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CHAPTER 26
urethral dilatation using increasing calibre of catheters may facilitate the development
of co-ordination between bladder and sphincter function. It must also be remembered
that while reflex—or, in incomplete lesions, voluntary-micturition is in progress—the
force of the urinary stream can be increased by raising the intravesical pressure by
contractions of the abdominal muscles, or in the case of paralysis in higher lesions above
Tf, manually.
A powerful function of the abdominal muscles is of particular importance in over
coming residual urine in lower motor neuron lesions affecting the spinal micturition
centre itself or its spinal roots in cauda equina lesions resulting in an autonomous bladder.
Emmett (1954) found that contraction of the intact abdominal muscles, as is the case in
lesions below Ti2, raises the intravesical pressure to 50-70 cm water, which we con
firmed in our cystometric studies and which is sufficient to evacuate the bladder, provided
there is no obstruction at the bladder or urethral outlet by hypertrophy of the bladder
neck, external sphincter or increased spasticity. Therefore early physiotherapy to the
abdominal muscles while the patient is confined to bed, and restoring his upright posture
as early as possible have proved essential in the management of residual urine. Moreover,
the full co-operation of the patient, who must be made aware of his bladder dysfunction,
is indispensable. This will be discussed in the section on reconditioning.
Surgical
In the vast majority of complete paraplegics and tetraplegics satisfactory reflex—or in
incomplete lesions, voluntary micturition can be established. There remains, however, a
group who in later stages develop structural changes at the urethra and/or vesico-urethral
levels causing disturbances of the hydrodynamics resulting in retention of urine and
larger amounts of permanent residual urine necessitating surgical treatment.
In general, surgical procedures designed to overcome urinary retention can be divided
(a) into those to overcome the structural resistance of the peripheral sections of the
urinary tract mentioned above, (b) into those to reduce or abolish the action of certain
components of the vesical and/or urethral nerve supply. Under certain circumstances a
combination of both procedures may be necessary.
(a) i: Transurethral resection of the external sphincter
In recent years the importance of the obstruction of the external urethral sphincter as
the cause of urinary retention has become more and more apparent. It was in particular,
Cosbie Ross and his colleagues (1958, 1960, 1963, 1966) who developed the resection
of the external urethral sphincter as a useful method to eliminate its resistance. The
indication for this operation is made by thorough observation with the aid of a vesico-
urethrogram and urethroscopy. The operation was carried out by Ross initially with the
cold punch technique, several strips being resected from the posterolateral aspect of
the external sphincter. Although this technique was successful, the postoperative
complication was severe and dangerous venous bleeding. Since Ross improved his
technique by coagulating first the two posterolateral areas to be cut with diathermy cur-
