VoL 114, August Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
INTERMITTENT CATHETERIZATION AND BLADDER REHABILITATION IN SPINAL CORD INJURY PATIENTS INDER PERKASH From the Spinal Cord Injury Center, Veterans Administration Hospital, Palo Alto and Department of Surgery (Urology), Stanford University, Stanford, California
ABSTRACT
A review was made of 111 spinal cord injury patients who underwent bladder rehabilitation. The essential mode of treatment was intermittent catheterization. About 91 per cent of the patients were free of the catheter after 3 to 168 days of intermittent catheterization. Acute patients given an initial dosage of 30 to 40 mg. bethanechol chloride 3 times daily for 2 to 3 weeks recovered reflex activity in almost half the period (average of 32 days compared to 79 days). Modified sphincterotomy at the bladder neck was performed in 10 patients. This procedure improved the results to 98 per cent catheter-free reflex bladder status in the group of patients. The role of intermittent catheterization in spinal cord injury patients is well established. Our technique and results of intermittent catheterization to remove Foley indwelling catheters in 76 spinal cord patients (67 complete and 9 incomplete lesions) from the Veterans Administration Hospital and the Baylor College of Medicine, Houston, Texas have been reported recently.' A total of 111 paraplegics and quadriplegics has been further submitted to analysis: the role of different dosages of bethanechol chloride to help establish an early reflex bladder has been evaluated, the role of surgery in stopping intermittent catheterization has been determined and the results of followup on infection in a group of 44 early patients with a followup of at least 9 months to more than 2 years is reported. MATERIALS AND METHODS
The present series of 111 patients includes 93 with complete paraplegia, quadriplegia or cauda equina lesions and 18 with incomplete paraplegia or quadriplegia. The period of the indwelling Foley catheter after the injury varied from 3 days to more than 5 years. There were 17 patients with complete lesions who had indwelling Foley catheters for less than 3 weeks and 50 patients who had them from 3 to 20 weeks after injury. In 26 cases of complete lesions with indwelling catheters from 24 weeks to more than 5 years, the plan of intermittent catheterization has been essentially the same as that which was reported previously. 1 After a detailed urological diagnostic study these patients were put on a program of intermittent Accepted for publication November 8, 1974. Read at annual meeting of South Central Section, American Urological Association, Denver, Colorado, September 15-19, 1974.
catheterization, including self-catheterization in paraplegics. The profile of fluid balance and urinary culture was done before the start of intermittent catheterization. Catheterization was done every 4 hours, day and night, until some spontaneous voiding (bladder triggering) was noticed. Then the schedule was changed to every 6 hours. The frequency of catheterization was reduced gradually with increasing spontaneous voiding. The procedure was stopped when the residual urine was less than 150 ml. Records of individual catheterization were maintained as shown in table 1. A separate program was used for acute and chronic patients. All catheterization was done aseptically by paramedical personnel and all paraplegic patients were trained to catheterize themselves. Patients who did not have any spontaneous micturition (triggering) were placed on gradually increasing doses of bethanechol chloride starting from 10 mg. 3 times a day to 30 to 40 mg. 3 times a day. However, in 13 patients the starting dosage of bethanechol chloride was 30 to 40 mg. 3 times a day. Electrocardiogra phic studies were done routinely on every patient and those showing any evidence of myocardial infarction were not given bethanechol chloride. Urine cultures were obtained at the start of intermittent catheterization and repeated every week until a reflex bladder was established and then the culture studies were done once every 2 weeks. Excretory urography was done at least once within the first 3 weeks of hospitalization and was repeated after 6 months. Patients maintaining a high residual 3 to 4 months after injury or those who were admitted to the hospital from other centers and were still on intermittent catheterization were submitted to detailed urological investigations, including voiding cystourethrography and cystometrogram.
230
231
INTERMITTENT CATHETERIZATION IN SPINAL CORD INJURY PATIENTS TABLE
1. Intermittent catheterization record -
Reflex Voiding Date
Time
Intake
Spontaneous
Stimulation
CLINICAL RESULTS
Table 2 shov,,s the results of intermittent catheterization in the 93 patients with complete lesions, The period of intermittent catheterization varied from 24 to 168 days in 54 patients with a mean of about 78 days, The patients had indwelling Foley catheters from less than 3 weeks to about 20 weeks, Those patients who did not exhibit spontaneous voiding were given bethanechol chloride 7 to 10 days after they were placed on an intermittent catheterization program as a bladder assist for the decreasing period of intermittent catheterization, The dosage of bethanechol chloride was increased in increments of about 10 mg, every week until the patients were placed on 30 to 40 mg, 3 times a day, In other words there was a lag period of about 4 weeks during the period of intermittent catheterization from the starting day before the patients were placed on the maximum dosage of bethanechol chloride, However, in 13 patients with indwelling catheters for less than 3 to 16 weeks higher dosage schedules, that is 30 to 40 mg, 3 times daily, were instituted 1 week after starting them on intermittent catheterization, It is noteworthy that the period of intermittent catheterization was shortened from an average of 79 days to about 32 to 47 days, In patients with indwelling catheters for 24 weeks or more no bethanechol chloride was used, The period of intermittent catheterization before a reflex bladder was established varied from 3 to 25 days with a mean of about 10 days, The bulk of patients with incomplete lesions were quadriplegics with central cord syndrome, Sixteen patients had an indwelling catheter from 21 to 77 days and 2 patients had it for about 3 days (table 3), In 9 patients only 8 to 10 days of intermittent catheterization were required before the procedure was stopped, In 9 other patients intermittent catheterization was carried out for 21 to 63 days with a mean of about 48 days, No bladder neck operations were done in any of these patients, INDICATIONS OF SURGERY
In 10 of 12 patients intermittent catheterization could not be after about 6 months post-
Residual
TABLE
Total
pH
Description
2, Results in 93 patients with complete lesions Period of Catheterization
No, Pts,
Initials
Indwelling
Intermittent (mean)
Bethanechol Chloride (starting dosage)
11
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
INTERMITTENT CATHETERIZATION AND BLADDER REHABILITATION IN SPINAL CORD INJURY PATIENTS INDER PERKASH From the Spinal Cord Injury Center, Veterans Administration Hospital, Palo Alto and Department of Surgery (Urology), Stanford University, Stanford, California
ABSTRACT
A review was made of 111 spinal cord injury patients who underwent bladder rehabilitation. The essential mode of treatment was intermittent catheterization. About 91 per cent of the patients were free of the catheter after 3 to 168 days of intermittent catheterization. Acute patients given an initial dosage of 30 to 40 mg. bethanechol chloride 3 times daily for 2 to 3 weeks recovered reflex activity in almost half the period (average of 32 days compared to 79 days). Modified sphincterotomy at the bladder neck was performed in 10 patients. This procedure improved the results to 98 per cent catheter-free reflex bladder status in the group of patients. The role of intermittent catheterization in spinal cord injury patients is well established. Our technique and results of intermittent catheterization to remove Foley indwelling catheters in 76 spinal cord patients (67 complete and 9 incomplete lesions) from the Veterans Administration Hospital and the Baylor College of Medicine, Houston, Texas have been reported recently.' A total of 111 paraplegics and quadriplegics has been further submitted to analysis: the role of different dosages of bethanechol chloride to help establish an early reflex bladder has been evaluated, the role of surgery in stopping intermittent catheterization has been determined and the results of followup on infection in a group of 44 early patients with a followup of at least 9 months to more than 2 years is reported. MATERIALS AND METHODS
The present series of 111 patients includes 93 with complete paraplegia, quadriplegia or cauda equina lesions and 18 with incomplete paraplegia or quadriplegia. The period of the indwelling Foley catheter after the injury varied from 3 days to more than 5 years. There were 17 patients with complete lesions who had indwelling Foley catheters for less than 3 weeks and 50 patients who had them from 3 to 20 weeks after injury. In 26 cases of complete lesions with indwelling catheters from 24 weeks to more than 5 years, the plan of intermittent catheterization has been essentially the same as that which was reported previously. 1 After a detailed urological diagnostic study these patients were put on a program of intermittent Accepted for publication November 8, 1974. Read at annual meeting of South Central Section, American Urological Association, Denver, Colorado, September 15-19, 1974.
catheterization, including self-catheterization in paraplegics. The profile of fluid balance and urinary culture was done before the start of intermittent catheterization. Catheterization was done every 4 hours, day and night, until some spontaneous voiding (bladder triggering) was noticed. Then the schedule was changed to every 6 hours. The frequency of catheterization was reduced gradually with increasing spontaneous voiding. The procedure was stopped when the residual urine was less than 150 ml. Records of individual catheterization were maintained as shown in table 1. A separate program was used for acute and chronic patients. All catheterization was done aseptically by paramedical personnel and all paraplegic patients were trained to catheterize themselves. Patients who did not have any spontaneous micturition (triggering) were placed on gradually increasing doses of bethanechol chloride starting from 10 mg. 3 times a day to 30 to 40 mg. 3 times a day. However, in 13 patients the starting dosage of bethanechol chloride was 30 to 40 mg. 3 times a day. Electrocardiogra phic studies were done routinely on every patient and those showing any evidence of myocardial infarction were not given bethanechol chloride. Urine cultures were obtained at the start of intermittent catheterization and repeated every week until a reflex bladder was established and then the culture studies were done once every 2 weeks. Excretory urography was done at least once within the first 3 weeks of hospitalization and was repeated after 6 months. Patients maintaining a high residual 3 to 4 months after injury or those who were admitted to the hospital from other centers and were still on intermittent catheterization were submitted to detailed urological investigations, including voiding cystourethrography and cystometrogram.
230
231
INTERMITTENT CATHETERIZATION IN SPINAL CORD INJURY PATIENTS TABLE
1. Intermittent catheterization record -
Reflex Voiding Date
Time
Intake
Spontaneous
Stimulation
CLINICAL RESULTS
Table 2 shov,,s the results of intermittent catheterization in the 93 patients with complete lesions, The period of intermittent catheterization varied from 24 to 168 days in 54 patients with a mean of about 78 days, The patients had indwelling Foley catheters from less than 3 weeks to about 20 weeks, Those patients who did not exhibit spontaneous voiding were given bethanechol chloride 7 to 10 days after they were placed on an intermittent catheterization program as a bladder assist for the decreasing period of intermittent catheterization, The dosage of bethanechol chloride was increased in increments of about 10 mg, every week until the patients were placed on 30 to 40 mg, 3 times a day, In other words there was a lag period of about 4 weeks during the period of intermittent catheterization from the starting day before the patients were placed on the maximum dosage of bethanechol chloride, However, in 13 patients with indwelling catheters for less than 3 to 16 weeks higher dosage schedules, that is 30 to 40 mg, 3 times daily, were instituted 1 week after starting them on intermittent catheterization, It is noteworthy that the period of intermittent catheterization was shortened from an average of 79 days to about 32 to 47 days, In patients with indwelling catheters for 24 weeks or more no bethanechol chloride was used, The period of intermittent catheterization before a reflex bladder was established varied from 3 to 25 days with a mean of about 10 days, The bulk of patients with incomplete lesions were quadriplegics with central cord syndrome, Sixteen patients had an indwelling catheter from 21 to 77 days and 2 patients had it for about 3 days (table 3), In 9 patients only 8 to 10 days of intermittent catheterization were required before the procedure was stopped, In 9 other patients intermittent catheterization was carried out for 21 to 63 days with a mean of about 48 days, No bladder neck operations were done in any of these patients, INDICATIONS OF SURGERY
In 10 of 12 patients intermittent catheterization could not be after about 6 months post-
Residual
TABLE
Total
pH
Description
2, Results in 93 patients with complete lesions Period of Catheterization
No, Pts,
Initials
Indwelling
Intermittent (mean)
Bethanechol Chloride (starting dosage)
11
