Pelvic Health Management in the Person with Neurologic Disease

Central nervous system damage or disease can have a significant negative impact on pelvic organ and pelvic muscle function, adding to the functional burden that we may observe with movement, ADL, and communication/cognition deficits. The intricacies of central nervous system involvement in pelvic organ function can be traced back to our early years of development. Learning to walk and talk as a child happens before the ability to control our bladder and bowel emptying. This level of control requires a well-developed, intricately organized central and autonomic nervous system. It is understandable then, that even minor damage to our central nervous system and nerve pathways can compromise the intricacies of the complexly integrated pelvic viscera and pelvic floor dynamic.

Neurogenic bladder, bowel, and sexual dysfunction are generally defined as an impairment in these organs that results from neurologic damage or disease. The prevalence of neurogenic bladder, bowel, and sexual dysfunction is somewhat uncertain due to limited studies in the neurologic population, however, typically the reports present a wide range. Neurogenic pelvic impairments can be highly variable and dependent on several factors including, but not limited to, lesion level, traumatic etiology (i.e., head, or spinal cord injury), non-traumatic etiology (i.e., stroke, Parkinson’s, Multiple Sclerosis), and comorbidities. The complexity of the person with a central nervous system pathology, whether it be damage or disease, can challenge even the most experienced clinician, and evaluating and treating these individuals can seem like a daunting and intimidating endeavor. Additionally, therapeutic intervention studies in the neurologic population are also less abundant, and individuals with neurologic deficits are often excluded.

Understanding your patient’s neurologic diagnosis, level of injury and corresponding probable neurological system impairments can help you decide on the best assessment and intervention strategy for your patient. Let’s first consider an upper motor neuron (UMN) lesion. This type of lesion can occur in the cortex and even down through the spinal cord descending motor tracts, which are located in the columns of the spinal cord. These individuals typically experience predominant bladder storage dysfunction or detrusor overactivity, increased muscle tone/spasticity in the pelvic floor, and reflexive bowel function. In contrast, a lower motor neuron (LMN) lesion can occur anywhere along the spinal cord within the LMN cell bodies in the anterior horns, along the pathway of a peripheral motor nerve, or at the motor neuromuscular junction. These individuals typically experience bladder storage or voiding symptoms, possible elevated post-void residuals if injury affects the sacral reflex arc, pelvic floor laxity or weakness, impaired descending and rectosigmoid transit, and areflexive bowel function.

In my course Parkinson Disease and Pelvic Rehabilitation scheduled for November 1-2, we will review basic neuroanatomy concepts. We will take a deep dive into the autonomic nervous system's control of the bladder, bowel, and sexual health organs. This will provide a general overview for considering the level of neurologic injury and the impairments you will likely observe. Parkinson disease will be our primary focus, however, my hope is that you can also begin to generalize this knowledge to other neurologic conditions that you treat in your clinic.

Resources:

• Fowler, C. J., Panicker, J. N., & Emmanuel, A. (Eds.). (2010). Pelvic organ dysfunction in neurological disease: clinical management and rehabilitation. Cambridge University Press.
• Lamberti, G., Giraudo, D., & Musco, S. (Eds.). (2019). Suprapontine Lesions and Neurogenic Pelvic Dysfunctions: Assessment, Treatment and Rehabilitation. Springer Nature.

AUTHOR BIO:
Erica Vitek, MOT, OTR, BCB-PMD, PRPC

Erica Vitek, MOT, OTR, BCB-PMD, PRPC (she/her) graduated with her master’s degree in Occupational Therapy from Concordia University Wisconsin in 2002 and works for Aurora Health Care at Aurora Sinai Medical Center in downtown Milwaukee, Wisconsin. Erica specializes in female, male, and pediatric evaluation and treatment of the pelvic floor and related bladder, bowel, and sexual health issues. She is board-certified in Biofeedback for Pelvic Muscle Dysfunction (BCB-PMD) and is a Certified Pelvic Rehabilitation Practitioner (PRPC) through Herman and Wallace Pelvic Rehabilitation Institute.

Erica has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman) BIG and is a trained PWR! (Parkinson’s Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. Erica is an LSVT Global faculty member. She instructs both the LSVT BIG training and certification course throughout the nation and online webinars. Erica partners with the Wisconsin Parkinson Association (WPA) as a support group, event presenter, and author in their publication, The Network. Erica has taken a special interest in the unique pelvic floor, bladder, bowel, and sexual health issues experienced by individuals diagnosed with Parkinson disease.