Genitourinary and Gastrointestinal Systems

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

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.

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.

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.

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.

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%).

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

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

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.