OBJECTIVE To define the aetiology of and therapeutic strategy for high-pressure peristaltic contractions within colo- and caecocystoplasties associated with symptoms of frequency, urgency and urge incontinence. METHODS In a series of over 150 subtotal supratrigonal colo- and caeco-cystoplasties, nine patients were identified with such symptoms. These patients underwent videocystometrography (VCMG) confirming the presence of phasic peristaltic contractions of > 35 cmH2O. RESULTS In three cases, there was urodynamic evidence of outlet obstruction and symptoms resolved when the obstruction was surgically relieved. In the other six cases, high-pressure peristaltic contractions were present without bladder outlet obstruction. The symptoms did not respond to anticholinergic medication. Three of the six patients had tolerable symptoms which did not warrant further intervention. The other three cases had disabling urge incontinence and underwent ileal patch cystoplasty. The symptoms resolved in all three cases, although later recurred in one patient, probably due to incomplete division of the taenia coli during ileal patch cystoplasty. CONCLUSIONS It appears that colonic smooth muscle can develop high-pressure contractions in response to neobladder outlet obstruction. Relieving the obstruction ameliorates symptoms associated with these contractions and reduces the magnitude of the peristaltic waves. Symptoms related to high-pressure peristaltic contractions without neobladder outlet obstruction do not respond to anticholinergic medication but can be successfully treated by ileal patch cystoplasty.