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Neurosurgery in the Treatment of Diseases of the Urinary Bladder III. The Treatment of Certain Types of Vesical Paralysis
NEUROSURGERY IN THE TREATMENT OF DISEASES OF THE URINARY BLADDER III. THE TREATMENT OF CERTAIN TYPES OF VESICAL PARALYSIS JAMES R. LEARMONTH Section on N ~urologic Surgery, The Mayo Clinic, Rochester, Minnesota
Submitted for publication January 14, 1931
Although it has been denied that the thoracicolumbar sympathetic outflow contains inhibitory fibers for the bladder of the human being, I have divided this part of the nerve supply of the viscus in 2 cases in which it seemed probable that the lesion was limited to the motor parasympathetic nervous pathway. In such cases the balance or sympathetic-parasympathetic, or in other words inhibitory-motor, innervation is upset. After restoration of the balance of innervation the bladder is enabled to function satisfactorily with what is left of its motor nerve supply. As a report on case 1 has been made elsewhere, only a summary will be given here. REPORT OF CASES
Case 1. A man, aged thirty-six years, had an acute infectious process involving the second, third, fourth and fifth sacral segments of the spinal cord; in short, the segments which supply motor, sensory, and reflex parasympathetic fibers to the bladder. Fourteen months after the onset he came to The Mayo Clinic complaining of inability completely to empty the bladder: the viscus could be partly emptied only in the sitting posture. On cystoscopic examination 270 cc. of residual urine was found, and anesthesia and loss of expulsive force were noted. The neurologic diagnosis was residual myelitis of the conus, and the opinion was expressed that the injury to the cord was permanent. In the hope of restoring the emptying power of the bladder and thus of avoiding pyelonephritis, resection of the presacral (or sympathetic) nerve was advised and was 229
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JAMES R. LEARMONTH
accepted. Following a convalescence complicated by severe epididymitis, the amount of residual urine decreased and finally disappeared. Two months after operation the patient was able to empty his bladder completely, although he still used the sitting posture. After his dismissal, the expulsive power of the bladder improved so t hat he could empty it in the standing posture, and repeated checks, made elsewhere, showed that residual urine was not present. Recently, a year after operation, the patient was reexamined at the clinic. The greatest amount of residual urine found at any test was 20 cc. He emptied his bladder in the erect posture, with some help from the abdominal muscles in starting the flow. A urogram by the intravenous method showed that the pelves and calices were not dilated; there was some dilatat ion of the lower segments of both ureters. The man had improved greatly in general health, in spite of t he fact that in the interval he had been much exposed to cold and wet. As had been foretold, the neurologic signs were the same as at the first examination. Case 2. A boy, aged eight years, was brought to The Mayo Clinic because for five years he had required catheterization three t imes a day. At the age of three years he had become so ataxic and weak in the legs, that he had been unable to walk for three months. This illness was accompanied by retent ion of urine, which had persisted, alt hough the power to walk had returned. From a neurologic standpoint there waK no somatic evidence of his previous illness. He could pass but little urine voluntarily, and he was unable to tell when his bladder was full, so that he regularly wet his bed. Four years before operation, a week's residual urine averaged 1840 cc.; immediately before operation this amount had increased to 2640 cc. A cystometrogram showed a large a tonic bladder. After resection of the presacral nerve, the patient's progress to recovery was uneventful. The first week after leaving hospital, the residual urine totalled 178 cc. For some t ime I insisted on daily catheterization at home, lest unnoticed overdist ention of the bladder should undo the postoperative improvement. At the present t ime, eight months after operation, he is being catheterized once a week, and for the last seven weeks the highest amount of residual urine drawn off has been 12 cc. The boy can micturate on request, knows when his bladder is full, and never wets his bed. This is an interesting contrast with the case reported by Riddoch. As a result of a gunshot wound of t he spinal cord, R iddoch's patient was left with only the sympat hetic (presacral)
NEUROSURGERY IN DISEASES OF URINARY BLADDER
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nerve connecting his bladder with the central nervous system; however, he knew when his bladder was full. Great credit for my patient's assiduous postoperative care is due to his family physician and to his mother. His general condition is excellent. COMMENT
There are several significant points in the after-treatment in such cases. First, so long as the patient remains in bed, the bladder should be drained by an indwelling catheter, for it is unfair to demand that its first efforts at normal expulsion should be made while the patient is prone after laparotomy. Second, so long as a patient was under observation, he received, twice a day, intramuscular injections of 0.1 gram acetylcholin hydrobromide, dissolved in 2 cc. of distilled water. This drug is a specific stimulant for the parasympathetic nerves; therefore it promotes contraction of the detrusor muscle, and after the indwelling catheter is removed facilitates the opening of the internal sphincter. Although the effect of each dose is transient, patients have remarked that they felt the bladder contract on the catheter following an injection, and I believe that the regular administration of the drug is of value in restoring tonus to the musculature of the bladder. Occasionally it will be found that a patient becomes unduly sensitive to the drug; in such cases severe abdominal pain and vomiting occur. These symptoms disappear when the injections are stopped. After a day or two the administration of acetylcholin may be cautiously resumed. Further, I believe that even after successful operation regular catheterization should be continued for periods varying with the individual case but at lengthening intervals; any overtaxing of the recovering bladder must be rigorously avoided. Although I have not yet had an opportunity of performing this operation, I feel that it might be usefully applied in cases in which, after an injury to the conus or the cauda equina, there is difficulty in completely emptying the bladder. In brief, the outstanding indication for the operation is evidence of injury to either the central or the peripheral part of the parasympathetic TH E JOURNA L OF UROLOGY , V OL. XXVI, N O.
2
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JAMES R. LEARMONTH
system, when the central or peripheral parts of the sympathetic system are intact. The patient must, of course, be continent. Both these cases provided favorable material from which physiologic conclusions can be drawn. In case 1, the injured part of the spinal cord could be defined with great accuracy; in case 2, the available evidence pointed to the second lumbar segment as the highest involved. In case 1, therefore, the whole of the sympathetic supply to the bladder was derived from intact segments of the cord, whereas in case 2 the highest affected segment corresponded to the lowest from which sympathetic fibers are known to arise. The improvement in micturition which followed sympathectomy ~ppears to me to admit of no other explanation than that the undiminished action of the inhibitory impulses transmitted by the intact sympathetic nerves overbalanced the few motor impulses which the parasympathetic nerves continued to transmit, and that this nervous imbalance was corrected by the sympathectomy. In selecting cases for this operation, the principles laid down in the preliminary report on case 1 should be followed: The clinical data must point to reduction of the function of the plevic nerves (aptly called by Rose the "emptying" nerves of the bladder), while the hypogastric nerves are uninjured; in other words, the balance of vesical innervation is disturbed, and injured pelvic nerves are handicapped in their task by the "brake" action of intact hypogastric nerves. As a corollary, there must not be total paralysis of the pelvic nerves, in order that after. removal of the brake the residual expulsive power of the detrusor muscle may be more equal to emptying the bladder. Again, the patient must be continent, through the action of the external sphincter muscle, for the hypogastric nerves are the motor nerves to the internal sphincter. Finally, there must be satisfactory renal function. REFERENCES (1) LEARMONTH, J. R., AND BRAASCH, W. F.: Resection of the presacral nerve in the treatment of cord bladder: preliminary report. Surg., Gynecol. and Obstet., October, 1930, Ii, 494-499. (2) RosE, D. K., AND DEAKIN, ROGERS : The cystometric diagnosis of central nervous system syphilis; a new appreciation of the term neurogenic bladder. Amer. Jour. Syphiiis, July, 1929, xiii, 371-390.
Submitted for publication January 14, 1931
Although it has been denied that the thoracicolumbar sympathetic outflow contains inhibitory fibers for the bladder of the human being, I have divided this part of the nerve supply of the viscus in 2 cases in which it seemed probable that the lesion was limited to the motor parasympathetic nervous pathway. In such cases the balance or sympathetic-parasympathetic, or in other words inhibitory-motor, innervation is upset. After restoration of the balance of innervation the bladder is enabled to function satisfactorily with what is left of its motor nerve supply. As a report on case 1 has been made elsewhere, only a summary will be given here. REPORT OF CASES
Case 1. A man, aged thirty-six years, had an acute infectious process involving the second, third, fourth and fifth sacral segments of the spinal cord; in short, the segments which supply motor, sensory, and reflex parasympathetic fibers to the bladder. Fourteen months after the onset he came to The Mayo Clinic complaining of inability completely to empty the bladder: the viscus could be partly emptied only in the sitting posture. On cystoscopic examination 270 cc. of residual urine was found, and anesthesia and loss of expulsive force were noted. The neurologic diagnosis was residual myelitis of the conus, and the opinion was expressed that the injury to the cord was permanent. In the hope of restoring the emptying power of the bladder and thus of avoiding pyelonephritis, resection of the presacral (or sympathetic) nerve was advised and was 229
230
JAMES R. LEARMONTH
accepted. Following a convalescence complicated by severe epididymitis, the amount of residual urine decreased and finally disappeared. Two months after operation the patient was able to empty his bladder completely, although he still used the sitting posture. After his dismissal, the expulsive power of the bladder improved so t hat he could empty it in the standing posture, and repeated checks, made elsewhere, showed that residual urine was not present. Recently, a year after operation, the patient was reexamined at the clinic. The greatest amount of residual urine found at any test was 20 cc. He emptied his bladder in the erect posture, with some help from the abdominal muscles in starting the flow. A urogram by the intravenous method showed that the pelves and calices were not dilated; there was some dilatat ion of the lower segments of both ureters. The man had improved greatly in general health, in spite of t he fact that in the interval he had been much exposed to cold and wet. As had been foretold, the neurologic signs were the same as at the first examination. Case 2. A boy, aged eight years, was brought to The Mayo Clinic because for five years he had required catheterization three t imes a day. At the age of three years he had become so ataxic and weak in the legs, that he had been unable to walk for three months. This illness was accompanied by retent ion of urine, which had persisted, alt hough the power to walk had returned. From a neurologic standpoint there waK no somatic evidence of his previous illness. He could pass but little urine voluntarily, and he was unable to tell when his bladder was full, so that he regularly wet his bed. Four years before operation, a week's residual urine averaged 1840 cc.; immediately before operation this amount had increased to 2640 cc. A cystometrogram showed a large a tonic bladder. After resection of the presacral nerve, the patient's progress to recovery was uneventful. The first week after leaving hospital, the residual urine totalled 178 cc. For some t ime I insisted on daily catheterization at home, lest unnoticed overdist ention of the bladder should undo the postoperative improvement. At the present t ime, eight months after operation, he is being catheterized once a week, and for the last seven weeks the highest amount of residual urine drawn off has been 12 cc. The boy can micturate on request, knows when his bladder is full, and never wets his bed. This is an interesting contrast with the case reported by Riddoch. As a result of a gunshot wound of t he spinal cord, R iddoch's patient was left with only the sympat hetic (presacral)
NEUROSURGERY IN DISEASES OF URINARY BLADDER
231
nerve connecting his bladder with the central nervous system; however, he knew when his bladder was full. Great credit for my patient's assiduous postoperative care is due to his family physician and to his mother. His general condition is excellent. COMMENT
There are several significant points in the after-treatment in such cases. First, so long as the patient remains in bed, the bladder should be drained by an indwelling catheter, for it is unfair to demand that its first efforts at normal expulsion should be made while the patient is prone after laparotomy. Second, so long as a patient was under observation, he received, twice a day, intramuscular injections of 0.1 gram acetylcholin hydrobromide, dissolved in 2 cc. of distilled water. This drug is a specific stimulant for the parasympathetic nerves; therefore it promotes contraction of the detrusor muscle, and after the indwelling catheter is removed facilitates the opening of the internal sphincter. Although the effect of each dose is transient, patients have remarked that they felt the bladder contract on the catheter following an injection, and I believe that the regular administration of the drug is of value in restoring tonus to the musculature of the bladder. Occasionally it will be found that a patient becomes unduly sensitive to the drug; in such cases severe abdominal pain and vomiting occur. These symptoms disappear when the injections are stopped. After a day or two the administration of acetylcholin may be cautiously resumed. Further, I believe that even after successful operation regular catheterization should be continued for periods varying with the individual case but at lengthening intervals; any overtaxing of the recovering bladder must be rigorously avoided. Although I have not yet had an opportunity of performing this operation, I feel that it might be usefully applied in cases in which, after an injury to the conus or the cauda equina, there is difficulty in completely emptying the bladder. In brief, the outstanding indication for the operation is evidence of injury to either the central or the peripheral part of the parasympathetic TH E JOURNA L OF UROLOGY , V OL. XXVI, N O.
2
232
JAMES R. LEARMONTH
system, when the central or peripheral parts of the sympathetic system are intact. The patient must, of course, be continent. Both these cases provided favorable material from which physiologic conclusions can be drawn. In case 1, the injured part of the spinal cord could be defined with great accuracy; in case 2, the available evidence pointed to the second lumbar segment as the highest involved. In case 1, therefore, the whole of the sympathetic supply to the bladder was derived from intact segments of the cord, whereas in case 2 the highest affected segment corresponded to the lowest from which sympathetic fibers are known to arise. The improvement in micturition which followed sympathectomy ~ppears to me to admit of no other explanation than that the undiminished action of the inhibitory impulses transmitted by the intact sympathetic nerves overbalanced the few motor impulses which the parasympathetic nerves continued to transmit, and that this nervous imbalance was corrected by the sympathectomy. In selecting cases for this operation, the principles laid down in the preliminary report on case 1 should be followed: The clinical data must point to reduction of the function of the plevic nerves (aptly called by Rose the "emptying" nerves of the bladder), while the hypogastric nerves are uninjured; in other words, the balance of vesical innervation is disturbed, and injured pelvic nerves are handicapped in their task by the "brake" action of intact hypogastric nerves. As a corollary, there must not be total paralysis of the pelvic nerves, in order that after. removal of the brake the residual expulsive power of the detrusor muscle may be more equal to emptying the bladder. Again, the patient must be continent, through the action of the external sphincter muscle, for the hypogastric nerves are the motor nerves to the internal sphincter. Finally, there must be satisfactory renal function. REFERENCES (1) LEARMONTH, J. R., AND BRAASCH, W. F.: Resection of the presacral nerve in the treatment of cord bladder: preliminary report. Surg., Gynecol. and Obstet., October, 1930, Ii, 494-499. (2) RosE, D. K., AND DEAKIN, ROGERS : The cystometric diagnosis of central nervous system syphilis; a new appreciation of the term neurogenic bladder. Amer. Jour. Syphiiis, July, 1929, xiii, 371-390.