Intermittent catheterisation is the preferred method of managing the neurogenic bladder in patients with spinal cord injury. However, spinal cord physicians experienced problems when trying to implement an intermittent catheterisation regime in some spinal cord injury patients in the northwest of England. We present illustrative cases to describe practical difficulties encountered by patients while trying to adopt an intermittent catheterisation regime. Barriers to intermittent catheterisation are (1) caregivers or nurses are not available to carry out five or six catheterisations a day; (2) lack of time to perform intermittent catheterisations; (3) unavailability of suitable toilet facilities in public places, including restaurants and offices; (4) redundant prepuce in a male patient, which prevents ready access to urethral meatus; (5) urethral false passage; (6) urethral sphincter spasm requiring the use of flexible-tip catheters and α-drenoceptor–blocking drugs; (7) reluctance to perform intermittent catheterisation in patients >60 years by some health professionals; and (8) difficulty in accessing the urethral meatus for catheterisation while the patient is sitting up, especially in female patients. These cases demonstrate the urgent need for provision of trained caregivers who can perform intermittent catheterisation, and improvement in public facilities that are suitable for performing catheterisation in spinal cord injury patients. Further, vigilance should be exercised during each catheterisation in order to prevent complications, such as urethral trauma and consequent false passages. Health professionals should make additional efforts to implement intermittent catheterisation in female spinal cord injury patients and in those >60 years.

Study Design: The functional outcome of the diaphragm after acute spinal cord injury was reviewed over a 16 year period for 107 patients who had required assisted ventilation in the acute phase. Objectives: To quantify the incidence of recovery of diaphragm function which occurred beyond the period of acute oedema; to produce a time-related pro®le of this as a guide to clinicians considering phrenic nerve pacing; and to assess the value of phrenic nerve testing in predicting recovery. Setting: The Southport Regional Spinal Injuries Centre, Southport, England. Methods: Bilateral phrenic nerve and diaphragm integrity was assessed clinically, by spirometry, and by¯uoroscopy without and with phrenic nerve stimulation. Results: Thirty-one per cent of all the ventilated patients (33 cases), with a level of injury between C1 and C4 (Scale A in ASIA Impairment Scale), had diaphragmatic paralysis at the time of respiratory failure. The subsequent diaphragm recovery which appeared in seven of these patients, between 40 and 393 days (mean 143), permitted weaning from ventilatory support at 93 to 430 days (mean 246) after the acute injury, with a vital capacity of over 15 ml kg 71 at that stage. The diaphragm recovery in a further ®ve patients, whose vital capacity remained below 10 ml kg 71 and who could not be fully weaned, occurred signi®cantly later, between 84 and 569 days (mean 290), P=0.053. Negative phrenic nerve tests were followed by weaning at a later interval in several cases. By contrast, one patient with an early positive phrenic stimulation test and subsequent diaphragm activity could not be weaned from the ventilator. Conclusion: Twenty-one per cent of the patients with initial diaphragm paralysis were ultimately able to breathe independently after 4 and 14 months, whilst a further 15% had some diaphragm recovery. Phrenic nerve testing should be repeated at 3 monthly intervals for the ®rst year after high tetraplegia.

Study design: A case report of xanthogranulomatous funiculitis and epididymo-orchitis. Xanthogranulomatous in¯ammation is an uncommon, non-neoplastic process characterised by destruction of tissue, which is replaced by a striking cellular in®ltrate of lipid-laden macrophages. Case report: A 21-year male sustained complete tetraplegia at C-6 level, after a fall in 1998. The neuropathic bladder was managed with an indwelling urethral catheter. He had many unsuccessful trials of micturition. Sixteen months after the cervical injury, he noticed swelling of the left side of the scrotum following removal of a blocked catheter. He was prescribed antibacterial therapy. Four weeks later, physical examination revealed a hard and irregular swelling encompassing the testis, epididymis and spermatic cord. The clinical diagnosis was epididymo-orchitis progressing to pyocele. Through a scrotal incision, the swollen testis, epididymis and diseased segment of the spermatic cord were removed en masse. Histopathology showed extensive areas of necrosis, with xanthogranulomatous in¯ammation in the spermatic cord and to a lesser extent in the testis/epididymis. Conclusion: Repeated episodes of high-pressure urinary re¯ux along the vas deferens during dyssynergic voiding, and subsequent interstitial extravasation of urine together with chronic, low-grade, suppurative infection possibly led to development of xanthogranulomatous in¯ammation in the testis and the epididymis. Since tissue destruction is a feature of xanthogranulomatous in¯ammation, the de®nite and curative treatment is either complete (or, where applicable, partial) excision of the a ected organ in most of the cases. Spinal Cord (2000) 38, 769 ± 772

Introduction: Spinal cord injury (SCI) results in disruption of synaptic in¯uences on the sympathetic preganglionic neurones. Remodelling of spinal cord circuits takes place in spinal neurones caudal to cord injury. There is an increased vascular alpha-adrenoceptor responsiveness, and peripheral a erent (bladder) stimulation in SCI subjects induces a marked noradrenaline spillover below the level of spinal lesion. These neurophysiological changes possibly contribute to the development of autonomic dysre¯exia, a condition of sympathetic hyper-excitability that develops after cervical, or upper dorsal cord injury with resultant paroxysmal rise in arterial pressure, and provide the scienti®c basis for the use of terazosin, a once-a-day, selective alpha-one adrenergic blocking drug. Objectives: The use of terazosin, a long-acting, alpha 1-selective blocking agent was investigated in SCI patients who developed recurrent symptoms of autonomic dysre¯exia, eg headache, sweating¯ushing of the face together with an increase in the arterial pressure.Design: An open, prospective study of the e cacy of terazosin in controlling recurrent autonomic dysre¯exia in traumatic tetraplegic/paraplegic patients manifesting clinical features of dysre¯exia in the absence of an acute precipitating cause such as a blocked catheter. Setting: The initial assessment and treatment were carried out in the Spinal Injuries Centre. Subsequently, the patients were followed-up in the community. They were monitored by telephonic interviews, follow-up visits by the patients to the hospital, and home-visits by the sta of the spinal unit. Subjects: Eighteen adults with tetraplegia (female: 1; male: 17), three children with ventilatordependent tetraplegia and three adult male patients with paraplegia who exhibited recurrent features of autonomic dysre¯exia in the absence of an acute predisposing factor for dysre¯exia eg performance of an invasive procedure such as cystoscopy, digital evacuation of bowels, or acute urinary retention, were enrolled in this study. Intervention: After discussion with the patients and their carers, terazosin was prescribed with a starting dose of 1 mg in an adult and 0.5 mg in a child administered nocte. The patients were observed for (1) drug-induced hypotension; (2) clinical symptoms due to side e ects of terazosin; and (3) continued occurrence of dysre¯exic symptoms.Step-wise increments of the dose of terazosin (1 mg in case of adults, and 0.5 mg in a child) was carried out at intervals of 3 ± 4 days, if a patient continued to develop dysre¯exia but did not manifest any serious side e ect. Outcome measures: Complete subsidence of dysre¯exic symptoms, or development of an adverse event necessitating termination of the terazosin therapy was the clinical end point. Results: The dysre¯exic symptoms subsided completely with the terazosin therapy in all the patients. The twenty-one adult patients required a dose varying from 1 ± 10 mg, whereas the paediatric patients required only 1 ± 2 mg of terazosin. The side e ects of postu...