D e c e m b e r, 1965 P H Y S I O T H E R A P Y Page 7 T HE M A N A G E M E N T OF T H E B L A D D E R I N S P I N A L P A R A P L E G I A T. C O E T ZE E , M.B., Ch.B., C h.M ., F.R .C.S.(Eng.), F.C.S. (S.A.), F.A.C.S. Lecture delivered to the S.A .S .P . Post Registration Course at the Ernest Oppenheimer Hospital, W elkom , M a y, 1965. The paraplegic an d the care o f the paraplegic bladder is a world-wide problem . In some cases the condition is the re su lt of disease; mostly it is man-made. W ith the advance o f industrialization and the increase in road accidents it can be safely assum ed, unfortunately, that the num ber of these patients will increase in the future. In this hospital our patients w ith paraplegia are mostly the victims o f industrial accidents: a fracture of the spine w ith injury of the spinal cord and/or cauda equina. In a m inority of cases paraplegia is the result o f spinal tuberculosis o r tum our. However, whether the paraplegia has resulted from traum a or disease of the spine or spinal cord, the problem s presented by the bladders are similar. Part o f what I shall be saying today is possibly not the direct concern o f the physiotherapist. However, it is my experience that sharply divided responsibilities in the care of the paraplegic reflects usually to the detrim ent of the patient. The surgeon, the nurse, the physiotherapist, the appliance expert, the hospital alm oner and social w orker— all these should w ork as a team if the most good is to be done for the patient. If this is so, then it also follows that the knowledge and experience o f these various disciplines should be pooled and each should have a w orking acquaintance with the methods of the others. I am therefore m aking no excuses for mentioning certain facts which may not be directly or prim arily the province o f the physiotherapist. If you will bear w ith me for a few minutes, I shall briefly present the anatom y and physiology necessary for the under­ standing o f the cord bladder. In the adult the spinal cord occupies the vertebral canal as far down as the lower border o f the first lumbar vertebra. In the corns medullaris—the tapering caudal extremity o f the spinal cord, all the sacral segments o f the cord are crowded into the p art o f th e cord lying opposite the first lumbar vertebra. Below this level, injury will result in pure cauda equina, i.e. nerve ro o t damage, above this level injury may be isolated cord dam age o r cord plus root damage. T he differ­ entiation is m ost im p o rtan t: injury to the spinal cord is irrecoverable, while regeneration is possible w ith ro o t damage. Above the conus level (for practical purposes dow n to D 11) the sacral segments of the cord are undam aged, spinal reflex paths rem ain intact; but cortical control is inter­ rupted. The motor nerves o f the bladder are the parasympathetic nerves contained in th e 2nd, 3rd and the 4th sacral nerves. These, as parasym pathetic nerves do, end in a peripheral plexus or actually in th e bladder wall from w here post­ ganglionic fibres are given to the bladder muscle. The external urethral sphincter is also supplied from the same spinal segments via the pudenal nerve. Urinary continence is usually acquired by the child before the age o f two y ears: this implies the awareness o f the sensa­ tion o f fullness o f the bladder, and the ability to postpone Jhe act o f urination until the time an d place is opportune. hi6 ^tedder muscle—the detrusor—possesses, to a rem ark­ able degree, the quality o f accommodation and the sensation ot fullness will pass away tem porarily if urination is not Possible, It will, however, return, m ore urgently as filling Proceeds, until th e sensation becomes acutely painful. Urination consists in the voluntary removal o f inhibition CORTICAL R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) of the sacral spinal segments, leading to parasym pathetic discharge, contraction o f the detrusor w ith opening of the bladder neck and outflow o f urine. T he external sphincter is merely a cut-off muscle on guard during stress or for voluntary interruption o f the urinary stream . N orm ally continence is m aintained by urethral resistance, the result o f the tone of its muscular walls. When spinal cord injury involves the sacral segments o f the cord, reflex urination is interfered with o r abolished. T he bladder has to be emptied by abdom inal straining or m anual compression. The patient often has a vague sensation o f bladder fullness. Para-sym pathetic discharge will occur, increasingly with time, from plexuses close to or in the bladder wall, to the extent th a t hypertrophy o f the bladder muscle and bladder neck may occur. T his has im portant consequences: the bladder wall thickens to the extent th at its capacity is seriously reduced an d obstruction develops at the bladder neck. T he patient usually dribbles or passes small amounts o f urine at frequent intervals and the residual urine is considerable. The best th a t can usually be achieved is total leak with a small residual, controlled with an external appliance. This type o f cord bladder is com m on as vertebral level T 12-L 2 is the most frequent site o f spinal injury. After injury at higher levels reflex bladder emptying will be retained. The bladder empties, involuntarily, when a certain degree o f filling has occurred. Em ptying can som e­ times be triggered by pressing over the hypogastrium , by scratching the inside of the thigh o r squeezing the glans penis. This type o f cord bladder has often been regarded, in the past, as a happy state o f affairs. However, bladder emptying is often incomplete, intervals o f dryness often short and unpredictable and there is often deterioration o f bladder function w ith time due to increased spasticity o f the urethral and pelvic floor m usculature. In some o f these cases successful bladder em ptying with retention o f reflex urination can be achieved by relieving bladder neck an d urethral resistance, either by bladder neck resection or pudendal neurectomy. In all cases o f spinal cord injury there will be, during an initial phase o f varying duration, complete flaccidity o f the bladder with retention o f urine. In all cases the aims o f treatm ent a r e : A. To avoid overdistension o f the bladder during the initial phase o f complete retention: It should be rem em bered that secretion of- urine is usually dim inished in th e im mediate post-traumatic phase. Relief o f urinary retention is there­ fore never dreadfully urgent. F o r instance, there is no need for a catheter to be passed at the scene o f an accident or at the dressing station or hospital outpatient departm ent. This is sometimes done and infection is often introduced when proper aseptic technique is not possible o r observed. C athe­ terization should be postponed until it can be perform ed, under ideal conditions, in the w ard or theatre. Many different techniques for m anaging the bladder during this phase o f retention have been recom mended. This varies from overflow plus expression, to suprapubic cystostomy, interm ittent catheterization, perineal urethros­ tomy and an indwelling urethral catheter—w ith simple drainage, regular bladder irrigation o r tidal drainage. Our personal preference is very definitely for indwelling catheter drainage, using for this purpose a 16 F latex rubber catheter with a retaining bulb draining into a container with a water seal. O ur experience w ith G ibbon an d other plastic catheters has no t been satisfactory. R outine bladder irri­ gations are not used but may sometimes be required, tem ­ porarily, in the presence o f urinary infection. T o avoid kinking and pressure at the peno-scrotal area, the catheter and penis is draped upw ards and outw ards over the lower abdomen. The catheter-penis ju nction is covered with gauze moistened in antiseptic. D rainage tubing an d receptacles are sterilized daily, observing aseptic precautions during removal and re-connection. The catheter is changed when necessary, using a new catheter every time. We like to have the pubic hair shaved—local cleanliness is m ade easier. Page 8 P H Y S I O T H E R A P Y December, 1965 B. To restore bladder emptying or improve its efficiency: R esum ption of detrusor activity can generally first be observed during cystom etography. M ore usually, the ure­ thral catheter is simply rem oved and bladder function assessed by noting the result o f voiding efforts, the occur­ rence o f spontaneous leakage, the result of expression and m easurem ent o f the residual urine. In o u r own work, a residual urine o f m ore than 100 ml. is regarded as too risky to accept. In such cases drainage will be reinstituted. It is most im portant not to perm it over­ distension o f the bladder during such a check-up. Ascending urinary infection has often started at this stage. I f sufficient bladder emptying has not been restored at three m onths following traum a, further investigations are instituted. T he most instructive investigation is the voiding cystogram —this will usually show the presence o f abnorm al resistance and its site and will indicate the nature o f any operative procedures that may be necessary. C. To control incontinence: In the male the most con­ venient m ethod is by using an external appliance. These vary in design but the object is to collect the urine from the penis by means o f a cuff w ith a w ater-tight fit and drain it into a collecting bag. In this way the patient m ay be kept dry and could attend to his daily task. T he m ain difficulty is to avoid m aceration and ulceration o f the penile skin, the glans penis and the external urethral m eatus. Some male patients prefer an indwelling catheter and may tolerate it well for many years. It is amazing what insults the urinary tract will sometimes tolerate. Some years ago I had the opportinity o f inter­ viewing an old gentlem an who attended in the outpatient departm ent of the hospital where I was then working. He had been catheterizing him self ever since an attack o f acute urinary retention and his only reason for attending was to obtain a new catheter. I to o k him to an exam ination room and asked him to dem onstrate his technique to me. H e took, from his wallet in an inside pocket, an old battered and scratched coude gum-elastic catheter, wiped it with his handkerchief, applied a liberal dash of saliva, directly, as a lubricant, and passed the instrum ent into the bladder. He had been doing this, using exactly the sam e technique, roughly four times a day, for 25 years. There was no evidence o f urinary infection. When I w arned him o f the dangers o f infection he explained th at he chewed tobacco and did not think th a t any organism could exist in th a t environm ent. . . . On other occasions a single, scrupulously aseptic, urethral catheterization will spark off a dangerous ascending urinary infection. N o suitable external appliance for the incontinent female is available as yet and a perm anent indwelling catheter is usually the best solution. In som e neglected cases w ith severe bladder contractions, upper tract d ilatation and deteriorating renal function it may be necessary to construct an ileal conduit. W ith an efficient ileostomy appliance this can be m ade to w ork very well. Several other aspects of the care o f the paraplegic patient has a close bearing on the m anagem ent of his b la d d e r: 1. The prevention o f pressure sores: In this hospital we are fo rtunate in alm ost never seeing a pressure sore—so much so th at we alm ost welcome the adm ission o f a patient w ith a pressure sore once in a while to be able to show our nursing staff why we insist on tw o-hourly turning o f the patient. T he prevention o f pressure sores is, in the acute phase, the responsibility o f the nursing staff. A t a later stage, w ith the patient in his wheelchair, the supervision by the physio­ therapist and th e co-operation o f the patient are the most im portant safeguards. Vigilance, in this respect, must continue for life. 2. The prevention o f urinary sepsis: This is w ithout doubt the m ost im portant aspect of the case o f the paraplegic as far as life expectancy is concerned. B ut a p a rt from this it has im mediate consequences o f great im portance. Any sepsis introduced will alter the whole sequence o f the evolution of th e cord bladder and will m ost often result, in a contracted R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) D e c e m b e r , 1965 bladder with incontinence and upper tract d ilatation, infec­ tion and form ation o f calculi in the kidneys or bladder. But, in addition, the infection (with that present as a result of pressure sores) will alter the whole behaviour o f the nervous system resulting for example in more severe flexor spasms. The problem of urinary sepsis is a perm anent one. The best m ethod o f prevention is to secure good emptying o f the bladder as early as possible and to check up th a t this is maintained. 3. The occurrence o f flexo r spasm .-This complicates bladder care. H ip flexion will m ake local m anipulations difficult and flexor spasms will often trigger bladder emptying. It is therefore most im portant to m aintain a full range o f passive movement in the p atien t’s lower extremities. 4. Priapism: This is no t often severe. It is usually more prom inent in the higher lesions. It is sometimes awkward when it occurs during cystoscopy, and urethritis is more frequent as elongation of the organ will cause the unsterile part o f an indwelling catheter to slide into the urethra. 5. The care o f the bowels: This is a most im portant aspect of the m anagem ent o f the paraplegic bladder. It has been repeatedly observed that a loaded rectum im pairs the patient’s ability to em pty his bladder. The care o f the bowel differs considerably in various clinics: in this hospital it was customary to adm inister a soap enema every second or third day. This was followed by a rectal exam ination to check on complete clearance and digital evacuation if necessary. A regular evening aperient was given—the most popular being milk of magnesia with paraffin or senokot. A high-bulk breakfast food was tried w ithout any noticeable improvement. Frequent digital evacuation may cause excoriation o f the anal canal and perianal abscesses may then form —these are very slow to resolve. A t present we use a contact-action suppository every second day and this appears to work well. It is a procedure which can easily be perform ed by the patient after leaving hospital. 6. Lastly—I wish to refer only briefly to a most im portant aspect o f the care o f the paraplegic—I am referring to his emotional rehabilitation. What it must mean for a young healthy adult to discover, after an accident, th at the lower h alf o f his body is dead and to be told, as he m ust be told, th a t the condition will be perm anent, is known only to those who have actually had the experience. It is the responsibility o f all those who have to attend to such a patient, to assist in persuading him to accept the condition, but, at the same time, to reassure him that all is not lost and th at, at least, an interesting and useful life is still possible. It is only when this healthy emotional state has been achieved th at physical rehabilitation will make progress. A patient who is not interested in even continuing to live, will certainly not show any interest in attending to the em ptying o f his bladder. I mention this particular aspect because it ties up with o u r main theme today. I hope th at these and other points will be raised during the discussion and it will be very interesting to hear w hat is being done in other clinics. In conclusion I wish to mention a few lines o f research which are now being actively p u rsu ed : Evacuation o f the paraplegic bladder by electrical stim u­ lation has been attem pted and the techniques have been used in the hum an patient. T here are tw o m ethods: In the nrst method electrodes are placed on the bladder wall with the connecting wires coming through the skin and these are connected to a source o f electrical stimuli. The second m ethod uses similar electrodes and these are connected to a small receiving apparatus which is im planted Just deep to the skin o f the hypogastrium . A transm itter is employed and this is held close to abdom en skin or its aerial >s placed near the body. T he receiver picks up the transm itted waves and these are conducted to the stim ulating electrodes Page 9 on the bladder wall. The type o f wave form its frequency and d u ratio n o f application, the voltage, the placement of the electrodes and their com position—all these have been w orked out in great detail. The main trouble with these m ethods have been infection, intolerable pain or stim ulation, and spread o f the stimulus especially to the muscles o f the pelvic floor and perineum. Successful results have been obtained and further experi­ mental w ork is proceeding. A completely different approach is to excise the whole paraplegic bladder, leaving only the bladder neck and to replace it with a substitute fashioned from an isolated loop of ileum. The ileum retains its parasym pathetic nerve supply (i.e. the vagus nerve) intact. Em ptying o f this new pouch, on stim ulation o f the vagus, has been observed. A m ethod which has been used to overcome incontinence will finally be mentioned. It also uses a transm itter and an im planted receiver as previously described but the electrodes are placed on each side o f the external urethral sphincter. As long as the transm ission lasts the sphincter will rem ain contracted. By m anipulation of a switch evacuation o f the bladder can be started. It seems appropriate, in our machine age, th at a patient who has wetted his bed, could possibly explain it by saying: “ Oh, m y battery failed” . l ean im agine sim ilar machine-age aids being used for other physiological deficiencies with even m ore disturbing results following “ battery” failure. W O R L D C O N FE D E R A T IO N F O R PH Y SIC A L T H E R A PY : F IF T H IN T ER N A T IO N A L C O N G R E SS Melbourne, 15th to 26th M ay, 1967 “ M O D E R N A P P R O A C H TO A N C IE N T IL L S” Preliminary Programme Monday, 15th M ay Morning: Registration. Opening o f Congress. Opening o f T rade Exhibition. O pening Lecture. Afternoon: “ Spina Bifida,” including lectures by a neurosurgeon, an orthopaedic surgeon, and a physiotherapist, followed by a dem onstration. Visits to Spina Bifida Clinic, R oyal C hildren’s Hospital, and Y ooralla H ospital School. Tuesday, 16th M ay Morning: “ Rehabilitation o f H ead Injuries,” including lectures on a specific brain condition by a surgeon, general considerations by a physiotherapist, and a “ Symposium on the R ehabilita­ tion o f the Patient w ith H ead Injuries” by a team o f lecturers including surgeon, physiotherapist, speech therapist, psy­ chiatrist, and occupational therapist, followed by discussion groups and dem onstration. Visits to A ustin H ospital, St. V incent’s H ospital, and H am pton and C oonac R ehabilitation Centres. Afternoon: “ Sports Medicine,” w ith a lecture on physiology o f exer­ cise by a physiologist, and a Symposium by a sports medicine specialist, an athlete doctor, a coach, and a physiotherapist, w ith a dem onstration on “ Strapping” by a physiotherapist, followed by discussion groups. Special Interest G roup. P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )