Secondary Conditions, Bowel/Bladder, and Pressure Injury Management
Neurogenic bladder
Localize the lesion. Suprasacral (upper motor neuron) injuries produce detrusor overactivity, often with detrusor-sphincter dyssynergia, risking high storage pressures, vesicoureteral reflux, stones, and renal failure. Sacral (lower motor neuron) injuries produce an areflexic, poorly contractile bladder with overflow incontinence. Clean intermittent catheterization is first-line for emptying; add antimuscarinics or a beta-3 agonist for storage pressures, intravesical botulinum toxin for refractory overactivity, and consider augmentation cystoplasty or sphincterotomy when pressures threaten the upper tracts. Monitor with urodynamics and upper tract imaging.
Bowel
Upper motor neuron bowel benefits from a scheduled program with digital stimulation and a suppository; lower motor neuron bowel often needs manual evacuation. Time the program after meals to use the gastrocolic reflex, ensure adequate fluid and fiber, and consider colostomy for refractory problems.
Pressure injury
Stage using NPIAP criteria: stage 1 nonblanchable erythema, stage 2 partial-thickness loss, stage 3 full-thickness loss, stage 4 full-thickness with exposed muscle, bone, or tendon; unstageable when eschar or slough obscures the base, and deep tissue pressure injury when intact skin shows persistent discoloration. Never downstage a healing wound. Prevention is the priority: repositioning, pressure-redistributing surfaces, skin checks, moisture management, nutrition, and treating spasticity and contracture.
Other secondary conditions
Heterotopic ossification (hips, knees), osteoporosis with fragility fractures, neuropathic pain, syringomyelia, and autonomic dysreflexia - a hypertensive emergency triggered by noxious stimuli such as bladder distension or fecal impaction.
Traps
Staging an eschar-covered wound as stage 3; treating every fever as urinary infection; missing dysreflexia.
Rule of thumb
High-pressure, low-compliance bladder is the enemy - catheterize, relax the detrusor, and image the upper tracts.