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Complete Vesical Paralysis: Report of a Case
COMPLETE VESICAL PARALYSIS REPORT OF A CASE
ALFONSO DE LA PENA, A. AMSELEM,
AND
R. RUIZ-OCANA
Madrid, Spain
The procedure to be adopted by the urologic surgeon who is confronted by a case of complete retention of urine attributable to paralysis following complete section of the spinal cord, is not yet very clearly laid down. Many authors believe that immediate cystostomy will forestall the stage of vesical overflow, with the disadvantages which attend it; namely, difficulty in keeping the patient dry and free from urinary infection. The latter is always an effect of frequent catheterization. Others believe that it is preferable to leave the patient alone, except for attempts to stimulate vesical automatism in several ways, until the automatic reflex makes possible normal emptying of the bladder and prevents death from uremia. A case of complete section of the spinal cord by gun-shot, encountered in an emergency hospital, in the course of the present Spanish Civil War, presented a few aspects that seem to us interesting to all urologists and neurologists. Case report. A soldier, 21 years of age, was wounded December 2, 1936, as he was scrambling on all fours trying to reach a wounded comrade. Suddenly he fell to the ground and was unable to move his legs or arms. When he was picked up he was incapable of voluntary motion. He stated that he was like a "pelele" (Spanish word for a toy resembling a clown). His bearers could move his limbs without his feeling a thing; the wounded man could not help his bearers in any way. The soldier was brought to the hospital in the evening of the day he was wounded. The wound of entrance of the missile was in the left dorsal region of the thorax, at the level of the fourth rib, and the wound of exit in the right suprascapular region. All reflexes of the arms, legs, abdomen and anus, as well as the cremasteric reflex, were lost. Complete retention of urine developed, and 24 hours after the patient's admission the dome of the bladder could be palpated rising high in the lower part of the abdomen and overflow incontinence began. Because of the fatal prognosis, and because of what we had read concerning the possibility of the automatic vesical mechanism developing, and also because we wished to avoid 642
COMPLETE VESICAL PARALYSIS
643
causing infection by repeated catheterization, we tried to cause the reflex vesical mechanism to develop. This we did by exciting, in several ways, the skin of the pubis, groins and perineum. These measures were not successful but we were able to cause the bladder to empty, apparently completely, by exerting firm but gentle pressure over it with one or both hands. By this procedure, easily learned by the nurses, we were able to keep the patient dry. On a few occasions, because of the exigencies of work under difficult circumstances, the periodical emptying of the bladder was omitted and the overflow incontinence returned. Then the decubitus ulcers, that had started on the fourth day of the illness, unfortunately became wet. These ulcers were over the coccyx and the prominence of the right trochanter. The urine was completely clear; microscopic examination did not reveal any leukocytes; the prostate gland was normal, and the history that there never had been any previous infections of the urogenital tract, gave us the hope that the patient could be maintained without urinary infection if we did not catheterize him. Much to our surprise, December 17, 15 days after the patient's admission, the urine was slightly cloudy and examination disclosed that it contained pus and blood. Nevertheless, we knew that no one ever had catheterized the patient. The patient's progress began to be unsatisfactory on account of the decubitus ulcers, the disuse of the legs and arms, and the rectal incontinence. Because of the excess of work, also, we were unable to empty his bladder regularly and again overflow incontinence developed. On December 21 vomiting and nausea appeared and the bladder reached almost to the umbilicus. The concentration of blood urea was high and we thought of performing cystostomy under local anesthesia. However, considering the unfavorable course of the case, together with the inconvenience of a new wound, we thought it better to use an indwelling catheter. After this had been inserted, the first urine to pass was cloudy and amber colored; toward the end of the flow it turned dark and contained clots of old, digested blood. Bacteriologic stains or cultures were not made. The concentration of blood urea became normal, all of the uremic signs disappeared and the patient lived comfortably, as far as 'the urinary tract was concerned, until December 23. On that day he died of cardiac failure, in spite of treatment. His temperature was subnormal for 27 hours before his death. SUMMARY
To our belief, the interesting points of this case are as follows: 1. The anatomic emptying reflex never developed. 2. The bladder was easily caused to empty by pressing over it, and thus a stream of urine of fairly good size was obtained. 3. Infection of the urinary tract developed,
644
ALFONSO DE LA PENA, A. AMSELEM, AND R . RUIZ-OCANA
although catheterization had not been performed and there had not been any previous infection of the genito-urinary tract. The question arises whether the infection was attributable to elimination through the kidneys of microorganisms growing in the dilated intestine or whether it was attributable to the usual enterorenal syndrome. 4. Blood was present in the urine although catheterization was not performed. The blood may have been attributable to the pelvic stasis and to infection of the vesical wall.
ALFONSO DE LA PENA, A. AMSELEM,
AND
R. RUIZ-OCANA
Madrid, Spain
The procedure to be adopted by the urologic surgeon who is confronted by a case of complete retention of urine attributable to paralysis following complete section of the spinal cord, is not yet very clearly laid down. Many authors believe that immediate cystostomy will forestall the stage of vesical overflow, with the disadvantages which attend it; namely, difficulty in keeping the patient dry and free from urinary infection. The latter is always an effect of frequent catheterization. Others believe that it is preferable to leave the patient alone, except for attempts to stimulate vesical automatism in several ways, until the automatic reflex makes possible normal emptying of the bladder and prevents death from uremia. A case of complete section of the spinal cord by gun-shot, encountered in an emergency hospital, in the course of the present Spanish Civil War, presented a few aspects that seem to us interesting to all urologists and neurologists. Case report. A soldier, 21 years of age, was wounded December 2, 1936, as he was scrambling on all fours trying to reach a wounded comrade. Suddenly he fell to the ground and was unable to move his legs or arms. When he was picked up he was incapable of voluntary motion. He stated that he was like a "pelele" (Spanish word for a toy resembling a clown). His bearers could move his limbs without his feeling a thing; the wounded man could not help his bearers in any way. The soldier was brought to the hospital in the evening of the day he was wounded. The wound of entrance of the missile was in the left dorsal region of the thorax, at the level of the fourth rib, and the wound of exit in the right suprascapular region. All reflexes of the arms, legs, abdomen and anus, as well as the cremasteric reflex, were lost. Complete retention of urine developed, and 24 hours after the patient's admission the dome of the bladder could be palpated rising high in the lower part of the abdomen and overflow incontinence began. Because of the fatal prognosis, and because of what we had read concerning the possibility of the automatic vesical mechanism developing, and also because we wished to avoid 642
COMPLETE VESICAL PARALYSIS
643
causing infection by repeated catheterization, we tried to cause the reflex vesical mechanism to develop. This we did by exciting, in several ways, the skin of the pubis, groins and perineum. These measures were not successful but we were able to cause the bladder to empty, apparently completely, by exerting firm but gentle pressure over it with one or both hands. By this procedure, easily learned by the nurses, we were able to keep the patient dry. On a few occasions, because of the exigencies of work under difficult circumstances, the periodical emptying of the bladder was omitted and the overflow incontinence returned. Then the decubitus ulcers, that had started on the fourth day of the illness, unfortunately became wet. These ulcers were over the coccyx and the prominence of the right trochanter. The urine was completely clear; microscopic examination did not reveal any leukocytes; the prostate gland was normal, and the history that there never had been any previous infections of the urogenital tract, gave us the hope that the patient could be maintained without urinary infection if we did not catheterize him. Much to our surprise, December 17, 15 days after the patient's admission, the urine was slightly cloudy and examination disclosed that it contained pus and blood. Nevertheless, we knew that no one ever had catheterized the patient. The patient's progress began to be unsatisfactory on account of the decubitus ulcers, the disuse of the legs and arms, and the rectal incontinence. Because of the excess of work, also, we were unable to empty his bladder regularly and again overflow incontinence developed. On December 21 vomiting and nausea appeared and the bladder reached almost to the umbilicus. The concentration of blood urea was high and we thought of performing cystostomy under local anesthesia. However, considering the unfavorable course of the case, together with the inconvenience of a new wound, we thought it better to use an indwelling catheter. After this had been inserted, the first urine to pass was cloudy and amber colored; toward the end of the flow it turned dark and contained clots of old, digested blood. Bacteriologic stains or cultures were not made. The concentration of blood urea became normal, all of the uremic signs disappeared and the patient lived comfortably, as far as 'the urinary tract was concerned, until December 23. On that day he died of cardiac failure, in spite of treatment. His temperature was subnormal for 27 hours before his death. SUMMARY
To our belief, the interesting points of this case are as follows: 1. The anatomic emptying reflex never developed. 2. The bladder was easily caused to empty by pressing over it, and thus a stream of urine of fairly good size was obtained. 3. Infection of the urinary tract developed,
644
ALFONSO DE LA PENA, A. AMSELEM, AND R . RUIZ-OCANA
although catheterization had not been performed and there had not been any previous infection of the genito-urinary tract. The question arises whether the infection was attributable to elimination through the kidneys of microorganisms growing in the dilated intestine or whether it was attributable to the usual enterorenal syndrome. 4. Blood was present in the urine although catheterization was not performed. The blood may have been attributable to the pelvic stasis and to infection of the vesical wall.