F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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urinary infection—he will have to drink 5-6 pints of fluid to flush the kidneys and ureters
and prevent stagnation in the urinary tract by more frequent micturition. Moreover, the
pH should be tested and the urine should be kept acid by taking acidifyers regularly.
The times at which fluid is taken has to be arranged in accordance with daily life activities
and the bladder emptying routine. Paraplegics who are at work, sports meetings, or
travelling abroad should take a bottle of fluid (water, fruit drinks, tea) with them to
continue their routine. During pyelitic attacks, in addition to a course of antibiotic
treatment the fluid intake has to be increased, if necessary by intravenous drip. In
complete, upper motor neuron lesions, especially above T5, the patient must learn to
appreciate the importance of certain sensations as indication of bladder distension, such
as tightness at the level of the lesion, vague ascending sensation, hot flushes in face and/or
upper chest, head fullness, headaches, sweating or goose skin. Therefore, he has also to
be acquainted with certain 'trigger' mechanisms such as coughing, straining deep breath
and rhythmic tapping of the suprapubic area, rubbing the inner side of the thighs or the
glans penis or peri-or intra-anal digital stimulation to set reflexly into action the emptying
mechanism of the bladder. Egede Blahn (1970) compared suprapubic rhythmic pressure
(SRMP), carried out by optimum technique i.e. using pointed pressure with the apex
of the fingers instead of flatly applied pressure with the palm or volar plan of the fingers
and other 'trigger' mechanisms. Measuring intravesical and abdominal pressure electro-
manometrically he found that SRMP setting up a stretch reflex of the bladder evoked
reflex micturition more effectively than other trigger mechanisms. The efficiency
increases with the duration and speed of SRMP.
In lower lesions of the spinal cord and cauda equina the strengthening of the abdominal
muscles by systematic exercises, starting while the patient is still confined to bed, are
essential for developing to a maximum the power of abdominal pressure to ensure satis
factory micturition with the least amount of residual urine. All this can also be achieved
in children with both upper and lower motor neuron lesions, if the training of the child
is started early, and the adopted habit of micturition is continued at home under the
supervision of the parents, especially the mother.
Jousse
et al.
(1964) also stressed the importance of training female paraplegics to
control their bladder dysfunctions and outlined a programme of training. Fifty per cent
of 80 cases with complete lesions and 80 per cent of 103 incomplete lesions regained
mastery of useful bladder control.
4. Continuous drainage by indwelling catheter in later stages
The number of paraplegics and tetraplegics who need permanent continuous drainage
by indwelling catheter has certainly decreased in recent years as a result of the advances
made in the initial management of the paralysed bladder. However, there are still those
who, because of a particular dysfunction of their urinary tracts, need this form of urinary
drainage either permanently or temporarily for varying periods during the intermediate
and late stages following cord and cauda equina lesions. Therefore, it is essential to
instruct the patient as well as his attendant at home, before his discharge from hospital,
in the basic principles and techniques of bladder care with an indwelling catheter.
