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Paraplegic 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.
Paraplegic bladder
 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 bladder
Paraplegic bladder
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).
 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
frequently.
T
 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
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.
 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
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.
 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,
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.
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 Catheterization
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.
 Spincterotomy
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
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 where
 the urethra has been instrumented, urethritis with
 stricture, sloughing of the floor of the urethra and
 epididymitis.
 depends upon
 unobstructed drainage,
 a very active urinary excretion, e.g. 120 oz. a day, and
 particular care of the patient's health.
Paraplegic bladder

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Paraplegic bladder

  • 2.  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.
  • 4.  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.
  • 5.  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
  • 9.  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.
  • 10.  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
  • 11.  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
  • 12. 1. The atonic paralysed bladder or atonic neurogenic bladder (this is the bladder in the initial phase wherever the injury).
  • 13.  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 frequently. T
  • 14.  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 be helpful.
  • 15.  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
  • 16.  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.
  • 17.  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
  • 19.  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.
  • 20.  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.
  • 21.  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.
  • 22. 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
  • 23.  AUTONOMOUS BLADDER to close this type of bladder were almost without exception followed by severe pyelonephritis necessitating reopening of the bladder.
  • 24. (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.
  • 25. 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.
  • 26.  Intermittent Catheterization 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.  Spincterotomy This surgical process weakens the bladder neck and sphincter muscle to allow urine to flow out more easily
  • 27.  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.
  • 28. 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  epididymitis.
  • 29.  depends upon  unobstructed drainage,  a very active urinary excretion, e.g. 120 oz. a day, and  particular care of the patient's health.