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Two hundred and six intravenous urograms on 119 patients with spinal cord injury were reviewed and the findings correlated with the clinical data. Fifty (42%) of 119 patients had pathological changes in their upper urinary tracts. The most common feature was impaired renal emptying. Patients with normal and pathological upper tracts had similar findings according to the number of positive urine cultures during the first post-injury year, but in the follow-up those with pathological urograms showed bacteriuria significantly more often. Febrile urinary tract infections at least once a year were encountered in the follow-up of 40% of the patients with pathological urograms, as compared with 8% with normal urograms. All patients with severe renal changes had impaired emptying from the kidneys. This supports the view that the basic patho-physiological mechanism leading to upper tract deterioration in patients with spinal cord injury is a functional or mechanical obstruction of the lower urinary tract. This should be treated actively before irreversible renal changes develop.

The cystometrographic patterns together with and sphincter electromyograms of 62 patients with recent spinal cord injury wer analysed. Four main patterns could be distinguished. The patients with well-developed detrusor reflex gained easy emptying of the bladder significantly more often than those with supranuclear injury but weak or unsustained detrusor contractions, or those with mixed spinal lesions. The patients with mixed lesions and low compliance bladders had the most severe incontinence problems. One fourth of the total series had various degrees of upper tract dilatation in their first urogram, and these changes occurred more often in patients with high detrusor activity. Urinary tract infections occurred in all patients but less often in those with areflexic bladders. This group of patients was also most suitable for intermittent self-catheterisation.

The characteristics of urinary tract complications in a series of 202 spinal cord injury patients are described. Repeated urinary infection was the most usual problem. Upper urinary tract changes were detected in 61 patients (30%). 56 patients (28%) underwent bladder outlet surgery for problems with voiding. Urinary diversion was done to 8 patients (4%), and 12 (6%) were treated with permanent indwelling catheter or self-catheterization. The high incidence of bladder stones (29%) and urethral complications (14%) was regarded as due to indwelling catheterization at the early stage post-injury. Despite the high urinary tract morbidity, only one patient has so far died of renal failure.

Eluates from 56 latex urinary catheters from seven manufacturers were divided into three categories according to covering material (siliconized, silicone elastomer coated and teflon coated) and tested for tissue toxicity by means of cell cultures based on the inhibition of DNA synthesis. The silicone elastomer coated catheters showed the lowest toxicity. Only 4 of 13 such catheters gave unacceptable toxic values, whereas half of the siliconized catheters were abandoned as toxic. Teflon and elastomer coatings had the best protective properties against toxic substances leaching from the catheter core. The surface contour of the catheters estimated by scanning electron microscopy (SEM) did not correlate with toxicity, whereas the cracks seen on the catheters did correlate with toxicity. The simple in vivo test methods used by the manufactures turned out to be insensitive to tissue toxicity testing of urinary catheters. The method used in this study was the most reliable for assessing the safety of latex urinary catheters. Thus manufacturers using multiple and in vitro cell culture tests had products of better quality than those using only a single test or simple in vivo tests.

The tissue toxicity of 23 urinary catheter batches (6 latex and 2 non-latex brands) was tested in vitro and in vivo. In vitro, a human T-cell leukemia line (JM) was cultured in the presence of different concentrations of eluates made from the catheters. The cytotoxicity of the eluates was assessed from their ability to inhibit DNA synthesis measured by incorporation of 3H-thymidine. In vivo, two methods were used. Strips of catheters were implanted into the rabbit dorsal muscle and pieces of catheters were implanted into the rat peritoneal cavity. After four days, the foreign body reaction, type of inflammation and necrosis were quantified macroscopically and by light microscopy. The results of the in vitro cytotoxicity test were correlated with those of in vivo methods. The rat peritoneal implantation test correlated better with the cell culture test (P less than 0.01) than with the rabbit muscle implantation test (P less than 0.05). Based on the clinical experience of urethral stricture complications caused by urinary catheters, catheters yielding eluate which at 30% dilution inhibited 50% DNA synthesis were regarded as toxic. According to this, the rabbit muscle implantation test was not reliable in testing the tissue toxicity of urinary catheters, while the cell culture test was quantitative and seemed to correlate with both the rat peritoneal implantation test and with the clinical complications observed.

Urological evaluation was performed on 63 spinal cord injury patients with micturition difficulties or repeated urinary tract infections. Detrusor external sphincter dyssynergia of varying degree was found in 36/63 (57%) of these patients with urological problems, and 15/36 (42%) of them were estimated to benefit by external sphincterotomy. Sphincterotomy was carried out in 11 patients. The effect on micturition problems was good, but intermittent bacteriuria continued despite the operation. However, marked febrile urinary tract infections appeared to subside.

Urethral stricture was found in 59 of 478 male patients who had undergone open-heart surgery between June 79 and December 81. In 40/59 cases the stricture showed a string-of-pearls configuration or long narrowing of the penile urethra on the urethrogram. Burning pain and dysuria were the main symptoms, and the urinary stream started to weaken immediately after the removal of the siliconized latex catheter which had been routinely inserted at the time of the heart operation and usually kept indwelling for 3 days. The stricture epidemic stopped after change of the latex catheters to silicone-ones. The different catheters were investigated for cell toxicity. Eluates of catheters were added at different concentrations to cultures of various cell lines. The cell proliferation was measured by thymidine incorporation. The results were uniform and showed marked toxicity of the latex catheters against all investigated cell lines.

The effect of sodium pentosanpolysulfate (Elmiron) in the treatment of interstitial cystitis was observed in an open controlled multicenter trial. We studied 87 patients with symptoms for more than 2 years at 17 centers in Finland and Sweden. Patient selection was based on the typical chronic symptomatology but the material subsequently was stratified according to objective cystoscopic findings. The medication (400 mg. daily in 2 oral doses) was discontinued after 6 months. The response was evaluated every 4 weeks during treatment and every 3 months thereafter. Most patients responded favorably, many with diminution of pain within only 4 weeks from the start of treatment. The frequency of micturition decreased significantly and the mean volume per void per 24 hours increased in the patients without bladder ulceration but such changes were not found in the patients with ulcer. The bladder capacity was smaller in the ulcer group. In these patients the pre-treatment intensity of pain was somewhat greater than in those without bladder ulcer but the pain was alleviated in both groups and this effect was stable at the 3-month followup. The differences in responses in the 2 groups indicate a probable fundamental difference between ulcerative and nonulcerative interstitial cystitis. Side effects of the drug were few, slight and transient. Therefore, the study indicates that a significant number of patients with interstitial cystitis can be expected to benefit from treatment with sodium pentosanpolysulfate.

The outcome of treatment for urethral stricture is evaluated in two groups of patients in a retrospective study: 51 patients were treated with urethroplasty and 41 with direct vision urethrotomy. The groups did not differ greatly as regards primary success. It was 59% in the urethroplasty group and 61% in the urethrotomy group. This favours the view that the primary treatment of a urethral stricture should be direct vision urethrotomy whenever possible.