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mittent catheterization as the method of choice for the treatment of the paralysed bladder
during the spinal shock and the early stages of paraplegia. In due course this method has
been further developed and its standard improved (Guttmann, 1949-63; Guttmann &
Frankel, 1966). Details of the method and its evaluation are described hereunder:
Intermittent catheterization is instituted if after 12-24 hours voluntary or reflex
function of the bladder has not developed and gentle manual pressure upon the bladder
region or digital massage per rectum has proved unsuccessful, and the bladder has
become distended.
The reason why intermittent catheterization in the immediate and early stages of
paraplegia is infinitely preferable to immediate continuous drainage by an indwelling
catheter, can be summarized as follows:
1
Immediate and early drainage of the paralysed bladder by indwelling catheter of
any type, including Gibbon's catheter, leads invariably to early bladder infection which
in a great number of cases occurs within 2-4 days if not within 24 hours. Therefore, in
this respect there is really no difference between indwelling urethral catheter and drainage
by suprapubic cystostomy whether with or without tube insertions.
2 An important reason for first using intermittent catheterization and not an indwelling
catheter is to allow the urethral mucosa to become accustomed gradually to the foreign
body. It must be remembered that in the state of spinal shock and flaccidity, the tone
of all tissues including that of the urethral and bladder mucosa is greatly diminished, and
as a result the threshold to pressure is lowered and injury to the mucosa facilitated.
Consequently, an indwelling catheter, especially one of larger size, kept
in situ
without
being changed for several days or even weeks, tends to produce ischaemia of the tissue
by constant pressure especially on the peno-scrotal angle of the urethra resulting in a
pressure sore leading to abscess and eventually to that most dreaded complication, peno-
scrotal fistula. Kyle (1968) stressed the obstructive effect of the catheter on the ducts of
the many glands which open in the urethra and considered this as the cause of the
persisting foci of infection 'which remained after the offending instrument has been
abandoned'.
3
In incomplete cord lesions and those complete ones, especially in young people,
where early return of voluntary or reflex function can be expected, provided no bladder
infection has occurred, intermittent catheterization encourages the physiological stimulus
for micturition, namely some bladder distension by setting up the appropriate impulses
to the spinal reflex bladder centre and thus promoting early return of detrusor activity
in these cases. Using this regime of bladder management, we found, particularly in young
patients with complete lesions above Tio, the appearance of automatic reflex-micturition
as early as 8-10 or 14 days after injury. Therefore, the old teachings of physiologists and
neurologists that automatic reflex-micturition after complete lesions occurs only after
6-8 weeks can no longer be accepted dogmatically.
The view held by urologists and other surgeons for so many years that, with inter
mittent catheterization, the paralysed bladder cannot be kept sterile longer than 2 days
is absolutely unfounded, provided proper aseptic precautions are taken. That the old
prejudice against intermittent catheterization has not been overcome, is shown by the
astonishing statement made as late as 1959 by Prather in the U.S.A.: 'It is generally
