Paralysis - Complications of paralysis

A person with paralysis can develop a number of complications, including autonomic dysreflexia, sexual problems and 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 is commonly 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's functions you don't have 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 of the injury to your spinal cord, the signal will be unable 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 anxiety and apprehension
intense sweating above the level of your injury
tightness in your chest
red blotches on your skin above the level of your injury
a slow heartbeat (less than 60 beats a 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 of autonomic 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 in the bladder
a blocked catheter (the tube used to drain the bladder)
the bag used to drain the bladder being 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 also lower 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 is blocked or twisted
your drainage bag is full
the catheter is fully inserted into the drainage bag
the drainage bag is higher than your bladder

If you have a full bladder or are unable to pass urine and 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 gloves is recommended. Any large, hard stools detected should be gently removed.

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

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

Depression

Coming to terms with paralysis, particularly if it occurred suddenly and unexpectedly, can be difficult and traumatic. Many people go through the classic stages of grief, as described below:

denial – initially, you may refuse to believe your condition is 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 feel your situation is hopeless
acceptance – in time, most people come to terms with being paralysed and begin to adapt to living with the condition

Some people with paralysis find it difficult to reach the acceptance stage and continue to be depressed. 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 as affecting your rehabilitation, symptoms can also quickly worsen if they are not treated promptly. Read more about depression.

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's sex life and fertility. However, even if you have severe paralysis, it does 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 as his 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 at sexually explicit images

As the nerves that control the reflex erection are located at the base of your spine, your ability to achieve this type of erection will usually be retained, even if your paralysis is severe.

However, the nerves that control a psychogenic erection are located much higher up the 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 are only able to have a reflex erection, it will still be possible for you to have sex, although you may find it difficult to maintain an erection for a prolonged period of time. This is known as erectile dysfunction.

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

Ejaculation

The type and location of your paralysis will also affect whether you will be able to ejaculate sperm.

If you lose the ability to ejaculate but you want to have children, a number of different techniques can be used to obtain a sperm sample.

The sperm can then be used in fertility 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, where a specially designed vibrator is placed against the underside of the penis.

The vibrator stimulates 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 stimulation is usually carried out in a private room at a fertility clinic.

If this is unsuccessful, an alternative technique known as rectal probe electroejaculation can be used. Again, this is usually carried out at 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 of concerns 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 is paralysed and pregnant cannot have a vaginal delivery during childbirth.

Pregnant woman with a spinal cord injury at T6 or higher have an increased risk of developing autonomic dysreflexia, so it is important to be aware of the symptoms and, if you experience them, that you inform your GP or midwife immediately.