Leading articles

overflow incontinence. Lower urinary tract infections in the neurogenic bladder are usually symptomless, and it therefore follows that the patient with a large residual urine and little or no incontinence is at high risk with regard to chronic infection leading inevitably to reflux nephropathy. Paradoxically, the patient who is totally incontinent with a small bladder often remains free of infection, but because of the social implication of his symptoms is more likely to seek medical advice. The old adage that 'the paraplegic patient is as old as his kidneys' still holds today. The organisms involved in urinary tract infections in the neurogenic bladder naturally tend to develop increasing resistance to the chemotherapeutic agents used and opportunist organisms such as Pseudomonas and Proteus species are commonly found. Indeed, when long-term indwelling urethral or suprapubic catheters are used these organisms are invariable, and in the presence of such a 'foreign body' in the urinary tract attempt at sterilization of the urine is quite useless. Treatment may be considered under the following headings: (1) management of acute spinal injury; (2) intermittent infections in the patient with early neurogenic bladder, or those with increased residual urine; (3) chronic relapsing infections in the more severely affected, including patients with indwelling catheter drainage; (4) patients with urinary diversion. Acute spinal injury

Acute retention develops in the spinal shock stage, and calls for immediate relief by some Watson, R. A. A., Landon, J., Shaw, E. J. & form of catheterization. The relative merits of Smith, D. S. Polarisationfluoroimmunoassayof intermittent catheterization and continuous gentamicin. Clinica Chimica Ada (In press). catheter drainage have been debated at length (Guttman & Frankel, 1966). There is no doubt that intermittent catheterUrinary tract infections in neurogenic bladder ization, 8 or 12 hourly can be carried out for Neurogenic bladder by reason of its aetiology long periods avoiding infection using strict is almost always a chronic problem. The aseptic techniques and involving a very few paraplegic patient may live for many years. specialized personnel, but such is the present For the spina bifida child the problem will be system of duty rotas for both nursing and lifelong. When developing as a complication junior medical staff that this is seldom if ever of such disorders as disseminated sclerosis, achieved, except in a few specialized centres. or diabetes mellitus, the patient may be faced Thirty ml of 1/10,000 of chlorhexidine instilled with many years of bladder dysfunction, and into the bladder before removal of the catheter with it the probability of recurrent or relapsing is ajustifiable prophylactic measure (Paterson, urinary tract infections. Barr & Macdonald, 1960; Gillespie, Lennon, For many patients with a neurogenic Linton & Slade, 1962). bladder, dysfunction takes the form of An indwelling catheter with a closed system chronic bladder retention with or without of drainage preventing entry and ascent of

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References Broughall, J. M. & Reeves, D. S. The acetyltransferase enzyme method for the assay of serum gentamicin concentrations and a comparison with other methods. Journal of Clinical Pathology 28: 140-5 (1975). Faine, S. & Knight, D. C. Rapid microbiological assay of antibiotic in blood and other fluids. Lancet ii: 375-8 (1968). Giamarellou, H., Zimelis, V. M , Matulionis, D. O. & Jackson, G. G. Assay of aminoglycoside antibiotics in clinical specimens. Journal of Infectious Diseases 132: 399-406 (1975). Noone, P. & Pattison, J. R. Methods for measuring serum gentamicin concentration (correspondence). Journal of Clinical Pathology 28: 83-4 (1975). Noone, P., Pattison, J. R. & Samson, D. Simple rapid method for assay of aminoglycoside antibiotics. Lancet ii: 16-9 (1971). Phillips, I., Warren, C. & Smith, C. E. Serum gentamicin assay: a comparison and assessment of different methods. Journal of Clinical Pathology 27: 447-51 (1974). Shanson, D. C. & Daniels, J. V. Factors affecting plate assay of gentamicin. I. Diluents. Journal of Antimicrobial Chemotherapy 1: 219-27 (1975). Shanson, D. C , Hince, C. & Daniels, J. V. Assay of gentamicin and tobramycin by a reliable 2i h Klebsiella plate method. Chemotherapy progress. Proceedings of the 9th International Congress of Chemotherapy 1975, Vol. 2. Plenum Press, New York (1976), pp. 147-53. Shanson, D. C. & Hince, C. J. Factors affecting plate assay of gentamicin. II. Media. Journal of Antimicrobial Chemotherapy 3: 17-23 (1976). Smith, D. H., Van Otto, B. & Smith, A. L. A rapid chemical assay for gentamicin. New England Journal of Medicine 286: 583-6 (1972). Ten Krooden, E. & Darrell, J. H. Rapid gentamicin assay by enzymatic adenylation. Journal of Clinical Pathology 27: 452-6 (1974).

Leading articles organisms up the catheter lumen can easily be achieved for many days—long enough to maintain a sterile urine in cases of mild injury with early recovery. For those requiring drainage for longer periods, it would seem more logical to culture the urine every day or so treating any infection that may arise rather than the use of prophylactic chemotherapy. Urine specimens for culture should be obtained by aspiration from the drainage tube with a syringe by a sterile technque, rather than disconnection of the drainage system which inevitably leads to infections (Miller, Gillespie, Linton, Slade & Mitchell, 1958).

of hexamine, 250 mg and methionine, 250 mg (6-8 tablets daily). Hiprex (hexamine hippurate) is a similar preparation (1 g 12 hourly). Alternatively, the urine can be kept acid to litmus by the use of large doses of ascorbic acid by mouth regulated by the patient. This form of therapy is particularly suitable where urea splitting organisms have been a problem.

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Chronic relapsing infections It is very difficult not to take a defeatist attitude when faced with the paralysed patient with a chronic mixed bladder infection. Best results are obtained by vigorous chemotherapy combined with surgery to reduce the residual urine in the bladder and relieve the dilated Intermittent infections in early neurogenic upper urinary tracts. This may take the form bladder This problem is most commonly seen in the of transurethral resection of the bladder neck child with spina bifida, early disseminated or external sphincterotomy either singly or in sclerosis and in the autonomically denervated combination. Chronic retention due to spasm bladder of a patient with long-standing or or dysfunction of the external bladder badly controlled diabetes. The organism sphincter is the most common situation, and found is usually Escherichia coli, but in un- sphincterotomy combined with several weeks circumcized boys, Proteus species are often chemotherapy is indicated. Mixed infections present (Maskell, Pead & Hallett, 1975). are often found involving Pseudomonas and Again the choice of management lies between Proteus strains. Unless special methods are the intermittent short course of chemotherapy available one or the other may be observed and long-term prophylaxis. The former would in the culture medium. Usually Pseudomonas appear to be more rational and less likely to appears to predominate. If the existence of result in development of resistant bacterial both organisms is not recognized at the outset strains, but involves more medical supervision chemotherapy may be discontinued before of the patient with regular (monthly) urine complete eradication allowing one or more culture, arrangements for treatment when organisms to re-appear. Combined therapy is infections are found, and follow-up urine sometimes indicated in this situation therefore, culture. A 2-week course of the appropriate for example, gentamicin with parenteral agent is indicated—where possible using the carbenicillin. sulphonamides, cotrimoxazole or nitrofuranThe problem of infections with Pseudomonas toin, reserving the newer broad spectrum is a difficult one. It is so often found in a antibiotics for possible future use. situation in which the underlying pathology is In spina bifida boys where Proteus urinary impossible to resolve. Moreover, it is usually infections are a problem and the same symptomless even in normal patients, and a organism is cultured from the preputial sac, symbiosis is readily achieved—the host only circumcision is indicated (Maskell et al., 1975). being at risk if the organism enters the blood Prophylactic management is most useful in stream. There is of course a risk not only to patients where regular screening is difficult by the patient himself during diagnostic or reason of inaccessibility to hospital or health therapeutic instrumentation but also the centre. Children tolerate sulphonamides, cotri- possibility of cross infection arising in a moxazole and nitrofurantoin remarkably well hospital ward. In a domiciliary situation for long periods, and cotrimoxazole is therefore many clinicians often withhold especially convenient because of its 12 hourly chemotherapy for Pseudomonas infections and dosage. Ampicillin is best avoided, especially in other multiresistant organisms in the presence females because of the likelihood of Monilia of long-standing underlying uroiogical abnormalities that cannot be successfully eradicated. infections. A possible compromise for those unhappy When a neurogenic bladder is managed with in the use of long-term antibiotic cover is a permanent indwelling urethral or suprapubic hexamine or its modern counterparts, which catheter, the probability of infection is decomposes into formaldehyde and ammonia absolute, and the possibility of permanent at a pH of 5-5 or less. G500 is a combination sterilization of the urine almost nil. In this

Leading articles situation local treatment by bladder washouts with chlorhexidine solution, or better still, noxyflex (noxytiolin) offers the best hope of keeping infection under control. This situation is fortunately becoming less common because of the more effective early management of neurogenic bladder, and the more frequent use of diversion of the urine by intestinal conduit in those with signs of upper urinary tract deterioration.

Paterson, Barr & Macdonald. Journal of Obstetrics

and Gynaecology of the British Commonwealth 67: 394 (1960). Slade, N. & Linton, K. B. Problems in the treatment of Ps. pyocyanea infections. British Journal of Urology I: 73-8 (1965).

310-2 (1958).

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Travellers' diarrhoea The traveller abroad has blamed in turn the food, the wine, the water and ice cubes for Diversion of the urine his attack of diarrhoea which may range in The purpose of this is to conduct the kidney severity from a minor nuisance to a severe urine uninterruptedly to the exterior by means and incapacitating calamity. Theories on its of an intestinal conduit (ileal or colonic), cause and cure are as frequent as its interand in some cases by direct ureterostomy. The national nomenclature—Malta dog, Delhi conduit must not be a reservoir or the whole belly, Montezuma's revenge, Aztec two-step, purpose of the operation is defeated. Urine turista In recent years increasing attention specimens from patients diverted in this way is focused on pathogenic enterotoxinoften contain a great amount of mucous and producing Escherichia coli (Rowe, Taylor & varying numbers of epithelial cells, and to Bettelheim, 1970; Gorbach et al, 1975; superficial examination look infected. More- Merson et al., 1976). E. coli produces two over, specimens for culture may mistakenly be forms of enterotoxin, heat-labile and heattaken from the collecting bag which is always stable toxins. The labile toxin was responsible heavily contaminated. for acute diarrhoea with but a short incubation It is therefore mandatory to obtain urine period in a large group of United States specimens by catheterization of the stoma students intensively investigated in Mexico which serves a dual purpose of obtaining an (Gorbach et al., 1975). Another prospective uncontaminated specimen and warning the survey was undertaken on gastroenterologists clinician of any increased residual urine in the and their families attending a World Congress conduit. of Gastroenterology in October 1974 in Infections in a properly devised diversion Mexico City by the U.S. Center for Disease are surprisingly uncommon. Those that occur Control (Merson et al., 1976). Faecal speci-. are usually symptomless, and may well mens were collected from participants before represent a simple colonization of the conduit. they went to Mexico, in Mexico City and When there are constitutional symptoms again after they had left Mexico. Sera were suggesting a renal infection, the nature of the also collected for E. coli and virus antibodies. infection may be confirmed (in the case of E. Of the 121 participants 114 were from the United States, the remainder were from coli) by antibody titre estimation. Treatment is usually by intermittent courses Canada, England or Holland. About one-half of chemotherapy as and when infections arise. of the physicians and spouses were ill and a pathogen was found in two-thirds of these; NORMAN SLADE most frequently toxigenic or invasive E. coli, Southmead General Hospital, but also Salmonellae, Shigellae, Vibrio paraBristol, England haemolyticus, Giardia lamblia and the human References reovirus-like agent. Onset of illness was 3 to 16 Gillespie, W. A., Lennon, G. G., Linton, K. B. (median 6) days and the median duration of and Slade, N. Prevention of catheter infection of illness was 5 days. On the day of the most urine in female patients. British MedicalJownal, severe symptoms, nine-tenths had 3 or more ii: 13-6 (1962). episodes of diarrhoea; and abdominal cramp, Guttman, L., Frankel, H. L. Value of intermittent catheterisation in the early management of nausea and anorexia were common. Illness traumatic paraplegia. Paraplegia 4:63-83 (1966). was not significantly associated with the 3 Maskell, R., Pead, L., Hallett, R. J. Urinary congress social functions, nor with illness in a pathogenis in the male. British Journal of consort, nor with consumption of water or Urology 41: 691-4(1915). ice, but there was a statistically significant Miller, A., Gillespie, W. A., Linton, K. B., association between the consumption of raw Slade, N., Mitchell, J. P. Catheter drainage and vegetable salads and infection with enteroinfection in acute retention of urine. Lancet i: toxigenic E. coli.

Urinary tract infections in neurogenic bladder.

Leading articles overflow incontinence. Lower urinary tract infections in the neurogenic bladder are usually symptomless, and it therefore follows th...
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