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 |
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Elmelund et al. 2014; Denmark |
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. |
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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. |
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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. |
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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. |
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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 |
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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) |
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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). |
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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. |
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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 |
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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. |
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Alexandrino et al. 2011; Brazil |
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. |
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Faaborg et al. 2011; Denmark |
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. |
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Ancha et al. 2010; USA |
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. |
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Kalpakjian et al. 2010; USA |
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. |
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Savic et al. 2010; UK |
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. |
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Emmanuel et al. 2009; UK |
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. |
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Faaborg et al. 2008; Denmark |
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. |
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Shim et al. 2008; South Korea |
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. |
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Alexandrino et al. 2004; Brazil |
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. |
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Scott et al. 2004; USA |
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. |
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Pannek et al. 2003; Germany |
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. |
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Pramjudi et al. 2002; USA |
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. |
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Konety et al. 2000; USA |
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. |
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Krogh et al. 2000; Denmark |
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. |
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Lynch et al. 2000; New Zealand |
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. |
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Sekar et al. 1997; USA |
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). |
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MacDiarmid et al. 1995; New Zealand |
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. |
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Dewire et al. 1992; USA |
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. |
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Lamid et al. 1988; USA |
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. |
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Menardo et al. 1987; Italy |
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). |
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Viera et al. 1986; USA |
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. |
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Kuhlemeier et al. 1984b; USA |
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. |
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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 fhat bowel dysfunction worsens over time for persons with SCI but three stor assistance from medications or persons does not change, while fecal incontinence decreases. It may be tudies (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 & Lammertse 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.