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CHAPTER 26
Ascoli (1968). The reason why this method has been given up by many workers, is the
difficulty in assessing accurately the height of the tidal drainage loop in accordance
with bladder dysfunction. Also the drip rate of the fluid has to be controlled.
In all patients with continuous catheter drainage, fluid intake or large quantities
(3-6 pints) is even more important than in catheter-free patients to avoid stagnation in
the upper urinary tract.
There is no doubt that, in the majority of paraplegics and tetraplegics who, because
of their particular bladder dysfunction in later stages, need long-term continuous
drainage by indwelling catheter, this regime of mechanical procedures has proved bene
ficial in keeping the bladder and upper urinary tract infection at a low grade. Moreover,
in catheter-free patients who, due to infection or, in the case of a sterile bladder, as a
result of changes in the co-ordination of the emptying and closing reflex mechanisms,
develop complications of the upper urinary tract, temporary indwelling catheter drainage
in combination with bladder washouts and increased fluid intake, can prevent further
deterioration of the bladder dysfunction and preserve the integrity and function of the
renal parenchyma. The efficiency of these procedures can be greatly increased by the
employment of acidifyers, chemical drugs and antibiotics.
(b) Antibacterial agents (acidifyers, chemotherapeutics, antibiotics)
Before the introduction of the sulphonamides and antibiotics, acidifyers such as hexa-
mine, mandelic acid, acid sodium phosphate, ammonium benzoate and ammonium
chlorate were the favourite drugs to combat infection of the urinary tract. Of these,
hexamine (10 g three times daily) certainly has an inhibitory effect on bacterial growth
by liberating formaldehyde in acid urine with a pH of 4-5. In pyelitic attacks, I found
previously intravenous injections of 5 cc cylotropin (hexamine, sodium salicylate and
caffeine) once or twice daily effective. However, prolonged treatment had the disadvan
tage, like urotropine (the trade-mark of hexamine) by mouth, in causing haematuria.
Ammonium benzoate and, in particular, ammonium chlorate are now seldom used
because of their adverse gastro-intestinal effects. Ascorbic acid (i g 3-4 times daily),
introduced by Donald & Murphy (1959) without the combination of chemotherapeutic
drugs, has not proved effective. In series of cases, throughout the years, we tried various
combinations of acidifying agents, amongst them a combination of hexamine and hippuric
acid to potentiate the acidifying effect, but this combination did not prove successful.
However, the combination ofmethionine (Kass & Sossen, 1959) and hexamine-mandelate,
manufactured as 0500 (see p. 349), has proved an effective acidifyer of urine, but it
cannot prevent alkalinity in severe infection with B. proteus because of its hydrolysing
effect of urea into ammonia. Moreover, some patients are hypersensitive to the unpleasant
taste and smell of methionine on prolonged treatment.
Of all the chemotherapeutic antibacterial agents, Furadantin (nitrofurantoin) has
proved very effective against Gram-positive and Gram-negative organisms, and it acts
well with acidification by G500. The doses prescribed are: 50-75 mg for adults and 5-10
mg for children four times a day during or immediately after meals, and this is given
