PARAPLEGIC’S BLADDER

In paraplegia your aim must be— (1) no bedsores, (2) no contractures, (3) an uninfected bladder, with the early

onset of reflex micturition in upper motor neurone lesions, and

(4) the patient’s ability to support himself with a craft.

PARAPLEGIA

Leaving a patient unturned for only four hours may start a bed sore that leads to osteomyelitis, dislocation of a hip, contractures, and a series of surgical operations lasting years.

THE FIRST 24 HOURS ARE CRITICAL

make sure he is adequately fed, and watch for anaemia.

Bedsores occur in sensory paraplegia and occasionally in any very sick or very old patient who is left in the same position too long without being moved.

TURN A PARAPLEGIC EVERY 2 HOURS

PARAPLEGIC’S SKIN

Paraplegic bladder

The two divisions of the autonomic nervous system are

---the sympathetic and parasympathetic nervous systems.

The nerves of the sympathetic nervous system originates in the thoracic and lumbar regions of the spinal cord and are often recruited during stress situations, such as fear, excitement, vigorous physical activity, etc.

A branch of the sympathetic nervous system originating from T11-T12 (see Figure 1 and 2) and mainly innervating the bladder neck increases bladder storage capacity.

Damage to this branch often results in urinary incontinence - the inability to store urine and lack of voluntary control over the loss of the urine

A branch of the parasympathetic nerve supply originates from the sacral cord at S2-S4 (see Figure 1 and 2) and travels to the bladder, governing the contraction of the smooth muscles of the detrusor. Activation of this branch of parasympathetic nerve promotes bladder emptying. Damage to this branch often leads to urinary retention - the inability to empty the bladder.

Spinal cord injuries can affect the parasympathetic supply to the detrusor muscles or the sympathetic supply to the bladder neck as well as somatic nerve supply to the external urethral sphincter. section

1. The atonic paralysed bladder or atonic

neurogenic bladder (this is the bladder in the initial phase wherever the injury).

CLASSIFICATION OF THE TYPES OF BLADDER

The Flaccid BladderA floppy bladder loses detrusor muscle tone (strength) and does not contract for emptying. This type of bladder can be easily overstretched with too much urine, which can damage the bladder wall and increase the risk of infection. Emptying the flaccid bladder can be done with techniques such as Crede, Valsalva, or intermittent catheterization. It is very important that you do not let your bladder get overfull, even if it means waking up at night to catheterize yourself more frequently.

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2. The reflex bladder or automatic bladder. This is the bladder some weeks after injury which cannot be inhibited by the patient and which evacuates some ounces of its contents, in some cases all its contents, at intervals varying from a few minutes to an hour or two. It occurs when the cord is interrupted above a surviving bladder centre.

The Reflex BladderThe detrusor muscles in a hyperactive bladder may have increased tone, and may contract automatically, causing incontinence (accidental voiding). Sometimes the bladder sphincters do not coordinate properly with the detrusor muscles, and medication or surgery may be helpful. 

3. The bladder in cauda injuries or injuries where its centre is destroyed, which many have called the autonomous bladder, and which may sometimes evacuate an ounce or two of its contents in a continuous stream, and which sometimes with the help of considerable strain will evacuate nearly all its contents. This condition is usually associated with dribbling by night and by day with residual urine and with back pressure dilatation of the ureters

To diagnose between a mechanical obstruction, an hysterical paralysis and an organic nervous disorder of the bladder

To know not only the level of lesion but also whether reflex activity of cord is present below the level of lesion

The next step in the diagnosis is the estimation of the presence and quantity of residual urine.

Diagnosis

The patient, at first sight so helpless and hopeless a person, can be aided to a remarkable degree by painstaking and skilful surgical care.

The best way of treating him is to use regular intermittent sterile catheterization. Infection is rare with this method

MANAGEMENT OF PARAPLEGIC BLADDER

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.

In the initial phase (atonic neurogenic bladder) early suprapubic cystotomy.

The suprapubic tube should be changed at weekly intervals when the track is well established.

TREATMENT

Foley or Suprapubic CatheterA tube is inserted through the urethra or abdomen and into the bladder, where a balloon on the end holds it in place. It remains in the bladder and drains constantly, so the bladder is never full.

Bladder Management

Type 2 (reflex) bladder

The suprapubic tube is removed and a catheter inserted for three or four days under cover, on this occasion, of penicillin, sulphonamides and streptomycin

AUTONOMOUS BLADDER to close this type of bladder were

almost without exception followed by severe pyelonephritis necessitating reopening of the bladder.

(i) After bladder closure to allow nature to take her course and a fair measure of continence may be-established,

(ii) following Guttmann (I946) to prepare the patient for closure by vigorous abdominal exercises so that he greatly develops his abdominal muscles and can empty his bladder by strain or

(iii) to follow the plan described by Emmett ('945)

and to resect the bladder neck.

There are essentiallythree methods of treatment

External Catheterization Condom Catheters These collection devices are worn by men for incontinence problems. They are made of latex rubber or silicone that covers the penis and attaches to a tube that drains into a collection bag.

External Continence Device (ECD)An ECD is a method of continence management that attaches only to the tip of the penis using hydrocolloid, a hypoallergenic adhesive commonly used in wound and ostomy care. Urine is directed into a collection bag and does not come in contact

with skin.

Intermittent CatheterizationYou drain your bladder several times a day by inserting a small rubber or plastic tube. The tube does not stay in the bladder between catheterizations.

SpincterotomyThis surgical process weakens the bladder neck and sphincter muscle to allow urine to flow out more easily

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.

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

The most important of these are severe ascending

urinary infection leading to prolonged pyrexia,stone formation in kidney or bladder, and

wherethe urethra has been instrumented, urethritis

withstricture, sloughing of the floor of the urethra

andepididymitis.

COMPLICATIONS

depends upon unobstructed drainage, a very active urinary excretion, e.g. 120 oz.

a day, and particular care of the patient's health.

Prevention of ascending infection

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