Vol. 118, October
THE JOURNAL OF UROLOGY
Printed in U.SA.
Copyright © 1977 by The Williams & Wilkins Co.
BALANCED BLADDER FUNCTION IN SPINAL CORD INJURY PATIENTS EDWARD J. MCGUIRE, G. DIDDEL
AND
FRANKLIN WAGNER, JR.
From the Department of Surgery, Sections of Urology and Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT
A urodynamic assessment was done on 55 patients with spinal cord injuries treated with intermittent catheterization and therapy for autonomic dysreflexia and external sphincter spasm. While 95 per cent of the patients with upper motor neuron lesions achieved balanced bladder function they were not necessarily free of a catheter. The results obtained in male patients compare favorably to those reported from specialized spinal cord injury centers. Fem,ale spinal cord injured patients generally were unable to achieve a catheter-free status. · Investigators in specialized centers have reported that the use of intermittent catheterization and treatment of detrusorsphincter dyssynergia can free 95 per cent of spinal cord injury patients from the catheter. 1-4 In a general hospital setting 55 spinal cord injury patients have been treated during the last 4 years in an effort to establish balanced bladder function and to free them from the catheter. All patients were begun on intermittent catheterization as soon as they were admitted to the study, which was continued until balanced bladder function was established. Weekly urine cultures were obtained during hospitalization, followed by monthly urine cultures thereafter. Excretory urograms were done on admission to the study and at 6-month intervals at followup. Urodynamic investigations included urethral pressure profile determinations, external urethral sphincter electromyographic studies, and simultaneous bladder and urethral pressure profiles with fluoroscopic voiding cystourethrography. The methodology has been reported in detail elsewhere. 5• 6 In 48 cases the patients were admitted to the study at the time of injury and intermittent catheterization was begun within 48 hours; 7 patients were admitted to the study 6 weeks to 15 years after injury. The results are reported for a minimum followup of 1 year and a maximum of 4 years, with a mean of 2.3 years. RESULTS
Intermittent catheterization was done on 55 patients for a total of 366 months. About 70 per cent of the catheterizations were done either by the patient himself or members of his family in a clean, non-sterile manner. Six patients had a febrile urinary tract infection during intermittent catheterization. The results of urine culture determination are given in table 1. Patients treated with indefinite intermittent catheterization had a higher incidence of positive urine cultures than those who achieved freedom from the catheter. However, all patients treated with catheter drainage or ileal loop diversion were infected constantly. Moreover, a substantial number of patients on intermittent catheterization and no catheterization are abacteriuric and the incidence of serious complications has been surprisingly small. There is no evidence in any patient of pyelographic deterioration other than in 1 patient who had a right ureteral calculus. UPPE.R MOTOR NEURON LESIONS
Of 47 patients with upper motor neuron lesions 45 achieved balanced bladder function, 30 of whom were eventually free of a catheter. While none of the 12 female patients with balanced bladder function is free of the catheter 30 of 35 male patients Accepted for publication December 17, 1976. Supported by United States Public Health Service Grant NS 10174-05.
626
have achieved a catheter-free status (table 2). In patients with upper motor neuron lesions balanced bladder function was not usually achieved without some surgical or medical treatment of detrusor-sphincter dyssynergia (table 3). Of35 patients with lesions above the T5 level 24 had autonomic dysreflexia, which interfered with the achievement of balanced bladder function and required treatment with phenoxybenzamine. Five patients in this group also exhibited detrusor-external sphincter dyssynergia, which required an external sphincterotomy. Ten additional patients were treated with dantroline sodium (Dantrium) for generalized skeletal muscle spasticity that may have masked detrusor-sphincter dyssynergia. Two elderly men required transurethral prostatic resection for prostatic hypertrophy. Patients with mid thoracic lesions (T6 to Tll) did not have autonomic dysreflexia but showed a higher incidence of detrusor-external sphincter dyssynergia (table 3). Generally, the time required for the development of reflex bladder activity was shorter in this group than in patients with higher lesions but considerable overlap occurred. No patient with an upper motor neuron lesion failed to achieve balanced bladder function solely because of persistent detrusor-sphincter dyssynergia. In 17 patients with upper motor neuron lesions, 12 of whom were female, the catheter was still necessary. Three male patients had been treated previously with suprapubic tube drainage and refused conversion to condom catheters. Two male subjects never had satisfactory reflex detrusor function despite urodynamic evidence that suppression of perineal floor electromyographic activity and relaxation of the smooth muscle of the urethra occurred with bladder filling (fig. 1). In female subjects with upper motor neuron lesions incontinence was a major problem. Of the 12 female patients in whom balanced bladder function developed 2 were subjected to ileal loop diversion, 5 were converted to lower motor neuron lesions, 2 remain on chronic catheter drainage and 3 responded sufficiently to medical detrusor suppression to remain on intermittent catheterization indefinitely. The use of various agents to depress hyperactive reflex detrusor responses in patients with upper motor neuron lesions has not been particularly rewarding. Of 39 patients treated in an effort to depress detrusor responses only 17 responded sufficiently for therapy to be considered effective. Sacral rhizotomy in female patients with upper motor neuron lesions has been successful in converting these patients to lower motor neuron lesions if combined with medical treatment to depress detrusor tone (fig. 2). LOWER MOTOR NEURON LESIONS
Of 8 patients, including 4 female subjects, with lower motor neuron lesions as determined by urecholine suprasensitivity testing, all had a level of injury at T12 or lower. All of these
627
BALANCED BLADDER FUNCTION IN SPINAL CORD INJURY PATIENTS TABLE 1.
Incidence of bacteriuria: monthly results of urine cultures 4 to 12 months after injury* Occasion-
ally Bacteriuric No.(%)
Always Bacteriuric No.(%)
Status
No. Pts.
Abacteriuric No.(%)
Free of catheter Intermittent catheterization Totals
29 19
19 (66) 6 (32)
9 (31)
1 ( 3)
11 (58)
2 (10)
48
Z5 (51)
20 (41)
3 ( 8)
* 90 per cent of the patients had at least l positive urine culture during acute
patients have been maintained indefinitely on intermittent catheterization. In 50 per cent of the cases return of pelvic floor electromyographic activity was noted within a year of the injury and all patients recovered significant vesical tone but no detrusor reflex responses. Urinary loss occurred with increasing bladder volµmes and appeared to be entirely owing to bladder tone with filling. All patients preserve profile ,esponses, irrespective of the return of pelvic floor electromyographic activity. No patient had any change in urethral pressure with bladder filling and all closely resembled pa-
hospitalization. TABLE
3. Incidence of syndromes associated with detrusor-sphincter
imbalance requiring treatment TABLE
2. Achievement of balanced bladder function and catheter-free
status in patients with upper motor neuron: lesions No. Pts. Male pts. Female pts.
35 12
Totals
47
Balanced Bladder No.(%)
Catheter-Free No.(%)
33 ( 91) 12 (100) 45 ( 91)
30 (86) 0
Level of Injury
Autonomic Dysreflexia No.(%)
No. Pts.
C5-T5
24 (69) 0 24 (51)
35 12
T6-Tll Totals
47
External Sphincter Spasm*
No.(%) 5
10 15 (32)
* Ten patients received dantroline sodium for generalized spasticity,
30 (64)
which
may have masked external sphincter spasticity.
Fm. 1. A, pelvic floor electromyographic (EMG), urethral pressure (U) and bladder pressure (B) recordings from 52-year-old quadriplegic man. X -radiographic exposures. Filling to 400 cc results in loss of electromyographic activity, decrease in urethral pressure and loss of urethral closing pressure (UCP) but no detrusor response occurs and voiding does not result.Band C, radiograms show closed urethra atX on left side of part A but widely patent urethra at X on right side.
L
C
A
30
u
ems
H 20
16
UCP 50
B
30
100
200
300ml
100
200
300ml
u
ems
H20
UCP B
50
Fm. 2. Bladder and urethral pressures in 24-year-old woman with complete mid thoracic lesion subjected to complete intradural sacral neurectomy. A, bladder filling results in slow increase in intravesical pressure (B) with no change in urethral pressure (U) and gradual loss of urethral closing pressure ( UCP). Crede maneuver (C) does not result in loss of urethral closing pressure but, ultimately, with continued bladder filling urinary leakage occurs (L). B, after treatment with dicyclomine (60 mg. Bentyl per day) there is loss of bladder tone response to filling and preservation of positive urethral closing pressure with no urinary loss.
·,
.-,
i
-
,:;::::::::r
:~ ,' :,
628
MCGUIRE, DIDDEL AND WAGNER
tients · subjected to sacral neurectomy in their response to anticholinergic agents. Voiding by straining or the Crede maneuver .was inefficient and not satisfactory. No attempt was made in these patients to decrease urethral closing pressure to enable voiding since all remained continent of urine on intermittent self-catheterization. These patients had a significantly higher rate of bladder stone formation (2 patients) and 1 patient had a ureteral calculus that required removal. DISCUSSION
The attempt to free from the catheter male patients with upper motor neuron lesions after spinal cord injury apparently is a practical endeavor. A considerable number of patients with high upper motor neuron lesions had autonomic dysreflexia. Chronic Foley catheterization or suprapubic tube drainage did not provide protection from this syndrome, nor was autonomic dysreflexia a contraindication to attempts to achieve balanced bladder function provided that alpha-sympathetic blocking agents were used for several days before attempts to establish voiding. While the precise identification of the area of the urethral closing mechanism involved in detrusor-sphincter dyssynergia requires complicated urodynamic assessment the development of patterns ofneurogenic vesical dysfunction, which appear to depend on the level of injury, has diagnostic and therapeutic significance. Dyssynergia associated with poor urethral smooth muscle relaxation and autonomic dysreflexia can be diagnosed clinically. External sphincter spasm is identifiable on a voiding cystourethrogram in most instances. However, 2 patients who failed to achieve balanced bladder function because they never had satisfactory reflex detrusor responses were impossible to identify without extensive urodynamic assessment. The etiology of the failure of reflex detrusor responses in these patients is not clear but it may be a complication of vesical overdistension during the early phase of intermittent catheterization after the acuie injury. Other investigators have reported similar findings. 2 • 3 Balanced bladder function in female subjects with complete upper motor neuron lesions was not practical. Attempts to achieve continence with medical suppression of the detrusor reflex were successful only in a small number of patients, most of them male. The highest percentage of urinary diversions or failure of intermittent catheterization occurred in female patients with upper motor neuron lesions. Complete sacral rhizotomy has been necessary to achieve a satisfactory bladder capacity and to permit intermittent self-catheterization in the majority of these patients but continued suppression of detrusor tone has been necessary for urinary continence.
Lower motor neuron lesions were managed with intermittent self-catheterization on an indefinite basis. Difficulties with this regimen have included the formation of bladder calculi in 2 patients and a ureteral calculus in a third. Patients with lower motor neuron lesions showed a surprising degree of vesical tonicity. Three of these patients had stones and 3 manifested a febrile urinary tract infection, a much higher proportion than those with upper motor neuron lesions. These complications may indicate that patients with vesical tone and external-sphincter activity may be treated better with a method other than prolonged intermittent catheterization. However, since 50 per cent of the patients in this group were female attempts to decrease urethral closing pressure were not made in an effort to preserve passive continence. REFERENCES 1. Perkash, I.: An attempt to understand and to treat voiding
2. 3.
4. 5. 6.
dysfunctions during rehabilitation of the bladder in spinal cord injury patients. J. Urol., 115: 36, 1976. Herr, H. W.: Intermittent catheterization in neurogenic bladder dysfunction. J. Urol., 113: 477, 1976. Yalla, S. V., Rossier, A. B. and Fam, B.: Dyssynergic vesicourethral responses during bladder rehabilitation in spinal cord injury patients: effects of suprapubic percussion, Crede method and bethanechol chloride. J. Urol., 115: 575, 1976. Perkash, I.: Intermittent catheterization and bladder rehabilitation in spinal cord injury patients. J. Urol., 114: 230, 1975. McGuire, E. J., Wagner, F. and Weiss, R. M.: Urethral closing pressure after spinal cord injury and its relationship to autonomic dysreflexia. Urol. Int., in press. McGuire, E. J., Wagner, F. M. and Weiss, R. M.: Treatment of autonomic dysreflexia with phenoxybenzamine. J. Urol., 115: 53, 1976. COMMENT
This is a good report and extends the previous description of bladder function recovery in male traumatic paraplegics to female subjects. However, the time must surely be past when the terminology of upper and lower motor neuron lesions is applied to detrusor function after spinal cord injury. 1- 3 The continued use of these terms implying active neural involvement in maintaining bladder tone will continue to isolate the findings of bladder function in patients with traumatic spinal cord injury from bladder dysfunction in the general population of neurologic patients. W.E .B. 1. Tang, P. C. and Ruch, T. C.: Non-neurogenic basis of bladder
tonus. Amer. J. Physiol., 181: 249, 1955. 2. Abramson, A. S., Roussan, M. and Feibel, A.: Pathophysiology of the neurogenic bladder. Bull. N. Y. Acad. Med., 49: 775, 1973. 3. Bradley, W. E., Timm, G. W. and Scott, F. B.: Innervation of the detrusor muscle and urethra. Urol. Clin. N. Amer., 1: 3, 1974.
THE JOURNAL OF UROLOGY
Printed in U.SA.
Copyright © 1977 by The Williams & Wilkins Co.
BALANCED BLADDER FUNCTION IN SPINAL CORD INJURY PATIENTS EDWARD J. MCGUIRE, G. DIDDEL
AND
FRANKLIN WAGNER, JR.
From the Department of Surgery, Sections of Urology and Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
ABSTRACT
A urodynamic assessment was done on 55 patients with spinal cord injuries treated with intermittent catheterization and therapy for autonomic dysreflexia and external sphincter spasm. While 95 per cent of the patients with upper motor neuron lesions achieved balanced bladder function they were not necessarily free of a catheter. The results obtained in male patients compare favorably to those reported from specialized spinal cord injury centers. Fem,ale spinal cord injured patients generally were unable to achieve a catheter-free status. · Investigators in specialized centers have reported that the use of intermittent catheterization and treatment of detrusorsphincter dyssynergia can free 95 per cent of spinal cord injury patients from the catheter. 1-4 In a general hospital setting 55 spinal cord injury patients have been treated during the last 4 years in an effort to establish balanced bladder function and to free them from the catheter. All patients were begun on intermittent catheterization as soon as they were admitted to the study, which was continued until balanced bladder function was established. Weekly urine cultures were obtained during hospitalization, followed by monthly urine cultures thereafter. Excretory urograms were done on admission to the study and at 6-month intervals at followup. Urodynamic investigations included urethral pressure profile determinations, external urethral sphincter electromyographic studies, and simultaneous bladder and urethral pressure profiles with fluoroscopic voiding cystourethrography. The methodology has been reported in detail elsewhere. 5• 6 In 48 cases the patients were admitted to the study at the time of injury and intermittent catheterization was begun within 48 hours; 7 patients were admitted to the study 6 weeks to 15 years after injury. The results are reported for a minimum followup of 1 year and a maximum of 4 years, with a mean of 2.3 years. RESULTS
Intermittent catheterization was done on 55 patients for a total of 366 months. About 70 per cent of the catheterizations were done either by the patient himself or members of his family in a clean, non-sterile manner. Six patients had a febrile urinary tract infection during intermittent catheterization. The results of urine culture determination are given in table 1. Patients treated with indefinite intermittent catheterization had a higher incidence of positive urine cultures than those who achieved freedom from the catheter. However, all patients treated with catheter drainage or ileal loop diversion were infected constantly. Moreover, a substantial number of patients on intermittent catheterization and no catheterization are abacteriuric and the incidence of serious complications has been surprisingly small. There is no evidence in any patient of pyelographic deterioration other than in 1 patient who had a right ureteral calculus. UPPE.R MOTOR NEURON LESIONS
Of 47 patients with upper motor neuron lesions 45 achieved balanced bladder function, 30 of whom were eventually free of a catheter. While none of the 12 female patients with balanced bladder function is free of the catheter 30 of 35 male patients Accepted for publication December 17, 1976. Supported by United States Public Health Service Grant NS 10174-05.
626
have achieved a catheter-free status (table 2). In patients with upper motor neuron lesions balanced bladder function was not usually achieved without some surgical or medical treatment of detrusor-sphincter dyssynergia (table 3). Of35 patients with lesions above the T5 level 24 had autonomic dysreflexia, which interfered with the achievement of balanced bladder function and required treatment with phenoxybenzamine. Five patients in this group also exhibited detrusor-external sphincter dyssynergia, which required an external sphincterotomy. Ten additional patients were treated with dantroline sodium (Dantrium) for generalized skeletal muscle spasticity that may have masked detrusor-sphincter dyssynergia. Two elderly men required transurethral prostatic resection for prostatic hypertrophy. Patients with mid thoracic lesions (T6 to Tll) did not have autonomic dysreflexia but showed a higher incidence of detrusor-external sphincter dyssynergia (table 3). Generally, the time required for the development of reflex bladder activity was shorter in this group than in patients with higher lesions but considerable overlap occurred. No patient with an upper motor neuron lesion failed to achieve balanced bladder function solely because of persistent detrusor-sphincter dyssynergia. In 17 patients with upper motor neuron lesions, 12 of whom were female, the catheter was still necessary. Three male patients had been treated previously with suprapubic tube drainage and refused conversion to condom catheters. Two male subjects never had satisfactory reflex detrusor function despite urodynamic evidence that suppression of perineal floor electromyographic activity and relaxation of the smooth muscle of the urethra occurred with bladder filling (fig. 1). In female subjects with upper motor neuron lesions incontinence was a major problem. Of the 12 female patients in whom balanced bladder function developed 2 were subjected to ileal loop diversion, 5 were converted to lower motor neuron lesions, 2 remain on chronic catheter drainage and 3 responded sufficiently to medical detrusor suppression to remain on intermittent catheterization indefinitely. The use of various agents to depress hyperactive reflex detrusor responses in patients with upper motor neuron lesions has not been particularly rewarding. Of 39 patients treated in an effort to depress detrusor responses only 17 responded sufficiently for therapy to be considered effective. Sacral rhizotomy in female patients with upper motor neuron lesions has been successful in converting these patients to lower motor neuron lesions if combined with medical treatment to depress detrusor tone (fig. 2). LOWER MOTOR NEURON LESIONS
Of 8 patients, including 4 female subjects, with lower motor neuron lesions as determined by urecholine suprasensitivity testing, all had a level of injury at T12 or lower. All of these
627
BALANCED BLADDER FUNCTION IN SPINAL CORD INJURY PATIENTS TABLE 1.
Incidence of bacteriuria: monthly results of urine cultures 4 to 12 months after injury* Occasion-
ally Bacteriuric No.(%)
Always Bacteriuric No.(%)
Status
No. Pts.
Abacteriuric No.(%)
Free of catheter Intermittent catheterization Totals
29 19
19 (66) 6 (32)
9 (31)
1 ( 3)
11 (58)
2 (10)
48
Z5 (51)
20 (41)
3 ( 8)
* 90 per cent of the patients had at least l positive urine culture during acute
patients have been maintained indefinitely on intermittent catheterization. In 50 per cent of the cases return of pelvic floor electromyographic activity was noted within a year of the injury and all patients recovered significant vesical tone but no detrusor reflex responses. Urinary loss occurred with increasing bladder volµmes and appeared to be entirely owing to bladder tone with filling. All patients preserve profile ,esponses, irrespective of the return of pelvic floor electromyographic activity. No patient had any change in urethral pressure with bladder filling and all closely resembled pa-
hospitalization. TABLE
3. Incidence of syndromes associated with detrusor-sphincter
imbalance requiring treatment TABLE
2. Achievement of balanced bladder function and catheter-free
status in patients with upper motor neuron: lesions No. Pts. Male pts. Female pts.
35 12
Totals
47
Balanced Bladder No.(%)
Catheter-Free No.(%)
33 ( 91) 12 (100) 45 ( 91)
30 (86) 0
Level of Injury
Autonomic Dysreflexia No.(%)
No. Pts.
C5-T5
24 (69) 0 24 (51)
35 12
T6-Tll Totals
47
External Sphincter Spasm*
No.(%) 5
10 15 (32)
* Ten patients received dantroline sodium for generalized spasticity,
30 (64)
which
may have masked external sphincter spasticity.
Fm. 1. A, pelvic floor electromyographic (EMG), urethral pressure (U) and bladder pressure (B) recordings from 52-year-old quadriplegic man. X -radiographic exposures. Filling to 400 cc results in loss of electromyographic activity, decrease in urethral pressure and loss of urethral closing pressure (UCP) but no detrusor response occurs and voiding does not result.Band C, radiograms show closed urethra atX on left side of part A but widely patent urethra at X on right side.
L
C
A
30
u
ems
H 20
16
UCP 50
B
30
100
200
300ml
100
200
300ml
u
ems
H20
UCP B
50
Fm. 2. Bladder and urethral pressures in 24-year-old woman with complete mid thoracic lesion subjected to complete intradural sacral neurectomy. A, bladder filling results in slow increase in intravesical pressure (B) with no change in urethral pressure (U) and gradual loss of urethral closing pressure ( UCP). Crede maneuver (C) does not result in loss of urethral closing pressure but, ultimately, with continued bladder filling urinary leakage occurs (L). B, after treatment with dicyclomine (60 mg. Bentyl per day) there is loss of bladder tone response to filling and preservation of positive urethral closing pressure with no urinary loss.
·,
.-,
i
-
,:;::::::::r
:~ ,' :,
628
MCGUIRE, DIDDEL AND WAGNER
tients · subjected to sacral neurectomy in their response to anticholinergic agents. Voiding by straining or the Crede maneuver .was inefficient and not satisfactory. No attempt was made in these patients to decrease urethral closing pressure to enable voiding since all remained continent of urine on intermittent self-catheterization. These patients had a significantly higher rate of bladder stone formation (2 patients) and 1 patient had a ureteral calculus that required removal. DISCUSSION
The attempt to free from the catheter male patients with upper motor neuron lesions after spinal cord injury apparently is a practical endeavor. A considerable number of patients with high upper motor neuron lesions had autonomic dysreflexia. Chronic Foley catheterization or suprapubic tube drainage did not provide protection from this syndrome, nor was autonomic dysreflexia a contraindication to attempts to achieve balanced bladder function provided that alpha-sympathetic blocking agents were used for several days before attempts to establish voiding. While the precise identification of the area of the urethral closing mechanism involved in detrusor-sphincter dyssynergia requires complicated urodynamic assessment the development of patterns ofneurogenic vesical dysfunction, which appear to depend on the level of injury, has diagnostic and therapeutic significance. Dyssynergia associated with poor urethral smooth muscle relaxation and autonomic dysreflexia can be diagnosed clinically. External sphincter spasm is identifiable on a voiding cystourethrogram in most instances. However, 2 patients who failed to achieve balanced bladder function because they never had satisfactory reflex detrusor responses were impossible to identify without extensive urodynamic assessment. The etiology of the failure of reflex detrusor responses in these patients is not clear but it may be a complication of vesical overdistension during the early phase of intermittent catheterization after the acuie injury. Other investigators have reported similar findings. 2 • 3 Balanced bladder function in female subjects with complete upper motor neuron lesions was not practical. Attempts to achieve continence with medical suppression of the detrusor reflex were successful only in a small number of patients, most of them male. The highest percentage of urinary diversions or failure of intermittent catheterization occurred in female patients with upper motor neuron lesions. Complete sacral rhizotomy has been necessary to achieve a satisfactory bladder capacity and to permit intermittent self-catheterization in the majority of these patients but continued suppression of detrusor tone has been necessary for urinary continence.
Lower motor neuron lesions were managed with intermittent self-catheterization on an indefinite basis. Difficulties with this regimen have included the formation of bladder calculi in 2 patients and a ureteral calculus in a third. Patients with lower motor neuron lesions showed a surprising degree of vesical tonicity. Three of these patients had stones and 3 manifested a febrile urinary tract infection, a much higher proportion than those with upper motor neuron lesions. These complications may indicate that patients with vesical tone and external-sphincter activity may be treated better with a method other than prolonged intermittent catheterization. However, since 50 per cent of the patients in this group were female attempts to decrease urethral closing pressure were not made in an effort to preserve passive continence. REFERENCES 1. Perkash, I.: An attempt to understand and to treat voiding
2. 3.
4. 5. 6.
dysfunctions during rehabilitation of the bladder in spinal cord injury patients. J. Urol., 115: 36, 1976. Herr, H. W.: Intermittent catheterization in neurogenic bladder dysfunction. J. Urol., 113: 477, 1976. Yalla, S. V., Rossier, A. B. and Fam, B.: Dyssynergic vesicourethral responses during bladder rehabilitation in spinal cord injury patients: effects of suprapubic percussion, Crede method and bethanechol chloride. J. Urol., 115: 575, 1976. Perkash, I.: Intermittent catheterization and bladder rehabilitation in spinal cord injury patients. J. Urol., 114: 230, 1975. McGuire, E. J., Wagner, F. and Weiss, R. M.: Urethral closing pressure after spinal cord injury and its relationship to autonomic dysreflexia. Urol. Int., in press. McGuire, E. J., Wagner, F. M. and Weiss, R. M.: Treatment of autonomic dysreflexia with phenoxybenzamine. J. Urol., 115: 53, 1976. COMMENT
This is a good report and extends the previous description of bladder function recovery in male traumatic paraplegics to female subjects. However, the time must surely be past when the terminology of upper and lower motor neuron lesions is applied to detrusor function after spinal cord injury. 1- 3 The continued use of these terms implying active neural involvement in maintaining bladder tone will continue to isolate the findings of bladder function in patients with traumatic spinal cord injury from bladder dysfunction in the general population of neurologic patients. W.E .B. 1. Tang, P. C. and Ruch, T. C.: Non-neurogenic basis of bladder
tonus. Amer. J. Physiol., 181: 249, 1955. 2. Abramson, A. S., Roussan, M. and Feibel, A.: Pathophysiology of the neurogenic bladder. Bull. N. Y. Acad. Med., 49: 775, 1973. 3. Bradley, W. E., Timm, G. W. and Scott, F. B.: Innervation of the detrusor muscle and urethra. Urol. Clin. N. Amer., 1: 3, 1974.
