Para sit skier Taiki Morii says for him, bladder and bowel management is a more serious problem than the impairment he experiences in his legs.
For some of the 120,000 people with spinal cord injuries in Japan who are dealing with excretory dysfunction, including Alpine skier Morii, it is literally a matter of life or death.
"I want people to know those challenges are bigger than a loss of function in the legs," Morii said.
The 41-year-old already had five medals from five previous Paralympics and won two more this past weekend in the first two of the five sitting Alpine events he plans on contesting in Beijing.
When he was 16, Morii sustained spinal cord injuries in a motorcycle accident. He began sit skiing after watching the Nagano Paralympics while hospitalized, and also took up para powerlifting competitively in 2018.
Morii's spinal cord damage prevents correct nerve signals between his bladder and brain. Being unable to control his bladder is a particularly acute issue when on the snow.
"I've had to take medicine before competition because of a urinary tract infection," he said.
Using a long-term indwelling urinary catheter, needed by people whose bladders will not empty fully or that empty involuntarily, was an option, but the discomfort hindered his sporting performance.
During the pandemic, his high body temperature also proved to be a roadblock. Temperature screening has become a normal part of life, and a body temperature of 37 C raises red flags in Japan.
"My normal body temperature has been in the 37 C range all through my 20-year career. But now there's the possibility of being denied entry to a gym or being unable to train overseas, so I became proactive about my health and had a checkup."
Morii was diagnosed with chronic cystitis, a long-lasting inflammation of the bladder characterized by an inflamed or irritated bladder wall.
"I made some lifestyle changes by drinking better quality water and emptying my bladder at regular times," said Morii, adding that he has not had any infection or fever issues since.
Morii's physician, Osamu Uemura, the head of the rehabilitation department at Murayama Medical Center in Tokyo, said bladder dysfunction can be stressful to deal with for any patient, but especially for sportspeople.
"Urologic conditions among athletes are very troublesome," he said.
According to the nonprofit Japan Spinal Cord Foundation, about 6,000 people are injured or diagnosed with a spinal cord injury every year in Japan. Uemura said some die from urinary complications.
Many people experience both bladder and bowel control problems. These conditions affect patients not only physically but emotionally.
It can be traumatic for a wheelchair user to experience bowel incontinence in public.
People who deal daily with bladder and bowel complications are said to experience a wide range of emotions, including fear, shame, embarrassment, guilt or the desire to isolate. Some avoid going out entirely or plan their activities around their proximity to a toilet.
Patients regularly share stories of traumatic incidents with Uemura, and he said one of his main concerns is helping them preserve their dignity.
"I learn about their living conditions and have them try different ways to deal with their situations through trial and error. I see that as the only way, slow but sure," Uemura said.
Spinal Injuries Japan representative Shinya Ando is a 47-year-old man paralyzed from the shoulders down with a functional bowel disorder.
"I would get nervous every time I get on an airplane. I wouldn't eat food for two days before a flight, it was so emotionally draining," he said.
After careful consideration, Ando opted for a stoma surgery, where the doctor sews the anus closed and makes a small opening called a stoma in the skin of the lower abdomen for excretion of digestive and urinary wastes from the body into a bag.
Seeing the need for more information on how to improve people's awareness of bladder and bowel health, Morii decided to offer education and support to those in need himself.
The Beijing Paralympian starred in a commercial for adult diapers delivering the message of "Rather than lament what we cannot do, let's enjoy what we can."
On YouTube, he has talked about how he manages his bladder and bowel functions, and how athletes like him, with conditions that impair this most normal of bodily functions, can have their day-to-day life impacted in unexpected and challenging ways.
Having such a vocal and inspiring spokesperson is making a difference, Ando believes.
"I'm so thankful that an influential figure is speaking out," he said.