Paraplegia (1976). 14.213-219
THE STATUS OF THE URINARY TRACT IN A SURVEY OF 92 CASES WITH NEUROGENIC BLADDER By M. MELZER, A. OHRY, M. HERTZ and R. ROZIN The Sir Ludwig Guttmann Spinal Cord Injury Center, The Chaim Sheba Medical Center and the Tel-Aviv University School of Medicine, Tel-Aviv, Israel
Abstract. Since 1973 intermittent catheterisation was introduced in our centre and this practically eliminated pathology of the urethra. More than half of the patients had a high and complete lesion. It is our impression that 5 years following injury more than half of the patients preserved a normal upper urinary tract; however, only 39 of the 92 patients had a follow-up of over 5 years. Nephrolithiasis was rare in comparison to other reports in spite of belonging to the stone belt area. Complications of the lower urinary tract including a 10 per cent incidence of vesico-ureteric reflux were compatible with other series. Narrowing of the external sphincter on voiding cystogram should be substantiated by a profile pressure record. One female patient is a candidate for ileal conduit. Most of the patients have some form of erection but the data on ejaculation should be accepted with reserve. Two patients in this series died more than 10 years after injury, one due to a myocardial infarction and the other due to chronic renal failure following secondary amyloidosis. Key words: Neurogenic bladder; urinary tract.
Introduction
A SURVEY of the urinary tract in a series of 92 cases with neurogenic bladder is presented with particular attention to the complications involved. More than half of the patients had complete lesions with para- or tetraplegia. Forty-six patients were below the age of 30 years, 34 between 31 and 49 years of age and 12 over 50. Methods
Neurogenic bladder was defined according to the classification of Bors and Comarr (1971). An intravenous pyelogram (IVP) and a voiding cystourethrography (VCU) were performed by the same technique as in normal patients, stimulating the bladder if necessary to provoke voiding. Cystometry was performed by the Lewis Cystometer, Merrill Air Cystometer and lastly CO2 was substituted for air. Profile pressure was performed according to the technique described by Brown and Wickham (1969). All patients had a follow-up every 2-3 months and at least once a year an IVP and VCU. Kidney function tests were repeated once a year. In some cases 2'5 mg Urecholine s.c. was used to prove denervation of the lower motor neuron and this drug together with anticholinergics and Dibenyline were used for different periods in bladder rehabilitation as reported elsewhere (Paz, 1973; Melzer, 1975)· Results
(see Table I) Road accidents and gunshot wounds represent 73 per cent of our trauma group and make up 57 per cent of all causes of neurogenic bladder. The remaining 21 Aetiology
213
21 4
PARAPLEGIA
TABLE I Etiology of neurogenic bladders of 77 males (84 per cent) and 15 females (16 per cent) Total
No. of cases
Trauma Accidents Gunshot wound Road accidents Falls Work accidents Diseases
27 25
I
71
J21
II
8 21
92
Total
TABLE II Level of lesion
Cervical C3-C8 High dorsal DI-DIO Low dorsal-lumbar DII-LI Cava equina syndrome
Complete
Incomplete
II
5 15
23 9
Total
5
16 8
48
44
Total
TABLE III Type of neurogenic bladders of the sample of 92 Female
Male
Total
------ --
Complete upper MNL* Incomplete upper MNL Complete lower Incomplete lower Mixed
5 5
3 2
15
Total
(16·3%) *
30 22 10 II
4
77 (83·9%)
l62 J 26
}
4 92
MNL, motor neuron lesion.
cases include a wide range of congenital and acquired diseases, eight of which were a result of operations for discus hernia and tumours of the spinal cord. (see Table II); Type of Neurogenic Bladder (see Table III) Over 50 per cent of the patients had a high and complete lesion.
Level of Lesion
THE URINARY TRACT IN 92 CASES WITH NEUROGENIC BLADDER
215
TABLE IV Upper urinary tract analysed by years after trauma 10
6-10
0- 5
Total
-��--
Complete lesions Incomplete lesions
N
P
N
P
N
P
N
P
12 30
9 2
5 6
4 3
7 4
8 2
64
38
N, normal;
P, pathologic.
TABLE V Pathological findings Upper MNL
Lower MNL
Mixed
Total
---_."------
Hydronephrosis hydroureter Chronic pyelonephritis Nephrolithiasis
16 5 3
3
1
20 5 3
MNL, motor neural lesion.
(see Table IV) We would like to stress that our criteria for the pathologic changes in the upper urinary tract were more severe than reported in other surveys in the literature as we were interested in underlining the number of cases with normal upper urinary tract. Pathologic changes in our survey (see Table IV) consider any dilatations of the calyces, pelvis and ureter as well as pyelonephritic changes. Our impression is that 5 years following injury there is no significant deterioration in the upper urinary tract. Changes in the Upper Urinary Tract after Lesions
(see Table V) It is interesting to note that only three patients developed stones in the upper urinary tract contrary to the expectancy in a country with a high incidence of nephrolithiasis (Wadewitz et al., I968). This is most probably due to the insistence on a very high fluid input and a very close follow-up. All positive urine cultures were actively treated even without general symptoms like fever, pain, etc. The total percentage of cases with hydronephrosis in our series is similar to that found in the literature (Wadewitz et al., I968; Scher, I975).
Pathological Findings
(see Table VI) As to the voiding cystogram pattern, two-thirds of the cases showed significant changes in the configuration of the bladder. Fifteen to I6 per cent of all cases included bladder neck obstruction which was more prominent in patients with upper motor neuron lesions. It is important to mention that the eight cases with incomplete lower motor neuron lesions and narrowing of the urethra at the level Voiding Cystogram
216
PARAPLEGIA
TABLE VI Voiding cystourethrograms of the sample of 92 Upper MNL (62)
Lower MNL (26)
42
16
4
3 8 2
2 2 2
Bladder trabeculations, sacculations, diverticuli Bladder neck closed, narrow Urethral stricture, fistulae, diverticulum External sphincter spasm, narrow Reflux vesico-ureteric
Mixed lesions
(4)
4
10 II 24 6
TABLE VII Operations
Nephrec tomy
Pyelouretero lithotomy
TUR
I
3
11+2*
Upper MNL Lower MNL Mixed lesion
I
External sphincter otomy
5
Excision of strictive fistula of urethra
2
Resection of Orchidectomy obturator +bilateral nerve vasectomy
4
2
3 I
2 *, twice, MNL, motor neural lesion; TUR, transurethral resection.
of the external sphincter, represent a radiological finding rather than spasm or sclerosis. Measurements of profile pressure were recorded in four of them and . values below 30 mm Hg were found. Since 1973 all cases at our centre were put on intermittent catheterisation as the method of choice to drain and re-educate the bladder ( Guttmann & Frankel, 1966). Since then, practically no pathology of the urethra was noticed in contrast to the occurrence of stricture, fistulae and diverticulae of the urethra in the past when using the indwelling catheter drainage for long periods. Vesico-ureteric reflux was identical with the findings in other series (Donnelly et at., 1972; Scher, 1975)·
(see Table VII) Nephrectomy was performed in one patient due to secondary amyloidosis and pyonephrosis. He died 5 years later with chronic renal failure. In one case re implantation of a severely refluxing ureter was performed and later the patient underwent sphincterectomy with incision of the bladder neck at 6 o'clock. This
Operations
THE URINARY TRACT IN 92 CASES WITH NEUROGENIC BLADDER
217
TABLE VIII Complications Upper MNL (62) Autonomous dysreflexia Elephantiasis of penis Pressure sores Permanent indwelling catheter
Lower MNL (26)
5 2 6 4
Mixed lesion (4)
2
1 1
TABLE IX Erection and ejaculation of the sample of 92
Erection Ejaculation
Complete lesion
Incomplete lesion
32 II
28 20
Total
%
60/92 31/60
incision of the bladder neck was performed in all five cases who underwent external sphincterotomy as suggested by Comarr (1974). Fourteen patients underwent transurethral resection of the bladder neck and in two cases we were obliged to operate twice. Orchidectomy and vasectomy was performed in two patients who did not respond to conservative treatment for orchiepididymitis. Resection of the obturator nerve was done in four female patients for severe adductor spasm interfering severely with catheterisation and re-education of the bladder. In one case it was necessary to perform an ileal conduit. Another female patient is a candidate for ileal conduit because of deterioration of the upper urinary tract in spite of the permanent catheter drainage. (see Table VIII) Autonomous dysreflexia was observed in the recovery phase after spinal shock and was treated by emptying the bladder and bowels, ganglion blockers and Dibenyline. Frontal headaches with nasal blockage were sometimes reported by patients having trouble to empty their bladder and bowels. Four female patients remained on a permanent indwelling catheter because of inability to stimulate the bladder or refusal to accept partial incontinence. One male patient chose to remain on a permanent cystostomy after further surgical treatment was postponed because of severe pleuro-pericarditis.
Complications
(see Table IX) Erections were observed by us on different occasions during hospitalisation or follow-up. This includes all forms of erection. One patient with a complete DS-6 lesion has normal erections and ejaculation and fathered two children. Sixteen patients fathered offspring and one female patient delivered two normal children.
Erections and Ejaculations
218
PARAPLEGIA
Another female patient had three abortions. Ejaculation data on all other patients are based on the information obtained from the patient or his partner. Sixty-five per cent of all patients have some type of erection and of these 52 per cent probably have ejaculation. RESUME Le sondage intermittent introduit dans notre centre depuis 1973 a pratiquement elimine la pathologie de l'uretre. Plus de la moitie des patients avaient une lesion haute et complete. Nous sommes d'avis que 5 ans apres la blessure plus de la moitie des malades ont preserve une voie urinaire superieure normale; cependant seuls 39 des 92 patients ont subi un controle de plus de 5 ans. La lithiase renale a ete rare en comparaison avec d'autres compte-rendus malgre Ie fait que nos malades se trouvaient en zone lithiasique. Les complications de la voie urinaire inferieure, y compris une incidence de 10 pour cent du reflux vesico-ureteral,se sont revelees compatible avec d'autres compte-rendus. Le retrecissement du sphincter externe en cystographie micturante,devrait etre etabli par enregistrement du profil de la pression. L'une des patientes soumises au sondage permanent devra neanmoins subir une intervention chirurgicale (conduit ileal). La plupart des patients ont des erections dans une mesure ou une autre, mais les donnees sur l'ejaculation doivent etre acceptees avec reserve. Deux malades dans cette serie sont decedes plus de 10 ans apres leur blessure, l'un par suite d'un infarctus du myocarde,et l'autre par suite d'une insuffisance renale chronique precedee par une amyloidose secondaire.
ZUSAMAMMENFASSUNG Das seit 1973 in unserem Zentrum eingefiihrte Behandlungsverfahren von inter mittierender Katheteriesierung der Blase, hat die Harnrohrenpathologie so gut wie vollig ausgeschaltet. Mehr als die Halfte des Krankengutes hatten ihre Verletzungen am oberen Riickenmark und zeigten eine vollstandige Durchtrennung desselben. Bemerkenswert ist die Tatsache, dass 5 Jahre nach den Verletzungen, mehr als die Halfte der Kranken ein regelrechtes, gesundes oberes urologisches System aufweisen konnten. Allerdings waren nur 39 von 92 Patienten in unserer Nachsorge langer als 5 Jahre. In Vergleich zu anderen Berichten waren Nierensteine bei unserer Reihe sehr selten, und zwar trotz der sogenannten Steingiirtelzone,in der die Kranken lebten. Komplikationen der ableitenden Harnwege, einschliesslich des Blasen-Harnleiter Riickflusses,stimmen mit anderseitigen Veroffentlichungen iiberein. Die Diagnose von Verengerungen am aiisseren Blasen-Schliessmuskel durch Entleerungs-Zystogramme gewonnen, sollte durch Profil Druck-Aufzeichnungen erhartet werden. Einer der weiblichen Kranken, die mitte1s Verweilkatheter behandelt wurde, steht eine ileale Operation-Ableitung beY�r. Der Grossteil der Kranken sind im Besitz von Erektionen in verschiedener Form. Angaben iiber Ejakulation sind mit Vorsicht zu akzeptieren. Zwie Kranke in unser Zahlenreihe verstarben und zwar, mehr als 10 Jahre nach ihrer Verletzung: einer-infolge von Herzinfarkt der andere an den Spatfolgen von chronischer Nierenversagung infolge einer sekundaren Amyloidosis.
REFERENCES BORS,E. & COMARR,A. E. (1971). Neurological Urology. S. Karger,Basel. BROWN,M. & WICKHAM, J. E. A. (1969). The urethral pressure profile. Brit. J. Urology, 41,21I. COMARR,A. E. (1974). Personal communication. DONNELLY, J., HACKLER, R. H. & BUNTS, R. C. (1972). Present urologic status of the World War 2 paraplegic: 25 year follow up. Comparison with status of the 20 year Korean war paraplegic and 5 year Vietnam paraplegic. J. Urology, 108, 558.
THE URINARY TRACT IN 92 CASES WITH NEUROGENIC BLADDER GUTTMANN, L. & FRANKEL, H. (1966).
219
The value of intermittent catheterisation in the early management of traumatic paraplegia and tetraplegia. Paraplegia, 4,63. MELZER, M. (1975). Bladder rehabilitation with Bethanechol. Harefua, 89, 513. PA Z, R. (1973). Diagnostic and therapeutic evaluation of cholinergic and anticholinergic drugs on human bladder. M.D. Thesis, Tel-Aviv University Medical School. SCHER, A. T. (1975). Changes in the upper urinary tract as demonstrated on intravenous pyelography and micturating cysto-urethrography in patients with spinal cord injury. Paraplegia, 13, 157. WADEWITZ, P., LANGLOIS, P. J. & BUNTS, R. C. (1968). Present urologic status of the World War 2 paraplegic: 20 year follow up. Comparison with status of the 10 year Korean war paraplegic. J. Urology, 98, 706.
THE STATUS OF THE URINARY TRACT IN A SURVEY OF 92 CASES WITH NEUROGENIC BLADDER By M. MELZER, A. OHRY, M. HERTZ and R. ROZIN The Sir Ludwig Guttmann Spinal Cord Injury Center, The Chaim Sheba Medical Center and the Tel-Aviv University School of Medicine, Tel-Aviv, Israel
Abstract. Since 1973 intermittent catheterisation was introduced in our centre and this practically eliminated pathology of the urethra. More than half of the patients had a high and complete lesion. It is our impression that 5 years following injury more than half of the patients preserved a normal upper urinary tract; however, only 39 of the 92 patients had a follow-up of over 5 years. Nephrolithiasis was rare in comparison to other reports in spite of belonging to the stone belt area. Complications of the lower urinary tract including a 10 per cent incidence of vesico-ureteric reflux were compatible with other series. Narrowing of the external sphincter on voiding cystogram should be substantiated by a profile pressure record. One female patient is a candidate for ileal conduit. Most of the patients have some form of erection but the data on ejaculation should be accepted with reserve. Two patients in this series died more than 10 years after injury, one due to a myocardial infarction and the other due to chronic renal failure following secondary amyloidosis. Key words: Neurogenic bladder; urinary tract.
Introduction
A SURVEY of the urinary tract in a series of 92 cases with neurogenic bladder is presented with particular attention to the complications involved. More than half of the patients had complete lesions with para- or tetraplegia. Forty-six patients were below the age of 30 years, 34 between 31 and 49 years of age and 12 over 50. Methods
Neurogenic bladder was defined according to the classification of Bors and Comarr (1971). An intravenous pyelogram (IVP) and a voiding cystourethrography (VCU) were performed by the same technique as in normal patients, stimulating the bladder if necessary to provoke voiding. Cystometry was performed by the Lewis Cystometer, Merrill Air Cystometer and lastly CO2 was substituted for air. Profile pressure was performed according to the technique described by Brown and Wickham (1969). All patients had a follow-up every 2-3 months and at least once a year an IVP and VCU. Kidney function tests were repeated once a year. In some cases 2'5 mg Urecholine s.c. was used to prove denervation of the lower motor neuron and this drug together with anticholinergics and Dibenyline were used for different periods in bladder rehabilitation as reported elsewhere (Paz, 1973; Melzer, 1975)· Results
(see Table I) Road accidents and gunshot wounds represent 73 per cent of our trauma group and make up 57 per cent of all causes of neurogenic bladder. The remaining 21 Aetiology
213
21 4
PARAPLEGIA
TABLE I Etiology of neurogenic bladders of 77 males (84 per cent) and 15 females (16 per cent) Total
No. of cases
Trauma Accidents Gunshot wound Road accidents Falls Work accidents Diseases
27 25
I
71
J21
II
8 21
92
Total
TABLE II Level of lesion
Cervical C3-C8 High dorsal DI-DIO Low dorsal-lumbar DII-LI Cava equina syndrome
Complete
Incomplete
II
5 15
23 9
Total
5
16 8
48
44
Total
TABLE III Type of neurogenic bladders of the sample of 92 Female
Male
Total
------ --
Complete upper MNL* Incomplete upper MNL Complete lower Incomplete lower Mixed
5 5
3 2
15
Total
(16·3%) *
30 22 10 II
4
77 (83·9%)
l62 J 26
}
4 92
MNL, motor neuron lesion.
cases include a wide range of congenital and acquired diseases, eight of which were a result of operations for discus hernia and tumours of the spinal cord. (see Table II); Type of Neurogenic Bladder (see Table III) Over 50 per cent of the patients had a high and complete lesion.
Level of Lesion
THE URINARY TRACT IN 92 CASES WITH NEUROGENIC BLADDER
215
TABLE IV Upper urinary tract analysed by years after trauma 10
6-10
0- 5
Total
-��--
Complete lesions Incomplete lesions
N
P
N
P
N
P
N
P
12 30
9 2
5 6
4 3
7 4
8 2
64
38
N, normal;
P, pathologic.
TABLE V Pathological findings Upper MNL
Lower MNL
Mixed
Total
---_."------
Hydronephrosis hydroureter Chronic pyelonephritis Nephrolithiasis
16 5 3
3
1
20 5 3
MNL, motor neural lesion.
(see Table IV) We would like to stress that our criteria for the pathologic changes in the upper urinary tract were more severe than reported in other surveys in the literature as we were interested in underlining the number of cases with normal upper urinary tract. Pathologic changes in our survey (see Table IV) consider any dilatations of the calyces, pelvis and ureter as well as pyelonephritic changes. Our impression is that 5 years following injury there is no significant deterioration in the upper urinary tract. Changes in the Upper Urinary Tract after Lesions
(see Table V) It is interesting to note that only three patients developed stones in the upper urinary tract contrary to the expectancy in a country with a high incidence of nephrolithiasis (Wadewitz et al., I968). This is most probably due to the insistence on a very high fluid input and a very close follow-up. All positive urine cultures were actively treated even without general symptoms like fever, pain, etc. The total percentage of cases with hydronephrosis in our series is similar to that found in the literature (Wadewitz et al., I968; Scher, I975).
Pathological Findings
(see Table VI) As to the voiding cystogram pattern, two-thirds of the cases showed significant changes in the configuration of the bladder. Fifteen to I6 per cent of all cases included bladder neck obstruction which was more prominent in patients with upper motor neuron lesions. It is important to mention that the eight cases with incomplete lower motor neuron lesions and narrowing of the urethra at the level Voiding Cystogram
216
PARAPLEGIA
TABLE VI Voiding cystourethrograms of the sample of 92 Upper MNL (62)
Lower MNL (26)
42
16
4
3 8 2
2 2 2
Bladder trabeculations, sacculations, diverticuli Bladder neck closed, narrow Urethral stricture, fistulae, diverticulum External sphincter spasm, narrow Reflux vesico-ureteric
Mixed lesions
(4)
4
10 II 24 6
TABLE VII Operations
Nephrec tomy
Pyelouretero lithotomy
TUR
I
3
11+2*
Upper MNL Lower MNL Mixed lesion
I
External sphincter otomy
5
Excision of strictive fistula of urethra
2
Resection of Orchidectomy obturator +bilateral nerve vasectomy
4
2
3 I
2 *, twice, MNL, motor neural lesion; TUR, transurethral resection.
of the external sphincter, represent a radiological finding rather than spasm or sclerosis. Measurements of profile pressure were recorded in four of them and . values below 30 mm Hg were found. Since 1973 all cases at our centre were put on intermittent catheterisation as the method of choice to drain and re-educate the bladder ( Guttmann & Frankel, 1966). Since then, practically no pathology of the urethra was noticed in contrast to the occurrence of stricture, fistulae and diverticulae of the urethra in the past when using the indwelling catheter drainage for long periods. Vesico-ureteric reflux was identical with the findings in other series (Donnelly et at., 1972; Scher, 1975)·
(see Table VII) Nephrectomy was performed in one patient due to secondary amyloidosis and pyonephrosis. He died 5 years later with chronic renal failure. In one case re implantation of a severely refluxing ureter was performed and later the patient underwent sphincterectomy with incision of the bladder neck at 6 o'clock. This
Operations
THE URINARY TRACT IN 92 CASES WITH NEUROGENIC BLADDER
217
TABLE VIII Complications Upper MNL (62) Autonomous dysreflexia Elephantiasis of penis Pressure sores Permanent indwelling catheter
Lower MNL (26)
5 2 6 4
Mixed lesion (4)
2
1 1
TABLE IX Erection and ejaculation of the sample of 92
Erection Ejaculation
Complete lesion
Incomplete lesion
32 II
28 20
Total
%
60/92 31/60
incision of the bladder neck was performed in all five cases who underwent external sphincterotomy as suggested by Comarr (1974). Fourteen patients underwent transurethral resection of the bladder neck and in two cases we were obliged to operate twice. Orchidectomy and vasectomy was performed in two patients who did not respond to conservative treatment for orchiepididymitis. Resection of the obturator nerve was done in four female patients for severe adductor spasm interfering severely with catheterisation and re-education of the bladder. In one case it was necessary to perform an ileal conduit. Another female patient is a candidate for ileal conduit because of deterioration of the upper urinary tract in spite of the permanent catheter drainage. (see Table VIII) Autonomous dysreflexia was observed in the recovery phase after spinal shock and was treated by emptying the bladder and bowels, ganglion blockers and Dibenyline. Frontal headaches with nasal blockage were sometimes reported by patients having trouble to empty their bladder and bowels. Four female patients remained on a permanent indwelling catheter because of inability to stimulate the bladder or refusal to accept partial incontinence. One male patient chose to remain on a permanent cystostomy after further surgical treatment was postponed because of severe pleuro-pericarditis.
Complications
(see Table IX) Erections were observed by us on different occasions during hospitalisation or follow-up. This includes all forms of erection. One patient with a complete DS-6 lesion has normal erections and ejaculation and fathered two children. Sixteen patients fathered offspring and one female patient delivered two normal children.
Erections and Ejaculations
218
PARAPLEGIA
Another female patient had three abortions. Ejaculation data on all other patients are based on the information obtained from the patient or his partner. Sixty-five per cent of all patients have some type of erection and of these 52 per cent probably have ejaculation. RESUME Le sondage intermittent introduit dans notre centre depuis 1973 a pratiquement elimine la pathologie de l'uretre. Plus de la moitie des patients avaient une lesion haute et complete. Nous sommes d'avis que 5 ans apres la blessure plus de la moitie des malades ont preserve une voie urinaire superieure normale; cependant seuls 39 des 92 patients ont subi un controle de plus de 5 ans. La lithiase renale a ete rare en comparaison avec d'autres compte-rendus malgre Ie fait que nos malades se trouvaient en zone lithiasique. Les complications de la voie urinaire inferieure, y compris une incidence de 10 pour cent du reflux vesico-ureteral,se sont revelees compatible avec d'autres compte-rendus. Le retrecissement du sphincter externe en cystographie micturante,devrait etre etabli par enregistrement du profil de la pression. L'une des patientes soumises au sondage permanent devra neanmoins subir une intervention chirurgicale (conduit ileal). La plupart des patients ont des erections dans une mesure ou une autre, mais les donnees sur l'ejaculation doivent etre acceptees avec reserve. Deux malades dans cette serie sont decedes plus de 10 ans apres leur blessure, l'un par suite d'un infarctus du myocarde,et l'autre par suite d'une insuffisance renale chronique precedee par une amyloidose secondaire.
ZUSAMAMMENFASSUNG Das seit 1973 in unserem Zentrum eingefiihrte Behandlungsverfahren von inter mittierender Katheteriesierung der Blase, hat die Harnrohrenpathologie so gut wie vollig ausgeschaltet. Mehr als die Halfte des Krankengutes hatten ihre Verletzungen am oberen Riickenmark und zeigten eine vollstandige Durchtrennung desselben. Bemerkenswert ist die Tatsache, dass 5 Jahre nach den Verletzungen, mehr als die Halfte der Kranken ein regelrechtes, gesundes oberes urologisches System aufweisen konnten. Allerdings waren nur 39 von 92 Patienten in unserer Nachsorge langer als 5 Jahre. In Vergleich zu anderen Berichten waren Nierensteine bei unserer Reihe sehr selten, und zwar trotz der sogenannten Steingiirtelzone,in der die Kranken lebten. Komplikationen der ableitenden Harnwege, einschliesslich des Blasen-Harnleiter Riickflusses,stimmen mit anderseitigen Veroffentlichungen iiberein. Die Diagnose von Verengerungen am aiisseren Blasen-Schliessmuskel durch Entleerungs-Zystogramme gewonnen, sollte durch Profil Druck-Aufzeichnungen erhartet werden. Einer der weiblichen Kranken, die mitte1s Verweilkatheter behandelt wurde, steht eine ileale Operation-Ableitung beY�r. Der Grossteil der Kranken sind im Besitz von Erektionen in verschiedener Form. Angaben iiber Ejakulation sind mit Vorsicht zu akzeptieren. Zwie Kranke in unser Zahlenreihe verstarben und zwar, mehr als 10 Jahre nach ihrer Verletzung: einer-infolge von Herzinfarkt der andere an den Spatfolgen von chronischer Nierenversagung infolge einer sekundaren Amyloidosis.
REFERENCES BORS,E. & COMARR,A. E. (1971). Neurological Urology. S. Karger,Basel. BROWN,M. & WICKHAM, J. E. A. (1969). The urethral pressure profile. Brit. J. Urology, 41,21I. COMARR,A. E. (1974). Personal communication. DONNELLY, J., HACKLER, R. H. & BUNTS, R. C. (1972). Present urologic status of the World War 2 paraplegic: 25 year follow up. Comparison with status of the 20 year Korean war paraplegic and 5 year Vietnam paraplegic. J. Urology, 108, 558.
THE URINARY TRACT IN 92 CASES WITH NEUROGENIC BLADDER GUTTMANN, L. & FRANKEL, H. (1966).
219
The value of intermittent catheterisation in the early management of traumatic paraplegia and tetraplegia. Paraplegia, 4,63. MELZER, M. (1975). Bladder rehabilitation with Bethanechol. Harefua, 89, 513. PA Z, R. (1973). Diagnostic and therapeutic evaluation of cholinergic and anticholinergic drugs on human bladder. M.D. Thesis, Tel-Aviv University Medical School. SCHER, A. T. (1975). Changes in the upper urinary tract as demonstrated on intravenous pyelography and micturating cysto-urethrography in patients with spinal cord injury. Paraplegia, 13, 157. WADEWITZ, P., LANGLOIS, P. J. & BUNTS, R. C. (1968). Present urologic status of the World War 2 paraplegic: 20 year follow up. Comparison with status of the 10 year Korean war paraplegic. J. Urology, 98, 706.
