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The Highland View Hospital Urinary Catheter Care Team was organised in 1962, primarily in response to the problems of increasingly drug resistant urinary infections and their complications in a chronic disease population which included patients with strokes, renal and liver failure and heart disease as well as those with spinal cord injury (SCI). When the spinal cord injury centre was formed in 1970 the team became an integral part of the service. The early problems in organising the team, its evolution into a valuable, economically viable, patient care service and its role in urological clinical research, are discussed.

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Verapamil, a calcium channel blocker, was tested alone and in combination with oxybutynin chloride for its clinical effectiveness in the treatment of detrusor hyperreflexia in a spinal cord injured population. Fourteen patients with detrusor hyperreflexia were included. All patients were treated with oxybutynin chloride alone and with the combination of oxybutynin chloride and verapamil. Six of the patients were also studied on no medication and verapamil alone. Cystometric and clinical comparisons were made with each change in drug dosage. Verapamil 240SL, when used alone, produced a delay in the first detrusor contraction as compared to no medication in 5 of the 6 patients but clinical improvement was insignificant. Clinical improvement with tolerable side effects was noted in 13 of the 14 patients treated with the combination of oxybutynin chloride and verapamil over oxybutynin alone. Our early experience with verapamil suggests that it may be a valuable adjunct in the treatment of detrusor hyperreflexia.

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During the past 25 years enormous progress has been made in the management of the neuropathic bladder, largely as a result of the adoption of intermittent catheterisation, together with improvements in catheter-related techniques, and the judicious use of antibacterial drugs and sphincter surgery. A few quadriplegic women can be trained to do self-intermittent catheterisation, using a special technique. For the majority of these women, however, there is no practical alternative at present to indwelling catheters. Bladder spasms resulting from the mechanical stimulation of the catheter and/or repeated infections may be difficult to control, and illustrative cases demonstrating some problems encountered are presented. There is an obvious need for an external collecting device for these women. The development in the field of such devices are presented and evaluated.

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Obtaining and sustaining an erection that is firm enough and adequate for vaginal penetration and satisfactory completion of intercourse are common problems for the male spinal cord injury patient. Intracavernous injection of vasoactive substances offers a new treatment option but it must be approached with caution in this population. During the last year we placed 20 spinal cord injury men (16 paraplegics and 4 quadriplegics) on self-injection of papaverine alone or with phentolamine. Of the patients 19 were able to obtain an erection adequate for penetration. The patient who did not obtain an adequate erection had anomalous penile venous drainage. Six episodes of priapism occurred in 3 patients: 1 had a surgical shunt placed elsewhere before he entered our program, and 2 were treated with aspiration of the corpora and injection of epinephrine. All 3 patients subsequently have been able to obtain satisfactory erections with use of lower doses of papaverine alone.

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Cystometry, using a portable CO2 cystometer, is a convenient method for detecting autonomic dysreflexia (A.D.) in response to bladder distention. Serial tracings on successive days were found to be consistent. This method was used to compare the effect of the antihypertensive drugs, phenoxybenzamine and nifedipine, in modifying the blood pressure responses of 12 tetraplegic patients. Given as regular medication twice daily, neither drug was effective in preventing A.D. responses to bladder filling, and a significant number of patients developed troublesome hypotension. Nifedipine by mouth was found to be a valuable drug for the treatment of attacks which developed, and capable of preventing an anticipated attack if given shortly before the stimulus. The condition of 'status dysreflexicus' and its appropriate management is described.

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From the results we obtained it seems clear that, even in the presence of Foley catheters and a history of previous urinary infections, low dose antibacterial therapy is effective in preventing repeated invasion of the bladder urine by pathogenic organisms in spinal cord injured patients. It should be emphasised however that the quality of catheter care must also be of high standard and that antibacterials alone cannot compensate for poor care. Nitrofurantoin in the dose we use has proven to be non-toxic and free of side effects, and has not resulted in the emergence of drug resistant bacterial strains. Moreover it would seem that pseudomonas organisms may, in the absence of traumatic catheter techniques be safely left to browse undisturbed in the neuropathic bladder.

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Self intermittent catheterisation (SIC) was taught to 24 women with neurological diseases involving the bladder. The major causes of neuropathic bladders were traumatic lesions of the spinal cord (17 cases, 70 per cent), diabetes and multiple sclerosis. Patients were aged 16--65 years (mean 36 years). Initial acceptance of the procedure proved to be a temporary problem in some fastidious women, but the majority eagerly accepted the opportunity to be free of permanent drainage equipment. A bladder relaxant drug was used in order to suppress spontaneous detrusor contractions in patients with intact lower motor neurones. A training period of 1 day to 2 weeks, depending on manual dexterity, was sufficient to ensure competence in the technique. All patients were able to perform the procedure with few incidents of infection while in the Hospital, but in four patients it proved to be impractical and was discontinued after 1 to 2 weeks. After discharge home three patients have gone back to permanent Foley drainage. Women who have good home settings or who are able to ambulate to some degree, do well on SIC, but the advantages of prevention of infection and freedom from drainage bags do not, as yet, outweigh the social problems for many women confined to wheelchairs such as architectural barriers, time schedules and suitable clothing. Selected patients must be both well motivated and independent in transfers so that while an excellent solution for some, SIC is far from being the solution for all women with neurological dysfunction of the bladder.

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The urinary antibacterial drugs cinoxacin (Cinobac) and nitrofurantoin (Macrodantin) were compared for efficacy and side effects in the treatment of uncomplicated lower urinary tract infections occurring in elderly patients admitted to a rehabilitation hospital. Twenty-five patients received cinoxacin and 27 received nitrofurantoin for an average of thirteen days' treatment. The antibacterial spectrum of cinoxacin was noted to be better than that of nitrofurantoin, but both drugs performed well in clearing the infections caused by susceptible organisms. There were no side effects from cinoxacin therapy, but 15 per cent of patients receiving the nitrofurantoin experienced anorexia and nausea, in some cases sufficiently severe to require early termination of therapy.

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A total of 234 patients with neuropathic bladder dysfunction and bacteria in the urine have been studied for the presence of antibody coating on the bacteria. Approximately one third of the patients so studied were found to have antibody coated bacteria in the urine (ACB+) by fluorescent microscopy. No correlation could be found between evidence of active tissue infection by the ACB test and the age, sex or catheter status of the patient, the radiological findings or the length of time since the neurological injury. There did, however, appear to be significant differences among the bacterial species isolated, in their ability to invade through urothelium. Testing for antibody coating is a useful epidemiological tool, but is not indicated for routine use as a guide to therapy. The choice of antibacterial drugs can, in most instances, be based on the identification of the bacterial isolate and its known potential for invasion of the upper urinary tract.

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The histories of 444 patients admitted to this spinal cord injury service were reviewed for the incidence of autonomic dysreflexia (A.D.). Forty-eight per cent of 213 patients with complete cord lesions at T6 or above exhibited A.D. The time of onset post-injury, exciting causes, unusual manifestations of attacks, and the persistence of the condition were studied. These findings and the experience with attempts at prevention by education and by the use of an alpha-adrenergic blocker and a non-adrenergic vasodilating agent are reported.

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The clinical efficacy and safety of cefaclor, a new oral cephalosporin, was compared with that of amoxycillin in the treatment of lower urinary tract infections in 61 patients with chronic non-urinary tract disease. Thirty-six patients received cefaclor and 25 received amoxycillin doses of 250 mg every 8 hours for 7 to 10 days. The therapeutic effectiveness of cefaclor was significantly better than that of amoxycillin, and it appeared to be well tolerated and free of adverse side effects. It produced no allergic reactions in 4 patients with a history of penicillin allergy and was effective against Klebsiella strains resistant to the ampicillins. There was no evidence of any haematological, renal or hepatic toxicity from either drug at the dosage used.

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Local and systemic infections represent major obstacles to the successful rehabilitation of patients following spinal cord injury. Their detection, prevention and management are greatly aided by the inclusion of a microbiologist in the rehabilitation team and by the provision of a simple laboratory in close geographic proximity to the spinal cord injury unit. The role and scope of activities of the SCI team-microbiologist, and the suggested location and basic equipment for a small laboratory are described. Some of the advantages to be gained from such microbiological monitoring are discussed.

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