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CHAPTER 26
Methods and techniques of management
We have to consider the following procedures used so far:
1
Permanent non-interference with urinary retention resulting in overflow inconti
nence.
2 Manual expression.
3 Urethral drainage by (a) intermittent catheterization, (b) continuous drainage through
indwelling catheter with or without tidal drainage or other forms of irrigation.
4 Suprapubic drainage (a) by aspiration, (b) suprapubic cystostomy and catheter
drainage, (c) cutaneous vesicostomy.
5 Urethrostomy.
6 Conservative and surgical methods of reconditioning in later stages.
A. INITIAL MANAGEMENT
There is general agreement that from the efficiency of the initial treatment of the paralysed
bladder the whole prognosis of spinal cord sufferers depends not only for their early
return to a useful life but indeed for their life expectancy. It must be remembered that,
even today, in spite of all advances made in the treatment of these patients during the
last 25 years, ascending infection of the urinary tract resulting in renal deficiency is
still the main killer. However, there is still discrepancy of opinion amongst workers in
this field regarding the most effective method of preventing over-distension, local
damage and infection of the bladder in the crucial initial and early stages of bladder
paralysis in spinal cord lesions. In the following, the various methods used in the initial
and early stages of bladder paralysis will be discussed and evaluated.
Non-interference
As a rule, the paralysed bladder is never sufficiently distended after an acute spinal cord
injury as to warrant immediate drainage by any method. In fact, voiding may occur
immediately as a result of the acute impact of the trauma, and patients have been admitted
to accident departments with wet underwear. Moreover, in many cases of spinal injury
the rate of renal secretion is retarded due to traumatic shock, especially in those associated
with injuries to other parts of the body (crush syndrome). Fluid intake should be restricted
during this period. This is particularly important in tetraplegics because of the disturbed
water metabolism as a result of the loss of the vasomotor control which follows the
interruption of the vasoconstrictor fibres in the cord. The belief that increased fluid
intake will establish at this stage micturition by reflex detrusor action is erroneous.
Moreover, as already pointed out, larger fluid intake in these high lesions carries the
danger of developing pulmonary oedema. Therefore, the bladder can be left alone for
12-24 hours until percussion of the suprapubic region reveals increasing distension of
the bladder or, in
a priori
incomplete lesions, distension provokes discomfort or distress
due to reflex responses of autonomic mechanisms. During the period of non-interference
