BLADDER TRAINING IN PATIENTS WITH SPINAL CORD INJURY E. B. MENON, M.B.B.S (SING.), M.R.C.P. (LOND.) E. S. TAN, A.M.(S), M.B.B.S. (SING.), D.P.R.M. (AUST.), F.A.C.R.M.
From the Department of Rehabilitation Tan Tack Seng Hospital, Singapore
(AUST.)
Medicine,
ABSTRACT-Immediately following severe injury to the spinal cord or conus medullaris, there is a stage of flaccid paralysis of the bladder. The smooth muscle of the detrusor and rectum is affected. Drainage of the bladder is very important in the early care of such patients. From August 1989 to August 1990, 55 spinal cord injury patients were studied on admission to our department. The current bladder training method used for these patients is presented. A patient was deemed to have been successjully bladder trained when catheterfree, continent, and able to consistently maintain a residual volume of 100 mL or less with the aid of tapping and compression. On discharge 45 patients (82 %$ were successfully bladder trained, 8 (15 %) employed a regimen of clean intermittent self-catherixation, and 2 went home/institutional care with an indwelling catheter. The material presented is applicable to any type of neurogenie bladder dysfunction.
Drainage of the bladder is very important in the early care of spinal cord injury (SCI) patients. 1,2The search for an ideal method during the period of spinal shock has continued since Curling (1833) described the dangers of indwelling catheterization in such patients. Since then, different methods have been tried such as cystostomy (Hugonet and Degerine, 1919), manual expression (Besley, 1917; Vellacott, 1919), and intermittent catheterization (Guttmann and Frankel, 1966).” Successful bladder training, effective modern rehabilitation, improved medical and surgical care has reduced the mortality of urinary sepsis in spinal cord injury patients from 80 percent in the 1920s and 30 percent in the 1960s to 6 percent in the 1980s.4B5 This article deals with current bladder training method used in our department for 55 spinal cord injury patients during the period of August 1989 to August 1990. Presented at First Regional Conference on Spinal Cord Injury, Bhubaneswar, India, February 1, 1991.
UROLOGY
/ NOVEMBER
1992
I
VOLUME 40, NUMBER 5
Material and Methods A total of 55 spinal cord injury patients (45 men and 10 women) admitted to our department were studied. Mean age was forty years (range 15-72) for men and forty-two years (range 19-75) for women. Their neurologic and urologic evaluations inclusive of an excretory urogram (IVU) and urodynamic study done within three months of the spinal cord injury were recorded (Tables I-III). Bladder training was started when: (1) the patient could tolerate catheter release every four hours with an indwelling catheter; (2) pyuria level was 110 WBCHPF; (3) patient was afebrile; and (4) no consistent bacteriuria was present. The method used for all patients was suprapubic tapping every four hours with or without compression followed by catheterization, the aim to keep the volume less than 100 mL at each catheterization (Table IV). The urine was cultured twice a week and midstream urine was collected twice weekly for
425
TABLE I.
Spinal cord injury on admission
-PatientsNumber
SC1
TABLE II.
Percent 53 31 16
29 17 9
Cervical cord injury Thoracolumbar injury Lumbosacral injury
Neurologic
TABLE IV.
deficit present
Neurologic Deficit
-PatientsNumber
Percent
Tetraplegia/paresis Central cord syndrome Brown-Sequard syndrome Paraplegia/paresis Cauda equina syndrome No neurologic deficit
17 9 1 21 4 3
31 16 2 38 7 6
Urodynamics study findings (within 3 months of spinal cord injury)
TABLE III.
Level of Injury Contractile bladders Intermediate Acontractile bladders Normal
3 5 9 0
0 3 5 1
19 11 16 9
(35) (20) (30) (15)
microscopic examination. Fluid intake was restricted to 2 to 3 L/day in divided doses from 6:00 AM to 6:00 PM. All volumes of urine voided by tapping and compression before catheterization and the residual volumes drained by catheterization were recorded by nursing staff on the patient’s bladder training chart. Results of the urine microscopic examination, cultures, sensitivity tests, and the antibiotic treatment given were recorded by medical officers in the individual patient’s urology card. As the volume of residual urine at each fourhourly catheterization fell, the frequency of catheterization was reduced, but the patient continued his four-hourly tapping and compression to aid in his voiding. When the daily residual urine for seven days was consistently below 100 mL, the patient was deemed to have been bladder trained. The voided volume was still charted for two weeks after the patient was bladder trained and the urology card was maintained until discharge. If the residual volume was persistently high and a trial of pharmacotherapy or surgical treatment failed to reduce
426
Method On admission Indwelling Foley catheter Voiding and intermittent catheterization On discharge Indwelling Foley catheter Voiding and tapping/compression Clean intermittent self-catheterization
-PatientsNo. Percent 43
78
12
22
2 45
3 82
8
15
the residual volume, usually after six to eight weeks post injury, clean intermittent self-catheterization was taught to our patients. The mean duration required for bladder training and the mean stay required for rehabilitation are given in Tables V-VII. Comment
SC1 Cervical Thoraco- Lumbar- Totals Cord lumbar sacral (%) 16 3 2 8
Method of bladder drainage
The urinary bladder has two primary functions: storage and evacuation of urine. Both functions are accomplished with low pressure to protect the integrity of the kidneys. Neural regulation is accomplished via peripheral and central reflexes which coordinate detrusor behavior with sphincter activity. Normal bladder capacity is about 400-500 mL. The general rate of formation of urine is 1.5 cc/min depending on the fluid intake, state of hydration of the person, and the surrounding humidity. The first desire to void is generally felt when the volume reaches 150 mL. A definite sense of fullness with the urge to void is when the volume reaches about 350 to 400 mL. Hence we void once every three to four hours during the day and usually voiding ceases once we go to sleep at night. With normal voiding, there should not be any residual urine and voiding should be accomplished without straining.es7 Spinal cord injury can be the result of trauma (our study group), herniated intervertebral disk, vascular lesions, tumor, infections, multiple sclerosis, or iatrogenic. Traumatic spinal cord lesions are of greatest clinical concern as partial or complete injuries cause equally severe genitourinary dysfunction. Lesions above the micturition center can lead to bladder and sphincter spasticity, voiding dyssynergia, detrusor hypertrophy, and urethral reflux. With time, under high voiding pressure, infection becomes recurrent, persistent, and combined with
UROLOGY / NOVEMBER1992 I VOLUME40, NUMBER5
TABLE V. Mean duration required for bladder training (n = 45) Type of SC1 Cervical cord injuries Thoracolumbar injuries Lumbosacral injuries
Incomplete
No. of Days (Range) 49 50 47
(37-86) (23-73) (32-79)
Recurrent
win
Bladder Type Contractile hyperreflexic (19 pts.) Intermediate (11 pts.) Acontractile (15 pts.)
No. of Days (Range) 43 (37-73)
39 (23-79)
55 (32-86)
TABLE VII.
Mean stay for rehabilitation Cfrom admission to discharge)
Type of SC1 Cervical cord injuries Thoracolumbar injuries Lumbosacral injuries
No. of Days (Range) 98 107 101
(30-161) (44-244) (43-156)
back pressure changes, loss of renal function is rapid and irreversible6 (Fig. 1). Lesions at the micturition center cause flaccidity of the bladder, a large capacity, low intravesical pressure, and a decreased tone of the perineal muscle and extensor sphincter. Loss of sensory input to the detrusor nucleus or to the dorsal horns of the cord result in loss of perception of bladder filling, overstretching, atony, and inefficient contractility resulting in significant residual urine and recurrent urinary tract infectionsS9-” Immediately following severe injury to the spinal cord or conus medullaris there is a stage of flaccid paralysis where the bladder becomes acontractile. The smooth muscle of the detrusor and rectum is affected resulting in overflow incontinence and constipation. This period of spinal shock may last a few days to about six weeks and inability to micturate is therefore the rule in the early weeks following injury. In our department we start bladder training in all our spinal cord injury patients as soon as they are transferred in, even during their spinal shock phase, provided they can tolerate fourhourly catheter release on an indwelling catheter, have no or low pyuria level s 10 WBC/HPF and no systemic infections and are afebrile. The
UROLOGY
/ NOVEMBER1992
/ VOLUME40,NUMBER5
ry
t Vesicourethral M Hydronephrosis enal
TABLE VI.
Mean duration required for bladder training according to bladder type (n = 45 pts.)
Bladder
FIGURE 1.
Effects
Emptying
t_;act
incection
reflux \ Pyelonephritis impairm knt
of detrusor sphincter
dyssyner-
gia.
method used by us is by four-hourly tapping with or without compression and intermittent catheterization, using strict aseptic techniques. Fluid intake is maintained at about 2 L/day (100 ml/hour). U rine microscopic examination and cultures are done twice a week and all urine volumes passed or catheterized are charted daily. Activity of the bladder after the spinal shock phase depends on the level of the neural lesion, In our patients with spinal cord injury above the micturition center, spasticity in the extremities, the return of some sensation, ability to feel bladder fullness and leakage of urine, the return of the anal tone, and certain reflexes like the bulbocavernosus and cremasteric reflex indicate that the spinal shock phase is over. These symptoms and signs may be present in those with lesions at or below the micturition center, but the end result is sometimes difficult to distinguish from spinal shock. With time, a variable range of detrusor reflex activity will return in most patients.12,13 In some, the contractile capabilities of the bladder will recover until a spastic state is reached. This group of patients, seen in 35 percent of our patients, will be able to empty the bladder reflexly by using tapping techniques to elicit a trigger point response, i.e., tapping or scratching the skin above the pubis or stroking the thighs. Detrusor hyperreflexia must be suppressed by anticholinergic drugs (e.g., oxybutynin, imipramine), detrusor sphincter dyssynergia treated with alpha receptor blockers (phenoxybenzamine), and urine evacuation done by intermittent catheterization (Table VIII). In others, no detrusor activity will return, and the bladder remains flaccid, seen in 30 percent of our patients, and partially emptied by tapping, compression, and then intermittent catheterization. Detrusor activity can be stimulated with
427
TABLEVIII.
Drugs wed in management neurogenic bladder
Action To reduce detrusor activity To reduce bladder outlet resistance To increase detrusor activity
of
TABLEIX.
Optimum requirements for clean intermittent self-catheterization
Drug
Absent or minimal detrusor activity High bladder capacity ?? Adequate bladder outlet resistance ?? Motor power level C8 and below for sufficient manual dexterity ?? Pain-free catheterization . Patient motivation ?? ??
Oxybutynin/imipramine Phenoxybenzamine Pyridostigmine/ubretid
TABLEX. cholinergic drugs for about two to four weeks (e.g., pyridostigminelubretid). A third group of patients with an intermediate type of bladder (20 % ), require a combination of tapping with/ without compression and intermittent catheterization together with pharmacotherapy. Surgi-
cal intervention is required for a small group of spinal cord injury patients (6%) who have marked spasticity of the bladder neck and external sphincter or an associated prostatomegaly causing outlet obstruction. Majority of our patients (82%) were catheter-free, continent, and able to adequately empty their bladders with the aid of tapping with/without compression by six weeks post spinal cord injury. This is the time we usually take to bladder train our patients and teach them to consistently maintain their residual volume s 100 mL. In the remaining (15%) patients who were not able to achieve a low residual urine, pharmacotherapy or surgical intervention was attempted, failing which, clean intermittent self-catheterization was taught to the patients before they were discharged (Tables IX and X). In these groups of patients their bladders were usually of the acontractile type with absent or minimal detrusor activity and a high bladder capacity. Mean serum creatinine level was 0.8 mg/lOO mL (range 0.4-1.1) for all our patients during their hospital stay. Intermittent catheterization,r4J5 the method used in our department to train patients with neurogenic bladders, requires consistency, whether four hourly, twice a day, or once in the morning, and a dedicated team of nursing staff and medical officers. We have had all these since this method was implemented in May 1988. In the past when indwelling catheters were used the infection rate in our department per month was 32 percent. Now after the introduction of the four-hourly intermittent catheterization regimen, the infection rate per month has fallen to 12 percent.
428
intermittent
Material for patients on clean self-catheterization at home/work
?? l?vo 10 cc plastic syringes . Plastic kidney dish ?? Sterile gauze or cotton wool ?? Lubricant gel (in tube form) ?? Foley catheter x 6 (can be reused after cleaning and disinfecting ?? Disinfectants containing chlorine (e.g., Dettol soap, Milton’s solution, or chlorhexidine (1: 1000) solution . Plastic storage bags (e.g., Ziploc bags)
In conclusion, the loss of normal bladder function in spinal cord injury patients is disabling and results in increased risk of recurrent urinary tract infection, giving rise to significant morbidity and occasional mortality. We have outlined the bladder training method used in our department with gratifying and significant success with the hope of preserving renal function, making our patients continent and helping them to live longer and more meaningful lives, the ultimate goal of any method of neurogenic bladder management. Stephen’s Hospital Tis-Hazari Delhi 110054, India (DR. MENON)
St.
ACKNOWLEDGMENT. To our dedicated team of nursing staff and medical officers, who have painstakingly documented all our patients’ investigations and to our typist Zaiton for typing the manuscript.
References 1. Barkin M, et al: The urological care of the spinal cord injury patient, J Urol 129: 335 (1983). 2. Fam BA, et al: Experience in the urological management of 120 early spinal cord injury patients, J Urol 119: 485 (1978). 3. Guttmann L, and Frankel H: Value of intermittent catheterization in early management of traumatic paraplegia and tetraplegia, Paraplegia 4: 63 (1966). 4. Achong MR: Urinary tract infections in the patient with a neurogenic bladder, in Block RF, and Basbaum M (Eds): Management of Spinal Cord Injuries, Baltimore, Williams & Wilkins, 1986, pp 164-179. 5. Anderson RU: Urinary tract infections in spinal cord injury
UROLOGY
I
NOVEMBER
1992
/
VOLUME 40, NUMBER 5
1974, pp 215-236. 11. Rossier AB, et al: Urodynamics in spinal shock patients, J Urol 122: 783 (1979). 12. Gosling J: The structure of the bladder and urethra in relation to function, Urol Clin North Am 6: 31 (1979). 13. Hackler RH: A twenty-five-year prospective mortality study in the spinal cord injured patient: comparison with the long-term living paraplegic, J Ural 117: 486 (1977). 14. McGuire EJ, and Savastno JA: Long-term follow-up of spinal cord injury patients managed by intermittent catheterization, J Ural 129: 775 (1983). 15. Rhame FS, and Perkash I: Urinary tract infections occurring in recent spinal cord injury patients on intermittent catheterization, J Urol 122: 669 (1979).
patients, in Walsh PC, Gittes RE, Perlmutter AD, and Stamey TA (Eds): Campbell’s Urology, vol 1, Philadelphia, WB Saunders, 1986, pp 888-899. 6. Tanagho EA: Interpretation of the physiology of micturition, in Hinman F, Jr (Ed): Hydrodynamics, Philadelphia, Charles C Thomas, 1971, pp 18-45. 7. Tanagho EA, and Miller ER: Functional consideration of urethral sphincteric dynamics, J Urol 169: 273 (1973). 8. McGuire EJ, and Brady S: Detrusor-sphincter dyssynergia, J Urol 121: 774 (1979). 9. Abrams P, and Torrens M: Urine flow studies, Urol Clin North Am 6: 71 (1979). 10. Tanagho EA: Vesicourethral dynamics, in Lutzeyer W, and Melchior H (Eds): Urodynamics, New York, Springer-Verlag,
UROLOGY
I NOVEMBER
1992
I
VOLUME
40. NUMBER
5
429
From the Department of Rehabilitation Tan Tack Seng Hospital, Singapore
(AUST.)
Medicine,
ABSTRACT-Immediately following severe injury to the spinal cord or conus medullaris, there is a stage of flaccid paralysis of the bladder. The smooth muscle of the detrusor and rectum is affected. Drainage of the bladder is very important in the early care of such patients. From August 1989 to August 1990, 55 spinal cord injury patients were studied on admission to our department. The current bladder training method used for these patients is presented. A patient was deemed to have been successjully bladder trained when catheterfree, continent, and able to consistently maintain a residual volume of 100 mL or less with the aid of tapping and compression. On discharge 45 patients (82 %$ were successfully bladder trained, 8 (15 %) employed a regimen of clean intermittent self-catherixation, and 2 went home/institutional care with an indwelling catheter. The material presented is applicable to any type of neurogenie bladder dysfunction.
Drainage of the bladder is very important in the early care of spinal cord injury (SCI) patients. 1,2The search for an ideal method during the period of spinal shock has continued since Curling (1833) described the dangers of indwelling catheterization in such patients. Since then, different methods have been tried such as cystostomy (Hugonet and Degerine, 1919), manual expression (Besley, 1917; Vellacott, 1919), and intermittent catheterization (Guttmann and Frankel, 1966).” Successful bladder training, effective modern rehabilitation, improved medical and surgical care has reduced the mortality of urinary sepsis in spinal cord injury patients from 80 percent in the 1920s and 30 percent in the 1960s to 6 percent in the 1980s.4B5 This article deals with current bladder training method used in our department for 55 spinal cord injury patients during the period of August 1989 to August 1990. Presented at First Regional Conference on Spinal Cord Injury, Bhubaneswar, India, February 1, 1991.
UROLOGY
/ NOVEMBER
1992
I
VOLUME 40, NUMBER 5
Material and Methods A total of 55 spinal cord injury patients (45 men and 10 women) admitted to our department were studied. Mean age was forty years (range 15-72) for men and forty-two years (range 19-75) for women. Their neurologic and urologic evaluations inclusive of an excretory urogram (IVU) and urodynamic study done within three months of the spinal cord injury were recorded (Tables I-III). Bladder training was started when: (1) the patient could tolerate catheter release every four hours with an indwelling catheter; (2) pyuria level was 110 WBCHPF; (3) patient was afebrile; and (4) no consistent bacteriuria was present. The method used for all patients was suprapubic tapping every four hours with or without compression followed by catheterization, the aim to keep the volume less than 100 mL at each catheterization (Table IV). The urine was cultured twice a week and midstream urine was collected twice weekly for
425
TABLE I.
Spinal cord injury on admission
-PatientsNumber
SC1
TABLE II.
Percent 53 31 16
29 17 9
Cervical cord injury Thoracolumbar injury Lumbosacral injury
Neurologic
TABLE IV.
deficit present
Neurologic Deficit
-PatientsNumber
Percent
Tetraplegia/paresis Central cord syndrome Brown-Sequard syndrome Paraplegia/paresis Cauda equina syndrome No neurologic deficit
17 9 1 21 4 3
31 16 2 38 7 6
Urodynamics study findings (within 3 months of spinal cord injury)
TABLE III.
Level of Injury Contractile bladders Intermediate Acontractile bladders Normal
3 5 9 0
0 3 5 1
19 11 16 9
(35) (20) (30) (15)
microscopic examination. Fluid intake was restricted to 2 to 3 L/day in divided doses from 6:00 AM to 6:00 PM. All volumes of urine voided by tapping and compression before catheterization and the residual volumes drained by catheterization were recorded by nursing staff on the patient’s bladder training chart. Results of the urine microscopic examination, cultures, sensitivity tests, and the antibiotic treatment given were recorded by medical officers in the individual patient’s urology card. As the volume of residual urine at each fourhourly catheterization fell, the frequency of catheterization was reduced, but the patient continued his four-hourly tapping and compression to aid in his voiding. When the daily residual urine for seven days was consistently below 100 mL, the patient was deemed to have been bladder trained. The voided volume was still charted for two weeks after the patient was bladder trained and the urology card was maintained until discharge. If the residual volume was persistently high and a trial of pharmacotherapy or surgical treatment failed to reduce
426
Method On admission Indwelling Foley catheter Voiding and intermittent catheterization On discharge Indwelling Foley catheter Voiding and tapping/compression Clean intermittent self-catheterization
-PatientsNo. Percent 43
78
12
22
2 45
3 82
8
15
the residual volume, usually after six to eight weeks post injury, clean intermittent self-catheterization was taught to our patients. The mean duration required for bladder training and the mean stay required for rehabilitation are given in Tables V-VII. Comment
SC1 Cervical Thoraco- Lumbar- Totals Cord lumbar sacral (%) 16 3 2 8
Method of bladder drainage
The urinary bladder has two primary functions: storage and evacuation of urine. Both functions are accomplished with low pressure to protect the integrity of the kidneys. Neural regulation is accomplished via peripheral and central reflexes which coordinate detrusor behavior with sphincter activity. Normal bladder capacity is about 400-500 mL. The general rate of formation of urine is 1.5 cc/min depending on the fluid intake, state of hydration of the person, and the surrounding humidity. The first desire to void is generally felt when the volume reaches 150 mL. A definite sense of fullness with the urge to void is when the volume reaches about 350 to 400 mL. Hence we void once every three to four hours during the day and usually voiding ceases once we go to sleep at night. With normal voiding, there should not be any residual urine and voiding should be accomplished without straining.es7 Spinal cord injury can be the result of trauma (our study group), herniated intervertebral disk, vascular lesions, tumor, infections, multiple sclerosis, or iatrogenic. Traumatic spinal cord lesions are of greatest clinical concern as partial or complete injuries cause equally severe genitourinary dysfunction. Lesions above the micturition center can lead to bladder and sphincter spasticity, voiding dyssynergia, detrusor hypertrophy, and urethral reflux. With time, under high voiding pressure, infection becomes recurrent, persistent, and combined with
UROLOGY / NOVEMBER1992 I VOLUME40, NUMBER5
TABLE V. Mean duration required for bladder training (n = 45) Type of SC1 Cervical cord injuries Thoracolumbar injuries Lumbosacral injuries
Incomplete
No. of Days (Range) 49 50 47
(37-86) (23-73) (32-79)
Recurrent
win
Bladder Type Contractile hyperreflexic (19 pts.) Intermediate (11 pts.) Acontractile (15 pts.)
No. of Days (Range) 43 (37-73)
39 (23-79)
55 (32-86)
TABLE VII.
Mean stay for rehabilitation Cfrom admission to discharge)
Type of SC1 Cervical cord injuries Thoracolumbar injuries Lumbosacral injuries
No. of Days (Range) 98 107 101
(30-161) (44-244) (43-156)
back pressure changes, loss of renal function is rapid and irreversible6 (Fig. 1). Lesions at the micturition center cause flaccidity of the bladder, a large capacity, low intravesical pressure, and a decreased tone of the perineal muscle and extensor sphincter. Loss of sensory input to the detrusor nucleus or to the dorsal horns of the cord result in loss of perception of bladder filling, overstretching, atony, and inefficient contractility resulting in significant residual urine and recurrent urinary tract infectionsS9-” Immediately following severe injury to the spinal cord or conus medullaris there is a stage of flaccid paralysis where the bladder becomes acontractile. The smooth muscle of the detrusor and rectum is affected resulting in overflow incontinence and constipation. This period of spinal shock may last a few days to about six weeks and inability to micturate is therefore the rule in the early weeks following injury. In our department we start bladder training in all our spinal cord injury patients as soon as they are transferred in, even during their spinal shock phase, provided they can tolerate fourhourly catheter release on an indwelling catheter, have no or low pyuria level s 10 WBC/HPF and no systemic infections and are afebrile. The
UROLOGY
/ NOVEMBER1992
/ VOLUME40,NUMBER5
ry
t Vesicourethral M Hydronephrosis enal
TABLE VI.
Mean duration required for bladder training according to bladder type (n = 45 pts.)
Bladder
FIGURE 1.
Effects
Emptying
t_;act
incection
reflux \ Pyelonephritis impairm knt
of detrusor sphincter
dyssyner-
gia.
method used by us is by four-hourly tapping with or without compression and intermittent catheterization, using strict aseptic techniques. Fluid intake is maintained at about 2 L/day (100 ml/hour). U rine microscopic examination and cultures are done twice a week and all urine volumes passed or catheterized are charted daily. Activity of the bladder after the spinal shock phase depends on the level of the neural lesion, In our patients with spinal cord injury above the micturition center, spasticity in the extremities, the return of some sensation, ability to feel bladder fullness and leakage of urine, the return of the anal tone, and certain reflexes like the bulbocavernosus and cremasteric reflex indicate that the spinal shock phase is over. These symptoms and signs may be present in those with lesions at or below the micturition center, but the end result is sometimes difficult to distinguish from spinal shock. With time, a variable range of detrusor reflex activity will return in most patients.12,13 In some, the contractile capabilities of the bladder will recover until a spastic state is reached. This group of patients, seen in 35 percent of our patients, will be able to empty the bladder reflexly by using tapping techniques to elicit a trigger point response, i.e., tapping or scratching the skin above the pubis or stroking the thighs. Detrusor hyperreflexia must be suppressed by anticholinergic drugs (e.g., oxybutynin, imipramine), detrusor sphincter dyssynergia treated with alpha receptor blockers (phenoxybenzamine), and urine evacuation done by intermittent catheterization (Table VIII). In others, no detrusor activity will return, and the bladder remains flaccid, seen in 30 percent of our patients, and partially emptied by tapping, compression, and then intermittent catheterization. Detrusor activity can be stimulated with
427
TABLEVIII.
Drugs wed in management neurogenic bladder
Action To reduce detrusor activity To reduce bladder outlet resistance To increase detrusor activity
of
TABLEIX.
Optimum requirements for clean intermittent self-catheterization
Drug
Absent or minimal detrusor activity High bladder capacity ?? Adequate bladder outlet resistance ?? Motor power level C8 and below for sufficient manual dexterity ?? Pain-free catheterization . Patient motivation ?? ??
Oxybutynin/imipramine Phenoxybenzamine Pyridostigmine/ubretid
TABLEX. cholinergic drugs for about two to four weeks (e.g., pyridostigminelubretid). A third group of patients with an intermediate type of bladder (20 % ), require a combination of tapping with/ without compression and intermittent catheterization together with pharmacotherapy. Surgi-
cal intervention is required for a small group of spinal cord injury patients (6%) who have marked spasticity of the bladder neck and external sphincter or an associated prostatomegaly causing outlet obstruction. Majority of our patients (82%) were catheter-free, continent, and able to adequately empty their bladders with the aid of tapping with/without compression by six weeks post spinal cord injury. This is the time we usually take to bladder train our patients and teach them to consistently maintain their residual volume s 100 mL. In the remaining (15%) patients who were not able to achieve a low residual urine, pharmacotherapy or surgical intervention was attempted, failing which, clean intermittent self-catheterization was taught to the patients before they were discharged (Tables IX and X). In these groups of patients their bladders were usually of the acontractile type with absent or minimal detrusor activity and a high bladder capacity. Mean serum creatinine level was 0.8 mg/lOO mL (range 0.4-1.1) for all our patients during their hospital stay. Intermittent catheterization,r4J5 the method used in our department to train patients with neurogenic bladders, requires consistency, whether four hourly, twice a day, or once in the morning, and a dedicated team of nursing staff and medical officers. We have had all these since this method was implemented in May 1988. In the past when indwelling catheters were used the infection rate in our department per month was 32 percent. Now after the introduction of the four-hourly intermittent catheterization regimen, the infection rate per month has fallen to 12 percent.
428
intermittent
Material for patients on clean self-catheterization at home/work
?? l?vo 10 cc plastic syringes . Plastic kidney dish ?? Sterile gauze or cotton wool ?? Lubricant gel (in tube form) ?? Foley catheter x 6 (can be reused after cleaning and disinfecting ?? Disinfectants containing chlorine (e.g., Dettol soap, Milton’s solution, or chlorhexidine (1: 1000) solution . Plastic storage bags (e.g., Ziploc bags)
In conclusion, the loss of normal bladder function in spinal cord injury patients is disabling and results in increased risk of recurrent urinary tract infection, giving rise to significant morbidity and occasional mortality. We have outlined the bladder training method used in our department with gratifying and significant success with the hope of preserving renal function, making our patients continent and helping them to live longer and more meaningful lives, the ultimate goal of any method of neurogenic bladder management. Stephen’s Hospital Tis-Hazari Delhi 110054, India (DR. MENON)
St.
ACKNOWLEDGMENT. To our dedicated team of nursing staff and medical officers, who have painstakingly documented all our patients’ investigations and to our typist Zaiton for typing the manuscript.
References 1. Barkin M, et al: The urological care of the spinal cord injury patient, J Urol 129: 335 (1983). 2. Fam BA, et al: Experience in the urological management of 120 early spinal cord injury patients, J Urol 119: 485 (1978). 3. Guttmann L, and Frankel H: Value of intermittent catheterization in early management of traumatic paraplegia and tetraplegia, Paraplegia 4: 63 (1966). 4. Achong MR: Urinary tract infections in the patient with a neurogenic bladder, in Block RF, and Basbaum M (Eds): Management of Spinal Cord Injuries, Baltimore, Williams & Wilkins, 1986, pp 164-179. 5. Anderson RU: Urinary tract infections in spinal cord injury
UROLOGY
I
NOVEMBER
1992
/
VOLUME 40, NUMBER 5
1974, pp 215-236. 11. Rossier AB, et al: Urodynamics in spinal shock patients, J Urol 122: 783 (1979). 12. Gosling J: The structure of the bladder and urethra in relation to function, Urol Clin North Am 6: 31 (1979). 13. Hackler RH: A twenty-five-year prospective mortality study in the spinal cord injured patient: comparison with the long-term living paraplegic, J Ural 117: 486 (1977). 14. McGuire EJ, and Savastno JA: Long-term follow-up of spinal cord injury patients managed by intermittent catheterization, J Ural 129: 775 (1983). 15. Rhame FS, and Perkash I: Urinary tract infections occurring in recent spinal cord injury patients on intermittent catheterization, J Urol 122: 669 (1979).
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