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International Standards to Document Remaining Autonomic Functio

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International Standards to Document Remaining Autonomic Functio Powered By Docstoc
					                                       Draft February 5, 2007
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    International Standards to Document Remaining Autonomic Function

                                   After Spinal Cord Injury




 Steering Committee: Marcalee Sipski Alexander, Fin Biering-Sorensen, Susan Charlifue, Volker Dietz, John
  Ditunno, Dan Graves, Michael Kennelly, Andrei Krassioukov, Ralph Marino, Steven Stiens, Lynne Weaver

  Urology Domain: Michael Kennelly, Diana Cardenas, Graham Creasey, Angelo Gousse, Bruce Green, Todd
                         Linsenmeyer, Brigitte Schurch, Jean-Jacques Wyndaele

                   Bowel Domain: Steve Stiens, Irene Estores, Klaus Krogh, Inder Perkash,

Sexual Function Domain: Marcalee Sipski Alexander, Don Bodner, Nancy Brackett, Stacy Elliott, Amie Jackson,
                                              Jens Sonksen

 Cardiovascular, Sudomotor and Thermoregulatory Domain: Andrei Krassioukov, Ann-Katrin Karlsson, Ralph
                        Marino, Christopher J. Mathias, Jill Wecht, Lisa Wuermser




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Abstract:

       The impact of specific spinal cord injury on a person’s neurologic function is generally

described through the use of the International Standards for the Neurological Classification of

Spinal Cord Injury. These standards document the remaining motor and sensory function that a

person may have; however they do not provide information about the status of a person’s

autonomic function. Based on this deficiency, the American Spinal Injury Association and the

International Spinal Cord Society commissioned a group of international experts to develop a

common strategy to document remaining neurologic function. Four subgroups were

commissioned: bladder, bowel, sexual function and general autonomic function and the experts

communicated via email and phone to develop a format. This on line communication was

followed by a face to face meeting held at the combined meeting of the two organizations on

Boston, Massachusetts in June 22nd, 2006. This paper presents the information which was

agreed upon at this meeting and presented in summary format at a course on Measurement in

Spinal Cord Injury, held on June 24th, 2006. Topics include an overview of autonomic anatomy,

classification of cardiovascular, sudomotor and thermoregulatory function, bladder, bowel and

sexual function. Primary anatomic diagnoses and secondary diagnoses are provided for the latter

three areas.




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Introduction

        Currently, The International Standards for the Neurological Classification of Spinal Cord

Injury are used to document impairments of motor and sensory function after spinal cord injury

(SCI). These standards are now in the sixth edition. A major revision occurred in 1992 when the

first internationally accepted standards were published.1 Changes included a revised definition of

complete and incomplete injuries, the modification of the Frankel scale to the ASIA Impairment

scale, and addition of sensory scores. Subsequently, a teaching package consisting of a reference

manual2 and videotapes was developed. Both the International Standards for Neurological

Classification of Spinal Cord Injury (ISNCSCI) and the reference manual have since been

revised, with the Standards reprinted in 20023 and the reference manual in 2003.4 The

International Standards increasingly have been used to document remaining spinal cord function

in clinical trials related to SCI.

        Despite success with the current standards, assessment of the spinal cord components of

autonomic function that affect a majority of organs is lacking. In fact, the measures included

thus far provide limited data to predict possible cardiovascular dysfunction, capabilities in

voluntary voiding, defecation and sexual responses. In contemplating bladder, bowel and sexual

function, it was clear that the autonomic contributions to organ level function are significant, but

changes in the autonomic nervous system are difficult to document via bedside examination.

Nonetheless, the significant contributions to quality of life that come from successful activities at

the person level such as voluntary voiding, defecation, social continence and sexual function

inspired the committee to seek out incremental measures of autonomic end organ function as

well as pelvic floor reflex and voluntary function that might be used to document remaining

autonomic function post SCI. Thus, these standards have been developed by an international



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committee, designed to include representatives from the American Spinal Injury Association

(ASIA), the International Spinal Cord Society (ISCoS) and other research groups performing

SCI clinical trials. In addition, participation of members from the basic science community was

sought.

          The goal of these standards is to describe the impact of SCI on particular organ systems

function. These standards are not meant to provide recommendations for treatment of specific

organ systems. Rather, the standards allow clinicians and researchers to describe the effects of

SCI on bowel, urinary bladder, sexual, cardiovascular, sudomotor and other autonomic functions.

          Because of anatomic relationships, the standards include a general anatomic diagnosis for

the impact of SCI on urinary bladder, bowel and sexual function. In addition, a secondary

classification describing the detailed impact of injury on each of these separate organ systems is

included. Definitions are also provided in each area. A similar though separate process is used

for the autonomic control of cardiovascular and sudomotor function, including thermoregulation.

General anatomic and physiologic considerations

          Blood vessels, heart, sweat glands, bowel, urinary bladder and sexual functions are under

nervous system control: autonomic (involuntary), somatic (voluntary) or both. During

micturition and defecation there are coordinated actions of the external urethral and anal

sphincters (both under voluntary cortical control by the somatic nervous system) and smooth

muscles of the bladder and the bowel (both under involuntary control by the autonomic nervous

system). Cortical control also plays an important role in sexual arousal resulting in psychogenic

erection and vaginal lubrication. However, erection and lubrication can be achieved with

peripheral stimulation, even when cortical influences are disrupted. On the other hand, many

aspects of cardiovascular and sudomotor control are primarily dependent on sympathetic and



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parasympathetic nervous system activity. SCI disrupts the descending spinal voluntary motor

and involuntary autonomic pathways, resulting in dysfunctions of the cardiovascular system,

sudomotor, urinary bladder, bowel and sexual organs. The level and the severity of injury to

these pathways results in a variety of autonomic dysfunctions depending on the altered balance

of activity between the sympathetic and parasympathetic nervous systems. 5




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         Figure 1: Autonomic nervous system: Schematic organization and innervation of major organs.
Sympathetic Parasympathetic
                    CN X




                    C1
   C1
                    C2
   C2                        Organ                                        Sympathetic       Parasympathetic   Somatic/Motor
                    C3
   C3                                                                     Nervous           Nervous System
                    C4
   C4
                    C5                                                    System
   C5
                    C6       Heart                                        T1-T5             Cranial Nerve X   None
   C6
                    C7       Blood vessels
   C7
                    C8       Upper body                                                                       None
   C8                                                                     T1-T5             None
                    T1
   T1                        Lower body                                   T5-L2
                    T2
   T2                        Urinary bladder
                    T3
   T3                        Detrusor
                    T4
   T4
                    T5       Bladder neck
   T5                                                                                       S2-S4
                    T6       Internal urethral sphincter                  T10-L2                              UMN+LMN
   T6
                    T7       External bladder sphincter
   T7
                    T8
   T8                        Gastro-Intestinal tract
                    T9
   T9
                    T10      From esophagus to splenic flexure
   T10
                    T11      From splenic flexure to rectum                                 CN X
   T11
                    T12      Internal anal sphincter                      T1-L2             S2-S4             UMN+LMN
   T12
                    L1       External anal sphincter
   L1
                    L2
   L2                        Reproductive organs
                    L3
   L3
                    L4
                             Penis
   L4                        Vagina                                       T10-L2            S2-S4             UMN+LMN
                    L5
   L5                        Uterus and other reproductive organs
                    S1
   S1                        Testicles and other reproductive organs
                    S2
   S2
                    S3
   S3
                    S4
   S4
                    S5                                                                                                   6
   S5
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Autonomic nervous system: anatomy and function

          The autonomic nervous system commonly is subdivided into two major parts: the

sympathetic and parasympathetic components.6 The enteric nervous system is specific to the

gastrointestinal tract and is often considered the third part of the autonomic nervous system.

Most of the visceral organs are innervated by both components of the autonomic nervous system.

The sympathetic and parasympathetic systems are integrated functionally with each other and

provide balanced regulation of innervated organs.

          Certain cortical structures, and the hypothalamus, contribute to regulation of the

autonomic circuits within the brainstem and spinal cord. These cerebral structures should be

intact morphologically but there may be functional alterations following SCI.

          Both divisions of the autonomic nervous system have two neuronal populations

interposed between the central nervous system and target organs. The first neuron is called the

preganglionic neuron, with the cell body within the gray matter of the brain or spinal cord.

Axons of these neurons, called preganglionic fibers, travel within the ventral roots of the spinal

cord or cranial nerves. These fibers synapse on the second group of neurons, called

postganglionic. This group of neurons is located within the autonomic ganglia in the peripheral

nervous system. The axons of these neurons, called postganglionic fibers, innervate the target

organs.

          Sympathetic preganglionic neurons reside in the spinal gray matter in the thoracic (T1-

T12) and upper lumbar segments (L1-L2) of the spinal cord.6,7 The majority of sympathetic

preganglionic neurons are localized within the lateral horns or intermediolateral nucleus of the

spinal cord. A small proportion of sympathetic preganglionic neurons are found near the central

canal of the spinal cord. Axons of the sympathetic preganglionic neurons exit through the



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ventral roots and synapse on postganglionic sympathetic neurons located in the spinal

paravertebral ganglia (sympathetic chain ganglia) and prevertebral ganglia (the celiac, superior

and inferior mesenteric ganglia). The postganglionic neurons then send their axons via the

peripheral nerves to innervate the target organs, including the heart, blood vessels, sweat glands,

sexual organs and smooth muscles within the gut and bladder (Figure 1).

       Parasympathetic preganglionic neurons are located within the nuclei of four cranial

nerves (CN III, VII, IX, X) in the brainstem and within the sacral spinal segments (S2-S4).

Parasympathetic control of the cardiovascular system and the upper portion of the

gastrointestinal tract is through the vagus nerve (CN X), which exits from the brain through the

base of the skull and synapses with the sino-atrial node and the nerve cells within the enteric

nervous system of the gut. There is no parasympathetic innervation of the peripheral

vasculature. Parasympathetic innervation of the bladder, reproductive organs, and lower portion

of the gut is provided by the sacral portion of the spinal cord (S2-S4).

       Neural control of cardiovascular system

       Vessels in the upper portion of the body and the heart receive sympathetic innervation

from the T1-T5 spinal sympathetic neurons (Figure 1), while the major vasculature beds in the

gut and lower extremities are under the control of the T5-L2 spinal sympathetic neurons (Figure

1). In addition to sympathetic fibers, the sino-atrial node is also innervated by postganglionic

parasympathetic fibers from the vagus nerve, providing tonic inhibition of the heart to lower

heart rate (CN X, Figure 1).

       Dual innervation of the heart and the segmental differences in sympathetic innervation to

a variety of vascular beds are particularly important for the understanding of basal blood pressure




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and heart rate, as well as cardiovascular responses following cervical, mid-thoracic, or lower

thoracic SCI. 8,9

        Neural control of sweat glands

        Similar to blood vessels, the sweat glands are predominantly under sympathetic control.

The difference however, is that sympathetic innervation to glands is cholinergic, unlike blood

vessels which are sympathetic adrenergic. Sweat glands in the upper portion of the body receive

sympathetic innervation from T1-T5 spinal sympathetic neurons (Figure 1), while the glands of

the lower part of the body are under the control of the T5-L2 spinal sympathetic neurons ( Figure

1). There is also supraspinal control of sweating, now better defined in humans using

neuroimaging studies.10

        Neural control of the lower urinary tract

        Lower urinary tract function is controlled by neural circuits in the brain and spinal cord

that coordinate the activity of visceral smooth muscle in the urinary bladder and urethra with

activity of striated muscle in the external urethral sphincter.11,12,13 Lower urinary tract function

involves central pathways (supraspinal and spinal) and peripheral pathways (pelvic

parasympathetic, lumbar sympathetic, and somatic pudendal nerve).

        Axons of Onuf’s nucleus in the sacral cord segments innervate the external urethral

sphincter via the pudendal nerve. The bladder also receives sympathetic innervation via

hypogastric nerves and parasympathetic innervation via pelvic nerves. Afferent information

from the bladder enters the sacral spinal segments and synapses on interneurons that either make

local segmental connections with motor pathways or send their axons to the brain. These

ascending neurons connect with structures in the brainstem, including the pons and

periaqueductal grey matter of the midbrain to execute reflex functions, and with higher centers of



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the brain mediating the conscious perception of sensations arising from the lower urinary tract.

Activation of the sympathetic circuits via spinal reflexes mediates detrusor muscle and bladder

neck relaxation with contraction of the internal urethral sphincter, resulting in storage of urine.

However, activation of the parasympathetic efferents results in detrusor contraction and

promotes voiding. Finally, volitional voiding can be achieved only with voluntary relaxation of

the external urethral sphincter, allowing release of urine.

       The lower urinary tract micturition reflex pathway has been described as a switch-like

function between two modes of operation: storage and elimination. In infants these switching

mechanisms function in a reflex manner to produce involuntary voiding; however, in adults urine

storage and release are subject to voluntary control as a result of connections between the

forebrain and brainstem.

       Neural control of the bowel

       Similar to the lower urinary tract, bowel function requires the coordinated activity of the

somatic and autonomic nervous systems. Colonic peristalsis is coordinated by a network of

neurons linking the brain to the colonic mucosa. Cranial nerve X courses from the brainstem

(Figure 1) and innervates the gut to the splenic flexure of the colon. The inferior splanchnic

nerve carries pelvic parasympathetic fibers from the sacral segments of the spinal cord to the

splenic flexure, the left colon, and rectum. The enteric nervous system includes the Auerbach’s

plexus (intramuscular myenteric), unmyelinated fibers and postganglionic parasympathetic cell

bodies that mainly coordinate motility. Under the mucosa, Meissner’s plexus relays sensory and

local motor responses. The internal anal sphincter is a continuation of the circular muscle layer

of the rectum under reflex control by the enteric nervous system segments S2-4 of the spinal

cord. The external anal sphincter and pelvic floor are supplied by the mixed motor and sensory



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somatic pudendal nerve providing voluntary control. There is also evidence of sympathetic

control of the external anal sphincter.

        The bowel functions of storage, stool propulsion, and defecation are dependent on

coordinated control from the two components of the autonomic nervous system, the enteric

nervous system and voluntary motor control of the skeletal muscles of the pelvic floor and

external anal sphincter.14,15

        Neural control of sexual responses

        Male and female sexual organs receive innervation from both components of the

autonomic nervous system. Similar to the lower urinary tract, sympathetic innervation is

provided via the hypogastric nerve and parasympathetic innervation via the pelvic nerve.

Psychogenic erection and vaginal lubrication are thought to be regulated by the sympathetic

nervous system in conjunction with the parasympathetic, whereas reflex erection and vaginal

lubrication are thought to be activated by the parasympathetic nervous system.16,17,18,19

        Ejaculation is a neurologically more complicated phenomenon and relies on the

coordination of the sympathetic (T11-L2) and parasympathetic nervous systems (S2-4) in

addition to the somatic nervous system via the pudendal nerve (S2-4). Ejaculation and orgasm do

not always coincide. The neurologic control of orgasm is less well understood; however, there is

evidence relating autonomic and sacral somatic nervous system function and orgasm.16




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       Assessment of autonomic function in SCI

       In addition to already established motor and sensory assessment standards, the

assessment of specific autonomic functions should be part of the clinical evaluation of

individuals with SCI.

       Assessment of cardiovascular, sudomotor and temperature regulation

       Autonomic dysfunctions, including abnormal blood pressure and heart rate control, and

disorders of sweating and temperature dysregulation are common consequences of SCI in

humans.8,9 However, there is relatively limited information on the relationship between the level

of SCI lesion and completeness and the degree of autonomic dysfunction. With time also there

may be changes in plasticity in cerebral areas of relevance to autonomic function that may

influence emotional, motivational and other behavioural responses in spinal cord injury.19

Although there are numerous clinical tests to assess autonomic functions,20 the complexity and

organization of the autonomic nervous system and its involvement in the control of almost every

system in the body makes it difficult to select autonomic function tests appropriate to SCI. This

is being addressed, in addition to autonomic tests that define the completeness of the lesion.

These have been described for sympathetic adrenergic and for sympathetic cholinergic

autonomic pathways.21,22 However, experience with these tests in the clinical assessment of

individuals with SCI is limited, and uniform operational definitions of dysfunction are lacking.

       The recognition and assessment of orthostatic hypotension, autonomic dysreflexia,

cardiac arrhythmias, temperature dysregulation, and abnormalities of sudomotor function is

recommended.23 Use of a table to document the specific autonomic dysfunctions that have

clinical implications is recommended. (Table 1)




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 Effects of Spinal Cord Injury on cardiovascular, sudomotor, temperature
 (Check if condition is present)




Condition                    Definition                                                                                             yes   no
Cardiac dysrhythmias         Bradycardia*
                             Ventricular tachydysrrythmias

Orthostatic hypotension      A symptomatic decrease in blood pressure usually exceeding 20 mmHg systolic or 10 mmHg
                             diastolic on moving from the supine to an upright position.
                             Symptoms include dizziness, headache or “coat hanger” neck ache, fatigue

Autonomic dysreflexia        A constellation of signs and/or symptoms in SCI above T5-6 in response to noxious or non-
                             noxious stimuli below the level of injury defined by an increase in blood pressure (more than
                             20mm Hg above baseline), and which may include one of the following symptoms: headache,
                             flushing and sweating above the level of the lesion, vasoconstriction below the level of the lesion,
                             and dysrhythmias. This syndrome may or may not be symptomatic and may occur at any period
                             following SCI.

Temperature                  Elevation or decrease in body temperature without signs of infection. It may result from exposure
dysregulation                to environmental temperature change.

Sweating abnormalities:
Hyperhidrosis                Non physiological sweating in response to noxious/non-noxious stimuli, positioning, etc.

Hypohidrosis                 Lack of sweating in denervated areas in response to a rise in temperature.

*It is recommended that after SCI, bradycardia is considered a heart rate under 60 bpm




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       Assessment of Urinary Bladder, Bowel and Sexual Function

       Primary anatomical classification

       The use of a primary anatomical classification to describe the impact of SCI on urinary

bladder, bowel and sexual function is recommended. This includes the terms supraconal, conal

and cauda equina. Supraconal refers to those injuries occurring above the conus medullaris. In

general these injuries cause an overactive or upper motor neuron pattern of damage affecting

these organ systems. Conal injuries include those affecting the conus medullaris of the spinal

cord. These injuries often cause a mixed lesion to these organ systems with a resultant overactive

or acontractile picture. Cauda equina injuries include those affecting the cauda equina. These

injuries generally cause an acontractile or lower motor neuron picture affecting these three organ

systems.

       It should be noted that the primary anatomical classification for autonomic function is

intended to be used in conjunction with the ISNCSCI, thus, in addition to using the above

terminology, one should provide information on the completeness of injury as determined by the

preservation of perianal and anal sensation, voluntary anal contraction, and the type of reflex

activity present.




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Detailed Urodynamic Classification
This classification is based upon urodynamic observations made during urodynamic studies. The
definitions of urodynamic observations associated with lower urinary tract dysfunction are in
accordance with the International Continence Society Standardization of Terminology report.24
The detailed urodynamic classification includes the status of the detrusor, sphincter and
sensation during filling.

   •   Sensation during filling (Se)
           o Normal (N)
           o Increased (I)
           o Reduced (R)
           o Absent (A)
           o Non-specific (X)
       Normal bladder sensation can be judged by three defined points noted during filling
       cystometry and evaluated in relation to the bladder volume at that moment and in relation
       to the individual’s symptomatic complaints.
                   • First sensation of bladder filling is the feeling the patient has during
                      filling cystometry, when he/she first becomes aware of the bladder filling.
                   • First desire to void is the feeling, during filling cystometry, that would
                      lead the patient to pass urine at the next convenient moment, but voiding
                      can be delayed if necessary.
                   • Strong desire to void is defined, during filling cystometry, as a persistent
                      desire to void without the fear of leakage.
       Increased bladder sensation is defined, during filling cystometry, as an early first
       sensation of bladder filling (or an early desire to void) and/or an early strong desire to
       void, which occurs at low bladder volume and which persists.
       Reduced bladder sensation is defined, during filling cystometry, as diminished
       sensation throughout bladder filling.
       Absent bladder sensation means that, during filling cystometry, the individual has no
       bladder sensation.
       Non-specific bladder sensations, during filling cystometry, may make the individual
       aware of bladder filling, for example, abdominal fullness or vegetative symptoms.

   •   Detrusor (D)
           o Normal (N)
           o Overactive (O)
           o Underactive (U)
           o Acontractile (A)
       Normal detrusor function: allows bladder filling with little or no change in pressure. No
       involuntary phasic contractions occur despite provocation. Normal detrusor Function in
       the voiding phase is achieved by a voluntarily initiated continuous detrusor contraction
       that leads to complete bladder emptying within a normal time span, and in the absence of
       obstructions.




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    Detrusor overactivity is a urodynamic observation characterized by involuntary detrusor
    contractions during the filling phase which may be spontaneous or provoked. Detrusor
    overactivity in the case of spinal cord injury is generally neurogenic detrusor
    overactivity. It is recommended this term is used in lieu of "detrusor hyperreflexia"
    Idiopathic detrusor overactivity can also occur without defined cause.
    Detrusor underactivity is defined as a contraction of reduced strength and/or duration,
    resulting in prolonged bladder emptying and/or a failure to achieve complete bladder
    emptying within a normal time span.
    Acontractile detrusor is one that cannot be demonstrated to contract during urodynamic
    studies.

•   Sphincter (Sp)
        o Normal urethral closure mechanism (Ncm)
        o Normal urethra function during voiding ((Ndv)
        o Incompetent (I)
        o Detrusor sphincter dyssynergia (D)
        o Non-Relaxing sphincter (NR)
    Normal urethral closure mechanism maintains a positive urethral closure pressure
    during bladder filling even in the presence of increased abdominal pressure, although it
    may be overcome by detrusor overactivity.
    Normal urethra function during voiding is defined as a urethra that opens and is relaxed
    continuously to allow the bladder to be emptied at a normal pressure.
    Incompetent urethral closure mechanism is defined as one that allows leakage of urine
    in the absence of a detrusor contraction.
    Detrusor sphincter dyssynergia is defined as a detrusor contraction concurrent with an
    involuntary contraction of the urethral and/or periurethral striated muscle during voiding.
    Occasionally, flow may be prevented altogether.
    Non-relaxing sphincter is defined as obstruction during voiding that usually occurs in
    individuals with a sacral and cauda equina lesions, such as meningomyelocele, and is
    characterized by a non-relaxing, obstructing urethra resulting in reduced urine flow.




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Detailed Bowel Function Classification
This information is based on the clinical examination and history.

Sensation of need for a bowel movement (Se)
       Normal, unchanged (N)
       Reduced (R)
       Absent, no sensation of need for a bowel movement (A)

Continence of stool (C)
      Normal (N)
      Reduced (R)
      Absent (A)

Bowel Movements per typical week (BM)
      Record number for each category: (X=number of occurrences)
      Unplanned BM per typical week (UX)
      Coordinated and voluntary BM per typical week (VX)
      BM facilitated with bowel care per typical week (FX)

Method of bowel care (M)
      Normal (N)
      Feels stool in rectum but needs to trigger bowel movement with bowel care (R)
      Does bowel care on schedule but does not sense need (BP)
      Absent bowel care method: allows involuntary bowel movement to occur (A)

Voluntary sphincter contraction (Sp)
       Normal contraction (N)
       Reduced (R)
       Absent voluntary sphincter contraction (A)

Average time for bowel care: ___________________minutes




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Detailed Male Sexual Function Classification
Definitions

Erection: Increase in penile tumescence with resulting increase in size and firmness of the penis.
In usual circumstances should be adequate to allow penetration. In able-bodied men erections are
usually a combination of psychogenic and reflex; however, in men with SCI, varying types of
erectile function may occur.

Psychogenic Erection: Erection that occurs solely based on arousal in the brain e.g. through
hearing, seeing, feeling or imagining erotic thoughts. Potential may be based on degree of
preservation of sensory function in T11-L2 dermatomes

Reflex Erection: Erection that occurs solely based on genital or sacral stimulation. Potential
may be based on presence of reflex function in S2-5 spinal segment

Ejaculation (antegrade): The release of semen externally from the penis.

Orgasm: The perception of pleasant sensations from sexual stimulation, or reaching a climax
after which the person with SCI feels satisfied. May be accompanied by an overall increase and
then decrease in muscle tone.

Sexual Dysfunctions:25

Sexual Desire Disorder (identical for males and females): Diminshed or absent feelings of
sexual interest or desire, absent sexual thought or fantasies and a lack of responsive desire. The
lack of interest is considered to be beyond a normative lessening with life cycle and relationship
duration

Erectile Dysfunction: the consistent or recurrent inability of a man to attain and/or maintain
penile erection sufficient for sexual activity.

Early ejaculation: ejaculation that occurs sooner than desired, either before or shortly after
penetration over which the individual has minimal or no control.

Delayed ejaculation: undue delay in reaching a climax during sexual activity.

Orgasmic dysfunction: inability to achieve an orgasm, markedly diminished intensity of
orgasmic sensations or marked delay of orgasm during conscious sexual activity.




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Classification:
Based primarily on history:

Sexual Dysfunction (Dys):
Based on history and presence of personal distress
Present, if present indicate type based upon above definitions: (P)
Absent (A)
Unknown (U)

Psychogenic erection (EP)
Normal (N)
Reduced: Possible, though partially impaired (R)
Absent (A)
Unknown (U)

Reflex arousal (RA)
Normal (N)
Reduced: Possible, though partially impaired (R)
Absent (A)
Unknown (U)

Ejaculation (Ej)
Normal (N)
Reduced: Present without devices (R+)
Reduced: Present with devices (R-)
Absent (A)
Unknown (U)

Orgasmic Function (O)
Potential since injury based on history
Normal sensation: Present with ejaculation (N+)
Normal sensation: Present without ejaculation (N-)
Reduced sensation: Present with ejaculation (R+)
Reduced sensation: Present without ejaculation (R-)
Absent (A)
Unknown (U)




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                                    Draft February 5, 2007
                   Not to be reproduced without permission of ASIA and ISCoS:
                           For further inquiries contact msipski@uab.edu


Detailed Female Sexual Function Classification
Definitions:

Genital arousal: increased genital vasocongestion that usually manifests itself with the presence
of clitoral engorgement and vaginal lubrication, among other signs.

Psychogenic genital arousal: increased genital vasocongestion and other changes that occur
solely based on arousal in the brain e.g. through hearing, seeing, feeling or imagining erotic
thoughts. Potential may be based on degree of preservation of sensory function in T11-L2
dermatomes.

Reflex genital arousal: increased genital vasocongestion that occurs solely based on genital or
sacral stimulation. Potential may be based on presence of reflex function in S2-5 spinal segment.

Orgasm: the perception of pleasant sensations from sexual stimulation, of reaching a climax
after which the person with SCI feels satisfied. May be accompanied by an overall increase and
then decrease in muscle tone. Research indicates that lack of S2-S5 sensation and absent BC and
anal wink reflexes (A) may lead to decreased orgasmic potential

Genital sexual arousal dysfunction: absent or impaired genital sexual arousal

Subjective sexual arousal dysfunction: absence of or markedly diminished feelings of sexual
arousal (sexual excitement and sexual pleasure), from any type of sexual stimulat ion. Vaginal
lubrication or other signs of physical response still occur.

Combined genital and subjective arousal dysfunction: absence of or markedly diminished
feelings of sexual arousal from any type of sexual stimulation as well as complaints of absent or
impaired genital sexual arousal.

Persistent sexual arousal dysfunction: spontaneous, intrusive and unwanted genital arousal
(e.g. tingling, throbbing, pulsating) in the absence of sexual interest and desire.

Orgasmic dysfunction: lack of orgasm, markedly diminished intensity or orgasmic sensations
or marked delay of orgasm from any kind of stimulation. There is a self-report of high sexual
arousal/excitement in this disorder.

Dyspareunia: persistent or recurrent pain with attempted or complete vaginal entry and/or penile
vaginal intercourse.

Vaginismus: the persistent or recurrent difficulties of the woman to allow vaginal entry of a
penis, a finger and/or any object, despite the woman’s expressed wish to do so. There is often
(phobic) avoidance and anticipation/fear of pain. Structural or other physical abnormalities must
be ruled out/addressed.

Sexual aversion disorder: extreme anxiety and/or disgust at the anticipation of/or attempt to
have any sexual activity.



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                                         Draft February 5, 2007
                     Not to be reproduced without permission of ASIA and ISCoS:
                             For further inquiries contact msipski@uab.edu




Classification
Sexual Dysfunction (Dys)
Present: If present indicate type: (P)
Absent (A)

Psychogenic Genital Arousal (AP)
Normal: (N)
Reduced: (R)
Absent: (A)
Unknown (U)

Reflex Genital Arousal (RA)
Normal: (N)
Reduced: (R)
Absent: (A)
Unknown (U)

Orgasmic Function (O)
Normal: (N)
Reduced: (R)
Absent: (A)
Unknown (U)

Menses
Normal: (N) Intact with sensory function similar to preinjury
Altered (Alt) Intact with altered neurologic phenomenon
Absent (A)


Conclusion:

         This document describes a new system that is in development to document the impact of
spinal cord injury on remaining autonomic function. Based upon current knowledge of the
neuroanatomy of autonomic function we have provided a framework with which to communicate
the effects of specific injuries on cardiovascular and sudomotor, bladder, bowel and sexual
function. Further revisions of this taxonomy are projected before it is proposed for general use. It
is anticipated these will be completed in 2007. In the interim, the reader is encouraged to pilot
use of the system as it exists and provide suggestions for change to Dr. Sipski at
msipski@uab.edu.




                                                                                                 21
                               Draft February 5, 2007
              Not to be reproduced without permission of ASIA and ISCoS:
                      For further inquiries contact msipski@uab.edu


References:




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