Vol. 114, August Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
EXPERIENCE WITH INTERMITTENT CATHETERIZATION IN CHRONIC SPINAL CORD INJURY PATIENTS CASIMIR F. FIRLIT,* JOHN R. CANNING, FREDERICK A. LLOYD, ROLAND R. CROSS AND ROBERT BREWER, JR.
From the Urology Section and Spinal Cord Injury Service, Veterans Administration Hospital, Hines, Illinois
ABSTRACT
Intermittent catheterization was used as a method to achieve reflex voiding and a catheter-free status in 111 chronic spinal cord injury patients. Of this group 70 patients achieved reflex (automatic) voiding within 90 days, or a mean of 19 days. Five patients required trans urethral incision of the external urethral sphincter after achievement of automatic voiding because of elevated residual urine. Chronic urinary tract infection persisted in 16 per cent of the patients after completion of the program. No sequelae occurred because of the coexistent urinary tract infection. An 18-month followup disclosed stability in renal function and appearance of pyelograms. Urethral, scrotal and bladder complications secondary to chronic indwelling urethral catheters have been eliminated in these patients. Patient endorsement and enthusiasm have been spectacular and have overwhelmingly contributed to an ongoing, successful program. For a number of years the method of management of lower urinary tract drainage in spinal cord injury patients has been the subject of considerable debate. Conventional methods, such as long-term indwelling urethral vesical catheterization, cutaneous vesicotomy and suprapubic cystotomy, have been the mainstay in the management of the lower urinary tract in these patients. Recently, intermittent catheterization has received favorable attention as a method of preference in the management of the lower urinary tract in spinal cord injury patients. In 1954 Guttmann proposed intermittent urethral vesical catheterization as the method of choice in the initial management of the lower urinary tract in acute spinal cord injury patients. Through the intervening years numerous reports have documented that intermittent catheterization, when performed aseptically, reduces the incidence of cystitis, urethritis, pyelonephritis, hydroureteronephrosis, vesical ureteral reflux, renal and/or vesical calculi, vesical diverticulosis, fistulas, prostatitis, seminal vesiculitis and epididymitis. 1 · 5 In addition, intermittent catheterization facilitated the return of the spinal shock (motor-sensory paralytic) bladder to an automatic (reflex) state. Numerous investigators and spinal cord injury centers have overwhelmingly confirmed the adv anAccepted for publication January 24, 1975. Read at annual meeting of North Central Section, American Urological Association, Columbus, Ohio, September 18-21, 1974. * Current address: Department of Urology, Northwestern University, Children's Memorial Hospital, Chicago, Illinois 60614.
tages of intermittent catheterization over longterm indwelling urethral vesical drainage.•· 11 Bors and Comarr applied intermittent catheterization as a form of urologic management in 198 spinal cord injury patients. They found that 88 per cent of the patients with cervical and thoracic ( 1 to 6), and 86 per cent of the patients with thoracic (7 to 12) and lumbar lesions were able to achieve a catheter-free status within 3 months of intermittent catheterization. Furthermore, 64 per cent of these patients achieved reflex voiding within 1 month of treatment.7· 9 Guttmann and Frankel reported the value of the early implementation of intermittent catheterization in preservation of urinary sterility in 476 acute spinal cord injury patients. Most of these patients were treated by this method within 48 hours of injury. Seventy per cent of the patients with incomplete lesions and 60 per cent of those with complete lesions had sterile urine when they were discharged from the hospital. Urinary sterility was preserved in 65 per cent of the male patients and 50 per cent of the female patients.' Less attention has been paid to the application of this technique in the management of chronic spinal cord injury patients. We herein describe our experience with this technique in reducing the morbidity of prolonged indwelling urethral catheterization and the establishment of reflex voiding in chronic spinal cord injury patients. MATERIALS AND METHODS
The study includes 111 male, spinal cord injury patients who were treated during the last 18 months with intermittent catheterization. All patients had had indwelling urethral catheters for 6
234
INTERMITTENT CATHETERIZATION IN CHRONIC SPINAL CORD INJURY PATIENTS
months to 2 years following spinal cord injury. The nature of the injury was predominantly traumatic in etiology and accounted for 80 paraplegic and 31 quadriplegic patients. The only patient qualification for acceptance was that they were willing to accept intermittent catheterization as an attempt to render them free of the catheter. Urologic evaluation included an excretory urngram (IVP), cystogram, cystoscopy, blood urea nitrogen and creatinine values, and urinalysis with culture and sensitivity. ~~·ov,w, was performed to exclude urethral stricture disease and wafer calculi. After the evaluation was completed the program of intermittent catheterization was initiated. Fluid restriction to 2,400 mL per 24 hours was imposed 48 hours before removal of the urethral catheter. Simultaneously, 10 mg. bethanechol (urecholine) orally, every 6 hours was initiated and maintained throughout the period of intermittent catheterization. In some instances bethanechol was increased to 75 mg, orally, every 6 hours and only discontinued if signs of cholinergic hyperstimulation became symptomatic. Each patient was placed on a long-term antibacterial preparation. No serious attempt was made to eradicate the chronic cystitis but the bladder was irrigated free of debris every 6 hours for 48 hours with 1 per cent neomycin sulfate solution prior to initiating the intermittent catheterization regimen. The spinal cord injury service nursing staff performed all catheterizations using the glovelessnon-touch technique. Prior to catheterization an attempt was made to stimulate reflex voiding by gentle suprapubic pressure, thigh stroking and/or penile or pubic hair traction. The glans penis was cleansed with hexachlorophene soap and a 14F Coude tip red rubber catheter, well lubricated with K-Y jelly, was inserted per urethram into the bladder. The catheter was left indwelling until the bladder was empty. Before removing the catheter 15 ml. of 1/5,000 furacin solution was instilled. This pattern was followed in a regimented fashion throughout the entire period of intermittent catheterization. Frequency of intermittent catheterization: As previously indicated oral fluid intake was restricted to 2,400 ml. per 24 hours. Initially, an arbitrary frequency of 6 hours was selected for intermittent catheterization and this was found to be quite adequate, since patient comfort was not compromised. The parameters of date, time, frequency of intermittent catheterization, residual urine volume and voided urine were recorded on a data flow sheet and used for purposes of regulating the frequency of catheterization. These catheterizations were performed in a regulated fashion until a decrease in residual urine volume occurred. When the residual urine volume decreased to 250 ml. with an associated increase in voided urine volume, the frequency of intermittent catheterization was decreased to once every 12 hours. In a :orrei,ocm
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
EXPERIENCE WITH INTERMITTENT CATHETERIZATION IN CHRONIC SPINAL CORD INJURY PATIENTS CASIMIR F. FIRLIT,* JOHN R. CANNING, FREDERICK A. LLOYD, ROLAND R. CROSS AND ROBERT BREWER, JR.
From the Urology Section and Spinal Cord Injury Service, Veterans Administration Hospital, Hines, Illinois
ABSTRACT
Intermittent catheterization was used as a method to achieve reflex voiding and a catheter-free status in 111 chronic spinal cord injury patients. Of this group 70 patients achieved reflex (automatic) voiding within 90 days, or a mean of 19 days. Five patients required trans urethral incision of the external urethral sphincter after achievement of automatic voiding because of elevated residual urine. Chronic urinary tract infection persisted in 16 per cent of the patients after completion of the program. No sequelae occurred because of the coexistent urinary tract infection. An 18-month followup disclosed stability in renal function and appearance of pyelograms. Urethral, scrotal and bladder complications secondary to chronic indwelling urethral catheters have been eliminated in these patients. Patient endorsement and enthusiasm have been spectacular and have overwhelmingly contributed to an ongoing, successful program. For a number of years the method of management of lower urinary tract drainage in spinal cord injury patients has been the subject of considerable debate. Conventional methods, such as long-term indwelling urethral vesical catheterization, cutaneous vesicotomy and suprapubic cystotomy, have been the mainstay in the management of the lower urinary tract in these patients. Recently, intermittent catheterization has received favorable attention as a method of preference in the management of the lower urinary tract in spinal cord injury patients. In 1954 Guttmann proposed intermittent urethral vesical catheterization as the method of choice in the initial management of the lower urinary tract in acute spinal cord injury patients. Through the intervening years numerous reports have documented that intermittent catheterization, when performed aseptically, reduces the incidence of cystitis, urethritis, pyelonephritis, hydroureteronephrosis, vesical ureteral reflux, renal and/or vesical calculi, vesical diverticulosis, fistulas, prostatitis, seminal vesiculitis and epididymitis. 1 · 5 In addition, intermittent catheterization facilitated the return of the spinal shock (motor-sensory paralytic) bladder to an automatic (reflex) state. Numerous investigators and spinal cord injury centers have overwhelmingly confirmed the adv anAccepted for publication January 24, 1975. Read at annual meeting of North Central Section, American Urological Association, Columbus, Ohio, September 18-21, 1974. * Current address: Department of Urology, Northwestern University, Children's Memorial Hospital, Chicago, Illinois 60614.
tages of intermittent catheterization over longterm indwelling urethral vesical drainage.•· 11 Bors and Comarr applied intermittent catheterization as a form of urologic management in 198 spinal cord injury patients. They found that 88 per cent of the patients with cervical and thoracic ( 1 to 6), and 86 per cent of the patients with thoracic (7 to 12) and lumbar lesions were able to achieve a catheter-free status within 3 months of intermittent catheterization. Furthermore, 64 per cent of these patients achieved reflex voiding within 1 month of treatment.7· 9 Guttmann and Frankel reported the value of the early implementation of intermittent catheterization in preservation of urinary sterility in 476 acute spinal cord injury patients. Most of these patients were treated by this method within 48 hours of injury. Seventy per cent of the patients with incomplete lesions and 60 per cent of those with complete lesions had sterile urine when they were discharged from the hospital. Urinary sterility was preserved in 65 per cent of the male patients and 50 per cent of the female patients.' Less attention has been paid to the application of this technique in the management of chronic spinal cord injury patients. We herein describe our experience with this technique in reducing the morbidity of prolonged indwelling urethral catheterization and the establishment of reflex voiding in chronic spinal cord injury patients. MATERIALS AND METHODS
The study includes 111 male, spinal cord injury patients who were treated during the last 18 months with intermittent catheterization. All patients had had indwelling urethral catheters for 6
234
INTERMITTENT CATHETERIZATION IN CHRONIC SPINAL CORD INJURY PATIENTS
months to 2 years following spinal cord injury. The nature of the injury was predominantly traumatic in etiology and accounted for 80 paraplegic and 31 quadriplegic patients. The only patient qualification for acceptance was that they were willing to accept intermittent catheterization as an attempt to render them free of the catheter. Urologic evaluation included an excretory urngram (IVP), cystogram, cystoscopy, blood urea nitrogen and creatinine values, and urinalysis with culture and sensitivity. ~~·ov,w, was performed to exclude urethral stricture disease and wafer calculi. After the evaluation was completed the program of intermittent catheterization was initiated. Fluid restriction to 2,400 mL per 24 hours was imposed 48 hours before removal of the urethral catheter. Simultaneously, 10 mg. bethanechol (urecholine) orally, every 6 hours was initiated and maintained throughout the period of intermittent catheterization. In some instances bethanechol was increased to 75 mg, orally, every 6 hours and only discontinued if signs of cholinergic hyperstimulation became symptomatic. Each patient was placed on a long-term antibacterial preparation. No serious attempt was made to eradicate the chronic cystitis but the bladder was irrigated free of debris every 6 hours for 48 hours with 1 per cent neomycin sulfate solution prior to initiating the intermittent catheterization regimen. The spinal cord injury service nursing staff performed all catheterizations using the glovelessnon-touch technique. Prior to catheterization an attempt was made to stimulate reflex voiding by gentle suprapubic pressure, thigh stroking and/or penile or pubic hair traction. The glans penis was cleansed with hexachlorophene soap and a 14F Coude tip red rubber catheter, well lubricated with K-Y jelly, was inserted per urethram into the bladder. The catheter was left indwelling until the bladder was empty. Before removing the catheter 15 ml. of 1/5,000 furacin solution was instilled. This pattern was followed in a regimented fashion throughout the entire period of intermittent catheterization. Frequency of intermittent catheterization: As previously indicated oral fluid intake was restricted to 2,400 ml. per 24 hours. Initially, an arbitrary frequency of 6 hours was selected for intermittent catheterization and this was found to be quite adequate, since patient comfort was not compromised. The parameters of date, time, frequency of intermittent catheterization, residual urine volume and voided urine were recorded on a data flow sheet and used for purposes of regulating the frequency of catheterization. These catheterizations were performed in a regulated fashion until a decrease in residual urine volume occurred. When the residual urine volume decreased to 250 ml. with an associated increase in voided urine volume, the frequency of intermittent catheterization was decreased to once every 12 hours. In a :orrei,ocm
