBD) score, and a single item on satisfaction with bowel management.
  1. 74% used ≥1 conservative bowel management method, specifically digital evacuation (35%) and mini enemas (31%). Transanal irrigation (TAI) and surgical interventions were used by 11% and 8%, respectively. Perianal problems were reported by 45% of the participants. Conservative defecation methods were most frequently used among all 3 strata.
  2. Severe NBD was present in 36% of all participants and in 40% of those using a conservative method. However, only 14% were (very) dissatisfied with their current bowel management.
  3. Dissatisfaction with bowel management was significantly associated with constipation and severe NBD.
  4. There was no indication of decreased bowel function over time. The proportion of participants with severe NBD decreased over time from 44% to 26%, and an increase in TSI was significantly correlated with a decrease in the total NBD score.
Schöps et al. 2015; Switzerland
Level 2
Longitudinal
N=246		 Population: 246 people with SCI (191 M, 55 F); mean age (y)=51±14; AIS A (47%), AIS B (14%), AIS C (12%), AIS D (26%)
Methodology: To investigate long-term urodynamic findings in patients with SCI with neurogenic lower-urinary tract dysfunction (NLUTD), data of the latest and earliest available urodynamic investigation (mean 6±3 years in between) were compared in SCI patients that were ≥5 YPI. Participants were evaluated from 2010-2014 in the Spinal Cord Injury Center, Balgarist University Hospital, Zurich. Participants were also evaluated in two groups – those who had the earliest available urodynamic assessment, and those who had the latest available urodynamic assessment.
Outcome Measures: Urodynamic parameters, urinary tract ultrasound
  1. At the earliest and latest available urodynamic investigation, more than half of the patients relied on intermittent self-catheterisation.
  2. During the course of NLUTD, there was a significant increase of patients undergoing onabotulinumtoxinA injections into the detrusor from 12% to 33%.
  3. Urodynamic findings at the earliest and latest available urodynamic investigation were within the safe limits. There were significant differences between both groups for maximum cystometric capacity, compliance and maximum detrusor pressure during storage phase. Vesico-uretero-renal reflux was detected in ~5% and it was generally low grade.
Zhang et al. 2014; China
Longitudinal
Level 2
N=112		 Population: 91 males and 21 females with SCI; <45 y/o (n=90), ≥45 y/o (n=22), range 18-57; cervical (n=34), thoracic (n=51), lumbosacral (n=27)
Methodology: Between 2009-2011, people with SCI were recruited in Beijing to receive a urodynamic test after the end of spinal shock. All participants were followed up for an average of 24 months (range 6-36 months) to investigate the risk factors for predicting upper urinary tract  (UUT) deterioration in people with SCI. Medical records, UUT imagings, and video urodynamic data were reviewed.
Outcome Measures: Presence of adverse outcomes such as recurrent UTIs and bladder stones, total renal function (serum creatinine), renal ultrasound or MRI.
  1. Serum creatinine values were observed to be normal for each patient before and after follow-up. In total, 55 patients (49.1%) had UUT deterioration at the end (48 males and 7 females).
  2. The incidence of deterioration in the indwelling catheter group was 81.5%, which was much higher than that in catheter-free group (38.3%), indicating that an indwelling catheter was highly significantly correlated with UUT deterioration
  3. Lumbosacral spinal cord lesions likely contributed to UUT deterioration. UUT abnormalities were present in 23 patients (65.7%) in a spontaneous voiding group, 10 patients (20%) in a clean intermittent catheterization group, 15 patients (78.9%) in an indwelling urethral catheterization group and 7 patients (87.5%) in a suprapubic Foley catheterization group.

Alexandrino et al. 2011; Brazil
Cross-sectional with AB comparison group
Level 3
N SCI=24
N controls=24

 Population: 24 men with SCI (Type A complete n=22, type C incomplete n=1, type D incomplete n=1); mean(SD) age 36.25(10.24) yrs; mean(SD) YPI 9.5(5.8), range 0.6-20 yrs; 24 age matched controls; mean(SD) age 36.5(10.31) yrs.
Methodology: Seminal zinc is considered to be a marker of prostate function. This study compared of seminal zinc concentration (SZC) between the SCI group and control group. Seminal zinc was determined by atomic absorption.
Outcome Measures: seminal zinc concentration.
  1. Significant difference between groups; Mean SZC in study group is 85.20 mg l-1 and 147.16 mg l-1 in control group.

Faaborg et al. 2011; Denmark
Longitudinal
Level 2
N=22

 Population: Group A: n=12 (8M 4F); mean age range 37.7-67.2 yrs; complete SCI N=4. Group B: n=10 (7M 3F); mean age range 29.7-71.9 yrs; complete SCI N=8.
Methodology: Assessed gastrointestinal transit times (GITTs) and colonic dimension changes in Group A; at 1 year after injury and again 12.8 years later; and Group B; at 18.7 years after injury and again 12.2 years later.
Outcome Measures: GITTs, colonic diameters.
  1. Decrease in rectosigmoid transit time from 1-13 years after SCI (Group A).
  2. No other significant changes in GITT and segmental colonic transit times.
  3. No statistically significant changes in colonic dimension.

Ancha et al. 2010; USA
Cross-sectional with AB controls
Level 3
N SCI=8
N controls=6

 Population: 8 men with SCI (tetraplegia (C5 or below) n=3, paraplegia (T5 or below) n=5; < 2 spontaneous bowel movements/wk; mean(SD) age 59(13) yrs, mean(SD) YPI 13(4); 6 gender matched AB controls, mean(SD) age 57(10) yrs.
Methodology: Comparison of high amplitude propogating contractions (HAPC) and other measures of motility by fixing a manometric probe to the colonic wall at the splenic flexure. Measurements pre-sleep phase (1hr before sleep), sleep phase, and post-sleep phase.
Outcome Measures:  High amplitude propagating contractions (HAPC), Motility index (MI), and number of waves were measured.
  1. HAPC were absent in individuals with SCI during pre-sleep, sleep and post-sleep.
  2. HAPC were significantly increased after awakening in the control group.
  3. The MI was lower in the SCI group during pre- and post-sleep than in the controls.
  4. There was a sleep-induced depression of colonic motility in both the groups.

Kalpakjian et al. 2010; USA
Prospective cohort

 Population: 62 women with SCI (injury levels C6 through T12; >36 months post-injury). 66 gender matched AB controls; 45-60 years of age.
Methodology: Self-report surveys collected 4 times (9 mos apart) over 4 years. Monthly diaries indicate day of bleeding, heaviness of blood flow, absence of period.
Outcome Measures: Mid Life Symptom Checklist, monthly diaries, self-report surveys.
  1. No significant differences between women with and without SCI for menopause status.
  2. No significant group differences for vaginal dryness, sleep problems or fatigue.
  3. Women with SCI had significantly greater bother of diminished sexual arousal, somatic symptoms and bladder infections than women without SCI. For both outcomes there was no significant interaction of group by menopause status.

Savic et al. 2010; UK
Longitudinal
Level 2
N=282

 Population: 282 individuals with traumatic SCI injured prior to 1971; age at injury 15-55 yrs; mean age at enrollment 52.7 yrs; 86.7% males; 29.2% tetra ABC, 49.8% Para ABC, 21.0% Incomplete injuries.
Methodology: Full physical assessment, diagnostic procedures, detailed medical and psychosocial interview, retrospective medical records review.
Outcome Measures: Medical History and Current Status; battery of outcomes including quality of life, depression, pain, and environmental factors.
  1. Most frequently reported medical problems: urinary tract infection (UTI), upper extremity pain, fatigue, pressure sores, constipation, and bowel accidents.
  2. No significant change over time in number of patients with UTIs (48% in 1993, 54% in 1996, 48% in 1999, 2002, 2006).
  3. Number of UTIs requiring treatment went down significantly; 3.9 persons in 1990 to 1.2 in 2006.
  4. Bowel evacuation methods changed significantly over time – increase manual evacuation, colostomy methods in 2006.

Emmanuel et al. 2009; UK
Cross-sectional
Level 5
N=55

 Population: 55 complete SCI participants (45M 10F); mean age 36 (range 19-68); mean time post-injury 34 months (range 13-134).
Methodology: Comparison of rectal muscosal blood flow.
Outcome Measures: Whole gut transit times; rectal electrosensitivity; stimulated defecation; laser Doppler studies of rectal mucosal blood flow; symptoms of constipation.
  1. 35 participants (27M 8F, mean age 36, range 20-68) were symptomatically constipated, representing 75% of the participants with lesion above T5 and 55% of those with lesion below T5.
  2. 32 participants who were symptomatically constipated had slow whole gut transit.
  3. Transmucosal rectal electrical sensation was abnormally high in all SCI participants, being significantly greater in those complaining of constipation (67.3mA in constipation, vs. 41.6mA in non-constipation SCI, vs. 36mA in control.
  4. 71% of participants with lesion above T5, and 61% of those below T5 were unable to expel a water-filled balloon and showed paradoxical sphincter contraction.
  5. SCI participants had significantly lower mucosal blood flow than asymptomatic SCI participants (183 vs. 267 FU); SCI participants with lesion above T5 had significantly lower resting blood flow than AB control, while SCI below T5 were similar to the control.

Faaborg et al. 2008; Denmark
Longitudinal
Level 2
N=159

 Population: 159 participants who participated in a survey in 1996 and a follow-up in 2006; mean age 37 yrs (range 15-70 yrs), mean YPI 10 (range 0-48 yrs), 63 cervical, 40 thoracic, and 56 lumbar.
Methodology: Assessed colorectal function over a 10 yr period.
Outcome Measures: A questionnaire consisting of 34 items describing constipation, obstructed defecation, fecal incontinence and impact on quality of life (QoL) or social activities.
  1. All items regarding symptoms of constipation increased significantly.
  2. The number of respondents reporting fecal incontinence at least once monthly decreased from 32 (22%) to 26 (17%).
  3. More correspondents report that their QoL or social activities were restricted by colorectal dysfunctions in general (39 vs. 60) and constipation (20 vs. 30).

Shim et al. 2008; South Korea
Cross-sectional with AB controls
Level 3
N SCI=31
N controls=31

 Population: 31 men with SCI, median age 58 yrs, range 45-81 yrs; median YPI 32, range 5-55 yrs; age and gender matched AB controls.
Methodology: Comparison of serum prostate specific antigen (PSA).
Outcome Measures: Serum levels of PSA; digital rectal examination; transrectal ultrasonography.
  1. No differences in PSA levels and prostate volume parameters between group with SCI and AB controls.

Alexandrino et al. 2004; Brazil
Cross-sectional with AB controls
Level 3
N SCI=44
N controls=44

 Population:  44 men with SCI, mean(SD) age 33.98(9.12) yrs, range 18-58 yrs; age and gender matched AB controls.
Methodology: Comparison of total serum prostate specific antigen (PSA) and seminal PSA.
Outcome Measures:  Serum and seminal levels of PSA.
  1. No differences in total PSA levels between group with SCI and AB controls.
  2. Total seminal PSA was lower in the SCI group compared to AB controls.

Scott et al. 2004; USA
Cross-sectional with AB controls
Level 3
N SCI=636
N controls=20949

 Population: 636 men with SCI; ages ³50; 945 men with prostate cancer and 20,949 AB controls.
Methodology: Comparison of incidence and characteristics of prostate cancer.
Outcome Measures:  SCI, cancer registry, and outpatient databases.
  1. 1.7% of SCI group had been diagnosed with prostate cancer compared to 4.4% of AB controls.
  2. Average serum prostate specific antigen (PSA) level at diagnosis was significantly higher in the group with SCI compared to AB controls.
  3. Group with SCI and prostate cancer (7; 63.6%) had locally advanced (stage T3) or metastactic prostate cancer compared to AB population (267; 29.1%).

Pannek et al. 2003; Germany
Cross-sectional with AB controls
Level 3
N SCI=100
N controls=575

 Population:  100 men with SCI; mean(SD) age 53.7(11.3) yrs, range 35-71; age and gender matched AB controls.
Methodology: Comparison of prostate size and serum prostate specific antigen (PSA).
Outcome Measures:  Prostate size; serum levels of PSA.
  1. No differences in prostate size or PSA levels between groups with SCI and AB controls.
  2. Mean serum PSA level in the AB controls was found to increase with age, but shown to be of a lesser extent in persons with SCI.

Pramjudi et al. 2002; USA
Cross-sectional with AB controls
Level 3
N SCI=366
N controls=371

 Population: 366 men with SCI; age range 40-79 yrs (40-49 yrs, 50-59 yrs, 60-69 yrs, 70-79 yrs); age and gender matched AB controls.
Methodology: Comparison of serum prostate specific antigen (PSA).
Outcome Measures: serum levels of PSA.
  1. No differences in PSA levels between group with SCI and AB controls.

Konety et al. 2000; USA
Cross-sectional with AB controls
Level 3
N SCI=79
N controls=501

 Population: 79 men with SCI; age range 40-89 yrs (40-49 yrs, 50-59 yrs, 60-69 yrs, 70-79 yrs, 80-89 yrs); age and gender matched AB controls.
Methodology: Comparison of serum prostate specific antigen (PSA).
Outcome Measures: Serum levels of PSA.
  1. No differences in PSA levels between group with SCI and AB controls.

Krogh et al. 2000; Denmark
Cross-sectional with AB controls
Level 3
N SCI=26
N controls=24

 Population: 26 participants with SCI (11M 15F); age range 17-69 yrs; YPI range 11-24 days
Methodology: Comparison of total gastrointestinal transit times (GITT) and segmental colorectal transit times (CTT).
Outcome Measures: GITT and CTT.
  1. GITT and CTT are significantly prolonged in SCI patients than in AB controls.

Lynch et al. 2000; New Zealand
Cross-sectional with AB controls
Level 3
N SCI=467
N controls=467

 Population: 467 participants with SCI (384M 83F); mean age 43.5 yrs, range 15-89; mean YPI 14, range 0.7-42.1 yrs. 467 age and gender matched AB controls.
Methodology: Comparison of bowel functioning.
Outcome Measures: Mean Fecal Incontinence Score, Bowel motion frequency, Haemorrhoidectomy, Time at toilet, Assistance at toilet.
  1. Group with SCI had higher rates of fecal incontinence, less frequent bowel motion, spent longer times on the toilet, and required more assistance.

Sekar et al. 1997; USA
Longitudinal
Level 2
N=1114

 Population: 1114 participants with SCI (915M 199F); mean(SD) age 31.25(13.79) yrs, range 1-87 yrs at injury.
Methodology: Evaluation of the effects of different bladder management on long term renal function who were followed for at least 10 YPI.
Outcome Measures:  Total and individual kidney effective renal plasma flow (ERPF).
  1. A decreasing trend in mean ERPF was detected over time after injury, except for a slight reversal at 10 YPI.

MacDiarmid et al. 1995; New Zealand
Longitudinal
Level 2
N=44

 Population: 44 participants with SCI (31M 13F); mean age 36 yrs, range 13-79 yrs.
Methodology: Reviewed the urological complications in patients treated with suprapubic catheterization at 12 to 15 mos post-injury.
Outcome Measures: Urodynamic studies and ultrasound.
  1. None of the patients had renal deterioration, vesicoureteral reflux or bladder carcinoma.
  2. Incidences of incontinence, urinary tract infections, and calculi were acceptable.

Dewire et al. 1992; USA
Longitudinal
Level 2
N=57

 Population: 57 men with cervical SCI.
Methodology: Comparison of incidence of urological complications and renal deterioration in SCI patients with and without a chronic indwelling urinary catheter from baseline to 10 YPI.
Outcome Measures:  Patients’ medical records excretory urogram.
  1. No significant difference of incidence of urological complications and renal deterioration found between patients with and without chronic indwelling urinary catheters.

Lamid et al. 1988; USA
Longitudinal
Level 2
N=32

 Population: 32 men with SCI; mean age at injury: 29.72 yrs, range 19-66 yrs.
Methodology: Medical chart review of annual visits from SCI patients with vesicoureteral reflux until 12 YPI.
Outcome Measures: Medical records with information on bladder function, including radiological and laboratory examinations.
  1. The majority of refluxes developed 1-2 YPI, and some disappeared spontaneously without causing damage to the urinary tract.
  2. After 4 YPI, the number of refluxes increased and progressed to grade II and IV, causing kidney damage with caliectasis.

Menardo et al. 1987; Italy
Cross-sectional with AB controls
Level 3
N SCI=11
N controls=37

 Population: 11 participants with SCI (8M 3F); age range 17-63 yrs; YPI range 2 mos-15 yrs. 37 age matched AB controls.
Methodology: Comparison of transit of contents through the large bowel
Outcome Measures: Gastrointestinal transit times (GITT).
  1. Compared to AB controls, GITT was slower in all patients with paraplegia.
  2. Flow contents through the left colon were markedly slower in group with SCI compared to AB controls, and transit of contents in 8 persons with SCI were decreased, and below the normal range of the AB controls.

Viera et al. 1986; USA
Longitudinal
Level 2
N=99

 Population: 99 participants with SCI (77M 22F); age range 14-65 yrs at injury.
Methodology: Investigated the effect of current bladder management techniques on renal function at 6 to 60 mos post-injury. Group comparisons were made between those using indwelling catheters and those using intermittent self-catheterization.
Outcome Measures: Serum creatinine; Excretory urogram; Determination of short renal clearance of iothalamate.
  1. In the indwelling catheter group (n=9), bladder calculi occurred in 3 patients at 7, 28, and 44 mos post-injury, and were the only group to develop bladder stones.
  2. Excretory urogram abnormalities tended to occur earlier in the intermittent self-catheterization group (first 18 mos) than in the bladder re-training group (third yr).

Kuhlemeier et al. 1984b; USA
Cross-sectional with AB controls
Level 3
N SCI=400
N controls=287

 Population: 400 participants with SCI (160 acute and 240 chronic); age range 16-60 yrs, YPI range for chronic 6-53 months.
Methodology: Comparison of renal function.
Outcome Measures: Total and individual kidney effective plasma flow.
  1. Both individual and global kidney effective plasma flows were decreased in the acute SCI group for persons who were 21-50 yrs old, but no difference existed for persons younger than 20 or older than 50.

Discussion

From the list of identified studies on the genitourinary system (see Table 9), there are four longitudinal studies (Viera et al. 1986; DeWire et al. 1992; MacDiarmid et al. 1995; Sekar et al. 1997) suggesting there are no differences in renal function over time among persons using various bladder management techniques. However, the samples of these studies did incur typical SCI-related complications such as UTIs and bladder stones, and there were some indications of renal decline. For instance, Lamid (1988) found that after 4 YPI, the number of vesicoureteral refluxes increased and progressed to grades II and IV, which caused kidney damage with caliectasis in 27 of 32 patients with SCI followed over 12 YPI. Finally, Sekar and colleagues (1997) reported that renal function (as measured by total and individual kidney effective renal plasma flow; ERPF) decreased over time in their SCI sample (N = 1114) with a slight reversal occurring at 10 YPI. A methodological strength of the study was the assessment of ERPF, which is thought to be a more sensitive measure of kidney function than serum creatinine (Kuhlemeier et al. 1984a). Based on the findings of the identified studies, it may be that significant declines in renal function occur approximately at 5 YPI.

Work regarding age of onset and the genitourinary system is also needed as the findings of a cross-sectional study by Kuhlemeier and colleagues (1984b) suggests that persons with acute SCI (N = 160) who were younger than 20 or older than 50 had comparable levels of individual and global kidney effective plasma flows compared to AB controls (N = 287), whereas persons with between 21-51 had impaired renal function.

Overall, the risk for prostate cancer appears to be lower in persons with SCI due to impaired testosterone levels, but prostate cancer screening should be encouraged given the possibility that males with SCI who do develop prostate cancer may have poorer outcomes than AB males (Scott et al. 2004).

With regard to women with SCI (n = 62), Kalpakjian and colleagues (2010) found that they experience greater symptom bother in certain areas related to menopause compared to AB controls (n = 66). Specifically, women with SCI reported greater bother of somatic symptoms, bladder infections, and diminished sexual arousal. However, the patterns of symptoms, transitioning through menopause, and age at final menstrual period transitions were comparable between groups. Overall, the authors concluded that in important ways, women with SCI appear to experience menopause similarly to their peers.

Although bowel function is clearly impaired in persons with SCI compared to AB controls, one study (Lynch et al. 2000) demonstrated that continence deteriorates with increasing age in an AB population (N = 467) but does not change with increasing age in persons with SCI (N = 467).This supports a Level 4 study that found that gastrointestinal transit times and colonic dimensions neither change during the first decade nor within the second decade post-SCI (Faaborg et al. 2011). However, a 10-year longitudinal study (Faaborg et al. 2008) suggests persons with SCI do incur an increase in constipation-related symptoms over time. One possible reason for this occurrence is due to the evidence that high amplitude propagating contractions (HAPC) are absent in persons with SCI compared to AB controls (Ancha et al. 2010). HAPC are often associated with colonic mass movements and are thought to be a precursor of bowel evacuation. Thus it is an important factor in the occurrence of difficulty with evacuation post-SCI.

Conversely, the need for assistance from medications or persons does not change, while fecal incontinence decreases. It may be that bowel dysfunction worsens over time for persons with SCI but three studies (Menardo et al. 1987; Krogh et al. 2000; Emmanuel et al. 2009) provide evidence that level of injury plays a primary role in the extent of bowel dysfunction. At this time, the SCI evidence on aging and the gastrointestinal system is limited, but attention to bowel symptoms should be incorporated into routine follow-up procedures and education (Charlifue et al. 2002).

Conclusion

There is Level 4 evidence (Viera et al. 1986; DeWire et al. 1992; MacDiarmid et al. 1995; Sekar et al. 1997) that there are no differences in renal functioning up to 4 YPI using various bladder management techniques with some decline occurring beyond that time.

There is Level 4 evidence (Lamid 1988) that repeated episodes of vesicoureteral reflux can cause kidney damage as early as four YPI in some persons with SCI.

There is Level 4 evidence (Sekar et al. 1997) that renal plasma flow declines until 10 YPI after SCI, at which time a slight reversal occurs.

There is Level 5 evidence (Kuhlemeier et al. 1984b) that suggests age of SCI onset may be an important factor related to renal function, with persons with SCI who are under 20 and older than 50 having comparable renal function to AB controls, whereas persons between those ages have impaired functioning compared to the general population.

There is Level 5 evidence (Lynch et al. 2000) demonstrating a deterioration in bowel continence with increasing age in an AB population but no change with age in persons with SCI.

There is Level 4 evidence (Faaborg et al. 2008) suggesting persons with SCI do incur an increase in constipation-related symptoms and decrease in fecal incontincence over time.

There is Level 4 evidence (Faaborg et al. 2011) that gastrointestinal transit times and colonic dimensions do not change over time in persons with SCI.

There is Level 5 evidence from three studies (Menardo et al. 1987; Krogh et al. 2000; Emmanuel et al. 2009) that level of injury, and not necessarily age or YPI, plays a primary role in the extent of bowel dysfunction.

Various bladder management techniques (indwelling catheterization versus intermittent catheterization) may not impact renal functioning in persons with SCI over time.

Repeated episodes of vesicoureteral reflux can cause kidney damage as early as four years post-injury.

After SCI, renal plasma flow declines until 10 years post-injury, at which time, a slight reversal occurs.

Age of onset may play a role in minimizing renal decline, with adults who are under 20 and older than 50 having comparable renal functioning to the able-bodied population, while those between those ages have impaired functioning.

Bowel incontinence increased with age in the able-bodied population but does not change in persons with SCI.

Persons with SCI may experience an increase in constipation-related symptoms and decrease in fecal incontinence over time.

Level of injury, and not age or years post-injury, plays a primary role in the extent of bowel dysfunction.

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