Tuesday, November 25, 2014

Historical Contribution: 1945, Lewis, Bladder Dysfunction after Trauma

Lewis LG. Treatment of Bladder Dysfunction after Neurologic Trauma. J Urol. 1945; 54; 3: 284-95.    


Lloyd G. Lewis, MD
LLoyd G. Lewis graduated the Brady Residency in 1933. He was remembered as a superb surgeon and co-author of The Physiology of Micturation, 1940 after undertaking a number of laboratory experiments involving the innervation of the feline bladder. During World War II, Lewis served as Chief of Urology at Walter Reed General Hospital in Washington, DC and succeeded in having Walter Reed approved for residency training during his time there. This manuscript was written while Chief of Urology at Walter Reed.

To understand the neurogenic bladder, one must first understand the normal mechanisms of bladder function. Therefore, Dr. Lewis begins this manuscript with a thorough description of the normal anatomy and neurophysiology of bladder storage and micturition as it was understood in the 1940's. Interestingly, the pathophysiology for abnormal bladder function came from studies of advanced syphilis patients (with tabes dorsalis) and pelvic surgery patients. Through careful observation and meticulous attention to detail, Lewis noted neurologic consistencies among patients with similar neurologic diseases or injuries, and tabulated the following observations:

  • The immediate effect of severe injury to the brain or spinal cord is urinary retention (a concept called spinal shock).
    • Spinal shock was believed to be relieved within 48 hours.
    • Failure to decompress the spinal cord within 48 hours would lead to permanent disability.
    • Lewis demonstrates 10 circumstances where bladder function was restored weeks to months following surgical decompression of the spinal cord.
  • Until the permanent neurourologic state is determined, treatment should focus on:
    • Prevention of ascending urinary tract infections (UTI).
    • Protection of paralyzed muscles.
    • Restoration of function.
  • To prevent UTI, HH Young preached "no instrumentation" of the urinary tract. Lewis noted that failure to drain the urinary system would lead to permanent dysfunction of the bladder, likely due to overstretching. Therefore, Lewis recommended:
    • No instrumentation for 24 hours.
    • If no voiding after 24 hours, a one-time, straight urethral catheter should be employed.
    • If the patient is unable to void, a second, indwelling urethral or suprapubic drainage should be instituted. 
    • Changing of the urinary catheter every 5 days in the acute setting.
      • Chronic catheter changes at 6 week intervals if needed. 
    • Use of acidic-solution irrigation if needed to prevent encrustation and infection of the catheter.
    • Perineal urethrostomy with catheter drainage (performed under local anesthetic) if periurethral abscesses.
  • Lewis described the outcomes of 16 patients with a variety of complete and incomplete spinal cord injuries resulting in urinary retention. From these observations, he concluded that:
    • Permanent drainage is indicated for complete injuries below L1.
    • Outlet obstruction cannot be relieved with surgical operations.
    • Presacral neurectomy (surgical transection of the parasympathetic nerves to the bladder) can be considered as an experimental treatment in patients with residual urine and no concern for ejaculatory function.
    • Patients are more comfortable with permanent cystostomy tubes than permanent incontinence.
    • Surgery to decompress or treat the neurologic injury should be instituted immediately; any surgery to treat bladder dysfunction should be delayed for months to years, as adequate neurologic function may return.
Interestingly, many of the principles laid forth by Lewis in 1945 remain the standard principles practiced by urologists today.

To read the entire manuscript: follow the link above, visit the Centennial Website or click here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

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