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Twelve patients with cirrhosis (nine men, three women) aged years, who were admitted consecutively with bleeding oesophageal varices, were studied three days after the bleeding had stopped. Three of these patients were studied again one month later. The As cimetidine does not affect portal pressure in patients with cirrhosis it probably does not reduce splanchnic blood flow. The possibility that it causes simultaneous vasoconstriction in the portal system to maintain portal pressure is highly unlikely. The original report' that cimetidine reduces blood flow to the liver in normal subjects has itself been challenged. In that study hepatic blood flow was measured by clearance of indocyanine green and the reduction after cimetidine interpreted as indicating decreased liver blood flow. The reduction in indocyanine green clearance after cimetidine may, however, have been caused not only by a decrease in blood flow to the liver but also by a decrease in extraction of indocyanine green. Such a decrease in extraction of indocyanine green after cimetidine has been shown in two patients with liver disease, in whom hepatic blood flow apparently increased.5 This provides further support for our conclusion that cimetidine does not have any effect on portal hypertension in patients with cirrhosis and so is unlikely to be beneficial in preventing recurrent bleeding from gastrooesophageal varices. Systemic lupus erythematosus has a variable clinical course, making assessment of treatment difficult. In association with steroids cyclophosphamide has been used to treat the disease for at least 20 years. Cyclophosphamide is claimed to reduce the dose of steroids required but is extremely toxic.We report on two women who developed bladder cancer after prolonged treatment with cyclophosphamide.Case 1-A 28-year-old woman developed systemic lupus erythematosus in 1969 after exposure to sunlight. Symptoms included rash, haemolytic anaemia, and proteinuria. Renal biopsy specimens showed proliferative glomerulonephritis. Treatment was started with steroids and with cyclophosphamide 50-100 mg daily, which was given intermittently for six years. In 1981 she presented with symptoms of urinary tract infection. Cultures were sterile. Intravenous urography disclosed a bladder tumour: biopsy specimens showed poorly differentiated keratinising squamous-cell carcinoma with extensive haemorrhage and necrosis. A short course of deep x-ray treatment was followed by total cystectomy and transplantation of ureters into an ileal conduit. Kidney function remained normal with no evidence of recurrence of the systemic lupus erythematosus.Case 2-A 45-year-old woman presented in 1969 with a five-year history of respiratory symptoms, bilateral pleural effusions, and moderate proteinuria and lupus erythematosus cells on testing. She was three months pregnant.Renal biopsy specimen's showed proliferative glomerulonephritis. She underwent hysterotomy and tubal ligation. Prednisone 50 mg and cyclophosphamide 100 mg daily were started: both were reduced to maint...

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The basic cause in the central nervous system of defective inhibition of bladder activity can only rarely be removed. Palliative suppression of the resulting frequency, urgency and incontinence by anticholinergic drugs such as propantheline or imipramine is usually inadequate in severe cases, and may have to be continued indefinitely. Palliative treatment by surgery depends on 2 principles-denervation or replacement of the over-active bladder muscle.The effect of denervation of the bladder by section of the pelvic splanchnic nerves in the female is inconsistent and produces severe constipation (Gibbon, 1967); in the male it might result in impotence. Excision and replacement of the detrusor by entero-cystoplasty is a rational procedure, but seems excessively major when the bladder itself is healthy.Selective denervation of the detrusor as described in 1967 by Turner-Warwick and Ashkenunder the title of "Supratrigonal Denervation : Cystocystoplasty"-would appear to be the ideal operative treatment for such cases. The rationale of this procedure is that nerve fibres to the detrusor enter the bladder about the level of the inferior vesical arteries and thence spread upwards into the detrusor, so that circumferential division of the bladder just above the level of the entry of the ureters disrupts the nerve supply to the detrusor leaving the sensory supply of the bladder base intact. Turner-Warwick and Ashken combined this transection "with division of all inferior lateral communications including the inferior vesical vessels". The blood supply from the superior vesical arteries to the denervated area was left undisturbed. This type of operation-but confined to the transection of the bladder-seems to have been first applied in the treatment of the enuretic syndrome ' in 1969' in (Yeates, 1970. The results in the first 2 cases were so satisfactory that it seemed justified to discuss the procedure with adult patients seen subsequently whose symptoms were severe and which showed no signs of abating.In addition, the operation has been used in the treatment of interstitial cystitis so that the patient could allow the bladder to distend without the production of pain (Worth and Turner -Warwick, 1973). Patients and MethodThe series of patients comprised: 14 with the enuretic syndrome, 1 with similar lifelong day symptoms but without nocturnal incontinence; 1 with multiple sclerosis, 2 with interstitial cystitis, and 1 with symptoms of doubtful origin.The enuretic cases were selected by the following criteria:(i) The failure to obtain an acceptable response from medical-often including psychiatrictreatment. (ii) The absence of any detectable urological abnormality, preferably with a normal bladder capacity under general anaesthesia, in contrast to the reduced functional capacity when not under anaesthesia.1 In this paper "enuresis" is used to indicate nocturnal incontinence of functional origin existing since childhood."Enuretic syndrome" is applied to those patients who have in addition deficiency of inhibition of bladder a...

The relative merits of cystoscopy alone and cystoscopy plus urethral dilatation were compared in a randomised study of women with recurrent frequency and dysuria. One hundred women were studied before and at least 6 months after operation. A detailed questionnaire was completed, the severity of the symptoms was scored and patients underwent urodynamic investigation. Forty-eight patients underwent cystoscopy alone and 52 underwent urethral dilatation. The two groups were well matched with regard to age, parity, menopausal status, previous gynaecological surgery and severity of symptoms. A significant improvement in symptoms was observed in both groups after treatment: 30% had no residual symptoms, 50% were improved and 20% were no better. However, no difference in final outcome was observed between those who had undergone cystoscopy alone and those who had undergone urethral dilatation. Furthermore, 7 patients who underwent urethral dilatation experienced transient stress incontinence of urine, a complication not observed in women who underwent cystoscopy alone. No benefit was observed from the addition of urethral dilatation to cystoscopy alone in women with recurrent frequency and dysuria.