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.
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
The two divisions of the autonomic nervous system are
---the sympathetic and parasympathetic nervous
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
A branch of the sympathetic nervous system
originating from T11-T12 (see Figure 1 and 2) and
mainly innervating the bladder neck increases bladder
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
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).
The Flaccid Bladder
A 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
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 Bladder
The 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
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
To know not only the level of lesion but also whether
reflex activity of cord is present below the level of
The next step in the diagnosis is the estimation of the
presence and quantity of residual urine.
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
(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
In the initial phase (atonic neurogenic bladder) early
The suprapubic tube should be changed at weekly
intervals when the track is well established.
Foley or Suprapubic Catheter
A 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.
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,
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-
(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.
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
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
You 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.
This 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
(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
The most important of these are severe ascending
urinary infection leading to prolonged pyrexia,
stone formation in kidney or bladder, and where
the urethra has been instrumented, urethritis with
stricture, sloughing of the floor of the urethra and
a very active urinary excretion, e.g. 120 oz. a day, and
particular care of the patient's health.