My coccyx, or tailbone, appears to have been removed during my stay in the ICU (Intensive Care Unit) of Changi General Hospital (CGH) in 2011. In fact, based on the Discharge Memo given to my parents by CGH, the reason I could not feel my coccyx with my fingers going over the back of my buttocks, is because I suffered a displaced fracture of the S5 vertebrae of my spine. So, my coccyx's position is likely to have shifted, so I can no longer feel it protruding out of my buttocks. This happened after my attempted suicide in Pasir Ris Park, of which I had little memory of. Evidently, I had leapt from a 3 storey watch tower in the park due to my schizoaffective disorder, a combination of schizophrenia and depression.
The injury at the S5 vertebrae and repositioning of my coccyx means that the entire coccygeal plexus, comprising of the S4, S5, and coccygeal nerve roots, was affected. This plexus contributes to the somatic and autonomic innervation of the anus, perineum and genitals. The gluteus maximus is also connected to the lateral coccyx and contributes to the feeling of pressure when seated, so it also affects my feeling of the "cushion effect" or lack of it while seated. The damaged nerves also affected the size of my buttocks, which is now smaller, meaning that there's less "cushion effect". I also have perianal/saddle anesthesia, which is the anesthesia of the posterior thigh, where I can't feel the region from my buttocks to the back of my thigh properly, thereby contributing to my skin picked sacral ulcer as described in my post: Skin Picking Disorder, Ischial Ulcer.
As noted in the Computerized Tomography (CT) scan report on my abdomen and pelvis on 08 Sep 2011 that's copied into my Discharge Memo, I have a list of injury impressions (the displaced S5 vertebrae was not included):
- Burst fractures of L4, L5 vertebral bodies with severe spinal canal stenosis.
- Fracture L3 transverse processes and L5 vertebral body.
- Extensive retroperitoneal hematoma.
- Right kidney laceration with associated perinephric hematoma.
- Bilateral rib fractures, lung contusions and right hemopneumothorax.
- Left temporal lobe and frontal lobe hemorrhagic contusions.
- No displaced skull vault or cervical spine fracture.
The fall from the tower damaged my spine at the lumbosacral plexus, at the level of the cauda equina, specifically the L3-5 vertebrae with the injury at L4 being the most severe because the spinal canal was "almost completely obliterated". If the injury had been worse, I would have been paralysed from the waist down. As it was, I was confined to a wheelchair for about 6 months. I stayed in CGH's ICU for about 4-6 days starting on 08 Sep 2011, in CGH for about 2 months until 09 Nov 2011 mostly bedridden, and then at SACH (Saint Andrew's Community Hospital) for about 4 months of rehabilitation, discharging on 14 Mar 2012. Even after I went home, I continued to do rehabilitation exercises at home. As of now, I can do some simple exercises every Saturday when it's not raining at the fitness corners near where I live, but my right ankle is permanently deformed, so I cannot walk properly, while my back requires a walking stick's support despite the Pangea pedicle screws with iliac bolts implants. There is a church at SACH called SACC (Saint Andrew's Community Chapel), where I was baptised on 08 April 2012, and confirmed on 11 Nov 2012. I was, in many ways, reborn.
While I was recovering at home, I still had to use catheters (called intermittent catheterisation) to help me pass urine for a few weeks, until I managed one day to use my bowel moving muscles (likely to be the levator ani) to pull the internal urethral sphincter apart for urine to flow out. For the first couple of years after I left SACH, I had problems detecting when urine would want to flow out. I still remember one embarassing day while I was working, my urine flowed out while I was still seated in the office after some sensations at my urethral sphincters, which I had ignored. My underwear, trousers and chair became wet. I can't remember what material the chair was made of, but it easily dried up in the air conditioned office. Fortunately, I was the only one in the room. From then on, I immediately visit the toilet upon feeling some pressure sensation on my urethral sphincters, or when I have the urge to defecate although it is urine that comes out when I sit on a toilet bowl. Hence, I now always sit on a toilet bowl to pass urine/pee. Sometimes, some liquid mucus will also come out of my anus when I pass urine because of the use of my levator ani muscle, which I'll have to use the toilet paper to wipe away.
Moving my bowels is a bigger problem because of my neurogenic bowels, a form of chronic constipation. I could not remember how I defecated in CGH as I was bedridden and comatose most of the time. According to CGH's Discharge Memo, Fleet Enema was used early in my stay. I also had abdominal pains due to constipation. In SACH, I remember taking Fybogel and lactulose (among other medications which might include senna), but my daily visits to the toilet were not regular and involves straining. When I left the hospital and started staying home, I remember using the help of the arms of my commode to move myself on the commode while straining, so that I can strain with different postures. Eventually, I ended up putting Fleet Enema directly into my anus and wearing diapers while lying down in bed to wait for my bowels to come out. Suppositories did not work for me. This continued (I can't remember how long) until the use of senna became effective with lactulose. This then continued until I realised senna alone was enough for daily bowel movement, but with straining. Eventually, senna's effectiveness wore off as it became tolerated by my body, and combining with lactulose did not work. A lesson learnt here was that I cannot take senna every day as it may lead to cathartic colon problems.
My bowels/stool are usually hard and lumpy, and are known as scybalous. This is due to the slower stool propulsion through my descending colon using segmental colonic peristalsis, which is coordinated by the myenteric plexus. This is caused by spinal cord injury lesions (injuries) at vertebral level T10 and below, of which my dominant injury, which is a burst fracture of vertebrae L4 and L5, belongs to. Hence, my descending colon wall likely has a lower resting tone and likely has no spinal cord mediated reflex peristalsis. This is a sign of the lower motor neuron pattern of dysfunction, where there are lesions to the inferior splanchnic nerve to the descending colon, and also to the pelvic nerve that's linked to the pelvic floor. Water absorption continues even though the transit through the colon is slow, so the stool becomes drier and harder.
Fortunately, my father is a TCM (Traditional Chinese Medicine) practitioner. His clinic Loo Eng Ngo Acupuncture Medical Centre is located near Kembangan MRT in Singapore. He tried various herbal remedies on me, and eventually, I began to take Nature’s Green Constipation Relief Granules twice a week when I wake up (usually at 7am) to move bowels on 2 days only (there are warnings against taking this medicine on consecutive days for more than 2 weeks). This is usually supplemented with senna taken the night before. The effects of the granules last the whole day and is usually affected by the amount of water I drink. In the morning, it is usually harder to move my bowels, so some straining is necessary. This is where the effects of senna can be felt. It usually becomes easier after a couple of toilet visits. In the afternoon and evening, when most bowels have been defecated, there may still be a tendency to move bowels, but what comes out is usually watery faeces/stools akin to diarrhoea. This usually stops by dinner time or some time before I sleep. If it doesn't, I usually take another TCM herbal remedy to stop it: Lophanthus pills.
Watery stools becomes a problem at work when I can't control them, resulting in my anus releasing the stools before I reached the toilet. This happened twice at work. The first time it happened, I immediately took half day leave to get home to change. The second time it happened, I did not take leave as I was worried I would run out of leave for other more critical times, so I ended up stinking up my seat and workplace. Fortunately, I could clean up myself to the best of my ability in the toilet, and the smell dissipated after one day.
I am also impotent because of my spinal cord injury, but I'm single, so I do not have problems with that. I cannot feel or control my perineum (the bulbospongiosus and ischiocavernosus muscles) properly. These are innervated by the deep branch of the perineal nerve, which is a branch of the pudendal nerve (from the S2-4 vertebrae). However, I have had several nocturnal emissions, also known as wet dreams except that there were no dreams, over the 6 years since I returned home from hospital. Semen flowed out upon emission waking me up, and dirtied my shorts on 2-3 occasions, while on the other occasions, my body's learnt reflex action (likely using the external urethral sphincter) to stop urine from flowing out also stopped my semen from flowing out. It is likely that I'll have to use artificial means to get my semen out if I get married and want to have children, which is likely available at KKH (KK Women's and Children's Hospital). These artificial means may include vibrostimulation, electroejaculation, or operative sperm retrieval.
References:
The injury at the S5 vertebrae and repositioning of my coccyx means that the entire coccygeal plexus, comprising of the S4, S5, and coccygeal nerve roots, was affected. This plexus contributes to the somatic and autonomic innervation of the anus, perineum and genitals. The gluteus maximus is also connected to the lateral coccyx and contributes to the feeling of pressure when seated, so it also affects my feeling of the "cushion effect" or lack of it while seated. The damaged nerves also affected the size of my buttocks, which is now smaller, meaning that there's less "cushion effect". I also have perianal/saddle anesthesia, which is the anesthesia of the posterior thigh, where I can't feel the region from my buttocks to the back of my thigh properly, thereby contributing to my skin picked sacral ulcer as described in my post: Skin Picking Disorder, Ischial Ulcer.
As noted in the Computerized Tomography (CT) scan report on my abdomen and pelvis on 08 Sep 2011 that's copied into my Discharge Memo, I have a list of injury impressions (the displaced S5 vertebrae was not included):
- Burst fractures of L4, L5 vertebral bodies with severe spinal canal stenosis.
- Fracture L3 transverse processes and L5 vertebral body.
- Extensive retroperitoneal hematoma.
- Right kidney laceration with associated perinephric hematoma.
- Bilateral rib fractures, lung contusions and right hemopneumothorax.
- Left temporal lobe and frontal lobe hemorrhagic contusions.
- No displaced skull vault or cervical spine fracture.
The fall from the tower damaged my spine at the lumbosacral plexus, at the level of the cauda equina, specifically the L3-5 vertebrae with the injury at L4 being the most severe because the spinal canal was "almost completely obliterated". If the injury had been worse, I would have been paralysed from the waist down. As it was, I was confined to a wheelchair for about 6 months. I stayed in CGH's ICU for about 4-6 days starting on 08 Sep 2011, in CGH for about 2 months until 09 Nov 2011 mostly bedridden, and then at SACH (Saint Andrew's Community Hospital) for about 4 months of rehabilitation, discharging on 14 Mar 2012. Even after I went home, I continued to do rehabilitation exercises at home. As of now, I can do some simple exercises every Saturday when it's not raining at the fitness corners near where I live, but my right ankle is permanently deformed, so I cannot walk properly, while my back requires a walking stick's support despite the Pangea pedicle screws with iliac bolts implants. There is a church at SACH called SACC (Saint Andrew's Community Chapel), where I was baptised on 08 April 2012, and confirmed on 11 Nov 2012. I was, in many ways, reborn.
While I was recovering at home, I still had to use catheters (called intermittent catheterisation) to help me pass urine for a few weeks, until I managed one day to use my bowel moving muscles (likely to be the levator ani) to pull the internal urethral sphincter apart for urine to flow out. For the first couple of years after I left SACH, I had problems detecting when urine would want to flow out. I still remember one embarassing day while I was working, my urine flowed out while I was still seated in the office after some sensations at my urethral sphincters, which I had ignored. My underwear, trousers and chair became wet. I can't remember what material the chair was made of, but it easily dried up in the air conditioned office. Fortunately, I was the only one in the room. From then on, I immediately visit the toilet upon feeling some pressure sensation on my urethral sphincters, or when I have the urge to defecate although it is urine that comes out when I sit on a toilet bowl. Hence, I now always sit on a toilet bowl to pass urine/pee. Sometimes, some liquid mucus will also come out of my anus when I pass urine because of the use of my levator ani muscle, which I'll have to use the toilet paper to wipe away.
Moving my bowels is a bigger problem because of my neurogenic bowels, a form of chronic constipation. I could not remember how I defecated in CGH as I was bedridden and comatose most of the time. According to CGH's Discharge Memo, Fleet Enema was used early in my stay. I also had abdominal pains due to constipation. In SACH, I remember taking Fybogel and lactulose (among other medications which might include senna), but my daily visits to the toilet were not regular and involves straining. When I left the hospital and started staying home, I remember using the help of the arms of my commode to move myself on the commode while straining, so that I can strain with different postures. Eventually, I ended up putting Fleet Enema directly into my anus and wearing diapers while lying down in bed to wait for my bowels to come out. Suppositories did not work for me. This continued (I can't remember how long) until the use of senna became effective with lactulose. This then continued until I realised senna alone was enough for daily bowel movement, but with straining. Eventually, senna's effectiveness wore off as it became tolerated by my body, and combining with lactulose did not work. A lesson learnt here was that I cannot take senna every day as it may lead to cathartic colon problems.
My bowels/stool are usually hard and lumpy, and are known as scybalous. This is due to the slower stool propulsion through my descending colon using segmental colonic peristalsis, which is coordinated by the myenteric plexus. This is caused by spinal cord injury lesions (injuries) at vertebral level T10 and below, of which my dominant injury, which is a burst fracture of vertebrae L4 and L5, belongs to. Hence, my descending colon wall likely has a lower resting tone and likely has no spinal cord mediated reflex peristalsis. This is a sign of the lower motor neuron pattern of dysfunction, where there are lesions to the inferior splanchnic nerve to the descending colon, and also to the pelvic nerve that's linked to the pelvic floor. Water absorption continues even though the transit through the colon is slow, so the stool becomes drier and harder.
Fortunately, my father is a TCM (Traditional Chinese Medicine) practitioner. His clinic Loo Eng Ngo Acupuncture Medical Centre is located near Kembangan MRT in Singapore. He tried various herbal remedies on me, and eventually, I began to take Nature’s Green Constipation Relief Granules twice a week when I wake up (usually at 7am) to move bowels on 2 days only (there are warnings against taking this medicine on consecutive days for more than 2 weeks). This is usually supplemented with senna taken the night before. The effects of the granules last the whole day and is usually affected by the amount of water I drink. In the morning, it is usually harder to move my bowels, so some straining is necessary. This is where the effects of senna can be felt. It usually becomes easier after a couple of toilet visits. In the afternoon and evening, when most bowels have been defecated, there may still be a tendency to move bowels, but what comes out is usually watery faeces/stools akin to diarrhoea. This usually stops by dinner time or some time before I sleep. If it doesn't, I usually take another TCM herbal remedy to stop it: Lophanthus pills.
Watery stools becomes a problem at work when I can't control them, resulting in my anus releasing the stools before I reached the toilet. This happened twice at work. The first time it happened, I immediately took half day leave to get home to change. The second time it happened, I did not take leave as I was worried I would run out of leave for other more critical times, so I ended up stinking up my seat and workplace. Fortunately, I could clean up myself to the best of my ability in the toilet, and the smell dissipated after one day.
I am also impotent because of my spinal cord injury, but I'm single, so I do not have problems with that. I cannot feel or control my perineum (the bulbospongiosus and ischiocavernosus muscles) properly. These are innervated by the deep branch of the perineal nerve, which is a branch of the pudendal nerve (from the S2-4 vertebrae). However, I have had several nocturnal emissions, also known as wet dreams except that there were no dreams, over the 6 years since I returned home from hospital. Semen flowed out upon emission waking me up, and dirtied my shorts on 2-3 occasions, while on the other occasions, my body's learnt reflex action (likely using the external urethral sphincter) to stop urine from flowing out also stopped my semen from flowing out. It is likely that I'll have to use artificial means to get my semen out if I get married and want to have children, which is likely available at KKH (KK Women's and Children's Hospital). These artificial means may include vibrostimulation, electroejaculation, or operative sperm retrieval.
01 June 2019 Update
I've changed the name of the link "Skin Picking Disorder, Sacral Ulcer" to "Skin Picking Disorder, Ischial Ulcer" in paragraph 2 of this post. The reasons are as described in the 01 June 2019 update in the post "Skin Picking Disorder, Ischial Ulcer" itself.
In paragraph 2 of this post, it is also mentioned that I now have smaller buttocks. In fact, this is the source of the confusion over whether my akathisia/restless legs syndrome symptoms as described in my post: Relooking my Onset of Schizophrenia, the Perceived Effects of Sounds on my Body, is due to a complication of my psychiatric medications, or the outcome/effect of sounds on my body as described in that post, or a reaction of my body due to the discomfort of a smaller set of buttocks due to my spinal cord injury that could not provide sufficient cushion for the weight of my body, thereby leading to discomforts and excessive movements. The 2 doctors I saw on 31 May 2019 at CGH Orthopaedic Surgery or Clinic U for pains which recurred in my spinal cord in Nov 2018, were of the quick opinion that I'll likely have to refer to my psychiatrist to resolve this issue. However, my post: Relooking my Onset of Schizophrenia, the Perceived Effects of Sounds on my Body, is specific in indicating that my body's movements were due to sounds extend beyond sitting.
04 Jan 2020 Update
I've made some additions to this blog post, mainly this update.
With regards to my akathisia/restless legs syndrome, I've discovered that it's more likely to be driven by the discomfort, and sometimes pain, in my buttocks while sitting.
With regards to the twice weekly movement of my bowels, I'm experiencing a wearing off of the effects of the combination of using the TCM herbal remedy in the morning, and Senna or Bisacodyl tablets and Lactulose taken the night before. There is no longer any diarrhoea effects, and sometimes, I have to supplement my medications with a Bisacodyl suppository in the afternoon or evening of the day I'm supposed to move my bowels in order to give my bowels moving a slight push. This lost of medication effectiveness worries me, because without these, I can't move my bowels. I may have to resort to bowel irrigation, literally gently hosing my anus-rectum with tap water to move my bowels. However, this is a dangerous procedure because I run the risk of developing perforated rectum if I use too much water. When I saw a doctor from the Gastroenterology department at CGH on 23 April 2019, I was told to continue using my existing medications if they work. If not, they still have one more medicine called Resolor. However, it may be expensive, and beyond that, they don't have other medications. This may lead to a second suicide attempt when I one day have no solutions to my problems, or if they are too expensive for me to afford, or if local authorities are still blind to the importance of having euthanasia in my country. I have no intention of feeling the pain and discomfort in my stomach and intestines when my bowels can't be moved.
With regards to my bladder, it may have now developed a new problem - hydronephrosis. This likely happens due to the thickening of my bladder walls which has gradually quicken its response to my sensations of urination/micturition urges and the medication I take for my neurogenic bowels. This means that my bladder is able to store less urine and I have to pee more frequently, and if I try to hold on to my urine by not trying to relax my internal urethral sphincter in the toilet, the urine will back-flow to my kidneys, resulting in hydronephrosis. Eventually, my kidneys will be damaged beyond repair. The seriousness of this was discovered during ultrasound scans of my bladder and kidneys at CGH on 2 Jan 2019, when I had to drink lots of water and try to hold them while waiting for an unbearably long time due to delays for my turn at having the ultrasound. I'm now awaiting a solution when I meet a doctor at CGH's Urology department on 17 Jan 2019. If no solutions are forthcoming, this will likely lead to another suicide attempt in future because I'll not be able to afford new kidneys.
This blog post continues here:
Spinal Cord Injury - Neurogenic Bowels and Bladder
I've changed the name of the link "Skin Picking Disorder, Sacral Ulcer" to "Skin Picking Disorder, Ischial Ulcer" in paragraph 2 of this post. The reasons are as described in the 01 June 2019 update in the post "Skin Picking Disorder, Ischial Ulcer" itself.
In paragraph 2 of this post, it is also mentioned that I now have smaller buttocks. In fact, this is the source of the confusion over whether my akathisia/restless legs syndrome symptoms as described in my post: Relooking my Onset of Schizophrenia, the Perceived Effects of Sounds on my Body, is due to a complication of my psychiatric medications, or the outcome/effect of sounds on my body as described in that post, or a reaction of my body due to the discomfort of a smaller set of buttocks due to my spinal cord injury that could not provide sufficient cushion for the weight of my body, thereby leading to discomforts and excessive movements. The 2 doctors I saw on 31 May 2019 at CGH Orthopaedic Surgery or Clinic U for pains which recurred in my spinal cord in Nov 2018, were of the quick opinion that I'll likely have to refer to my psychiatrist to resolve this issue. However, my post: Relooking my Onset of Schizophrenia, the Perceived Effects of Sounds on my Body, is specific in indicating that my body's movements were due to sounds extend beyond sitting.
04 Jan 2020 Update
I've made some additions to this blog post, mainly this update.
With regards to my akathisia/restless legs syndrome, I've discovered that it's more likely to be driven by the discomfort, and sometimes pain, in my buttocks while sitting.
With regards to the twice weekly movement of my bowels, I'm experiencing a wearing off of the effects of the combination of using the TCM herbal remedy in the morning, and Senna or Bisacodyl tablets and Lactulose taken the night before. There is no longer any diarrhoea effects, and sometimes, I have to supplement my medications with a Bisacodyl suppository in the afternoon or evening of the day I'm supposed to move my bowels in order to give my bowels moving a slight push. This lost of medication effectiveness worries me, because without these, I can't move my bowels. I may have to resort to bowel irrigation, literally gently hosing my anus-rectum with tap water to move my bowels. However, this is a dangerous procedure because I run the risk of developing perforated rectum if I use too much water. When I saw a doctor from the Gastroenterology department at CGH on 23 April 2019, I was told to continue using my existing medications if they work. If not, they still have one more medicine called Resolor. However, it may be expensive, and beyond that, they don't have other medications. This may lead to a second suicide attempt when I one day have no solutions to my problems, or if they are too expensive for me to afford, or if local authorities are still blind to the importance of having euthanasia in my country. I have no intention of feeling the pain and discomfort in my stomach and intestines when my bowels can't be moved.
With regards to my bladder, it may have now developed a new problem - hydronephrosis. This likely happens due to the thickening of my bladder walls which has gradually quicken its response to my sensations of urination/micturition urges and the medication I take for my neurogenic bowels. This means that my bladder is able to store less urine and I have to pee more frequently, and if I try to hold on to my urine by not trying to relax my internal urethral sphincter in the toilet, the urine will back-flow to my kidneys, resulting in hydronephrosis. Eventually, my kidneys will be damaged beyond repair. The seriousness of this was discovered during ultrasound scans of my bladder and kidneys at CGH on 2 Jan 2019, when I had to drink lots of water and try to hold them while waiting for an unbearably long time due to delays for my turn at having the ultrasound. I'm now awaiting a solution when I meet a doctor at CGH's Urology department on 17 Jan 2019. If no solutions are forthcoming, this will likely lead to another suicide attempt in future because I'll not be able to afford new kidneys.
This blog post continues here:
Spinal Cord Injury - Neurogenic Bowels and Bladder
25 July 2024 Update
I've realised that I'm no longer completely impotent, but due to my financial and jobless situation, I'll likely be single all my life.
- Memo, Changi General Hospital, 09 November 2011
- Sacral (S1-S5) Spinal Cord Injuries, www.spinalcord.com/sacral-spine-s1-s5-vertebrae-injuries-sacral-sparing
- Neurogenic Bowel Dysfunction Treatment & Management, emedicine.medscape.com/article/321172-treatment
- Distribution of Spinal Nerves, courses.lumenlearning.com/boundless-ap/chapter/distribution-of-spinal-nerves/
- Tailbone Pain and Bowel Problems, tailbonedoctor.com/tailbone-pain-and-bowel-problems/
- Anatomy of the Coccyx (Tailbone), www.spine-health.com/conditions/spine-anatomy/anatomy-coccyx-tailbone
- The Coccyx and Bowel Function, hermanwallace.com/blog/the-coccyx-and-bowel-function
- Peripheral neuropathy, medlineplus.gov/ency/article/000593.htm
- Walter R. Frontera et al, Essentials of Physical Medicine and Rehabilitation: Musculoskeletal, Third Edition, 2014
- Gopal H. Badlani, Continence: Current Concepts and Treatment Strategies, 2008
- Vernon W. Lin et al, Spinal Cord Medicine - Principles and Practice, Second Edition, 2010
- Jacques c, David Ginsberg, Gilles Karsenty, Textbook of the neurogenic bladder, 3rd Edition, 2015