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After clinical evaluation, imaging is extremely important in determining the type of treatment and approach of micturition disorders in elderly. In this article, the advantages and limitations of each of the relevant techniques are reviewed and highlighting, with correlation to clinical evaluation. Sonography has become the most widely used technique to study bladder dysfunction. CT and MRI have specific indications.

We performed surgery in twenty-four cases of urethral prolapse between 1973 and 1989 at the hospital of Fort-de-France. Urethral prolapse is a benign lesion of the terminal urethra and is predominant in young, 3 to 6 year-old black females. Vulvar hemorrhagic is the most usual initial symptom, and diagnosis is readily made by examination and urethral catheterization. Excision of the prolapsed mucosa followed by immediate muco-mucous suture permits a generally uneventful recovery without prolonged hospitalization.

Duplication of the female urethra is quite uncommon. A case of complete urethral duplication is reported in a 2.5 year old girl seen for pyuria. Physical examination showed and epispadiac meatus with dribbling urine just above a bifid clitoris associated with an orthotopic meatus. The two urethras were patent and situated on the same sagittal plane as seen on the cystography. The treatment consisted of excising the whole epispadic urethra using a combined perineal and suprapubic approach enlarged by symphyseal section for a better repair of the bladder outlet. Postoperatively, the patient was content and free of symptom. The main features of urethral duplication in girl are reviewed.

Dysfunction of the rhabdosphincter results from an increase (dyssynergia) or decrease in activity of either neurological or non-neurological origin. We have defined dyssynergia as the absence of urethral relaxation and/or sphincter contraction during and/or before detrusor muscle contraction. Non-invasive exploratory methods include flowmetry, anal contact EMG and an abdominal pressure or EMG examination. Invasive techniques are of various types: urethro-cystometry with EMG, via the perineum in males and the endo-urethral approach in females, provides quantitative data on extent of altered function and relative involvement of either smooth or striated muscle sphincters. An essential complement to urodynamic exploration is a conventional mictional cystogram. We have proposed an etiologic classification of dyssynergia: tonic dyssynergia is pathognomonic of supra-sacral medullary lesions while clonic dyssynergia reflects the bladder-sphincter conflict, whether it be of neurologic or other origin. Clonic dyssynergia in patients with neurologic affections is seen mainly in those with supra-sacral medullary lesions at whatever level, and with a 50 to 100% frequency. Its serious nature is not related to the bladder-sphincter equilibrium but to the high pressures developed by the system. The neurologic rhabdosphincter presents characteristic persistent reflex activity at the spinal shock phase and a possible course leading to fibrosis. In patients without neurologic disease the terms dyssynergia or pseudodyssynergia are used depending on whether the sphincter contraction during bladder contraction is involuntary or voluntary. To explain this non-neurologic pseudodyssynergia, Lapides suggested as a basis the theory of the evolution of sphincter control, Tanagho that of sphincter spasticity. In reality it involves a vicious circle centered on the bladder-sphincter conflict, entry being possible at various levels: bladder instability, urethral instability, urethral hypersensitivity, rhabdosphincter spasticity. These disturbed functions induce the urethral syndrome, repeated urinary infections, reflux and sometimes even renal stasis. Deficient sphincter activity of neurologic origin presents pathognomonic electromyographic signs; from a functional point of view valid data can be obtained from measurement of variations in maximum urethral pressure during a retention effort. Among the neurologic etiologies, the rhabdosphincter is only rarely affected by poliomyelitis or amyotrophic lateral sclerosis.(ABSTRACT TRUNCATED AT 400 WORDS)

75 cases of posterior urethra valves have been seen and treated from 1952 to 1984. The average follow-up is 11 years. The clinical symptomatology is described and the different treatments are analyzed from a critical point of view. A the present time the progress made by pediatric intensive care, minimization of endoscopes, better understanding of lesions, indicate that the only treatment has to be the valves. A urinary diversion is to be considered only if the life of the boy is in danger. It is rare to have to reimplant the ureters. 3 boys died. From the cases with long follow-up, 4 have high blood pressure, 16 have renal insufficiency, of these one had a successful renal transplant, 6 are dialyzed. The problems of urinary continence and fertility are discussed.

Simultaneous urethrocystometry, the advantages of which are outlined, enabled us to diagnose 27 cases of pure urethral instability (male and female) and 16 cases of mixed instability (urethral and bladder instability). We analysed the relationship between the main symptom, this urethral dysfunction and the competence of the bladder neck. Definition, characteristics and frequency of urethral instability are discussed. It is responsible of: frequency or urgency, in the absence of bladder instability, when the bladder neck is closed, intermittent sphincteric incontinence, in the presence of a normal closure pressure on the urethral pressure profile, when the bladder neck is incompetent, enuresis, particularly in case of stable bladder; a new treatment is proposed for this entity. The clinical interest of this diagnosis is stressed in these three situations.

The visualisation of the lower urinary tract by the mean of a fiberscope makes an advance when compared to rigid endoscopy mainly in male patient. Technical features of the fiberscopes suitable for urology thus basic technique of the examination are described. Main advantages are painfree and total visual scanning of the mucosa. Disadvantages are very low.

The authors report their experience about 26 cases of urethral instability. This dysfunction is not rare; both sexes are involved, children was well as adults. Diagnosis is based on the data of simultaneous urethro-cystometry. Three clinical patterns are recognized: intermittent urinary leakage (6 cases), frequency and urgency (3 cases) and enuresis (17 cases). The urethral instability was pure in 13 cases and associated to detrusor hyperactivity in the other thirteen. But, in one of these the bladder instability was pure. A treatment based on alpha-adrenergic drugs has assured clinical relief and urodynamic stabilization of bladder and urethra.

The authors report 13 cases of prolapse of the urethral mucosa. This is a benign lesion of the terminal portion of the urethra, seen above in black girls aged from 6 to 10 years. The usual presentation is vulval bleeding. The lesion is recognised by inspection and urethral catheterisation. Resection of the prolapse with muco-mucosal suture, not followed by the insertion of an indwelling catheter, is adequate and may be performed in a day hospital.

The authors briefly report some clinical aspects of this dystrophy which, although more commonly seen in Negroes, can also be found in Caucasians. It is important to be able to identify it not to be impressed by this vulvar mass which so easily bleeds when touched.

From 11 personal case studies, the authors conduct a general review of the problems raised by Cowper's glands. Cowper's glands, accessory sexual glands, are made up of main glands situated behind and on either side of the bulbar urethra right at the level of the urolgenital diaphragm and of accessory glands situated in the thickness of the bulbar spongy body. The main glands are drained by long canals (several centimeters in length) which empty into the bulbar urethra by paramedian orifices. The fusion of these canals into one single canal at the urethral opening, although rare, could lead to obstruction. These canals can be the site of cystic dilatation ranging from a few millimeters to as much as 6 cm in diameter. These cysts are rarely due to terminal canal obstruction as the result of chronic inflammatory urethritis. Most often they are congenital. The cysts which develop at the level of the accessory glands are usually obstructive while those which develop at the level of the main glands rather have a perineal expansion. The indicative signs of this particular pathology are not specific (pyuria, hematuria, enureis, known urethral stenosis, dysuria with pollakuria, perineal pain with post voiding urethral dripping). Voiding urethrography investigation (the best) shows: --either cystic dilatation seen as a lacuna on the ventral aspect of the urethra, --or opacification of the dilated cavities of the exretory canals which have been spontaneously broken or opened by endoscopic manoeuvres. The opacification of these cavities leads often to the erroneous interpretation of "diverticula" of "incomplete duplication of the urethra" and yet their essential characteristic is twofold: they are oriented in an anterior-posterior direction with respect to the urethra and lead back and away from it; they have a canal type of morphology for at least part of their course.

Fourteen boys, aged 2 to 13, have been examined in the last six years for blood spotting from urethra between voidings, rarely associated with some degree of dysuria. No anomaly was seen on IVP, except in two cases which showed mild stenosis of the posterior urethra. Endoscopic evaluation was completely negative in 5 cases; moderate inflammation or hypervascularisation, some what a subjective aspect, was noticed in 4 cases; a definite "posterior urethritis" already described by others in the literature was demonstrated in 5 cases. The etiology of such a lesion remains unknown; no story of external or internal trauma was reported. Although these urethrorrhagia are of benign nature, we do not feel like others (1) that endoscopy should be considered as unnecessary, but on the contrary that it should help for correct evaluation and follow up of these patients, rather prone to be lost especially when no treatment has been prescribed.