All right, well, good afternoon. We can come on in and grab a seat, please. We'll go ahead and get started. Thank you all for being here. I was just informed this session is being live streamed, so we do have audience members who are participating with us virtually. So just a reminder that if you have questions at the end, and we do want to save time for questions, I will ask that you come to one of the, I guess, the center mic so that those folks who are watching virtually can hear the questions as well. So with no further ado, I want to thank you for attending this session. We're going to be covering two significant topics in the area of spinal cord injury. One is neurogenic bowel dysfunction, and the other is neurogenic lower urinary tract dysfunction. And I'm really pleased I have two esteemed colleagues with me, Gianna Rodriguez and Mike Kennelly. Gianna, you might know, is a PM&R physician, SCI medicine physician. Mike is a urologist. So I thank you both for making the trip out here and look forward to your participation and comments. I will also say Gianna and I work closely together. If you've had an opportunity to review the updated PVA guidelines in neurogenic bowel dysfunction, Gianna and I worked on those updates together. And Mike was recently on the, I think it was the AUA guidelines for neurogenic lower urinary tract dysfunction. So we're going to be giving you the latest and greatest in both of these clinical areas. I have nothing to disclose. Gianna has the two disclosures listed. And Mike will hand out a list afterwards. I think they're all on one slide or maybe two, but they're coming up later. So we want to quickly just cover a little bit about reminders for all of you about anatomy, innervation, physiology, pathophysiology, and then quickly get into actually management, which is the more important. But to do that, you've got to understand the basics. So bowel innervation you see here from a Netter drawing, which looks relatively complex, but I'm going to break it down in a couple of ways. The first is through somatic innervation. And the key areas here is through the pedendal nerve, S2 through 4, which innervates skeletal muscle, external anal sphincter, pelvic floor musculature, including the puborectalis and levator ani. And you're going to hear more about these in the course of the talk. So we'll come back to this. The sympathetic system, which is primarily from T9 down through L2, with hypogastric nerve being one of the key pathways of innervation. And the sympathetic system works to decrease GI motility and secretions. And it provides a tonic, some tonic tone to the internal anal sphincter. The parasympathetic system comes through the vagus nerve down through about the mid-transverse colon, and then through S2 through 4 through the pelvic nerve. And the parasympathetic, as a reminder, increases colonic motility. It relaxes the internal anal sphincter. It increases secretions. So a difference between bowel and bladder, there are many differences. But one key difference is that for bowel, there are also intrinsic enteric nervous system modulatory mechanisms that influence the motility, influence stool propulsion, influence secretions separate from that extrinsic innervation that I just talked about. There are also pacemaker cells that provide some degree of electrical rhythm to these colonic contractions. So for the normal process of defecation, just walking stepwise, so there's distention of the distal colon and rectum that sends sensory feedback to the brain that then, with systems intact, there's voluntary control to maintain continence until there's a socially acceptable time and place to allow and induce defecation. So that continence is maintained by a contracted internal anal sphincter and pelvic floor muscles. But that internal anal sphincter tone is actually inhibited by rectal distention from the stool, increasing the importance then of the pelvic floor musculature and, again, the intact innervation extrinsically. So then when it's the socially acceptable time and place to defecate, there's a voluntary contraction of the abdominal muscles. There's relaxation of the puborectalis and the external anal sphincter to allow for defecation. So along with all of this, there are several key reflexes that you'll hear more about. One is the colocolonic that allows propulsion of stool via the myenteric plexus, intrinsic nervous system, or enteric nervous system. The gastrocolic reflex that increases GI motility and colonic contraction about 30 minutes after a meal. The rectocolic reflex that promotes colonic peristalsis in response to chemical or mechanical stimulation via the pelvic nerve. And the anal rectal reflex that I just mentioned that actually induces relaxation of the internal anal sphincter with that rectal distention. So with that, I want to turn it over to Gianna, who's going to tell us why is all this important and what are we going to do with it. Good afternoon, everybody. It's my pleasure to be here with you today to talk about neurogenic bowel dysfunction. So the information in my presentation was essentially derived from the PVA clinical practice guidelines on neurogenic bowel dysfunction for evaluation and management. So this is just a quick look at the protocol that was set forth by the PVA clinical practice guidelines. And I am going to talk about each component in a little bit more detail. So this is just to go over what Jeff went over quickly with some illustration here. So as the rectum is filled with stool, it starts to fill up. And with this, you have distention of the rectum, which essentially informs the brain. And it tells your brain, OK, I'm getting filled up. You kind of have to start thinking about possibly emptying me at one point. Then it starts to fill up more. And at this point, there is an autonomic reflex that tells your brain once again that, OK, I'm filling up more. You need to do something about it. Your internal anal sphincter starts to relax. And at that point, you have the urge, because the distention is getting more. And what gives us control over our bowel movements is our external anal sphincter. So at this point, if you're not able to move your bowels, your external anal sphincter is in full force, saying, OK, I can't really move right now. And so therefore, I need to wait. And this is under your sympathetic control. But once you're able to defecate or start the defecation process, your external anal sphincter relaxes. Your abdominal walls contract. Your diaphragm contracts as well. And then your pelvic floor muscles actually help with pulling up, opening your sphincters, and allowing stool to pass. So there are three phases to defecation. You have the holding phase. And this is where you want everything to be shut down, because you can't have a bowel movement. So you have your puberrectalis muscles and both your internal and external anal sphincters taught. And then as you start to relax, you go into the initiation phase, where you have your puberrectalis and your external anal sphincter muscles start to relax. And your levator ani, abdominal muscles, diaphragm muscles, help with opening things up. And then you go into completion so that you're able to pass stool adequately and appropriately. So what happens when you have a spinal cord injury? When you look at the greater GI world, they have a classification called the Rome IV classification. And spinal cord injury actually falls into two impairments, which is essentially, one, transit and motility, where you have slowing of your colon. And then two, where you have an impairment of evacuation of stool. So this is where your pelvic floor and sphincter muscles are abnormal, and they can be discoordinated. And so therefore, you're not able to pass stool appropriately and adequately. You can have a picture of areflexia or hyperreflexia, or hyperreflexia, or just being a little bit more reflexic. So you also have a sensation diminished, so meaning you don't feel the urge. You don't know when your rectum is full. There are some patients with spinal cord injury who might have some retention of vague abdominal discomfort when they have rectal distension. And as mentioned, muscles of continence are impaired. So you lose control of your bowel movements altogether. So primarily, you know, in the acute phase of spinal cord injury, you have your colonic transport impaired and prolonged, OK? But if that is not taken care of, so meaning if you don't put a patient on a good regimen that allows for more normal movement of your colon, with chronicity, we find that the small intestines and your stomach start to be impaired with prolongation of your motility as well. But overall, digestion and absorption remain intact. So the problems with the movement in your GI tract are related to the reduction in giant migratory contractions or decrease in peristalsis. I'm sorry, prolongation of peristalsis. Sorry, primary again. So it's important to take a good GI history because your management is dependent on a lot of what the patient and their caregivers will tell you about the history. So frequency of defecation, OK, is important. Stool consistency, we use the Bristol Stool Scale. Volume of stool per bowel movement. If you have like a small turd of stool, then that's not an adequate bowel movement. Time of day of bowel movement. So do they tend to have three, four times a day of bowel movement? Is it, you know, occurring mostly in the morning or in the evening or there's no pattern to their bowel movements? Duration of their bowel movement. So meaning, you know, I have some patients sit in the toilet for three or four hours. Nobody wants to do that, right? There's much more to life than doing that. Do they have some sort of urge or sensation that their rectum is full? And are they able to control some of the passage of their stool? Are they aware of any episodes of incontinence when they do have incontinence? And do they have any abdominal pain, discomfort, bloating, or distention or even early satiety? So what oral and bowel medications, oral and rectal bowel medications are they on? Or what have they tried and what has not worked for them? What have they tried in combination with each regimen as well? So when do they take their bowel medications or at least their oral bowel medications? When do they take them? Do they take them in the morning, the evening? When do they use their rectal medications or rectal methods for emptying? And then which strategies do they use? Do they do digital rectal stimulation? Do they do manual evacuation? Do they use T-animus or transanal irrigation? And how long does it take for them to complete their bowel care? So does it take them 30 minutes, an hour, two hours? And do they need a caregiver or do they need some assistance for either positioning or help with emptying their rectum? And obviously pre-morbid GI function plays a role and then all the medications that they're on and we know whether they are in the acute phase or chronic phase they are on a lot of different constipating medications. What kind of diet do they have? What is their fluid intake? And are they active? And we all know that what happens distally actually affects everything proximally. So you have constipation, fecal incontinence, diarrhea and it tends to inform your upper GI system and vice versa and you have symptoms. You have nausea, abdominal discomfort, pain, gassiness and this can be very limiting to patients overall. Moving to the physical examination. We do the basics, inspection, palpation of your abdomen checking if there are bowel sounds and then we try to determine is this patient reflexic? Do we have reflexes preserved or do we have reflexes hypo or areflexic? Does the patient have sphincter tone? Does the patient have the ability to squeeze their sphincters, relax their sphincters? Are they able to push or what happens with pushing? So with simulated defecation what happens with your finger in the rectum? And then also there are a good number of patients who have pain in their perineal area and a lot of times there are puborectalis muscle trigger points and so do you have some trigger points in your levator ani muscles. And then obviously hemorrhoids and anything else like a prolapse or rectocele or whatnot can actually contribute to discomfort in the rectal area. So important and I know it's a little inconvenient but it gives you a lot of information if you do a digital rectal exam. You put your finger into the rectum and ask the patient to voluntarily anal squeeze because with just that even if it's slight you have the patient incomplete. You know that the patient is incomplete if they have voluntary anal squeeze even though if it's not normal. If it's present then at least it makes them an AISC. And then also you want to know are they hyper with their tone when you put your finger in there. So you can have hyper sphincters and so can you have hyposphincters. And then again with simulated defecation so your finger's in the rectum and you ask the patient can you squeeze, can you push my finger out. So that sort of simulates defecation. And if they're able to push your finger out then that's very promising, right. That they have some sort of preserved coordination of the muscles and the sphincters to be able to evacuate stool. And it also gives us an idea whether or not you have rectal sphincter dysinertia. It gives an idea of how weak the sphincters are and if the muscles in the pelvic floor actually participate or contribute to what's going on in the dysfunction. So basic bowel management is important. So we obviously start off with something but it's important for us providers and it's important for us to educate the patients and their caregivers about okay, because it's hard, all right. So they have to have something to go by. All right, goals of the bowel program, daily or at least every other day bowel movements. At least three times per week, okay. Official definition of constipation is less than three adequate bowel movements per week. We want regularity. So when we plan with the patients we ask them, do you want to have or do you want to plan your bowel movements in the morning or in the evening? Complete evacuation of stool from the rectum as best as possible. So meaning, you know, you might not empty out completely but at least if you have adequate elimination of stool on a regular basis then, you know, you're preventing severe constipation from occurring. Obviously we don't want any episodes of incontinence and we keep the stool soft but formed and we want it to be between Bristol stool type 4 to 5. And ideally less than 30 minutes but I know that's, you know, reaching for the moon sometimes. It's helpful to have a bowel diary or a stool diary particularly for the patients and their caregivers so that they can see patterns of what might be going on. Or if they're not able to, you know, read it themselves they are at least able to bring it to their providers to show them, okay, this is what's going on and perhaps you can problem solve with me on how to make this a better bowel program. We all know nutrition plays a part and as opposed to the bladder what you eat contributes to your stools, right? So a healthy diet obviously is much better where you have natural fruits and vegetables in your diet rather than using supplemental fiber. But if we're not able to do that then, okay, we can use supplemental fiber. And then taking enough non-caffeinated fluids per day obviously is helpful as well. And, you know, of note it has to be balanced with bladder management. So first and foremost you have to make sure that you try to decrease the number of constipating medications opiates, anticholinergics, which sometimes we really can't avoid. And then, you know, we try to encourage good dietary fiber intake or fiber intake in general. However, we must be cautious in patients who tend to get severely constipated because more fiber can actually be detrimental to them. And then optimizing the use of oral agents and I'm going to talk about this a little bit more both osmotics and stimulants. All right. So the reason why you ask about consistency of stools is so that if the stools are hard so meaning if it's Bristol stool 3, 2, 1 they're hard and they're dry that means you need to make the stool softer. And this is where your osmotics come in. Okay. So we have a number of different osmotics and I'll give you a chart, all right. And then stimulants. If let's say you've achieved good consistency of stools, but somehow you're only eliminating half a cup of stool, perhaps you need a stimulant to encourage or to move the stool from more proximal to the rectum. And then the rectal medications help with initiating the bowel movement, all right. And it also tries to complete the bowel movement or it helps with completing the bowel movement. So do other strategies, you know, meaning enemas, digital rectal stimulation, and suppositories. And the timing of when you give the medications is important to when you time bowel evacuation. So I typically, and this is not evidence-based at all, but I typically have patients take their oral medication at least six to eight hours prior to the intended time of evacuation of stool, okay. To give it a chance to move from, you know, upper, from the upper area of the colon down to the rectum. Because whatever you do rectal-wise will not be, will not work so well unless you have the stool in the rectum. All right. This is a list of your oral bowel medications. So again, your stimulants. We don't really have a whole lot, simple bowel stimulants. We have senna and bisacodyl. Osmotic laxatives, we have, you know, polyethylene glycol, your magnesium-based medications, your lactulose. Stool softeners are also kind of like a weaker osmotic. So you have your mineral oils and your Colace. I feel that Colace does work for a good number of patients. I know the GI folks poo-poo Colace, but I still give it to my patients. Here we have the bulk forming agents, and I particularly find it useful to use the fiber agents for those who have lower tone and, you know, when their sphincters are pretty hypo or if you don't have enough reflexes or tone in your sphincters to bulk up stool. So there are newer agents that help draw water into the stool. You have your Lubiprostone, your Linaclothide, which are chloride channel activators. And then you have your Procalipride, which probably came out in the market about a year and a half ago, and it's still kind of expensive, and it's called Motegrity. And it's a nice motility agent because it actually moves your stomach all the way down to your colon. And then you have the agents that are mu-opioid receptor antagonists, and these are used for patients who are on opiates and need help with moving their colons. So okay, so the goal was to get your stool from the more proximal colon down to the rectum, and you're using your oral osmotics and your stimulants, okay, and your fiber and your fluids, et cetera. So now we have the stool in your rectum, and this is where you need to evacuate, right? And there are ways to evacuate. Again, it's nice to choose the same time of day every day to habituate your system. Digital rectal stimulation is one method of doing so. It allows for your rectum to contract to effectively move out your stool, right? It also relaxes your sphincters. Put your finger into the rectum, it relaxes your sphincter. It helps with, through reflexes, contract your rectum so that you're able to eliminate stool. However, this can lead to autonomic dysreflexia, so you have to watch out for blood pressures or headaches. For those who are hyporeflexic or are areflexic, digital rectal stimulation is not effective, and so therefore you will need to do manual evacuation of stool. And it's important to note that you have adaptive equipment, suppository inserters, adaptive digital stimulators, that, you know, for people who have higher cervical cord injuries or higher thoracic cord injuries need to help with evacuation of stools. And then you must consider the equipment that is needed, shower chairs, commode chairs, and then, you know, transferability of the patient, skin integrity as well, and postural stability altogether. And obviously, the more upright you are, the better outcomes you have for bowel elimination or stool elimination. And if you go to the clinical practice guidelines, it will have a whole chart outlining level of injury, functional performance for bowel care, bathroom equipment, assistive devices. So use of suppositories, enemas, and irrigation, all this is to empty your rectum, okay? You have your rectal medications for bowel management, you have your docusate mini enemas, which is enemes, and your bisacodyl suppositories, and the polyethylene glycol-based ones are better. Glycerin suppositories can be helpful as well, but not as much as the bisacodyl or the docusate mini enemas. And you have enema formulations, but we only recommend that this be used intermittently for severe constipation, and there are many different formulations for that. There's transanal irrigation as well, where you have a catheter with a balloon which is connected to a device which is inserted into the rectum. And the balloon, when inflated, is able to create a seal. And so when water is instilled into the rectum, you're able to create the pressurized system to essentially clean out and stimulate the peristalsis in the lower part of your colon to help with more efficient evacuation of stool. And there is evidence on transanal irrigation out there that it improves quality of life, decreases pharmaceutical use, and improves constipation and fecal incontinence. So surgical intervention to manage neurogenic bowel dysfunction, you have your colostomy, which is the most common, and you typically go this route if there are other treatments failed or with significant complications. A lot of patients who've had colostomies report superior quality of life outcomes, and it decreases time in bowel care, hospital admissions, and improves physical and psychosocial health and independence. So we also have the Malone Antigrade Continence Enema, where there's surgical creation of entry through the appendix, which is attached to the abdominal wall. And the enemas that are performed are from the proximal colon, so it's essentially, that's why it's called antigrade. So you flush out from the proximal colon down into the rectum for bowel or stool emptying. So there are a number of complications that do present if we're not able to prevent severe constipation from occurring. We have altered visceral sensation, which can be very uncomfortable and actually very limiting in quality of life. There's anorexia, so with chronicity, patients lose appetite and they're not able to eat and they become malnourished. And obviously, as we see patients for the arousal issues, we have to watch out for complete bowel obstructions or anything leading up to complete bowel obstruction with fecal infection, autonomic dysreflexia, and skin breakdown. So hemorrhoids are also a big, big problem and can lead to autonomic dysreflexia. Typically, our colorectal surgeons will not do any surgical interventions because it does recur. So the importance is to try and prevent it from occurring by preventing chronic constipation, straining, pressure on the perineal area. And it's important to educate our patients, our caregivers, and other providers about trying to promote a good bowel program and regimen for our patients so that we do not have any bowel issues. And to remember that we have psychosocial aspects related to bowel problems and can lead to significant problems with quality of life, depression, anxiety, fear of leaving the house. I can't tell you how many patients I have who do not want to leave the house because of this reason. And also, we have to be sensitive about diversity and cultural beliefs surrounding bowel care. All right. Thank you. Well, thank you very much. It's a pleasure to be here. I'm Michael Connelly. I'm from Charlotte, North Carolina. It's very interesting as a urologist being here at a PM&R meeting. I think it's fantastic. I've worked within PM&R most of my life, at least clinically. One of the things I would say, remember we started off with number two, which was bowel. We're now going to move to number one, which is bladder. So welcome. These are my disclosures. For this talk, really the disclosure that's of meaning is probably that I was part of the guidelines panel, which we'll go through regarding neurogenic lower urinary tract dysfunction. These are the topics I'd like to highlight, at least during this part. Dr. John's actually reviewed some of the neuroanatomy, but I'll talk about neuroanatomy from the bladder perspective. We'll then review some of the evaluations, our goals, kind of talk about some of the treatments, and then towards the end, we're going to talk about some case scenarios. And Gina's going to come up talking about some bowel case scenarios also. So when I went into urology, my goal was really to study an organ that's simple. The bladder just does two things. It fills and it empties. It fills and empties. That's it. At least that's what I thought. It's like a light switch. The capacity should turn on and turn off. And I think if you think of the light switch of doing it, what does it really do? In order for something to store, you have to have a reservoir that is large enough capacity. You also have to have a reservoir that doesn't have a lot of spasm to it. But not only the reservoir, which is the bladder, but you have to have the outlet, the urethra. The urethra has to have enough tone, smooth muscle control to stabilize that area. Remember it's a unit, the bladder and the pelvic floor. In order to actually empty, the bladder has to kind of have the switch turn, where now the muscle has to contract with enough strength and consistency to evacuate, but you also have to have relaxation of the pelvic floor to allow it to come through in a steady fashion. And so I think a concept that I'd want to get through is think of the bladder in those two phases, the storage phase and the emptying phase. When you get into it under a little bit more detail, there is unfortunately some neuroanatomy that goes involved. It does involve the autonomic nervous system. You also have the somatic nervous system. And when you think of it in two areas, the autonomic nervous system has main control centers that are really the pontine micturition center traveling down through the spine. For the somatic system, it's the sacral micturition center, which is in the S2 to S4 area. If you go in a little bit more detail, how the bladder really functions is, if this highlighter works, the bladder being here, as it functions, as the bladder starts to fill, you actually activate A-delta and C-receptors. Those are afferent receptors. Those afferent receptors then get triggered to the spinal cord, and then it travels up the spinal thalamic tracts to the periatric ductal gray. Once you're at the periatric ductal gray, it centers it throughout the brain, goes to the forefront, goes to the cingulate gyrus, and then from there, the pontine micturition center. And really, that is all leading to the forebrain causing an inhibitory aspect. The inhibitory aspect is sending sympathetic signals down back to the bladder and the pelvic floor to relax the bladder and also tighten the pelvic floor. But then all of a sudden, urgency starts. The brain switches, and you will then activate, turn off the sympathetic component. You'll then, through the spinal thalamic tracts, activate the parasympathetic component, leading to detrusor contraction. And so you have this sort of natural pathway that is the sympathetic and parasympathetic systems working in coordination with the somatic system. So the sympathetic system actually runs through the T10 to L12 area. It goes through the hypogastric nerve, and it goes out to the detrusor muscle. It mainly goes through beta 3 receptors, which causes relaxation to the detrusor. There's also alpha agonist receptors that go to the stem of the bladder, and those are adrenergic driven, and those will cause contraction at the sphincter. The sympathetic tone goes down to the S2 to S4 area. It then travels out to the pelvic nerves, and there it goes to the M2 and M3 receptors of the detrusor, releasing acetylcholine, causing contraction. The somatic aspect goes to the S2 to S4 area, going down to the pelvic floor, and that's adrenergic receptors causing relaxation and contraction of the pelvic floor under voluntary control. So we try to break things up within this area to either superpontine, between the pontine area and the suprasacral area and the sacral area. And there's many different neurogenic diseases or neurologic diseases that impact these areas. Knowing where these areas affect is really critical, and that's part of the diagnostic evaluation. But really, why should you care? Well, the reason to care is because obviously we're clinicians, we're taking care of patients, but we realize what it does to them. It affects their quality of life significantly. Bladder and bowel issues have consistently been the top one and two issues regarding our patients with neurological conditions. It leads to a lot of embarrassment. They lose the ability to go out in society, and so if they can get control, they want to have better, improved lives. I was fortunate to be part of a panel that we were able to come out with finally guidelines. One of the things that the PMR community was asking urology is, what is our guidelines regarding neurogenic patients, spinal cord patients? How do you follow them up? What's appropriate? So at least now we have a resource. In 2021, we came out with these guidelines. And what we're really trying to do is to look at, for the practicing clinician, what needs to be done at the bedside? What do we have to do in follow-up and surveillance? So what we looked at is really putting things not based on the neurological condition, but based on risk assessment of what that risk would do and how the follow-up should be. And our risk assessment comes down to location of injury, looking at the renal function, the post-trial residual. We also look at urinary tract imaging and urodynamics testing. And when you break it up into risk assessment, we want people to know, are you at low risk, moderate risk, or high risk? And the risk is really to the upper tracts, the damage to the kidneys. So as you can see, when we look at someone who has low risk, they really have normal findings. They have renal function that's in the normal range. They have minimal post-trial residual. They have a normal upper urinary tract within the kidneys. And their voiding parameters are normal. As you move along the pathway, dysfunctions can come to occur. And those dysfunctions then lead to how often we should tend to follow these patients. So the strategy going forward when you're evaluating patients is always looking at kind of the baseline scenario, history, physical. You're trying to assess, are they in the low risk category, or are they unknown? If they're unknown, then you're going to have to do some more investigations to try to get them into that right stratification. And remember that patients' conditions regarding their bladders can change over time. And so really, each intervention that they come back at your clinic when you're talking to them, you really should reassess the risk assessment. The real main question that they're asking urology from your community was like, how do I follow these patients up? And this is really the answer. If you have a low risk patient, which really has normal things, there's really no urologic follow-up that's needed. It's really when you come down to the moderate and high risk. The moderate risk patients are always going to be seen on an annual basis. They're always going to get a renal function test. And then the question is, a renal ultrasound is really dictated every one to two years. Your dynamic testing is really only needed if you identify some change. For the high risk group, and that's the risk group that does have upper tract issues, staghorn stones, poor bladder compliance, urinary incontinence issues, those patients definitely need to be seen annually. They need to have renal function tests done. They should have ultrasound imaging or some upper tract imaging on an annual basis. And your dynamics really when changes occur, which usually be one to two years in that fashion. So let's go through a little bit in detail. Some of the highlights are what are needed. Well, the baseline during the clinic visit, when you're seeing them, everyone's going to get a history. The low risk patients, well, when you see someone, you identify their low risk. Typically a super sacral spinal cord injury, excuse me, a super pontine spinal cord injury above the pontine area is automatically a low risk patient. You really don't need to do a lot of assessment. You will do a postphoresidural urinalysis. If the PBR is high, that moves them to the unknown and should undergo some evaluation. If you have someone who you don't know what their area is, they should undergo evaluation, which is a history, physical urinalysis, and a postphoresidural assessment. The evaluation, just like in the bowel, you want to ask the details about it. The bladder function, you should do the same. Really, how are they managing the bladder? Are they voiding? Is urine coming out volitionally? Do they have just reflex voiding? Do they have urgency? Do they have incontinence? Are there obstructive symptoms? Are there sort of irritative symptoms? But in addition to bladder, you really need to look at other functions because they give you a window of opportunity of what may be there to go forward. How is their skin hygiene? How do they, sort of their function mobility, do they have good hand function, good eyesight? Because those things will make a difference. And it's also important to look at sexual function. The one thing that I think it's really challenging, and I kind of smirked a little bit when the encouragement was to do a digital rectal exam for the bowel function. The fact of the matter is for the bladder function, you really probably should do the same. You know, you've got to look at least below the belt. Please at least look. Do you have to do a pelvic exam on a female? No, but you need to look. And the reason to look is because you want to know how is their perineal hygiene. Do they have incontinence, excoriation, skin issues? For the male, you want to see, once again, are there irritative issues going on? Do they have components? And then during the exam, you're looking for the reflexes. The key reflexes to look at, at least within the pelvis area, is sensation, obviously touch and pinprick. I do recommend trying to get anal tone because, as you noted, that can tell an incomplete versus a complete lesion. But you're identifying, is there a native tone, absent tone, or hypertone? And then if you want to try and do a vulvocarbonosis reflex, that would be appropriate. If it's a male, a cremasteric reflex would also be an idea to kind of look in that area. So those are good functions, at least, to try to do. I apologize that this slide didn't do it, but the initial diagnostic testing actually should include a urinalysis on everyone. The things you're looking for is obviously glycoseria, proteinuria, hematuria, which would identify other issues to be addressed. You want to assess a post-toward residual of some fashion. The normal, most people, if it's going to be less than 150 to 200 would be probably within a range of normal. If it's higher than that, that's something to look at. The other components, too, that looking at are a renal function test. Most people are using a creatinine. We do know that for the spinal cord injury population, cystatin C is probably a better test. It may not be available in all of our communities, and so using one of those two would be appropriate. From a upper tract imaging standpoint, from ease of use and X-ray guidance, probably a renal ultrasound would be appropriate. Oftentimes, now with new technologies, renal ultrasounds, you can get 3D, have them go down to look at the bladder function to tell you whether there's stones, bladder wall thickness. that also aids in that area. And then CT scans are used for people who have abnormal architecture. Dynamic renal scans using MAG-3 scans are really not utilized, not for a screening type of test. And then urodynamics, as you said, are only needed if conditions. I apologize that this didn't submit, but cystoscopy, this is one of the things that PM&R doctors kind of were wondering about in the guidelines. Cystoscopy is not utilized for any patient with neurologic urinary tract dysfunction. It is only utilized if there is a indicated aspect. An indicated aspect would be if you have hematuria, if you have repeated UTIs, if you have known bladder stones. So for patients who have a chronic folic catheter, chronic suprapubic tube, the risk of bladder cancer is small and it's recommended not to do cystoscopy. Yes, if they do have hematuria, if they have recurrent UTI, that would initiate cystoscopy, but not for routine maintenance within cystoscopy. As far as urodynamics, urodynamics are a key component for patients who are unknown or certainly patients with spinal cord injury. Urodynamics is a big umbrella term. There's a lot of components to urodynamics. We're not gonna go through those in detail, but just to know that the bladder cystometry, the filling cystometry, affects the filling phase of the bladder. If you're looking for the voiding phase of the bladder, you're looking for a pressure flow test. If you're actually looking for the EMG activity of the pelvic floor, that's where you're gonna have the EMG, specifically for detrusive sphincter dyssynergia. And then if you're looking, if someone has urinary incontinence such as stress incontinence, you're looking for leak point pressures. So the keys to urodynamics, it's really critical for patients that have an unknown neurological condition. We use urodynamics to diagnose. We use urodynamics to determine what our treatments may do, and it may provide some benefit in the future. I'm fortunate that I think within the PM&R area, urodynamics are becoming kind of standard within most spinal cord injury units, and so I think that's a key thing. Uriflow is just a measure of flow. It grades the amount of urine that comes out, the speed of flow, the patterns that tend to go with it. PVR is the best assessment, is with an ultrasound probably these days. It's non-invasive. If you can do intermittent catheterization, that's great. However, it is invasive, does carry a little bit of risk assessment to that area. As far as systometry, what you're looking at is the sensory awareness. Do they have first sensation, first desire? Do they have urgency, and what's their bladder capacity? Most bladders can fill between 16 to 20 ounces, but the main thing that we're looking at is really compliance. Compliance is how the bladder fills. Compliance is a change in pressure versus the change in volume. As the bladder fills, it should fill without any pressure. However, a poorly compliant bladder is just like a balloon. Every breath of air you put into a balloon, the pressure gets tighter and tighter and tighter, and that is what will actually harm a patient. Here is one of the classic findings that you'll see regarding detrusor sphincter dysinertia on urodynamics. As you see, as the bladder's being filled, here, the detrusor pressure is rising. There's no change in abdominal pressure, but you notice also that the EMG activity is also increasing, and if you did do fluoroscopic imaging where you see the bladder, this is a male where it's wide open to the bladder neck. There's contrast in the proximal urethra, but it narrows down right at the external sphincter, and the long-term sustained pressure over time actually is what causes upper tract damage. The other key component to look at from urodynamics is really poor compliance. Here, this is the bladder filling, and you're seeing as each sort of fluid goes in the bladder, the pressure gets tighter and tighter and tighter, and at some point, you're gonna start to see reflux going up to the kidney. This is what you're trying to inhibit. Another part would look at leak point pressures, meaning there's a difference between a detrusor leak point pressure, which is, as someone here, this is, again, a poorly compliant bladder. There's really no change in abdominal pressure, but it reaches a certain threshold where urine will leak out. The bladder pressure's so high that it tends to leak, and it's been known that if pressures are greater than 40 centimeters of water, that stops the peristalsis of the ureter. Once the ureter stops peristalsing, pressure is automatically transmitted up to the kidneys, leading to higher kidney pressure, hydronephrosis, and renal destruction. A valsalva leak point pressure is different. This is a pressure where, as you're sort of standing, someone is coughing, someone is straining, so you'll notice that not only the bladder pressure will go up, but the abdominal pressure goes up, causing leakage of urine. Remember that spinal cord patients, neurologic patients, can still have stressed urinary incontinence to that area. EMG activity you're very familiar with, looking for detrusor-strictor dysinertia, and it is recommended from the guidelines. If you have the ability using fluoroscopy to image the bladder, looking for a vascular ureter reflux, looking for a detrusor-strictor dysinertia, it's likely a good way to do it from the guidelines. So I think one thing to know is that urodynamics can be somewhat predicted based on the level of injury. So a suprapontine area oftentimes will have detrusor overactivity, but they have synergic voiding. If you have lesions that are in the suprasacral area, these are patients who have detrusor-strictor dysinertia, detrusor overactivity, non-relaxation of the pelvic floor. And then if you have a sacral or sub-sacral injury, you'll have patients who have an areflexive bladder. The bladder just tends to fill, but they have no ability to contract to try to empty the bladder. And as stated, patterns often rely on that, and that's why our guidelines sort of stratify people based on suprapontine or low risk versus the suprasacral or unknown. However, as I stated earlier, neurologic patients also have common diseases. Some of them have pelvic prolapse, some have BPH, some have stress-urinary incontinence. So things can overlap, and consequently, that's why urodynamic testing is really recommended. So when we look at our guidelines that are out this day, again, every patient that comes in the first part is gonna get a history of physical urinalysis, PVR. You're basically risk assessing, are they in low risk or unknown? From that area, the low risk patients, again, we talked about were normal functions based on creatinine, based on PVR, based on upper tracts, and based on urodynamics, which they shouldn't get. The unknown risk are patients who are gonna get those evaluations and get assessment. If you have a spinal cord patient, a spinal cord patient, by de facto, is not low risk. So consequently, those patients are either gonna be moderate or higher risk, and they do need evaluation. The thing to realize is that patients, again, can intermingle at each visit. You wanna reassess them, and as stated before, moderate risk has an annual visit. They have an annual sort of renal function test, upper tract imaging, presumably the renal ultrasound is one to two years, and urodynamics, only when conditions change. Maybe urinary incontinence begins, they have repeated UTIs, would be indications. But the reason that we're looking at this is because our goals of management are really to protect the upper urinary tract. We know that lower urinary tract dysfunction with urinary incontinence, urinary tract infections, those are certainly quality of life issues, but long-term durability for kidney function is maintained at the upper tracts. And as with bowel function, bladder function has a lot of headwinds. We have a lot of barriers that we have to overcome. Patients not only with their neurological deficits have it, but they also have sort of psychological deficits, they have maybe eye deficits, they have lack of adaptive equipment, they have lack of resources, and so consequently, you've gotta look at what avenues can you match to sort of optimize the bladder health. So our first priority is always gonna be safety. We're looking at protecting the upper tracts. Our second priority is kind of looking at components to help improve, decrease UTI, decrease incontinence. This is a component picture of really poor bladder compliance that will, over time, silently kill the kidneys and end up in renal insufficiency. So how can we do that? How can you, within your clinical area, help these patients? It's really broken down to three different areas. How can you improve a larger storage pressure at low volume? How can you adequately empty the bladder without any signs of obstruction? And then how can you keep good urethral closure mechanisms so they don't have stress incontinence? And when you look at trying to improve bladder storage, we do that through many ways. Obviously, drugs, neurotoxins, and surgical reconstruction. If you're looking at trying to improve bladder emptying, intermittent catheterization, catheters, superpubic tubes, the neuromodulation is an option. And then when you're looking at the urethral outlet, we have devices, medicines, bulking agents, and surgical therapies. So we'll kind of go through these in a little bit detail to give a little more component to it. This is a good way to classify the bladder. Remember, classifying the bladder is either a failure to store or a failure to empty. In addition to that, classifying the bladder based on the bladder component and the pelvic floor urethral outlet component. You can see the diagram or images here are a good way to tell that. If you have a dark and bolden area that's overactive, you can have normal active as a normal line or underactive. So let's look at the case. A patient who has failure to store if they're leaking urine, is it because of a bladder dysfunction or is it because of the urethral outlet dysfunction? That's what you're trying to figure out. So if a patient has failure to store due to the bladder, what do we have available? Guidelines show us that anti-muscarinic therapy is amenable to this. We have seven different anti-muscarinic agents that are out there. There's no one agent that's better than the other at this component. Each agent has kind of different side effects. As a group, we do know that the side effects of constipation, blurred vision, somnolence is an issue. There's more and more sort of white papers coming out regarding cognitive dysfunction within the community. So looking at cognitive dysfunction for our patients is gonna be something. Beta-3 agonists have come to the market. There's only two that are out there currently. The data is a little bit weak, but beta-3 agonists so far have shown promise in regards to managing neurogenic low urinary tract dysfunction. In regards to botulinum toxin, this has probably the most evidence to try and improve bladder storage and it's been studied the most. Clearly, it will increase bladder capacity. It decreases or it improves bladder compliance and it also allows people to become drier in that fashion. There is a potential risk. Obviously, it has UTI risks that go along with it and for patients who are not currently doing intermittent catheterization, it may run the risk of tipping them over to have incomplete bladder emptying requiring intermittent catheterization. Other ways to do it from a surgical standpoint is really surgery where we use augmentation cystoplasties and it's shown here based on guidelines that patients who are refractory to their botulinum toxin therapy, beta-3 agonist or anti-muscarinic therapy that using an augmentation cystoplasty would be appropriate. We do have ability to do channels just like the molone antigrade condensamide for the bowel function. We have the catheterizable channel for the bladder if patients have adequate hand function to be able to catheterize themselves through the abdominal stomal area. Well, what about patients who have a failure to store because of the urethra, because the urethra outlet is poor? Here, we're trying to increase the tone. The guidelines show that bulking agents and there have been several out there predominantly used in the female population, FDA approved in the United States, bulking agents are effective but not great. So the recommended clinicians may use those. They have a tendency to require repeat treatments over time. Other options that we do are slings. These are support straps that are placed in under the urethra, both in the male and the female. The recommendation for neurologic impaired patients is that we do not use synthetic slings. We recommend using either autologous slings of their own fascia or using biological slings. Main reason for this is because patients have to catheterize through these sling areas and we have to put these slings a little bit tighter to give them support. Whereas if you have a synthetic sling, the concern regarding erosion is a risk factor. Artificial sphincters, at least in the male population, have been utilized. Remember, if you have a mechanical sphincter that has a belt that's placed around the urethra, the patients will push the pump to open it but they then will often need to catheterize. Patients should typically catheterize with a 12-french catheter, oftentimes a hydrophilic catheter, and be careful because with each catheterization does run the risk that it can damage the device. If the device does get damaged, surgery is needed to remove the device but then possibly replacing it. There is, in Europe, they do have this artificial sphincter approved for females. They're currently sort of evaluating that in the United States. For people who have refractory outlets, maybe from a chronic Foley catheter that's been there too long, their urethra is dilated, these patients oftentimes need bladder neck closure. This is a surgical component done either from the vaginal area in females or suprapubically in the males and females. It is effective but then they'll need some way to manage their bladder either with a catheterizable channel or with a suprapubic tube as a management. Another way that we're very familiar with is intermittent catheterization. Our guidelines do state that catheterization is probably the easiest way and best way to manage. Chronic catheters do run the risk of UTI, stone formation and decreasing compliance to the bladder. They don't sort of state whether you use one type of catheter versus the other. The guidelines, there's still a question out there. Obviously, UTIs are a component but remember, now that we have PCR technology, everyone has bacteria within the bladder. True UTI versus colonization versus true catheter associated UTI needs to be sorted out and it's really based on symptoms. Symptoms are the driver and then you follow that up with objective evidence regarding urinalysis. The other component would be chronic catheters. The guidelines do state that if you have a need for a Foley catheter or a suprapubic tube versus a choice, it's recommended that a suprapubic tube in the long term is better, mainly because it's trying to preserve urethral function. Once you destroy the urethra of a poor outlet, whether it's a male urethra or a female urethra, we oftentimes cannot reconstruct those urethras and consequently, continuous incontinence can occur. Another way for male patients who have a failure to empty, sphincterotomy is an option. This has sort of gone out of favor over time. We thought we could do maybe a chemical sphincterotomy with botulinum toxin but that requires repeat treatments along the way and so that's not really quite as well. Neuromodulation is an up and coming area where we're using neuromodular implants. Now that we have MRI compatible devices, we're starting to look at that in the neurologic patient. Not necessarily a complete spinal cord patient but ones who have some neurologic component, maybe an MS patient, Parkinson and others but that will be to determine in time. The other component are patients who are, let's say they have lack of hand function, they have overactive bladder, detrusor sphincter dysinertia, how do you manage those patients? A ileochimney, which is basically taking a small piece of intestine, you put it on top of the bladder, bringing it out to the skin. That is replacing kind of a suprapubic tube. These patients must have sort of a small contracted bladder, they must have a good urethral outlet so they don't leak from the urethra. One thing that the guidelines do state is that these patients need to be followed over time because it seems as though the detrusor loses some of its contractility over time and they may retain more urine which may risk increasing UTIs. And for the recalcitrant patient who really doesn't have good hand function, doesn't have good attendant care, or for a urethral bladder that's really non-functional, using a supravesical urinary diversion with an ileoconduit, which is taking a piece of small intestine, the ureter's plugged into it, out to the skin. The other component to doing things is a continent reservoir. For here, the patients obviously have to have good psychological support, they have to have good hand function and know what they're getting into to be able to do catheterizations of themselves. So, what we're gonna do now is talk kind of quickly through a couple cases and see if we learned anything. So I'll talk about the patient here. Here's a 28-year-old man. He's had spinal cord injury just nine months ago. It was due to a motor vehicle accident, a T7 patient. He's out of spinal shock at this point in time. He originally had a Foley catheter while he was in the rehab hospital, converted to intermittent catheterization. He's now coming to your office, we're seeing him. He's stating he's leaking in between catheterizations. He was discharged on oxybutynin, 10 milligrams, Excel on a daily basis. He's had a couple UTIs in the hospital, but none recently. He's catheterizing now four times a day, but he's leaking. His physical exam is really unremarkable. His creatinine is 0.5. So the question that I have from people, what's the risk stratification? How many people would say it's low risk? Raising your hand. How many people moderate? How many people high? How many people don't? The don't know is correct. The people who voice the don't know, you don't know. You're just using your presumption knowledge that they're either moderate or high, put it that way. So you're probably all right, but the answer is you really don't know. And what happens is anyone who comes in, you know part of the story, but you don't know it all. And so the key thing is you wanna find out what's going on with their upper tracts. What's going on neurodynamically to see where they fit in, because then that will tell you where things are at. So in this person, we know the physical exam's normal. When you're looking at an upper urinary tract component, which test would you do? Of these tests out here, are you gonna get a CT of the abdomen and pelvis? Are you gonna do cystoscopy? Are you gonna do an ultrasound, neurodynamics? Ultrasound? Anyone know you do anything else? Right, so ultrasound and neurodynamics are the key. In looking at things when you do the ultrasound, this person has a three millimeter non-obstructing stone. Neurodynamics are shown as below and guiding you through neurodynamics. What you're seeing is detrusor overactivity along this area. So there is some overactivity with leakage. So the question now is, what's the risk status of this patient? They're either moderate or high. And why would they be high? Okay, well the true answer is they're moderate. So let's go through this. So renal function we know is normal. They have an elevated PVR because they're doing intermittent catheterization. But when you look at the urinary tract, there's no hydronephrosis. There is a stone, but to put it in the high risk group, they need to have multiple stones, obstructing stones or a staghorn stone. Just having a small stone non-obstructing is not anything that's really worrisome at this point. It does need to be followed over time. And so this person at this category is moderate. And what that means is that the person should have kind of follow-up. Now, the question is, knowing that they have a stone, what would you get in follow-up? Remember, this person could have an ultrasound imaging every one to two years. They're gonna come back in a year. Would you image them again? And if so, what image would you do? So they're coming back in one year. What I would do with a known three millimeter stone, I would probably repeat an ultrasound at the one year mark. And really the ultrasound is giving me some idea, is it growing or not, the location of it. At standard KUB in a neurogenic patient, it's hard to see a small stone. The biogas patterns are high. And so ultrasound can give you a lot more information in that scenario. If I found out that it's a still three millimeter stone a year later, I would probably push off an ultrasound for a couple of years, unless they're symptomatic with things. So again, this is upper tract imaging every one to two years. So what would you do for this patient? They're leaking, they have detrusor activity. We know the stone we're just gonna follow, but would you, so if someone says add mirbegron, would someone use onabotulinum toxin A, blood augmentation? I think within your own practices, unless you're doing Botox yourself, certainly mirbegron. I think the fact of the matter is combination therapy is probably, we don't have the evidence to it. We know that great evidence using onabotulinum toxin A is probably the best evidence we have for this patient if they'd like to use that. Blood augmentation would be a little too strong for that. So I think with that, I'm gonna pause in this next one and kind of bring it to Gina to take through her case. Yeah, so the question was for this patient would you probably fluid restriction regarded I think I think one thing we didn't talk about is actually voiding logs is really a key component. You really want to see what the patient is doing and how sort of compliant they are. And so, yes, you want to do everything you can do beforehand before pharmaceutical therapy or other modalities to do that. And so I think that is a key component. One thing that's going to be exciting in our technology coming forward is we do have technologies of personal ultrasounds. So patients do have the ability to put little personal ultrasounds on, and they will have their phone kind of ring when it gets to a certain volume. There's also innovative technology coming that actually instead of just ultrasound, we actually have monitoring of volume and pressure within the bladder ambulatory. And so there's going to be a day where our patients will have what I call a closed-loop system. Basically, we all know when our brain senses urgency, they're going to have a closed-loop system that says, oh, your bladder is now 400 mLs. You should catheterize. Or your bladder has reached 15 centimeters of water. You should catheterize. And so there may be a day that we don't need to look at volume of intake. There may be a day that just says, we're going to program it and tell you when you're going to be at risk, and consequently then catheterize. I think that's going to happen, and hopefully that happens in the next few years. But... I think we're going to bypass... I think we're going to... I think from a time standpoint, I may bypass the other cases. I hope that's okay. I already have a couple of questions that have come in from our online participants that I do want to get to those. If there are other questions in the room, please come up to the mic in the center. I'll start with the first question from online, and it says, we have found that skilled nursing facilities are not willing to accept people needing digital stimulation or manual evacuation. Has this been your experience, and if so, have you been able to convince SNFs to accept admission or change the bowel program? I'll look to you as well. So... Actually, my most recent experience with this was actually this week, that the denial was not... It wasn't a denial. The message that we got back was not around the bowel care. It was actually around intermittent catheterizations. And they said very clearly, we will not do that when the patient gets to the skilled nursing facility. So we had to put in an indwelling catheter in order to get that patient to the skilled nursing facility. My experience around the bowel care is just knowing that it's generally not going to be done well. They'll read the orders, and they'll say, well, we can do a suppository every day. But it's not with proper positioning. It's not with manual evacuation. It's not with digital stimulation. It's not the rest of the bowel program. But if they interpret that as, yes, I can do a suppository every day, we haven't had denials based on that. Your experience? Same. Same. Okay. And then the other online question, I think will be quick, to Mike. Do you suggest any long-term screening for bladder cancer in people with SCI? I don't know. Can you turn on the mic? Some regards? So long-term screening, actually, the guidelines we have are really based on the symptoms of hematuria. Hematuria is going to be the biggest component to it. And if you have hematuria, not just microscopic, but gross hematuria, then that requires a full evaluation, not only in upper tract imaging, but lower unit tract with cystoscopy would be the key. And using cytologies has not been found to be very effective in patients who have neurogenic lower unit tract dysfunction, unless you have known bladder cancer. Thanks. So thank you all for your input. I have a number of patients who, despite as much education as we try to give them, use their autonomic dysreflexia as a signal to either use their suppository or an enema or to straight cath themselves. And have you found anything that's effective to get them to not use that strategy? I guess I tell them as long as it's not persistent. I mean, you know, I think there's fluctuations in blood pressure even in like normal folk, right, when your bladder is full and you need to go. So same thing for people with spinal cord injury. So as long as it's not persistent and it is relieved right away, as soon as possible is my response. Thanks so much for the talk. So with Senna, I've had some, so on pediatric rehab, I've had some pediatric GIs really not like Senna because of the staining, obviously, of the colon. And so then later colonoscopies being difficult. And so some people talk about doing a washout period so you're not missing anything. I've also seen, you know, when they had some, you know, opinions about Senna, I looked into literature and there's a handful of things wondering if there's a connection with colon cancer. So it doesn't seem like any of the evidence there is very strong at all. So I'm just wondering how you navigate that. Do you talk to your patients about, there's this question in the literature that's not very clear. I'm just curious. Yeah. I think you're right. My understanding of literature is it's not very clear. So my general conversation is something along the lines of everything in medicine is risk and benefits. So if that's what we've landed on as this is what's needed for an effective bowel program and you can avoid a lot of the other complications and quality of life issues, and we don't know. what the real risk is from a cancer standpoint, it's a conversation and it's education. And I really choose SANA first because before oral bisacodyl, only because oral bisacodyl actually creates more discomfort in patients. So we want them to be compliant and we don't want them to have pain. And so therefore the choice of SANA before, and we don't have too many options. I enjoyed the lectures. Regarding the pathways, I guess the four pathway circuits, whatever, you mentioned bladder distension goes to the brain. I didn't quite get where it went to and then to the cingulate gyrus. And the cingulate gyrus suppresses the pontine mixturition center? As you tend to go, once it gets to the pontine mixture center is basically in the brainstem, but it moves up to the periatrodactyl gray. That's actually the component to it. And from there, it actually goes to four different areas. So it's not like a straight on and each area then has its internal component coming back to the periatrodactyl gray and the pontine mixtures in the center. And I can meet with you afterwards to kind of go through in detail. Yeah, like that. Thank you. I think we have time for the last two questions here. Go ahead. Thanks, John Lewis, Brady Children's here in San Diego. Do you have a preferred bowel clean out both inpatient and outpatient? You know, the post-PICU who's all backed up versus the person who's at home? We actually did talk about this about, oh, this was one of the cases. No, we talked about this in our clinical practice guidelines about do we come up with recommendations particularly around colonoscopy prep and things like that. And there really weren't good studies. There's no good evidence. So it's a lot of clinical practice and expert opinions. But what did you land on in your case? So essentially, we use what we like using. And this is just for not colonoscopy prep, right? This is just like for regular. I mean, to me, the easiest is using magnesium citrate because it's smaller volume and easier for patients to take. And they're more compliant. And you don't necessarily need to get to the point where you're doing colonoscopy prep, right? You just want to flush things out. And in addition to that, and this is not evidence-based, this is just the way I do it. You know, I add on maybe two to three tablets of SENA with every bottle of magnesium citrate. And it depends on, I do an abdominal x-ray to see how backed up they are. If they're severely backed up, then I get more aggressive. I do three times per day for two days, right? If they're not that backed up, if there's like moderate constipation, then I would probably just do two days. Thank you for the talk. I had a question. I'm also from Rady Children's as well here in San Diego. I had a question about your transanal irrigation. For the anal probes, the ones that have patchless, wide open anuses, they can't hold the anal balloon in there. So we end up using cone enemas. For the volume of cone enemas, or a transanal irrigation system, what volumes do you use? Because we typically use 20 mLs per kilogram up to about 1,800 mLs. And then I also saw you mention milk and molasses. What volume of milk and what volume of molasses would you use for a cone enema? Thank you. There are recipes out there. Again, it's not evidence-based, but I think it's one part, or one mL of molasses to 10 mLs of milk, at least. And there, again, there are many different recipes. And I like choosing milk and molasses because it's more organic than soap suds or fleets or whatever. And for the cone enemas, you can go up to one liter, 1,000 mLs if you need to, or more. Again, with a cone, you don't get as high up, so you might need more volume rather than doing the catheter with a balloon. I do think we have one more online question, and then we're gonna wrap up. But it says, for a pediatric bladder, what percent PVR is an indication for intermittent cath? So the guidelines are actually for adult. They were not pediatric guidelines. And I think the pediatric population, there's no real known PVR. A lot of it's still based on, if you look at functional bladder capacities, meaning what their voided amount is versus their PVR. Normally if someone is more than 1 3rd PVR than their voided amount, it would be time to do catheterization. Great. So thank you all. I really appreciate your attention. Thank you for coming. Couple of take-home points. You notice some of the terminology difference with the new guidelines in both of these areas. One is that it's neurogenic bowel dysfunction, not just neurogenic bowel. So just try to ingrain that. We've also switched from referring to upper motor neuron and lower motor neuron bowels. They're reflexic and areflexic, giving increased attention and recognition of the enteric or intrinsic nervous system that's helping to regulate. And then the term neurogenic lower urinary tract dysfunction rather than neurogenic bladder. So thank you very much. Thank you.

spinal cord injury

neurogenic bowel dysfunction

neurogenic lower urinary tract dysfunction

management strategies

Gianna Rodriguez

Mike Kennelly

bowel management

bladder management

patient education

individualized care

clinical guidelines