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CHAPTER 26
Recently Stickler
et al.
(1971) studied the mode of development of urinary infection
in 9 male paraplegics who were treated by intermittent catheterization during the early
stage of paraplegia. In 4 of the 9 cases the organisms eventually responsible for the
bladder infection could be isolated from the urethra or from its external meatus before
they invaded the urine. They found variation in the rate at which different organisms
established themselves in the urinary tract and reached a level of io 5 organisms/ml in
the urine. In 5 of these 9 patients the invading bacteria were present at io 5 organisms/ml
of urine prior to the production of a pyogenic infection. From these few observations,
the authors came to the conclusion that the penile cleansing performed before the inser
tion of the catheter rarely sterilized the external meatus of the urethra. To conclude that
4 sterile cases out of 9 constitutes a rare incidence is in itself open to question. Although
this should not lead to generalization, in view of the vast number of sterile bladders
achieved by the non-touch technique of countless intermittent catheterizations described
above and by other authors, it demonstrates the importance of meticulous cleansing of
the meatus before inserting the catheter and the education of the medical staff in this
respect. As already mentioned, in this connection, early circumcision in paraplegics is
highly recommended in particular in patients with long foreskin, to diminish the danger
of transferring infection from the meatus and urethra.
Continuous drainage by indwelling catheter
In the foregoing section some reasons have been given why continuous indwelling
catheter drainage of the paralysed bladder is an unsuitable method for the immediate
and early treatment, the most important being that it leads invariably to early infection.
This seems to be now the general view of all experienced workers in the field of spinal
cord injuries. Hardy (1968), in his comprehensive analysis of 400 cases treated in a io
year period between 1956 and 1965 by indwelling catheter drainage, states 'all but a very
small number of the 400 cases had some infection at some time during the catheter
period' and 'that infections make up the most significant part of the complications of the
indwelling urethral catheter and that cases with infection of the epididymis were the
most troublesome'. Of special interest is the high incidence of calculi formation in
Hardy's cases following indwelling catheter drainage, namely 49 out of 400 (12-25 Per
cent). These unsatisfactory results were obtained in spite of the fact that Hardy employed
a meticulous technique of catheterization, including apparatus which had been pre
packed and autoclaved, and there was a separate pack for each procedure in each case.
Chlorhexidine solution was used for cleaning the meatus and foreskin and i per cent
Chlorhexidine cream was instilled into the urethra before the passage of the catheter,
which was changed only once a week and was connected with a closed drainage system
comprising a polythene tube and drainage system. The catheter mainly used was a self-
retaining Foley type catheter 16 to 22 French gauge with a 5 cc balloon. The defects of
this type of catheter described by Hardy are:
1
insidious deflation of the balloon,
2 occlusion of the lumen of the catheter by pressure within the balloon,
