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Urethral meatal colonization with potential urinary tract pathogens was studied before bacteriuria in 31 consecutive acute spinal cord injury patients on an open ward (137 cultures) and 18 renal homotransplant patients in reverse isolation (80 cultures). All patients required indwelling urethral catheterization and no antimicrobials were given. Daily quantitative cultures of the urethral meatus, and bladder and drainage bag urine were obtained. The urethra was the source for 11 of 31 episodes of bacteriuria (35 per cent). Urethral meatal colonization with the organism responsible for bacteriuria, that is Escherichia coli (5 episodes), Staphylococcus aureus (2), Streptococcus faecalis (2) and Staphylococcus epidermidis (2), was persistent and present from 2 to 5 days before bacteriuria. In each ward 81 per cent or more of the cultures obtained on day 1 of catheterization showed no gram-negative colonization. Subsequently, the gram-negative colonization density increased in both groups but the increase was significant (p less than 0.001) only for patients on the open ward. Similar trends were observed for gram-positive colonization. The prevalence of potential pathogens was similar for patients whether or not they suffered bacteriuria. An increased density of bacterial colonization was associated with increased susceptibility to bacteriuria but the specific urethral meatal flora was not always predictive of the species responsible for bacteriuria.

We determined the incidence and source of bacterial colonization of the bladder in 31 consecutive patients with acute spinal cord injury who required indwelling urethral catheterization. Patients were randomized to conventional drainage or to conventional drainage with a secondary sterile bag for periodic administration of saline or 3 per cent hydrogen peroxide. The hydrogen peroxide group maintained sterile bladder urine significantly longer than the conventional drainage group (p less than 0.05). Cultures suggested that the reservoir for bladder colonization was the bag in 5 of 12 patients (42 per cent) on conventional drainage. Instillation of hydrogen peroxide prevented bacterial contamination of the drainage bag before bladder bacteriuria (p less than 0.01) and also reduced drainage bag bacteriuria in patients with urinary infections (p less than 0.0005). The data indicate that bacterial contamination of the drainage bag is a frequent source of bladder bacteriuria that can be eliminated effectively by periodic instillation of hydrogen peroxide.

The effect of D-mannose on adherence of 73 Escherichia coli strains to vaginal and buccal epithelial cells from women with recurrent urinary tract infections, and on agglutination of human and guinea pig erythrocytes was tested. Urinary, vaginal or anal isolates from women with such infections were used. Of the strains 66 (90 per cent) demonstrated adherence to epithelial cells. D-mannose inhibited completely the adherence of 25 strains (42 per cent) that adhered to vaginal cells and inhibited an additional 11 strains (18 per cent) by at least 50 per cent. Similar results were obtained with buccal cells. The inhibitory effect of D-mannose was similar regardless of the origin of the strains. Hemagglutination frequently was inhibited by D-mannose but no consistent association between hemagglutination, and epithelial cell adherence and the effect of D-mannose was observed. The results suggest that mannose-sensitive as well as mannose-resistant adhesins frequently mediate Escherichia coli adherence to vaginal epithelial cells, and may contribute to vaginal colonization and cystitis.

We examined the roles of excretory urography and cystoscopy in the evaluation and management of 153 otherwise healthy women seen consecutively with recurrent urinary tract infections. The excretory urograms were entirely normal in 89 per cent of the patients; the abnormalities were incidental findings with no influence on subsequent management. These results, combined with the known expense and risks inherent in the use of iodinated radiologic contrast material, suggest that excretory urography be limited to those patients possessing other risk factors. These include a history of unexplained hematuria, obstructive symptoms, neurogenic bladder dysfunction, renal calculi, analgesic abuse, severe diabetes mellitus or bacteriologic evidence of rapid recurrence suggesting bacterial persistence within the urinary tract or an enterovesical fistula. On the other hand, cystoscopy under local anesthesia has essentially no risks and occasionally will yield information helpful in future management.

Forty-four consecutive patients, without residual urine or infecttion, were operated upon for urinary stress incontinence by endoscopie suspension of the vesical neck. All patients had preoperative and post-operative lateral view cystograms which showed after operation substantial upward and forward elevation of the urethrovesical junction as measured by the posterior urethrovesical angle, the angle of urethral inclination, and elevation of the base of bladder. Despite a significant history of an urgency component to their incontinence in many patients, as well as 44 previous operations in 22 of the patients, a carefully performed cystometrogram and cholinergic sensitivity test were not helpful in detecting abnormalities of the detrusor muscle. Fourty-one patients were cured, and in three others, the condition was not cured, the failure group. The lateral view cystogram was the most diagnostic test in that two in the failure group did not show preoperatively the roentgenographic hallmark of stress urinary incontinence.

The HLAs of the major histocompatibility complex in humans have been associated statistically with many diseases [1]. The possibility that recurrent UTIs in women are controlled in part by genotypic traits was suggested by the observation that adherence of Escherichia coli in vitro to both vaginal and buccal cells was greater for patients with such infections than for healthy control subjects and that there was a strong correlation between vaginal cell and buccal cell receptivity [2]. A3 antigen was identified in 12 (34%) of the patients. This frequency was significantly higher in patients than in healthy control subjects, but it was not significantly different from the frequency observed in the reference population. After correction for the number of comparisons made, there was no statistically significant difference between patients and control subjects with any other antigen. These data suggest that HLA A3 may be associated with increased risk of recurrent UTIs.

This monograph is derived from a 1976 symposium on disorders of the urethrovesical junction. The 14 chapters cover a wide range of topics, but unfortunately there is considerable overlap. The reader is reminded with annoying frequency of the importance of an adequate history and physical examination, the appropriate questions that should be asked, the values of various diagnostic procedures, and the advantages and disadvantages of a variety of surgical techniques. When an attempt is made to summarize, as in the three-page chapter on "the results in the treatment of stress urinary incontinence," the majority of the procedures advocated in the monograph are not even mentioned. A Table lists the results achieved by one surgeon, without mentioning the type of operation he performed. It is no wonder that the author concludes that "the surgical correction of stress urinary incontinence remains complex and distressing." The illustrations and photographic reproductions vary considerably in