F - CLINICAL ASPECTS OF SPINAL CORD INJURIES
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by instrumentation, repeated attempts by
gentle
manual pressure and massage upon the
lower abdomen or combined with digital massage per rectum may be carried out to elicit
voiding.
Retention and overflow incontinence.
However, it cannot be overstressed that
permanent non-interference with urinary retention allowing maximal distension of the
bladder resulting in overflow incontinence has proved a most unsatisfactory method
resulting in chronic over-distension, hydronephrosis through back pressure and detrusor
damage, and must be condemned, the more so as it does not prevent bladder infection.
Continuous manual expression.
Vellacott & Webb Johnson (1919) described seven
cases of spinal cord injuries in which manual expression only was carried out and an auto
matic bladder developed after three weeks. Four of these patients had sterile urine but
three developed infection of the bladder. This method, although abandoned in due course
because of its hazards, such as inability to prevent ascending infection of the urinary
tract and the danger of rupture of the bladder as already reported in one of Vellacott's &
Webb Johnson's cases, has been recently revived by Golding (1968) who claimed satis
factory results in twenty-five patients. He found that by this method an automatic
bladder developed in 7 to 30 days and the residual urine slowly decreased; moreover all
patients showed a normal intravenous pyelogram. However, Cook & Smith (1971) who
tried this method on six patients who had not been catheterized previously and had a
normal intravenous pyelogram on admission, found that all patients developed urinary
infection and hydronephrosis; three of them developed deep vein thrombosis. In view
of these disastrous results these authors rightly discontinued further trials with this
method.
Urethral drainage.
While, during the Second World War, urologists and other surgeons
following Thomson-Walker's views condemned urethral catheterization and advocated
suprapubic cystotomy as the method of choice for the initial treatment of the paralysed
bladder, which was then widely accepted, further experience during and after the war
has revealed the hazards and disadvantage of this method. Today, this method is rarely
used by spinal cord specialists unless there is a strict indication (see later). It is now gener
ally agreed that the method of choice for the immediate and early management of the
paralysed bladder is urethral catheterization. However, authors still differ whether at
this stage urethral drainage should be done by continuous drainage with an indwelling
catheter, with or without a closed receptacle system and with or without irrigation or
tidal drainage, or by intermittent catheterization.
THE NON-TOUCH TECHNIQUE OF INTERMITTENT
CATHETERIZATION
In 1947 following experiences with paraplegics who were admitted to the Stoke Mande-
ville Centre immediately after injury, I advocated the non-touch technique of inter-
