F CLINICAL ASPECTS OF SPINAL CORD INJURIES
369
represents an ideal medium for bacteriological growth, is avoided by a high fluid
intake.
Cystometric studies should be carried out in that stage to ascertain the development
of the reflex activity of the detrusor and its expulsive power. Parasympathetico-mimetic
drugs such as Carbamylcholine chloride (Carbachol, Doryl), the urethane of choline,
in doses of 1-5 mgm by mouth 2-4 times daily or 0-00025-0-0005 gms intramuscularly
have proved useful in improving reflex micturition by increasing the expulsive power of
the detrusor and promoting voluntary micturition in incomplete lesions. Another very
effective cholinergic agent in hypotonic bladder is Urecholine (Beta-Methylcholine
urethane) recommended by Lee (1950) in doses of 5 mgm subcutaneously or 5-50 mgm
orally 3-4 times daily. Side effects of these cholinergic drugs are gastro-intestinal disturb
ances, sweating and lacrimation and they should be avoided in patients with a history of
gastro-duodenal ulcers and asthma. Moreover, we found that the beneficial effect of
these drugs is by no means uniform in neurologically comparable lesions of the same level;
in fact in some cases the degree of urinary retention increased, presumably, these drugs
stimulate the sphincter complex as much as the detrusor.
Treatment of retention in later stages
Conservative
In later stages, when the reflex activity of the isolated or diseased spinal cord is increased,
larger amounts of residual urine may be due to the increased reflex activity of the internal
and external sphincter complex. There are no specific drugs available to relax solely the
heightened reflex function of the sphincter mechanism. Moreover, in this stage the reflex
activity of the detrusor itself is increased resulting in frequent but ineffective micturition
with greater or lesser amounts of residual urine. One has, therefore, to rely on drugs
which have a generally depressant effect on spasticity, which are discussed in the section
on spasticity. However, temporary local suppression of the heightened reflex activity
of the sphincter complex including the pelvic floor muscles by local anaesthesia of
urethra and bladder outlet through instillation of anaesthetics such as 60 ml of 0-1-0-25
per cent solution of Pantocaine can be achieved, thus diminishing the resistance of the
sphincters and increasing the expulsive power of the detrusor. The increase of detrusor
capacity by topical anaesthesia was described by Bors & Comarr (1970), who in addition
found that suppression of the mucosal impulses also results in the reduction of the skeletal
spasticity in some patients. Whether it is necessary to achieve relaxation of the pelvic
floor by simultaneous anaesthesia of the external anal sphincter by instillation of 5-10 ml
of Nupercainal ointment into the rectum will have to be decided from case to case.
Relaxation of the external anal sphincter was demonstrated electro-myelographically
(Bors & Blinn, 1957; Rossier & Bors, 1962). One can fully agree with these authors that
this simple procedure can be carried out with impunity several times weekly or even
daily before more drastic procedures (see later) are contemplated to eliminate or greatly
reduce residual urine by increasing the expulsive force of the detrusor. In some cases,
the temporary reduction of urethral resistance of the urinary outflow by repeated
