64.16 Paraplegic’s bladder

If a patient has any significant degree of paraplegia, he will be unable to urinate voluntarily from the moment of the injury. His bladder will fill up slowly and will be full by about midnight on the day of admission. If you leave it, it will overflow, so anticipate this and prevent it. The best way of treating him is to use regular intermittent sterile catheterization. Infection is rare with this method. It imitates the natural cycle in which the bladder fills and empties. By leaving it almost empty for a significant period, this method relieves the pressure on its walls, both pressure of urine and pressure from the the balloon of a Foley catheter. This is important, because distension or pressure of any kind reduces the ability of the bladder to resist infection. It is also good training for student nurses. The disadvantage of this method is that it requires more nursing care, and if the patient is to do it himself, as described below, he must be cooperative. Some consultant surgeons in teaching hospitals say they cannot use this method, because they don’t have the staff, and wonder that it can ever be done in smaller ones. In fact, some smaller hospitals can do it excellently. Don’t use: (1) an indwelling catheter if you can possibly avoid doing so because infection is so common, or, (2) continuous suprapubic drainage, because it produces a small contracted bladder.

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Figure 64.19: TWO REGIMES FOR A PARAPLEGIC BLADDER. A, intermittent catheterization. Early on this is done in a sterile manner by the ward staff. Later, it can be done in a clean but non–sterile manner by the patient himself. B, an indwelling Foley catheter is much less satisfactory—avoid it if you can. Kindly contributed by Peter Bewes.

INTERMITTENT STERILE CATHETERIZATION Use a 14 Ch soft rubber Jacques catheter. Boil it and use gloved hands or sterile forceps. Pass it every 4 to 6 hours from the moment of the patient’s injury. Later it can be every 6 to 8 hours. Empty the patient’s bladder completely by suprapubic pressure and then remove the catheter. Repeat the process 6 hours later, and again and again, four times a day. Record that catheterisation has been done on the chart which is used to record when he is turned.

CAUTION! When you make rounds, check his bladder from time to time to make sure that it really is being emptied.

Continue, either until his cord recovers, or until an automatic bladder develops, usually in 2 to 3 months.

CATHETERIZE THE PATIENT WITH FULL STERILE PRECAUTIONS

Automatic bladder

If a patient’s spinal injury is above his lumbar enlargement, his bladder will eventually develop its own micturition reflex. After 2 to 8 weeks of intermittent catheterization he may discover a method of starting micturition himself. Fit him with a condom catheter or a Paul’s tube and encourage him to try. He may be able to do this by stroking the side of his thigh, or his penis, or by pressing suprapubically. Such training may take a long time, it is not easy, and the nurses will require considerable persistence. Although training him may be difficult, it will save time in the end. When he has found a method which works, encourage him, to use it more and more. Let him do this before he is catheterized. Don’t stop catheterising him until his residual urine on catheterization after micturition has fallen to 75 ml, or less. Even when it has fallen to this volume, catheterize him once a week to make sure that he is not partly retaining his urine. If you find that his residual urine is more than 75 ml, consider referring him for resection or division of the external sphincter of his prostatic urethra (external sphincterotomy).

Intermittent clean but non–sterile self catheterization

If a paraplegic’s bladder is isolated from spinal control, emptying depends on a local reflex which is much less effective than a reflex arc via his cord. He does not develop an automatic bladder, and he has to catheterize himself. He can either boil up a catheter each time and try to pass it in a sterile manner, or he can catheterize himself regularly and cleanly, but without using sterile precautions.

Suprisingly, non-sterile self catheterization has many advantages. Because a patient does not need to boil up the catheter each time, he can catheterize himself more often, and does not allow his bladder to fill up. This reduces the incidence of infection, and in practice he is infected less often than if he waits and tries to sterilize a catheter. But for this method to succeed, he must empty his bladder as completely as possible with the help of suprapubic pressure continued until the moment that he pulls the catheter out. A bladder that is not emptied after catheterization will contain some organisms, but a bladder that is completely emptied will contain very few.

Many patients easily learn this method which has many advantages. For example, a patient can go to a football match, cheer widely, and in the interval go to the toilet, catheterize himself, and then return to the match! A patient who has been told to use sterile catheterization will either not be able to go to any such matches ever, or he will be inhibited from catheterizing himself in the toilet, so allowing pressure to build up in his bladder and running the risk of a urinary infection.

Some surgeons in the developing world say that they have never succeeded with this method; others are enthusiastic about it.

INTERMITTENT NON–STERILE SELF CATHETERIZATION

Give a man a Jacques rubber catheter. If he has difficulty, give him one with a small beak, such as an oliviary tipped Tieman catheter, or a coude catheter. Teach him which way to point the beak. Give a woman a small handbag mirror to help her find her urethral meatus.

Encourage the patient to catheterize himself cleanly. (1) He must keep the catheter clean. (2) He should if possible wash his hands and the tip of his meatus.

CAUTION! Make sure he knows how important it is to empty his bladder completely.

INFECTION If his urine becomes infected and he has symptoms:

(1) Encourage him to catheterize himself at more frequent intervals. Usually, the reason for the infection is that he has not been catheterizing himself often enough.

(2) Give him an appropriate antibiotic. He has not been on a prophylactic antibiotic, so his infection is usually easy to treat; sulphonamides may be enough. Don’t try to prevent infection by giving antibiotics routinely.

(3) If the first two methods fail, admit him to hospital for continued, intermittent, non–sterile catheterization under supervision, together with bladder wash–outs.