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is available to carry out this important part of the comprehensive management of these
seriously ill patients in the early stages of paraplegia.
Generally speaking, a newly paralysed patient needs 150-200 intermittent cathe-
terizations before the return of automatic or autonomous bladder function, in young
patients and incomplete lesions naturally less. If one balances the time taken by the
medical officer to carry out proper intermittent catheterization, which preserves a sterile
bladder for many weeks or throughout and avoids early complications, against time-
consuming and costly treatment of later complications arising from continuous drainage
by indwelling urethral catheter or suprapubic drainage, including repeated surgical
procedures with all the paraphernalia involved, one can be in no doubt that in the
patient's interest the employment of sufficient medical staff is more than justified.
B. MANAGEMENT IN THE INTERMEDIATE AND
LATE STAGES
The aims of management in the intermediate and late stages are to make the patient
catheter-free as soon as possible and to adjust him to his ultimate bladder dysfunction.
Hand in hand with these aims goes the control of bladder infection by mechanical
procedures, chemotherapy and antibiotics to prevent ascending infection and safeguard
the kidneys from destruction. Although the treatment is divided into conservative and
surgical procedures, in practice both are interrelated in many cases.
The objects to be pursued can be summarized as follows:
1
Control of residual urine and retention in the early intermediate stage.
2 Control of incontinence.
3
Reconditioning of the patient to his micturitional dysfunction.
4 Continuous drainage by indwelling catheter in later stages.
5
Control of infection by mechanical procedures, acidifiers, chemotherapy and anti
biotics.
6 Management of late complication.
i. Control of residual urine and retention in the early intermediate stage
In the early intermediate stage of bladder dysfunction, following the stage of spinal
shock in complete lesions above the lumbo-sacral cord, the reciprocal reflex mechanism
between the expulsion forces of the detrusor contractions and the relaxation of the
sphincter complex and the muscles of the pelvic floor are imperfect for some time in
ensuring complete evacuation of urine, and persistent residual urine results. This occurs
in cases following discontinuation of indwelling catheter drainage who are infected as
well as in cases treated by intermittent catheterization who have sterile urine. Therefore,
intermittent catheterization must be continued at gradually increasing intervals and
residual urine tests must be carried out systematically to ascertain the amount of residual
urine, which may vary within wide limits. If it is small in amount (under 1-2 oz) with
a bladder capacity of at least 10 oz there is no harm, as long as stagnation of urine, which
