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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2745_Библиотеки_им_академика_М_И_Перельмана
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Case Study
A patient with a neurogenic bladder in follow-up presented
with the lower GI complaints of bowel irregularities now
exacerbated by the bladder therapy. Her symptoms included
severe constipation of up to 6 to 7 days longer then her
initial presentation with flatulence, cramping, and increasing
malaise, culminating with massive, often unexpected, bowel
movements. Stools were described as a mix of hard lumps
both large and medium seen initially with lumps and formed
stool. There is no hematochezia. Her stool pattern is
consistent with Bristol types 1 and 2 (Figure 17.1). These
episodes of constipation were followed by intermittent
attacks of diarrhea, which could last 1 to 2 days before
“settling down to my normal routine.” Laboratory data
reviewed were normal. Medications were re-evaluated. On
pelvic examination, a small rectocele and fecal impaction
was noted. Abdominal flat plate x-ray demonstrated severe
constipation (Figure 17.2). Neurological examination was
intact.
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FIGURE 17.2 Abdominal flat plate x-ray: severe
constipation.
Treatment
An important aspect of treating bowel disturbances in the
patient with MS is to recognize that, with MS, disease
progression, exacerbations, and remissions affect bowel
function. Revisiting the problem at regular intervals is
necessary to best maintain consistency and predictable
outcomes for the patient, reduce unwanted secondary effects
of medications on bowel regularity and adequacy of bowel
movements, and reduce secondary effects from constipation,
fecal incontinence, or both. The first line of treatment for
constipation with incontinence is lifestyle modification (Table
17.7) or a bowel training program.
TABLE 17.7
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Bowel Dysfunction in Multiple Sclerosis: Treatment—Lifestyle
Modifications
5
High-fiber diet: 25 g/d young females; 21 g/d for women >50 y; 38 g/d
males
Avoid gas-producing aliments such as sugar substitutes, caffeine, and
alcohol
Total fluid intake should be 2000 mL per day
Digital rectal stimulation
Daily abdominal massages
Exercise: CMSC Consensus Panel recommends walking 10-30 min per
day or more intense activity if patient mobility allows
PT/OT: to optimize mobility and upper and lower body strength and
enhance ADL functioning
Eat regular meals and try to have a bowel movement 15-30 min after a
warm meal
In an upright seated position with feet on the floor/stool, attempt at
defecation with abdominal Credé maneuver to facilitate the bowel
movement
ADL, activity of daily living; CMSC, Consortium of Multiple
Sclerosis Centers; PT/OT, physical therapy/occupational
therapy.
A bowel training program should:
Normalize stool consistency
Establish a regular pattern of defecation
Stimulate rectal emptying before rectal overload and
overflow leading to incontinence
Avoid diarrhea, constipation, and incontinence as side
effects
Improve quality of life
Bowel training program is reported to take 3 to 4 weeks to
establish.
13
Exercise:
Improves digestion
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Stimulates the contraction of intestinal muscles
Speeds transit time
It lessens the amount of water absorbed from the stool into the
body, which reduces the occurrence of hard, dry, painful
stools.
For patients with MS who are immobile, a home exercise
program can be devised by a physical therapist.
The role of timing elimination:
Patients should be recommended to eat at regular intervals and
choose a time about 20 to 30 minutes after a warm meal or
beverage, when the gastrocolic reflex produces an urge to
defecate, to try and have a bowel movement. Timed voiding
and bowel movements are useful in patients who do not sense
the urge to eliminate.
13
If lifestyle modifications do not result in effective elimination,
nonprescription stool softeners, stimulants, or osmotically
active laxatives that cause rhythmic contractions can be used
(Tables 17.8 and 17.9).
TABLE 17.8
Bowel Dysfunction in Multiple Sclerosis (MS): Medications That
Relieve Constipation
11
Stimulant Laxatives
Fleet Bisacodyl enema/Cascara sagrada/Senekot
Fiber Supplements/Bulk Formers
Benefiber/Citrucel/Fiberall/FiberCon/Metamucil/Naturacil/Perdiem
Stool Softeners
Colace/Chronulac syrup/Surfak
Osmotically Active and Saline Laxatives
MiraLAX/Milk of Magnesia/Modane/Pericolace
Harsh Products to be Avoided in Patients with MS:
Castor Oil
Correctol
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Dulcolax tablets
Ex-Lax
Feen-a-Mint
TABLE 17.9
Bowel Dysfunction in Multiple Sclerosis: Medications That Relieve
Diarrhea
11
Antidiarrheals (Loperamide)
Imodium and Imodium AD
Kaopectate II
Maalox Antidiarrheal
Pepto Diarrhea Control
Bulking Agents
Natural Bran
Benefiber
Citrucel
Fiberall/FiberCon
Metamucil
Perdiem
Case Study
The patient was counseled in lifestyle modifications, given a
PT/OT referral, and treated successfully with osmotically
active laxative, Miralax.
The Consortium of MS Centers Consensus Panel on
Elimination Disorders divided patients with MS-related bowel
dysfunction into two groups: constipation with incontinence
and incontinence only. These two groups were further divided
on the basis of mobility status, mobile and immobile (Figure
17.3). A minimum trial period of at least 4 weeks is
recommended for each treatment regimen to determine
efficacy of care.
5,13
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FIGURE 17.3 Consortium MS Centers Consensus Panel
Bowel Symptoms Algorithm. ADL, activity of daily living; GI,
gastrointestinal; OT, occupational therapy; PT, physical
therapy.
Reprinted with permission from Namey M, Halper J, Aliotta P, et
al. Elimination dysfunction in multiple sclerosis. Int J MS Care.
2012;14(Suppl 1):1-26. Copyright © 2012 by the Consortium of
Multiple Sclerosis Centers and Rehabilitation in Multiple
Sclerosis.
3
Sexual Dysfunction in Multiple Sclerosis
In the patient with MS, sexual dysfunction is reported to affect
80% to 90% of men and 40% to 80% of women.
4,29
Neurogenic erectile dysfunction is the inability to obtain and
maintain a penile erection to the mutual satisfaction of both
partners because of existing neurological disease. 30 It involves
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the central nervous system or the peripheral neural pathway.
Sympathetic innervation from T10 to L2 is responsible for
psychogenic erections. Parasympathetic S2 to S4 innervation
is responsible for reflexogenic erections. Somatic innervation
S2 to S4 originating in Onuf nucleus innervates the
ischiocavernous and bulbocavernosus muscles needed for
penile sensation and penile rigidity. 31 Sustained erection is
seen with increased activity in the secondary somatosensory
and temporal cortex, inferior frontal gyrus, the insula, anterior
cingulatem, and medial nucleus of the amygdala. Erection
occurs with increased activity in the hypothalamus
(paraventricular nucleus and medial preoptic area). Erectile
dysfunction in the presence of neurological disease may not be
caused by damage or pathology confined to any one area
involved in the physiology of the human sexual response but
can occur as a result of impaired neural transmission to
associated structures, afferent or efferent nerve pathways
necessary in the penile erectile response, and may be further
compromised by irregularities in steroid hormone imbalance.
30-32
The female sexual response is similar to that of men. The
erectile response in women is characterized by increased
vaginal blood flow, vaginal lubrication, and clitoral
engorgement.
33
Sources of Sexual Dysfunction
A model defining the sources for sexual dysfunction in MS
was put forth by Foley and Iverson
34,35
(Table 17.10). I have
modified the model by including “neuroendocrine” factors as
part of the primary sexual dysfunction category that affects
sexual performance as well as nerve function and clinical
presentation.
34-37,48
Gender issues play a role in sexual
dysfunction in the patient with MS. The literature is conflicted
with respect to the predominance of sexual dysfunction in one
sex over another. Historically, it was thought that sexual
dysfunction was more prevalent in men, but in a recent study
by Celik et al., 49 women report more sexual dysfunction than
men and had more secondary sexual dysfunction complaints
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than men.
38,39,49,50
Although sexual dysfunction is more
prevalent in women, the prognosis is better for women than for
men.
51,52
TABLE 17.10
Sources of Sexual Dysfunction in Multiple Sclerosis (MS)
34-47
Primary Sexual
Dysfunction:
Neurological
Physiologic
impairments due
to demyelinating
lesions in the
spinal cord
and/or brain
Numbness, sensory paresthesia in
genitalia, erectile dysfunction, loss of
vaginal lubrication
Primary Sexual
Dysfunction:
Neuroendocrine
Physiologic
impairment
involving:
Hypothalamicpituitaryadrenal axis
(HPA)
Hypothalamicpituitarygonadal axis
HPA hyperactivity: increased cortisol,
adrenocorticotropic hormone (ACTH),
dehydroepiandrosterone sulfate
(DHEAS)
The HPA hyperactivity is accompanied
with progressive disease and global
neurodegeneration
MS disturbs steroid hormone
metabolism and damages the
hypothalamus, affecting sex hormone
levels
MS interferes with the protective role of
estrogen and progesterone in myelin
metabolism and by preventing neuron
apoptosis interfering with intracellular
neuron cell death cascades
Menstrual cycle changes: Lower levels
of progesterone are associated with
more frequent MS
relapses/exacerbations.
Demyelination and cytokine release are
associated with lower testosterone
levels, hypogonadism, and impaired
semen parameters
Secondary
Sexual
Dysfunction
Nonsexual
physiological
changes affecting
sexual response
Fatigue, spasticity, bladder-bowel pelvic
floor dysfunction, and pain
Tertiary Sexual
Dysfunction
Psychosocial and
cultural issues
that interfere with
sexual
satisfaction or
performance
Role changes that stem from MS, low
self-esteem, depression, demoralization,
communication difficulties, family
support network, fear of rejection, fear
of dependency, anger
Conflicting data exist as to the effect of age, disease duration,
and occurrence. Symptoms severity of sexual dysfunction in
MS is reported by Foley and by Zorzon et al. to be related to
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disability and duration of MS.
53,54
Greer et al. reported that
age, time since diagnosis of MS, and the Expanded Disability
Status Scale score were not correlated with the incidence or
severity of sexual dysfunction.
55
Sexual dysfunction is a major cause of distress, 56 and patients
with bladder and sexual dysfunction have poorer quality of
life, as measured by the Short-Form 36 survey.
57
Normal sexual functions require the integrity of the nervous
system. 33 MS lesions on the occipital cortex compromise
female sexual arousal. Left insular cortex lesions impair
vaginal lubrication.
Arousal and lubrication issues are not affected by age, severity
of disease, time since diagnosis, cord involvement, or
depression.
58
Sexual Arousal Models
Masters and Johnson identified four stages of physiologic
response to sexual stimulation: (1) sexual desire, (2) sexual
arousal, (3) sexual orgasm, and (4) the resolution phase. These
phases of the sexual response cycle were originally proposed
as a linear model, meaning that desire must precede arousal,
arousal must precede orgasm, and so on, in a fixed linear
sequence. This model appears to work for men but is felt to
not be representative of women.
59
As evidenced from the many models put forward (Table
17.11),
28,40-43,59-64
gender differences in sex drive, sexual
motivation, sexual concordance, and capacity for orgasm exist.
Acknowledging the four phases in the Masters and Johnson
model, Basson postulated that the female cycle begins with
women feeling a need for intimacy, which leads her to seek
out and be receptive to sexual stimuli; women then feel sexual
arousal, in addition to sexual desire, resulting in an enhanced
feeling of intimacy; many women experience sexual arousal
and responsive desire simultaneously when they are engaged
in sexual activity. Kaplan in the three-phase model defined the
psychological aspect of desire as driving the two physiological
responses of arousal and orgasm.
28,40-43,60-64
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TABLE 17.11
Sexual Arousal Sexual Response Models
Male Sexual Response Cycle Models Female Sexual Response Cycle
Models
Masters and Johnson four-stage linear
model of sexual arousal and response
Kaplan triphasic linear model of
sexual response
Singer’s three sequential phase model
of sexual arousal
Toates incentive-motivation model of
sexual response
Masters and Johnson four-stage linear
model of sexual arousal and response
Kaplan triphasic linear model of
sexual response
Singer’s three sequential phase model
of sexual arousal
Whipple and Brash-McGreer circular
model of sexual arousal
Toates incentive-motivation model of
sexual response
Basson’s nonlinear model of sexual
response
In men, erectile dysfunction (Table 17.12) 33 is the most
commonly reported sexual problem that directly affects quality
of life. Cord involvement in MS may initially result in partial
erections and erections on morning waking. This presents a
diagnostic dilemma in that practitioners erroneously equate
morning erections and intermittent successful erectile response
to be diagnostic of psychogenic erectile dysfunction. As the
neurological disability progresses, men will experience
complete erectile failure as well as ejaculatory dysfunction.
33
TABLE 17.12
Most Common Sexual Dysfunction Symptom Presentation in Multiple
Sclerosis by Gender
Male Female
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