Introduction: Throughout the two World Wars, many patients experienced traumatic spinal injuries resulting in neuropathic bladders. Providers at the time operated under the principle of preventing bladder distention through long-term urethral or suprapubic catheterization. However, the main drawback of these methods was the high prevalence of infection and sepsis resulting in mortality rates estimated as high as 80%. In response came the Guttmann Era, which improved patient outcomes dramatically but relied on sterile technique to intermittently catheterize patients. Dr. Guttmann believed it was the introduction of bacteria from the catheters that led to the high mortality rate, but this was challenged by one of his students, who would go on to further revolutionize the management of neuropathic bladders.
Methods: A review was conducted on the history of intermittent catheterization using PUBMED and Google Scholar.
Results: Jack Lapides, a physiologist turned urologist, attended lectures by Guttmann, but believed that these infections were of a different etiology. To Lapides, it was the bladder distention and high intravesical pressure that led to local ischemia, leaving tissue vulnerable to organisms from the patient’s own gut via hematogenous or lymphatic spread. This theory led to the then-controversial idea that catheterizations could be done clean, instead of sterile. This new method was first used on a 30 year old woman who denied a bladder augmentation procedure for her neuropathic bladder. Dr. Lapides decided to intermittently catheterize the patient, with good results. The patient herself claimed that she once dropped the catheter on the floor of a public restroom and proceeded with self-catheterization with no complications. Most importantly, the patient reported a vastly increased quality of life as she was able to resume her social and sexual activities, with her recurrent urinary infections becoming a thing of the past. This culminated in a 14 patient study of non-sterile intermittent self-catheterization, wherein all participants noted significant improvement in daily life without any significant complications noted.
Conclusions: Currently the treatment of choice in neuropathic bladders, clean intermittent catheterization was a revolutionary idea and further improved on Guttmann’s approach. Lapides attributed this idea from his early training days during which “the Boss [Dr. Reed Nesbit] never wore gloves.” Clean intermittent catheterization improves patient autonomy while preventing not only infections, but unnecessary surgical procedures and surgical waste as well.
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