15

THE GENITO-URINARY ASPECTS OFPROLONGED DECUBITUS

H. F. ANDERSON, F.R.C.S.St. Georges Hospital, London

:;;;e ::..a·M;::f r'0¢

;~~~.t.:o'iF

FIG. a.-Vesical calculi due to infected urine after acauda equina lesion.

On July I3, 1951 a healthy young man of 27fell to the pavement from a height of 40 ft. Hesuffered multiple injuries, of which the mostserious were crush fractures of several vertebraein the lumbo-dorsal area, and an associated partialcauda equina lesion. He was unable to passurine, so intermittent catheterisation was employedfor a few days followed by tidal drainage throughan indwelling catheter.

Recovery of the cauda equina lesion was rapid,and after i6 days the tidal drainage apparatus wastaken down and voluntary micturition re-established. There remained, however, a constantresidual urine of 8 oz., and this, combined witha severe urethritis caused by the indwellingcatheter, led to a chronic bacillus coli urinaryinfection which was resistant to all the availableantibiotics. This infection persisted throughouthis stay in hospital, for the first ten weeks of which

*:.... -

.R -l : : ;. -

FIG. ib.-Decubitus calculi in the kidney and ureter ofa woman aged 35, five months after a severe attackof poliomyelitis.

he was wholly recumbent on account of hisskeletal injuries.

After his discharge the urinary infection wascontrolled by terramycin, but it had recurredwithin a month. No treatment had much effect,and on May 2, 1952, ten months after his injury,an intravenous pyelogram was performed as hissymptoms were getting worse. The X-ray (Fig. I)revealed two large stones in the bladder, and itwas not until after these were removed at operationthat the urinary infection finally subsided.

copyright. on M

ay 25, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.30.339.15 on 1 January 1954. D

ownloaded from

6POSTGRADUATE MEDICAL JOURNAL Yanuary 1954This patient's record illustrates the three most

important genito-urinary complications of pro-longed decubitus. They are difficulty with mic-turition, urinary infection, and calculus formation.In the management of such patients attentionmust, therefore, be directed towards the preventionof these complications, and towards their treatmentwhen they occur. The greatest effort should bemade to prevent their occurrence, and it is with theproblem of their prevention that this paper ismainly concerned.

There are many causes of prolonged decubitus,but the majority of patients fall into one of twogroups. In the first group the genito-urinarysystem is normal, in the second it is abnormal.The first group comprises children and youngadults suffering from chronic diseases, accidents,and affections of the skeletal system. The secondgroup comprises, for the most part, older patientswith bladder neck obstruction and chronic urinaryinfection, and includes those bedridden by ageand cerebral thrombosis; it also includes, however,younger patients who, through injury or disease,have lost control of micturition. In the first groupthe prevention of urinary calculus is the paramountconsideration. This applies equally to the secondgroup, but in addition the treatment of retention,incontinence and established infection have to beconsidered.

Patients with normal urinary tracts DecubitusCalculusAetiologyThe most striking genito-urinary complication

of recumbent patients is their tendency to formrenal calculi. In the older group of patientswith urinary symptoms certain well known factorsin the formation of calculi, such as renal backpressure, stasis, infection and an alkaline urine,are already present. In the younger group ofpatients, however, calculi form all too readily inthe absence of these complications, and .muchresearch has been devoted to this phenomenon.The essential feature is a change in calcium

metabolism. Calcium is mobilized from thebones, the blood calcium rises and the urinaryexcretion of calcium increases. Calcium ions arenormally held in supersaturated solution in theurine, and any increase in the calcium concentra-tion produces conditions in which precipitation,and consequent stone formation, is more likely tooccur. If in addition stasis and infection are

present, resulting in an alkaline urine whichfavours the precipitation of the calcium and phos-phate ions already present, the chances of calculusformation are much increased.

According to Stevenson (1952), recumbency intuberculous patients has an injurious influence

on the metabolism of calcium and nitrogen,of which one of the effects is an increasedexcretion of calcium. That osteoporosis occursas a result of disuse and recumbency is wellknown. Histologically this is a true osteoporosis,the bony trabeculae becoming thin (Sissons, 1952).Physiologically there is an imbalance of osteoblastand osteoclast activity; bone formation decreasesbut bone resorption continues normally (Albrightand Reifenstein, 1948). Biochemically, there isan increase in the blood calcium up to 12.6 mg.per cent., and a consequent increase in the urinecalcium. Deitrick et al. (I945) immobilized fournormal young men in plaster of Paris casts for sixweeks and found calcium losses over the periodof immobilization of 9 to 24 g. (In this connec-tion it should be noted, perhaps, that McCuskey(1950) reported an average blood calcium of 13.8mg. per cent. during the first five days in ambula-tory fracture patients.) According to Howard(i945) and Swartz et al. (1950), immobilization inbed is followed within a few days by increasedexcretion of calcium in the urine. The danger ofcalculus formation is therefore present from theearliest days of recumbency.

There are other factors concerned in the for-mation of decubitus calculus. In the patientlying on his back the calyces of the kidneys arethe most dependent part of the renal drainagesystem, the pelvis lies below the ureter, and eventhe upper part of the ureter slopes upwards fromthe renal fossa as far as the pelvic brim. Thereis thus a tendency for urine to stagnate by theaction of gravity alone in the pelvi-calyceal area.In the upright position, only the lower group ofcalyces lie below the outlet of the renal pelvis,and it is interesting to observe that it is in thisdependent situation that most renal stones in alltypes of patient occur.

Infection predisposes to stone formation in twoways. In the first place, groups of bacteria andepithelial debris may form a nucleus around whichcrystalloids are precipitated. In the second place,if the infecting organisms are urea 'splitters,' ahighly alkaline urine results which leads to pre-cipitation of calcium salts. The aetiological factorsconcerned in the formation of decubitus calculimay be summarized thus:

I. Hypercalcinuria.2. Stasis.3. Infection.4. Alkalinity.

ProphylaxisFrom what has already been written it follows

that one of the fundamental considerations in thecare of recumbent patients is the prevention ofrenal calculi. There is no one panacea, just as

copyright. on M

ay 25, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.30.339.15 on 1 January 1954. D

ownloaded from

3anuary 'I954 ANDERSON: I'he Genlto-Urinary Aspects of Prolonged Decubitus

... ...... ... ...'..:.

~~~.........!··ii ii:'l :ii'th

i......

M~~ ~~..;ER...W ... ....ner... .SE.S ,1

.......

~:i~?,!i?,

- 11i~i:.~11:11:iii

.......

L.... .....

.::

FI.a.Thm:a.

.:::·::::::,:::~~.

.... i,i'iiij itj iiiiii'i::i:.:i.iiiiii:::'

i: :i·i·:ii:,ii.. ·:i: .'..'......... .i:ijLiiilillii;lili;l !il:li ii...... .....ii::·i~l:se~ll.i..,i::::..........;:

....=...=....=.=...=

--lp bedd y Hoskins and Ng.

·iiiW$!I!IU.......·i· iI·r :: ·:·':,i.'ii:riiiii... ......·i:

.:::.I.:.::.: iii:l'".. .. ... .. ... .. ........iirlsl1!:;lll!!;I!E;iB ~::;;....

WNPB"

Al"&:::J-':i"'M

Fir, 2.-Themovablpully beddesignd by oskinsand Nngle'

copyright. on M

ay 25, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.30.339.15 on 1 January 1954. D

ownloaded from

POSTGRADUATE MEDICAL JOURNAL January 1954

.....':·'i ::·:::i:"' :i.ll ·::i: :·.::··:i ··

..................:i.:·.·i.. .. ...........i;' ':';:'........... .... .. ....

FIG. 2b.-To show lateral tilt of the Hoskins, Nangle bed.

there is no one cause, but careful attention toa number of medical, nursing and dietetic measureswill usually p1revent the formation of a calculus.

Diet. An acid ash diet with high vitamin A andB content, which contains a large proportion ofmeat, fish and cereals is advocated by manyauthorities (Joelson, 1945; Kimbrough et al.,I950; Swartz et al., I950). The purpose of thisdiet is to maintain urinary acidity, but accordingto Howard (1945) it has no effect on the excretionof calcium in the urine.

Fluids. A high fluid intake is essential. Itprevents stasis in the kidneys and provides a diluteurine in which precipitation of crystalloids is lesslikely to occur. A daily intake of 4,000 ml. anda urinary output of 2,000 ml. should be maintained.

Drugs and the Control of Infection. Every effortmust be made to keep the urine acid. In a patientwith a normal urinary tract the urine will probablyremain acid and the routine administration ofurinary acidifiers is not necessary. At the firstsign of alkalinity, however, urinary acidifiers must

be administered to try and change the pH of theurine. Acid sodium phosphate may be givenover long periods, though acidification is difficultif the infecting organisms are urea ' splitters.'Furthermore, in patients with impaired renalfunction, there is a danger of acidosis (Shorr et al.,1950). Infection is attacked along usual lineswith the sulphonamides, streptomycin andchloramphenicol.

Posture. It has already been explained howrecumbency in the supine position may lead tostasis in the renal pelvis and ureter. To over-come this difficulty the advantages of nursing thepatient in the prone position have been stressedby Dick (I952); first, the calyces drain better;second, the patient, especially if paraplegic,exercises his arms more. A third advantage,according to Craig and Barr (1947), is that recum-bency hypercalcinuria is less if active use of thearms and shoulders is maintained.

Prone nursing may not always be feasible ordesirable, however. Frequent changing of the

copyright. on M

ay 25, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.30.339.15 on 1 January 1954. D

ownloaded from

January 1954 ANDERSON: The Genito-Urinary Aspects of Prolonged Decubitus 19

10s,! b(,

.......

l <.......

FIG. 3.-Details of pulley used in Hoskins, Nangle bed.

patient's posture is nevertheless most important.In this direction Hoskins and Nangle (195i) havemade a notable advance with their movable pulleybed (Figs. 2 and 3). The frame or plaster shell inwhich the patient is immobilized is suspended overa pulley and counterweight system from beamserected over his bed. By pulling on the cordspatients soon learn how to move themselves, andduring the day they remain suspended and movingthemselves about. At night the pulleys areunhooked and the frame allowed to remain on thebed.

Urinalysis. It is well recognized that the pre-senting symptom of renal calculus is often haema-turia. This not uncommonly follows unusualmovement or manipulation, such as lumbarpuncture or a visit to the X-ray department. Aneven earlier sign, however, is the presence of redblood cells in the urine. These will only be dis-covered by microscopical examination and, there-fore, every recumbent patient should have hisurine routinely analyzed at fairly frequent in-tervals. Haematuria or the presence of red cellsin the urine call for an immediate search for calculi.

Radiology. A 'silent' stone will only be dis-covered by X-ray examination. Straight X-rayexamination of the kidneys should, therefore, bemade at monthly intervals, supplemented bypyelography where necessary.'Reduction of Phosphate Absorption. If theamount of phosphate in the urine can be reduced,the tendency to form stones is correspondinglylessened. This can be achieved by administeringby mouth aluminium hydroxide. This substancecombines with the phosphorus in the bowel to

form aluminium phosphate. Aluminium phos-phate is an insoluble salt which is not absorbedby the bowel and is excreted in the stools. Thisleads to a fall in the inorganic serum phosphateand consequently a fall in the urinary phosphate.Normal phosphate excretion is two-thirds of

the intake. Of the i g. of phosphorus taken dailyin an average diet, 600 mg. are excreted in theurine. This can be reduced to oo00 mg. by theadministration of aluminium salts. The patientremains in positive phosphorus balance, and cal-cium metabolism is but little altered; there is aslight increase in the urinary calcium, but this ismuch less than the fall in phosphorus. The alkalireserve is unaffected.Aluminium is best administered in the form of

gels, either as the hydroxide (aludrox) or thecarbonate. Dosage is high; 90 to 200 ml., or 40tablets, are required daily (Shorr et al., 1950).This high dosage, which is not very palatable, mustbe continued for the duration of recumbency,even though this be for years. The regime maycause constipation, nausea and distaste, but thereare no serious complications. It must be con-trolled by monthly determination of the 24-hourphosphorus excretion. Shorr et al. also maintaintheir patients on a constant diet containing I,300mg. of phosphorus and 700 mg. of calcium.

Satterthwaite (I947) has reported some con-vincing results of this treatment in paraplegics.In a control series of io6 patients, 60 (56.6 percent.) developed vesical and I8 (17 per cent.)renal stones. In a second series of 43 patientstreated by aluminium gels and postural drainage,one developed vesical and none renal stones.

Hyalurodinase. Butt et al. (quoted by the Lancet,1953) have recently shown that hyalurodinase mayhave some effect in controlling and preventingstone formation. The subcutaneous injection ofhyalurodinase mixed with isotonic saline madeturbid urines containing sediment much clearer. Itwas suggested that hyalurodinase increases the col-loid content of the urine and that this in turn pre-vents crystal formation and growth. Clinically themethod requires daily injections and control bycomplicated biochemical estimations, but successin the prevention of stones in habitual 'stoneformers' has been reported. Further work willdetermine whether there is a place for hyaluro-dinase in the routine of stone prevention.TreatmentOn the whole, surgical removal is the most

satisfactory treatment of a stone, followed byrigorous efforts to prevent recurrence. Providingit is not causing irreparable harm to the kidney,however, some surgeons prefer to leave the stonefor the duration of recumbency, arguing that as

copyright. on M

ay 25, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.30.339.15 on 1 January 1954. D

ownloaded from

POSTGRADUATE MEDICAL JOURNAL january 1954

·li'".*:.:]· ." ':.'·il.·'..:·i::.iiiii:'i....t;:i:.:ii.:i

:i:i

Iiiir.iSBl$saCulla.exs·smraar'R.'.."RI·B

:··

:·i·l·i':: ·ii·..i ii:i:

,illlEl.s.B. I''·::.,iiiii ·:.·.:i·

:::·:

.iiliiii.·i·:·:..

.·ii:::ii:i::..'iilB.BBP" eas8ilv.an.a...aa.!.by.i.es..i.:i:i

:::.·····:::*:

:::

.,1.

··;:;;·.

·::.·

... :;

iii·

'' ·:· "li.:'·' "'" ···"'.rl..ei iieil

FIG. 4.-Small stones little more than a radio-opaque sludge dispersed by forcing a copious fluid intake.

long as stone-forming conditions persist recur-rence is almost inevitable after removal. Certainlysmall stones confined to the calyceal system maybe watched, and if they do not enlarge be leftalone. Attempts have been made to dissolvesmall stones by irrigating the pelvis of the kidneythrough a ureteric catheter with solution G, butthis method has not been successful (Riches,I943). On the other hand, small stones, detectedby routine radiography when they are probablylittle more than a radio-opaque 'sludge,' may bedispersed by mechanically washing them out ofthe calyces by forcing a copious fluid intake(Stevenson, I953). The stones shown in Fig. 4were washed away in this manner.

Patients with Abnormal Urinary TractsRecumbent patients with pre-existing or con-

comitant urinary disease are treated according togeneral principles, especially with regard to theurinary infection which is nearly always presentin such patients. Three problems, however,require special consideration, though in practicethey often overlap. They are:

I. Retention due to disorders of the nervouscontrol of micturition.

2. Retention due to prostatic obstruction.3. Senility.

Disorders of Nervous ControlParalysis of the bladder is most often encoun-

tered as the result of injury to the spinal cord withparaplegia. Such injuries occur as the result ofcivil accidents and in war from gunshot wounds,and less frequently as complications of spinal

tumours and thrombosis, disseminated sclerosis,secondary neoplastic deposits in the vertebrae,and Paget's disease. On account of the skeletalinjury and paraplegia, the patient is often confinedto bed for a long period.No really satisfactory treatment has been

evolved for the 'paraplegic bladder.' This ispartly because it is impossible to foretell how longthe paralyzed bladder will remain atonic beforeit develops automatic reflex emptying, and partlybecause urinary infection is almost inevitable.According to Thomson-Walker (I937), urinaryinfection was largely responsible for the 80 percent. mortality amongst paraplegics in the firstworld war. Constant and prolonged attack againstsepsis must, therefore, be maintained, chiefly byforcing fluids and administering urinary anti-septics such as potassium or sodium citrate,mandelic acid, hexamine and sulphonamides.The most difficult problem is the drainage of

the bladder during the paralytic phase. Theavailable methods have been recently summarizedby Dick (1952). Briefly they are:

I. Intermittent catheterization.2. Indwelling catheter.3. Indwelling catheter with tidal drainage.4. Suprapubic cystotomy.5. Manual compression.6. Non-interference: retention with overflow.Each of these methods has a place in individual

patients, but the most universally applicable aresuprapubic cystotomy and tidal drainage. Withthe introduction of the less irritating Foleycatheter, it is likely that tidal drainage through an

copyright. on M

ay 25, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.30.339.15 on 1 January 1954. D

ownloaded from

January 1954 ANDERSON: The Genito-Urinary Aspects of Prolonged Decubitus 2I

indwelling catheter will become the method ofchoice.

Prostatic ObstructionIt is a common observation that the elderly

man suddenly corifined to bed is likely to developacute retention of urine. Occasionally the passingof a catheter once or twice relieves the condition,and no further treatment is necessary. Usually,however, the retention is due to bladder neckobstruction caused by an adenomatous or a fibrousprostate. Operation is required in these patientsto relieve the obstruction. The choice of operationdepends on the pathology of the prostate and thecondition of the patient, and is determined bynormal urological practice.SenilityThe population is ageing, and the care of the old

is becoming an increasingly important social andmedical problem. Many old people, enfeebled inmind and body and stricken with chronic disease,become completely bedridden. Frequently theyhave little control over their normal bodily func-tions, and incontinence is common. A great dealcan be done for these patients if they can becoaxed or cajoled out of bed, even if it is onlya matter of lifting them on to a bedside commode(Nisbet, 1953). If they can be sufficiently re-assured and rehabilitated to make their own wayto the lavatory, they will be well on the way tobeing cured of their incontinence. Old men cansometimes be cured by the simple expedient ofleaving a urine bottle constantly by the bedside,and others will respond to the assurance that abedpan will never be asked for in vain. Othersimple measures are reducing the fluid intake latein the day, frequent regular bedpan rounds, andoffering the bedpan before as well as after meals.Incontinence is sometimes due to urinary infec-tion and, in such instances, treatment of theinfection will cure the incontinence.There remains the group of hopelessly en-

feebled, unco-operative, bedridden and totallyincontinent patients. Something can be done,especially in males, by the use of incontinenceappliances, such as rubber urinals strapped to thethighs. For completely hopeless immobile patientsthe Brocklehurst bed (Brocklehurst, 195). may beused; this consists essentially of a bed in which

there is a hole cut in the mattress under theperineum through which urine and faeces maypass to a receptacle below. Some of these patientsare not only incontinent but filthy, and to improvethe nursing of these patients Arnott and Nisbet(1952) have recently designed a gown whichprevents the patient's hands from coming incontact with the perineum.Summary

I. The urological problems arising from pro-longed recumbency are considered.

2. Of these the most important is decubituscalculus. Its aetiology, prevention and treatmentare described in detail.

3. Reference is made to the management of theparaplegic bladder, retention of urine and senileincontinence.

I wish to record my thanks to Dr. F. HarwoodStevenson of the Royal National OrthopaedicHospital and to Mr. M. F. Nicholls for their greathelp in the preparation of this article. I also wishto thank Mr. E. J. Nangle and the Institute ofOrthopaedics for permission to use Figs. 2 and 3and Messrs. Blackwell Scientific Publications forthe loan of the blocks.

BIBLIOGRAPHYALBRIGHT, F., aitd REIFENSTEIN, E. C. (1948), ' The Para-

thyroid Glands and Metabolic Bone Disease,' London,Balliere, Tindall & Cox.

ARNOTT, A., and NISBET, N. H. (1952), Lancet, ii, 2zo6.BROCKLEHURST, J. C. (I95I), 'Incontinence in Old People',

Edinburgh.CRAIG, W. McK., and BARR, J. S. (I947), 3. Internat. Col. Surg.,

xo, i8.DEITRICK, J. E., WHEDON, G. D., SHORR, E., and BARR,D. P. (I945), ' Conference on Metabolic Aspects of Convalescence,

Transactions of 9th Meeting,' J. Macy Foundation, p. 68.DICK, T. B. S. (1952), Brit. J. Utology, 24 (2), 1oI.HOWARD, J. E. (I945),.. Amer. Med. Ass., 129, 159.JOELSON, J. J. (1945), Ibid., 129, I56.KIMBROLUGH, J. C., DENSLO W, J. C., and WORGAN, D. K.

(1950), Ibid., 142, 787.Lancet (I953), ' Annotation,' I, 332.McCUSKEY, JOHN F. (1950), J. Amer. Med. Ass., 142, 789.NANGLE, E. J. (x95I), 'Instrumsnts and Apparatus in Ortho-

paedic Surgery,' Oxford, Blackwell Scientific Publications.NISBET, N. H. (I953), Lancet, i, I84.RICHES, E. W. (I943), Brit. J. Surg., 31, I35.SATTERTHWAITE, R. W. (19+7), Paper read before the Ameri-

can College of Surgeons, Section on Urology, New York.SHORR, EPHRAIM, and CARTER, ANNE C. (1950), J. Amer.

Med. Ass., i44 (I8), I549.SISSONS, H. A. (1952), J. Bone & Joint Surgery, 34-B (2), 256.STEVENSON, F. HARW03D (1952), Ibid., 34-B (2), 256;

(I953), Personal communication.SWARTZ, D., and TAYLOR, J. R. (I950), Canad. M. A. J., 63,

559-THOMSON-WALKER, SIR J. (I937), Proc. Roy. Soc. Med., 30,

I233.

copyright. on M

ay 25, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.30.339.15 on 1 January 1954. D

ownloaded from