F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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advisable to prevent infection of meatus and urethra and paraphymosis. In patients who
are admitted in the first few days after injury with an indwelling catheter already
in situ,
it is advisable to take a swab for culture from the meatus and urethra as well as a urine
specimen before intermittent catheterization is started to ascertain whether or not infec
tion had already occurred. In such a case it is safer to start antibiotic treatment, even if
there is only bacteriuria without increase of white cells and protein.
Cervical patients have, not infrequently, an initial period ofwater retentionwith oliguria
during the first few days after injury and during this time need only, as a rule, twice
daily catheterization. At about the 3rd-6th day or soon after, often a profound diuresis
occurs, and 3 or 4 litres of urine may be secreted in 24 hours. During such diuresis, the
fluid intake should be temporarily reduced, and the patient be catheterized four or more
times a day. If the period of diuresis is overlooked by the medical and nursing staff, over-
distension may occur in this acute stage resulting in discomfort and exaggerated reflex
responses of autonomic mechanisms, especially increase of blood pressure. After the
diuresis is over, fluid intake should be adjusted so that each catheterization at approxi
mately 9 a.m., 2.30 p.m. and 10 p.m. yields between 500 and 700 ml in adults, and every
care must be taken to see that the bladder never becomes over-distended. This in itself
shows the great responsibility of the staff concerned with the management of paralysed
patients in the acute stage. On three times daily catheterization in patients who are unable
to pass any urine, the fluid output in correlation with fluid intake should average 2 to 3
litres in 24 hours.
Care must also be taken to empty the bladder completely, as it is known that in the
recumbent patients, in particular those with flaccid lesions, the lowest point of the bladder
is not necessarily drained by the catheter (Doggart, Guttmann & Silver, 1966). Therefore,
change of position and abdominal pressure is used at the end of the catheterization to
obtain any residual urine and thus prevent stagnation in the bladder. The importance
of regular turning of the patient in the acute and early stage and the early restoration of
his upright position to avoid stagnation in the urinary tract cannot be overstressed. When,
in adults, the residual urine becomes less than 500 ml, catheterization can be reduced to
twice daily, and when less than 250 ml to once daily, and when less than 100 ml catheter
ization can be stopped provided an efficient automatic reflex bladder, in lesions above the
thoracolumbar junction, or an autonomous bladder in conus-cauda equina lesions,
emptied by powerful abdominal pressure has developed. However, the residual urine
has to be checked once or twice a week for several more weeks.
Before 1954, it was our practice to give prophylactic penicillin or sulphonamides or
alternatively Aureomycin or later Tetracyclin during the first week or two of cathe
terization. However, since antibiotics are not given routinely as urinary prophylactics, the
patients with associated injuries should be treated with intramuscular penicillin or other
antibiotics for the first week or two for the prevention or treatment of chest or other
infections. This applies, of course, also to patients who have been admitted with infected
urine as a result of an indwelling catheter.
In recent years, I introduced a combination of hexamine-mandelate (250 mg) and
methionine (250 mg) manufactured in one tablet as an acidifying agent and called 0.500
(this drug is manufactured by Harker, Stagg Ltd, Emmott Street, London E.I). This
