The evaluation of urodynamic function by symptomatology, clinical examination, static radiography and endoscopy is considerably less reliable than is sometimes appreciated.Since the establishment of our Urodynamic Clinic we have reviewed more than 6,000 patients with dysfunctional voiding (Turner-Warwick and Whiteside, 1969) ; synchronous cine/pressure/ flow cystography has been used in the last 3,000 of these (Bates, Whiteside and Turner-Warwick, 1970). This communication is an attempt to summarise some aspects of our present thinking related to problems of bladder neck dysfunction and outflow impairment.In considering bladder outflow obstruction we must seriously question some commonly held precepts relating to the significance of various facets: symptomatology ; the absence of post-voiding residual urine; the endoscopic evaluation of the bladder neck ; trabeculation of the bladder; the actual size of the prostate; etc.

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In our original paper we discussed the place of cystolysis in the management of interstitial cystitis when the bladder had a capacity of at least 400 ml under general anaesthesia (Worth and Turner-Warwick, 1973).I have continued to use this technique, obtaining good symptomatic improvement in the majority of patients. I have tried extending its use in, for example, the patient with a sensitive and painful bladder whose type of chronic cystitis differs histologically from interstitial cystitis. This group has included 2 men. I have also used the technique in patients with severe frequency and a cystoscopically normal bladder (usually with an above average capacity) and who also have an incontinence problem. Although it is relatively easy to combine this technique with a suprapubic repair procedure, the results are unsatisfactory because the denervation cannot really affect the trigone.I think it is fair to say that in urological practice the type of patient who might benefit from the operation is seen infrequently. It is likely that such patients have already had a considerable number of different medications (often including steroids), usually administered systemically rather than intravesically.These patients are very symptomatic, with pain and frequency. When drug treatment has failed, the alternatives to cystolysis are either cystoplasty or diversion. The technique of cystolysis has not altered and remains relatively simple; morbidity is low and the procedure does not compromise any subsequent surgery. The results remain unpredictable in the long term, but in the short term pain becomes negligible and as a result frequency is much reduced.If symptoms return post-operatively, further cystoscopy should be undertaken. It is always possible that the bladder capacity has diminished and this may occur because the blood supply to the dome has been too severely compromised -hence care should be taken during operation to preserve at least one superior vesical artery.As the next procedure I would recommend cystoplasty (preferably caecocystoplasty) rather than diversion, since cystoplasty in interstitial cystitis gives excellent results. ReferenceWorth, P. H. L. and Turner-Warwick, R. (1973). The treatment of interstitial cystitis by cystolysis with observations on cystoplasty. British Journal of Urology, 45, 65-71. 232

A retrospective study of the functional alteration of the urethra following hysterectomy was made in 98 patients. Three groups were identified. Sixty per cent (group A) had stable stress urinary incontinence, 27.8% (group B) had high pressure detrusor instability and 12.2% (group C) had voiding dysfunction. Some of the patients in group A were treated medically and others surgically. Those in group B were treated with oxybutinin and those in group C were treated surgically. The cure rate in group A ranged from 55 to 89%; in group B it was 82% and in group C between 90 and 100%.

The value of a prophylactic antibiotic before a routine cystometrogram has been assessed in a controlled trial of 100 patients. The infection rate was low and not statistically different in both groups. Subsequent symptoms of dysuria and haematuria had a mechanical aetiology.