Complications of paralysis

Aperson with paralysis can develop a number of complications, including autonomic dysreflexia, sexual problemsand depression.

Autonomic dysreflexia

Autonomic dysreflexia is a potentially life-threatening complication. It can affect people with paralysis as a result of a spinal cord injury at the middle of the chest or higher.

It iscommonly seen in tetraplegia (where both the arms and legs are paralysed, also known as quadraplegia).

Autonomic dysreflexia is caused by a problem with the autonomic nervous system,the part of your nervous system that regulates many of the body'sfunctions you don'thave to think about, such as blood pressure, digestion and breathing.

It occurs when something interferes with the normal function of your autonomic nervous system. Your nervous system will send a signal to your brain to find out how to deal with the irritant. However,because ofthe injury to your spinal cord, the signal will beunable to reach your brain.

The blocked signal will then trigger a series of abnormal reflexes, which cause your autonomic nervous system to raise your blood pressure and slow your heartbeat.

Symptoms of autonomic dysreflexia

Signs and symptoms of autonomic dysreflexia include:

• a severe, pounding headache
• an intense feeling of Generalised anxiety disorder and apprehension
• intense sweating above the level of your injury
• tightness in your chest
• red blotches onyour skin above the level of your injury
• a slow heartbeat (less than 60 beatsa minute)
• dilated (widened) pupils
• goosebumps
• high blood pressure (hypertension)

If it's not treated, autonomic dysreflexia can cause seizures and bleeding inside the brain, which can be fatal.

Triggers of autonomic dysreflexia

The most common trigger ofautonomic dysreflexia is a problem with the bladder, such as:

• a urinary tract infection an infection of the kidneys, bladder, ureter or urethra
• too much urine inthe bladder
• a blocked catheter (the tube used to drain the bladder)
• the bag used to drain the bladderbeing too full
• bladder stones

Other triggers for autonomic dysreflexia include:

• constipation
• haemorrhoids (piles)
• pressure ulcers
• ingrown toenail
• burns , including sunburn
• sexual activity
• period cramps
• labour and giving birth
• bone fractures

Treating autonomic dysreflexia

The first thing to do if you suspect autonomic dysreflexia is to sit up (if possible) or raise your head upright. You should alsolower your legs if you can.

Identifying the trigger is the next important step. The most common trigger is a bladder problem, so you should check your catheter system first. Check whether:

• your catheter isblocked or twisted
• your drainage bag isfull
• the catheter isfully inserted into the drainage bag
• the drainage bag ishigher than your bladder

If you have a full bladder or are unable to pass urineand you do not have a catheter attached, you may need urgent urinary catheterisation .

If your bladder does not appear to be the trigger, check your bowel next. Use your finger or ask your trained carer to do so to check whether there are any hardened stools in your back passage.The use of lubricated glovesisrecommended. Any large, hard stools detected should be gently removed.

If neither your bladder or bowel seemto be the trigger,check your skin for any pressure ulcers or an ingrown toenail. Loosen any clothing from skin or toes that appear tobedamaged.

If you are unableto identify the trigger or relieve the symptoms using the advice above, contact your care teamimmediately. If this is not possible,call NHS 111 .

Depression

Coming to terms withparalysis, particularlyif it occurred suddenly andunexpectedly, can bedifficult and traumatic. Many people go through the classic stages of grief, as described below:

• denial initially,you mayrefuse to believeyour conditionis incurable and think you will be able to continue with your former lifestyle
• anger you may lash out at friends, family or medical staff
• bargaining you may try to bargain with your doctors, asking for any sort of "miracle cure"
• depression you may lose all interest in life and feelyour situation is hopeless
• acceptance in time, most people come to termswith beingparalysed and begin to adapt to living with the condition

Some people with paralysis find itdifficult toreach the acceptance stage andcontinue to bedepressed. It is estimated about 20 to 30% of people with permanent paralysis are affected by depression.

It is important not to ignore any signs or symptoms of depression.As well asaffecting your rehabilitation, symptoms can also quicklyworsen if they are not treated promptly.

People who experience depression after paralysis usually come to terms with the condition. One study, which looked at people living with paraplegia (paralysis of the lower limbs) for many years, found 83% reported having either an above average or average quality of life.

Sex life and fertility

Paralysis can often have an impact on a person'ssex life and fertility .However, even if you have severe paralysis, itdoes not necessarily mean you will be unable to have children or sexual intercourse.

Paralysis can sometimes affect a man's ability to get and maintain an erection, as well ashis ability to ejaculate sperm.

Erection

There are two types of erection:

• a reflex erection caused by something touching your penis or another sensitive part of your body
• a psychogenic erection caused by sexual thoughts or looking atsexually explicit images

As the nerves that control the reflex erection are located at thebase of yourspine, yourability to achieve this type of erection will usually be retained, even if your paralysis issevere.

However, the nerves that control a psychogenic erection are located much higher upthe spine, so men with high-level partial paralysis and almost any type of complete paralysis are unlikely to be able to have a psychogenic erection.

If you areonly able to have a reflex erection, it will still be possible for you to have sex, although you may find it difficultto maintain an erection for a prolonged period of time. This is known as erectile dysfunction.

Treatment options for erectile dysfunction include medication, such as sildenafil (Viagra), which increases the blood flow to your penis, and penis pumps, which create a vacuum and cause blood to flow to your penis.

Thesperm can thenbe usedinfertility treatment, such as intrauterine insemination (where a sample of sperm is implanted into a woman's womb through a tube).

A widely used technique is known as penile vibratory stimulation, wherea specially designed vibrator is placed against the underside of the penis.

The vibratorstimulates the nerve endings of the penis, triggering ejaculation. The process usually takes about 10 to 30 minutes to complete.

As it is important to store the sperm sample as quickly as possible,penile vibratory stimulationis usually carried out ina private roomat a fertility clinic.

Ifthisis unsuccessful, an alternative technique known as rectal probe electroejaculationcan be used. Again,this is usually carried outat a fertility clinic.

During the procedure, an electric probe is inserted into the rectum (back passage). The probe delivers a small electrical pulse to the rectum, which stimulates the nerves and triggers an ejaculation. The sperm can then be collected.

Women

In women with paralysis, physical libido (sex drive) and fertility are usually unaffected.

Many women may experience a reduction in their sex drive because ofconcerns about their body image or having to use a bladder or bowel control system.

You will probably find your vagina no longer becomes lubricated when you are sexually aroused. This is because nerves located higher up the spine trigger the process of lubrication.

You can compensate for this by using an artificial water-based lubricant, such as KY jelly. Do not use petroleum jelly (Vaseline) as it will irritate your vagina.

There is usually no reason why a woman who isparalysed and pregnantcannot have a vaginal delivery during childbirth.

Pregnant woman with a spinal cord injury atT6 or higher have an increased risk of developing autonomic dysreflexia, so it is important to beaware of the symptoms and, if you experience them, that you inform your GP or midwife immediately.