DISEASES OF THE URETHRA AND BLADDER.
Before considering in detail the diseases of the urethra and bladder,
it will be necessary to describe the modern methods of examining these
structures.
The examination of the urethra and bladder has been very much
facilitated by the methods and instruments that have been popularized
in this country by Kelly. The following apparatus is required: a female
catheter; a urethral calibrator; a series of specula with obturators; a
head-mirror and light or an electric headlight; long, delicate toothed
forceps (Fig. 184); an inclined plane or several hard pillows for
elevating the pelvis; small balls of absorbent cotton about the size of
a pea, or strips of absorbent gauze cut 1 inch in width and about 10
inches long, for drying out the bladder.
[Illustration: FIG. 184.--Mouse-tooth forceps for bladder.]
[Illustration: FIG. 185.--Urethral dilator: short lines indicate
diameter in millimeters.]
The urethral calibrator or dilator (Fig. 185) is a conical metal
instrument with a maximum diameter of twenty millimeters. The diameters
in millimeters of the various portions are indicated by numbers upon
the instrument.
The urethral calibrator is useful for dilating the external meatus
to a degree sufficient to admit the necessary speculum. The external
meatus is, as a rule, the only portion of the urethra that requires
dilatation. Any instrument that will pass through the meatus will pass
through the rest of the canal.
[Illustration: FIG. 186.--Kelly’s cystoscope or vesical speculum.]
The speculum (Fig. 186) is a cylindrical metal tube fitted with a
handle on which is the number indicating the size of the instrument.
There are a number of specula, varying in diameter from 5 to 20
millimeters. Each speculum is fitted with an obturator. The most useful
specula are those ranging from 8 to 12 millimeters in diameter. The
urethra may readily be dilated up to 12 millimeters, with little if
any, external laceration. Dilatation sufficient to admit the largest
instrument (20 millimeters) is always accompanied by considerable
laceration of the urethral opening. Dilatation of the urethra should
never be practised beyond this degree, on account of the danger of
subsequent incontinence of urine.
An anesthetic is usually required for the examination, unless the woman
be capable of enduring considerable pain, or has become accustomed
to the procedure from previous experience. Local anesthesia of the
urethra with cocaine (gr. x to ℥j) is often sufficient.
The woman is placed on the table in the lithotomy position, and the
bladder is emptied with the catheter. The external meatus is then
dilated to the requisite size by inserting the graduated calibrator
with a general rotary movement. When the meatus has been stretched
sufficiently, as indicated by the number on the calibrator (usually
about 12 millimeters), the instrument is withdrawn, and the speculum
of corresponding number, armed with the obturator, is introduced; the
obturator is then removed.
The hips of the woman are now elevated on the pillows or the inclined
plane, or the foot of the table is raised, so that the hips shall be
from 10 to 20 inches above the level of the shoulders.
The examiner, armed with the head-mirror or light, is then prepared to
inspect the interior of the bladder. If the mirror is used, the light
(Argand burner or electric drop-light) should be held close to the
pubis of the patient.
[Illustration: FIG. 187.--Vesical probe or applicator.]
Usually a small quantity of urine remains in the bladder after
catheterization, or is secreted during the preliminary procedures,
and it is necessary to remove this before complete examination of the
bladder can be made. This may be done by means of the small balls of
absorbent cotton or the strips of gauze grasped with the long-toothed
forceps and passed in through the speculum; or some form of suction
apparatus may be employed, consisting of a rubber exhaust bulb and a
long metal tube perforated at the distal end by small openings.
The elevated position of the hips is an essential part of this method
of examination; it permits the intestines to gravitate out of the
pelvis, and, as soon as the urethra is opened, the bladder becomes
distended with air, so that all of its interior may be readily
inspected, and applications to the surface may be directly made through
the speculum. In some cases it is difficult to produce the requisite
distention of the bladder by elevating the hips. This difficulty may
arise in the case of very fat women. It then becomes necessary to place
the patient in the knee-chest position, when the requisite distention
is readily accomplished.
As the speculum is withdrawn from the bladder the internal meatus and
the urethral walls may be examined as they fall together beyond the
distal end of the instrument.
DISEASES OF THE URETHRA.
The female urethra is a musculo-membranous canal averaging 1¾ inches
in length, and, when not stretched, about ¼ inch in diameter. The
urethra is normally closed by the apposition of its walls. In the
neighborhood of the external meatus it is an antero-posterior slit. In
the neighborhood of the internal meatus it is a transverse slit. In the
middle portion the mucous membrane is arranged in longitudinal folds,
and a transverse section shows a stellate closure.
The muscular coat of the urethra contains both striped and unstriped
muscular fibers.
The mucous glands of the urethra are most numerous in the region of
the external meatus. Skene first described two glands that are worthy
of special mention. _Skene’s glands_ are two tubules, large enough to
admit a No. 1 probe of the French scale, that lie upon the floor of
the urethra immediately within the external meatus. They lie parallel
to the long axis of the urethra, and in length vary from ⅜ to ¾ of an
inch. They are placed beneath the mucous membrane, in the muscular
coat. The orifices of the glands are on the free surface of the mucosa,
immediately within the external meatus. In young women the orifices
are found about ⅛ of an inch above the plane of the external meatus.
If the external meatus be patulous, or if there be any prolapse or
inflammation of the mucous membrane of the urethra, the orifices of
Skene’s glands may be seen upon each side of the urethral orifice as
soon as the labia are separated. In gonorrhea their position is often
indicated by a small drop of pus exuding from the orifices. The upper
ends of the glands may terminate in a number of divisions.
=Urethritis.=--Urethritis is much less frequent in women than in
men. In the great majority of cases it is caused by gonorrhea. Aside
from microscopic examination, urethritis, acute or chronic, may be
considered one of the strongest evidences of gonorrheal infection that
we have.
Urethritis is also rarely caused by the exanthematous diseases,
irritation of concentrated urine, vaginal discharges, chemical
irritants, and traumatism.
_Symptoms._--The symptoms of urethritis in the acute stage of the
disease are frequent and painful urination. Burning and scalding
sensations are experienced along the course of the urethra during
urination. Occasionally a few drops of blood escape during or after
urination. As the disease progresses toward cure or passes into the
chronic stage, the intensity of these symptoms diminishes, and finally
they disappear.
Examination of the parts shows that the external meatus is red and
swollen. The swollen mucous membrane may bulge through the opening,
giving the appearance of prolapse. The orifices of Skene’s glands
may be conspicuous. If the woman have not recently urinated, a drop
of pus may appear at the meatus, or it may be brought into view by
vaginal pressure along the course of the urethra. Pressure upon the
urethra through the vagina causes pain. This is one of the best tests
of inflammation of this structure. The urethra may feel hypertrophied,
indurated, or cord-like to the touch. The urethral discharge should
always be examined microscopically for the gonococci.
In chronic urethritis the subjective symptoms are usually
absent--except, perhaps, frequency of urination. The diagnosis is made
by physical examination. If the woman has not urinated for several
hours, the examiner will be able to express, by vaginal pressure along
the course of the urethra, a drop of muco-purulent fluid resembling the
gleety discharge of the male.
The endoscope reveals the presence of congestion and inflammation of
the mucous membrane.
_Treatment._--In the acute or the painful stage of the disease no
local applications should be made. The external genitals should be
bathed several times a day with hot water, preferably by means of
sitz-baths. Vaginal douches are not indicated unless the vagina be
involved in the inflammation. The vaginal syringe may be the means
of carrying infection higher up in the genital tract. Rest in the
recumbent position, if possible, is desirable. The diet should be
non-stimulating, and large quantities of diluent drinks, such as
flaxseed tea, should be prescribed. The bowels should be kept loose by
saline purgatives.
In the subacute or the chronic stages of the disease boracic acid (gr.
x-xx three or four times a day), salol, oil of sandal-wood, cubebs,
copaiba, and other drugs used for the similar condition in the male are
indicated. After painful micturition has ceased, the physician may make
local applications to the urethra, in case the inflammation does not
subside satisfactorily without them. Such local applications are not
always necessary, and they may do harm unless proper care is exercised
in their administration. Asepsis and gentleness are necessary, and the
applications should never be too strong or irritating.
Frequent douching of the urethra (two or three times a day if possible)
with sterile hot water is often of much benefit. Skene’s reflux
catheter should be used (Fig. 188). The shaft of this instrument is
fluted or grooved to permit the return of the fluid. The catheter
should be introduced as far as the internal meatus; a fountain syringe
should be attached to it, and the urethra should be washed out with a
quart of hot water.
After the irrigation the catheter should be withdrawn and a urethral
injection of nitrate of silver (gr. j or ij to ℥j) should be
administered. The injection may be given by means of a glass pipette
the nozzle of which is large enough to encircle the external meatus.
The nozzle should be placed over, not in, the meatus. The female
urethra will hold about 15 minims of fluid; more than this should
not be injected. As the condition improves the frequency of these
treatments may be diminished.
[Illustration: FIG. 188.--Skene’s reflux catheter.]
If the condition does not yield to such treatment within a few weeks,
application should be made directly to the mucous membrane of the
urethra through the endoscope. The urethral canal should be washed out
as just described, and the endoscope should be introduced as far as the
internal meatus. As it is slowly withdrawn the application should be
made over the whole inner surface of the urethra by a fine applicator
wrapped with cotton. Nitrate of silver (gr. v-x to ℥j) should be
employed.
Sometimes it is found that the suppuration persists in Skene’s glands.
A small drop of pus may be found exuding from the orifice of the gland
after the rest of the urethra has been restored to a healthy condition.
In such a case the gland should be split up on the urethral surface by
introducing into it one blade of a fine scissors, and the tract should
be carefully wiped out with pure carbolic acid or a strong solution of
nitrate of silver.
In every case of urethritis of gonorrheal origin it is of the greatest
importance that every trace of the disease should be eradicated before
the patient gives up treatment. There is always danger of infection
extending to the upper parts of the genital tract.
=Stricture of the Urethra.=--Stricture of the urethra in the woman,
unlike the similar condition in the male, is very rare. It is caused
by gonorrhea, injury at childbirth or other traumatism, and caustic
applications. The stricture may exist at any part of the urethral
canal. The form most usually seen is that which occurs at the external
meatus, and is caused by the removal of abnormal growths with caustic
or with the knife.
The _symptoms_ of urethral stricture in women are much less marked than
those in men. There is frequent and difficult urination. Occasionally
there is incontinence or partial retention of urine.
If the stricture exist at the external meatus, it may be readily seen
and its dimensions determined. If it exist in the upper portion of the
urethral canal, it may sometimes be felt by palpation along the course
of the urethra through the vagina, the position of the stricture being
indicated by local thickening and induration. Its location may also be
determined, as in man, by the use of the bulbous bougie or sound.
_Treatment._--When the stricture is situated at the external meatus,
it may be divided with the knife or forcibly stretched. When it is
situated in the upper portion of the urethra, it is best treated by
forcible dilatation.
[Illustration: FIG. 189.--Female urethral sound.]
The small uterine dilator is the most convenient instrument to use.
The dilatation should not extend beyond half an inch, for fear of
injuring the urethral walls or producing incontinence. In order to
prevent contraction, it is advisable to pass the large urethral sound
(10 millimeters) at intervals of one or two days after this operation,
until the patency of the urethra is ensured.
In some cases the continual subsequent use of the sound is necessary,
as in stricture in the male. The woman may be readily taught the use of
the instrument herself.
=Prolapse of the Mucous Membrane of the Urethra.=--Prolapse of the
urethral mucous membrane is of unusual occurrence. Prolapse may be
limited to part of the circumference of the meatus, or it may extend
around the whole canal. The condition is usually found in weak,
debilitated women. It may occur during childhood.
The prolapse may be caused by dilatation of the urethra and the
external meatus or by the traction of a neoplasm of the urethra. It
sometimes occurs after labor. It may be produced by continual vesical
tenesmus, the result of cystitis, calculus, or a tumor of the bladder.
The _symptoms_, vesical tenesmus and dysuria, are usually present.
Sometimes incontinence of urine occurs. The protruding mucous membrane
may become irritated and inflamed, and cause much local pain. It has
been known to slough off.
_Treatment._--The treatment should be directed, in the first place, to
the relief of any causative condition, such as cystitis or calculus.
Inflammation of the protruding mucous membrane should be relieved by
local applications of hot water and by rest in bed. The mucous membrane
should then be gently replaced within the urethra, and contraction of
the canal should be promoted by the use of astringent injections of
tannic acid or alum.
If the disease does not yield to this treatment, the prolapsed mucous
membrane should be excised, and the edges of the mucosa should be
stitched to the margin of the meatus by fine suture.
After this operation there is sometimes cicatricial contraction of the
external meatus, which may readily be cured by forcible dilatation.
=Vesico-urethral Fissure.=--Vesico-urethral fissure is an ulcerated
crack of the mucous membrane situated at the internal urinary meatus.
The upper portion extends into the bladder, the lower portion is in
the urethra. Skene describes it as “from ¼ to ⅜ of an inch in length,
and from 1/12 to ⅙ of an inch in width at the center, but tapering off
at each end. The deepest part has a yellowish-gray color, like that of
an indolent ulcer, while the edges are red and actually inflamed, like
those of an irritable ulcer.”
Vesico-urethral fissure is usually caused by urethritis. It may also
result from injuries during confinement or from the bungling use of the
catheter.
_Symptoms._--There is a constant desire to urinate, and urination is
followed by severe tenesmus. There is a burning pain at the neck of
the bladder, increased immediately after urination. Pressure upon the
internal meatus through the vagina may cause lancinating pain.
The symptoms resemble closely those of urethritis and cystitis.
[Illustration: FIG. 190.--Skene’s urethral endoscope.]
The _diagnosis_ of vesico-urethral fissure can be made with certainty
only by seeing the fissure through the endoscope. The existence of the
condition may be suspected in a woman who presents the symptoms just
described, and in whom no signs of inflammation or other disease of the
urethra or the bladder can be detected.
The open endoscope is not satisfactory for detecting this condition,
because the fissure is hidden from view by the folds of mucous membrane
at the upper end of the instrument. Skene, who has especially directed
attention to vesico-urethral fissure, states that he never was able
to detect the lesion until he used the form of endoscope introduced by
him (Fig. 190), which consists of a small glass tube like the ordinary
test-tube, into which is passed a mirror on a holder. The instrument is
passed into the urethra, and light is thrown in by means of the concave
head-mirror. By moving the small mirror in the tube, different parts of
the urethral walls may be examined. The instrument opens out the folds
of mucous membrane immediately above the fissure and renders it visible.
_Treatment._--The cure of vesico-urethral fissure is often difficult.
The lesion is exposed to continuous irritation from the urine and from
the sphincteric action of the muscular fibers at the vesical neck--an
action which is much increased by the tenesmus present. This constant
muscular action impedes healing, as in the case of fissure of the anus.
The internal urinary meatus should be dilated under anesthesia to the
extent of ½ inch by means of the graduated bougies or the uterine
dilator. After dilatation the woman should be kept in bed and the urine
should be rendered as unirritating as possible by the use of diluent
drinks and boracic acid.
If this treatment does not result in cure, a vesico-vaginal fistula
should be made, so that, by carrying off the urine by this means, rest
from functional activity will be furnished to the region of the vesical
neck.
No effort need be made to keep the fistula open, as by the time it has
closed spontaneously the fissure will have healed.
=Dilatation of the Urethra.=--Dilatation of the urethra producing
symptoms that require treatment is unusual. It may be due to congenital
defect, to spontaneous expulsion, or instrumental extraction of a
calculus or tumor of the bladder, to excessive dilatation by the
surgeon; and it may occasionally follow pregnancy. Skene says, “the
hyperemia of the urethra which occurs in pregnancy and which tends to
produce overdistention of the veins favors dilatation of the whole
urethra.”
The urethra may be so dilatable that it will admit the penis--coitus
having been practised in this way in a number of instances.
In dilatation of the urethra there may be continuous incontinence of
urine, or the urine may escape only during acts of straining, coughing,
or lifting.
The condition may be determined by the insertion of sounds or the
finger.
_Treatment_ should be directed to the cure of any inflamed condition
of the urethra which may accompany dilatation, and to the use of
astringent injections of tannic acid.
If incontinence of urine persists it may be necessary to perform a
plastic operation, excising a portion of the anterior wall of the
vagina and the posterior wall of the urethra, and closing the wound by
transverse sutures.
In _urethrocele_ the dilatation is confined to a portion of the
urethra, usually the middle third. There is a sacculated condition of
the posterior wall of the urethra extending into the vagina. The usual
cause of this condition is traumatism during labor. The symptoms are
painful and difficult micturition and partial incontinence of urine.
The condition may be diagnosed by the use of the sound or the probe,
which may be inserted in the sac through the urethra, when the point
may be felt by a finger on the anterior vaginal wall. Sometimes the
urethrocele produces a distinct bulging in the anterior wall of the
vagina.
If the annoying symptoms of urethrocele continue after any accompanying
inflammation of the urethra has been relieved, it may be necessary to
excise the sacculated portion of the urethra by incision through the
vaginal wall and close the wound by suture.
URETHRAL NEOPLASMS.
=Urethral Caruncle.=--The urethral caruncle is a small raspberry-like
tumor situated at or just inside of the external meatus. It is composed
of dilated capillaries set in a dense stroma of connective tissue and
covered with mucous membrane. The tumor varies in size from a pin-head
to a hickory-nut. In color it varies from a pale to a bright red. It is
usually situated upon the posterior wall of the urethra. There may be
two or more such· tumors around the circumference of the meatus, and
occasionally they are found in the vestibule. The growth is usually
sessile.
The caruncle is often erectile in character, and increases in size at
the menstrual period.
The growths bleed very easily on manipulation, and are exquisitely
sensitive. The urethral caruncle is the commonest neoplasm of the
urethra.
_Symptoms._--The most marked symptom of urethral caruncle is pain.
Intense pain is experienced at micturition and upon contact with
the clothing or other body. Sexual connection is sometimes rendered
impossible.
There is usually more or less hemorrhage from the tumor, which may
rarely be so profuse as to cause marked anemia. The general health
suffers, and nervous symptoms, resulting from the pain and loss of
sleep, are often present to a pronounced degree.
_Treatment._--The treatment consists in the total extirpation of the
growth. It should be picked up with forceps and excised with the knife
or scissors. The edges of the mucous membrane should be united by
sutures.
Excision should be complete or the tumor may return. In case of
recurrence a second operation should be performed.
=Urethral Cysts.=--Small cysts are occasionally found in the course
of the urethra. They may occur at any point from the internal to the
external meatus. They are caused by obstruction and distention of the
urethral glands. They produce no symptoms unless large enough to cause
obstruction to the flow of urine. They may be seen by the endoscope or
may be palpated through the vaginal wall.
The _treatment_ consists of incision and removal of part of the
cyst-wall.
=Polypus.=--Mucous polyp of the urethra is of very rare occurrence.
The tumor generally has a delicate pedicle, and may protrude from the
meatus. It is painless, and causes discomfort only by obstructing the
flow of urine.
The _treatment_ consists of removal by torsion, ligature, or excision.
=Sarcoma= and =cancer= of the urethra have rarely been observed. The
phenomena are those similar to cancer in other parts of the body.
The _treatment_ consists in thorough removal.
DISEASES OF THE BLADDER.
The urinary bladder has three coats--an outer incomplete peritoneal
investment, a middle muscular coat, and an inner lining of mucous
membrane.
The empty bladder is always collapsed, its walls being in apposition.
A median sagittal section of the bladder and urethra shows a
Y-shaped fissure lying between the symphysis pubis and the
uterus, the uterus lying anteverted upon the upper surface of the
bladder.
For convenience of description the bladder is divided into three
parts--the corpus, or body, the fundus, or base; and the cervix, or
neck.
The body of the bladder is all that portion that lies above the plane
of the vesical orifices of the ureters and the center of the symphysis
pubis.
The part lying below this plane is the base.
The vesical triangle, or the trigone, is that triangular area in the
base of the bladder, the angles of which are marked by the vesical
orifices of the ureters and the internal meatus of the urethra.
The neck of the bladder is the funnel-shaped portion where the bladder
merges into the urethra.
The mucous membrane of the bladder is covered partly with squamous,
partly with cylindrical epithelium. The mucous membrane is loosely
attached to the muscular coat throughout the body of the bladder, so
that when the organ is contracted the membrane is thrown into uneven
folds. The mucous membrane is much more closely attached to the
underlying structures in the region of the vesical triangle, and it
here preserves a smooth surface when the bladder is collapsed.
The vesical triangle is more richly supplied with nerves than are the
other portions of the bladder, and is consequently the most sensitive
portion.
The vesical orifice of the ureter appears as a dimple, a small
truncated cone, or a pin-hole or slit on the mucous membrane.
A transverse band or fold of mucous membrane, known as the
intra-ureteral ligament, extends between the orifices of the ureters.
The dimensions of the vesical triangle are subject to individual
variations. The triangle is usually equilateral, its sides varying
from 1 to 1½ inches in length. The vesical orifices of the ureters are
therefore situated at points lying from ½ to ¾ of an inch from the
median line--a useful fact to remember in opening the bladder through
the vagina.
The vascular supply of the bladder is intimately associated with that
of the uterus--a fact that explains the sympathetic disturbance of
the bladder in uterine disease. The interior of the normal bladder is
of a dull gray-red color. When distended, as in making an endoscopic
examination, the minute arteries and veins may be plainly seen upon the
surface.
The pressure of the urine in the bladder may be determined by the
manometer. In the erect posture the intra-vesical pressure has been
found to vary from 12 to 16 inches of mercury. In the recumbent posture
the pressure is reduced to from 4 to 6 inches.
=Cystitis.=--Cystitis, especially of the subacute or the chronic form,
is a common disease in women. The pathological changes resemble those
seen in inflammation of mucous membrane in other parts of the body.
In the acute stage the mucous membrane is swollen and relaxed, and of a
deep-red or hyperemic appearance. Partial exfoliation takes place. The
surface may be covered with thick, tenacious mucus or pus.
In the chronic stage the mucous membrane is of a muddy gray color, and
may be more or less covered with a muco-purulent secretion. Ulceration,
superficial or deep, may occur. The ulcer is sometimes deep and ragged
and extends into the muscular wall.
In chronic cystitis we often find on the surface of the mucous membrane
small localized areas of inflammation varying in size from ½ inch to
2 inches in diameter, and presenting a congested, granular, or eroded
appearance, while the rest of the mucous membrane appears perfectly
normal. These areas of inflammation bleed readily when touched. They
are most often found in the base of the bladder, though they may occur
in any part. When chronic cystitis is limited, it is usually confined
to the vesical triangle.
The outer coats of the bladder may be involved in the inflammatory
process, and become much thickened and hypertrophied. The ureters and
the kidneys may become in time affected, through direct extension of
the inflammation in the form of a ureteritis and pyelitis, or through
obstruction of the vesical orifice of the ureters from inflammatory
thickening. The alteration in the character of the urine is usually
marked except in the mild forms of chronic inflammation. The specific
gravity is low, varying from 1005 to 1018. In the chronic disease the
urine is alkaline and ammoniacal. It contains blood, mucus, pus, and
epithelial cells from the vesical mucosa.
Cystitis in women is usually caused by infection at catheterization.
The very great improvement in the asepsis of this procedure that has
taken place in recent years has in a corresponding degree diminished
the frequency of cystitis.
Infection at catheterization is caused not only by the use of a dirty
catheter, but by the conveyance of septic material from the external
genitals or the urethra into the bladder. For this reason the nurse or
the physician should never pass the catheter by touch, as was sometimes
formerly taught. The parts should be exposed to view, and the external
genitals, vestibule, and meatus should be cleansed.
Cystitis may also be caused by extension of urethritis; by inflammation
of adjacent organs; by abnormal urine; by constitutional diseases, as
the exanthemata; by injuries to the bladder and displacement of this
organ; and by retention of urine.
_Symptoms._--The symptoms of cystitis vary with the stage and the
character of the affection. Pain, frequent urination, and tenesmus are
usually present.
In the acute stages there may be an elevation of temperature. There is
a feeling of fulness in the bladder, with pain in the region of this
organ. The pain is increased by motion and by the erect position, which
increases the intra-vesical pressure. The pain is constant, and is not
relieved by evacuation of the bladder. Pressure upon the base of the
bladder through the vagina causes pain. This is a useful diagnostic
point. There is a frequent desire to urinate, and the passage of urine
is followed by straining efforts or tenesmus. The alteration in the
character of the urine has already been mentioned.
In time the general system suffers from secondary renal disease and
from absorption, through the bladder, of the ingredients of decomposed
urine and septic material from the mucous membrane.
The _diagnosis_ of cystitis is easily made by proper examination. It
should always be remembered that not every woman who complains of
painful and frequent urination and vesical tenesmus is necessarily
suffering with cystitis. These symptoms are often caused by disease of
the urethra, by displacement of the uterus, which drags upon the neck
of the bladder, by the pressure of a tumor, or by displacement of the
bladder such as may follow laceration of the perineum.
Women may often be seen who have been treated for weeks for cystitis
without avail, and who are immediately relieved of all symptoms by the
replacement of a retroverted uterus or the closure of a torn perineum.
These conditions may in time result in cystitis, but the disease
usually disappears with the cure of the causative lesion.
It is of the first importance, therefore, for the physician to make a
careful pelvic examination, and to exclude all conditions that might
cause irritation of the bladder. Microscopic examination of the urine,
by revealing the presence of pus and blood and the epithelial cells
of the bladder, is of value in making a diagnosis. The urine for
examination should be drawn with the catheter, to prevent contamination
from vaginal discharges.
Examination of the urine does not, as a rule, enable one to exclude
inflammation of the ureters or of the pelves of the kidneys. If there
is any doubt, it may be removed by the use of the endoscope, which will
reveal the true condition of the bladder-wall.
As has already been said, tenderness upon pressure through the vagina
on the base of the bladder is of diagnostic value in determining the
presence of cystitis. In the mild forms of chronic cystitis--those
characterized by local areas of inflammation--examination of the urine
may throw no light upon the condition, as the secretion of pus or mucus
is very slight. The diagnosis can then be made only by means of the
endoscope.
It is perhaps advisable in all cases of chronic cystitis to use
the endoscope, not only to confirm the diagnosis, but to begin the
treatment by making direct local applications.
_Treatment._--The treatment of cystitis is general and local. Local
treatment should never be used in the acute stages of the disease. Many
cases recover completely without any local treatment whatever.
In acute cystitis the woman should be put to bed. The irritation of
the bladder is much relieved when the intra-vesical pressure is thus
diminished.
The diet should be carefully regulated, all stimulating ingredients
being withdrawn. An exclusive milk diet is the best.
Saline laxatives should be administered, and continued to the point of
mild purgation. One dram of Rochelle salts every two or three hours,
given in half a tumblerful of soda-water, is useful for this purpose.
Large quantities of diluent drinks should be given, such as flaxseed
tea or Vichy water.
If the urine is acid, citrate of potassium may be administered with the
diluent drinks, so that from 1 to 2 drams of the salt are taken during
the day. Bicarbonate of potassium in similar doses is also useful.
When the urine becomes ammoniacal, boracic acid, in doses of 10 grains
from three to six times a day, is most useful. Benzoic acid, in doses
of 10 grains three or four times a day, is also valuable.
A very good method is to make a pint or a quart of flaxseed tea, to
dissolve in it the requisite amount of citrate of potassium or of
boracic acid (as the urine is acid or alkaline), and to administer this
in divided doses during the day. This treatment, with rest in bed,
should be continued as long as the vesical pain and tenesmus continue.
If the pain and tenesmus are severe, small doses of opium may be given.
It is, however, not advisable to use opium unless the suffering of the
woman demands it.
If the disease, as the symptoms become less acute, does not progress
satisfactorily toward cure, medicines that have a more stimulating
effect upon the mucous membrane should be given, such as cubebs and
copaiba, oil of turpentine, oil of eucalyptus, and oil of sandalwood.
Many cases of acute cystitis, if carefully treated in this way, will
recover completely without the use of local treatment. If, however,
the disease does not yield to these measures, local treatment becomes
necessary.
In many instances the woman first comes under treatment when the
disease has reached a chronic stage; or it may be that the disease has
begun subacutely, and has gradually progressed without having presented
any symptoms of acute onset. Local combined with general treatment is
then often advisable from the beginning.
_Local treatment_ consists of general applications made to the whole of
the interior of the bladder through the catheter; direct application,
limited to the diseased portions of the mucous membrane, through the
endoscope; and operation, or the formation of a vesico-vaginal fistula.
[Illustration: FIG. 191.--Apparatus for washing the bladder.]
Washing out the bladder with sterile warm water, either pure or
medicated, is often very useful. Gentleness in manipulation and asepsis
should be carefully observed in this procedure, or much more harm than
good may result from it. The operation, if properly performed, should
never give pain to the woman.
A very simple apparatus is required, consisting of a soft-rubber
catheter, of moderate size, attached to a small glass funnel by means
of a rubber tube and a piece of glass tubing. The whole is about 2 feet
long (Fig. 191).
The catheter, slightly lubricated at the point, should be gently
introduced into the bladder, and the urine should be slowly withdrawn.
As the urine flows into the funnel its character may be observed.
The rapidity of the flow of the urine may be regulated by raising or
lowering the funnel. As the last portion of the urine is withdrawn the
flow should be very slow, in order to prevent injury to the vesical
mucous membrane from dragging it into the eye of the catheter.
When the bladder is emptied, sterile hot water may be introduced
through the funnel and the process of withdrawal repeated. The mucus,
pus, or blood which had remained in the bladder after evacuating the
urine may be examined as the water flows into the funnel. This process
may be repeated several times if necessary to wash out the bladder.
The water should be about the temperature of the body (100° F.). It
is less irritating to the mucous membrane if there is dissolved in it
boracic acid or common table salt, about 1 dram to the pint, though
these ingredients should not be added if they act chemically on the
substances subsequently used in the medicated solution.
The quantity of water introduced into the bladder may be regulated by
the feelings of the patient. The distention of the bladder should never
be great enough to cause pain. Usually an ounce of fluid is all that
can at first be tolerated without producing pain. As improvement takes
place more fluid may be introduced in the subsequent treatments.
After the bladder has been washed out in this way, applications may
be made to the interior by pouring through the funnel the desired
medicated solution, the most useful one being a weak solution of
nitrate of silver (gr. j or ij to ℥j). This solution should be retained
in the bladder for a few minutes, and should then be withdrawn.
A solution of sulphate of copper (gr. j-iv to ℥j) is also useful.
At first daily irrigation and application should be thus practised.
As the case improves the intervals between the treatments should be
lengthened.
This local treatment should always be combined with the general
treatment already prescribed--rest in bed if possible, a milk diet, and
the administration of boracic acid internally.
_Application through the Endoscope._--If the endoscope is used in the
first place for diagnosis in a case of chronic cystitis, much time
that might otherwise be wasted in unnecessary or useless forms of
treatment may be saved. The condition of the parts maybe accurately
determined, and the proper form of treatment may be instituted. It may,
for instance, be seen that deep ulceration is present, or that other
lesions of the bladder are so extensive that the quickest plan of cure
will be to proceed immediately to the formation of a vesico-vaginal
fistula, without attempting to treat the disease by applications.
Applications may be readily made through the endoscope to any part of
the interior of the bladder. Applications made in this way are most
useful when the disease is localized. Stronger solutions may be used
on the affected areas than when the application is made to the whole
surface of the organ.
When the disease is limited to the vesical triangle or to local
areas situated elsewhere, the inflamed spots should be touched with
a solution of nitrate of silver (gr. v-xx to ℥j). Much benefit is
frequently derived from one such application, in connection with the
general treatment already indicated. The applications may be made every
few days. The procedure causes less discomfort to the woman as she
becomes accustomed to it.
_Cystotomy._--In cases of ulceration of the mucous membrane, or
when the disease has resisted the milder forms of treatment, it may
become necessary to perform cystotomy, to furnish an opening for
the continuous drain of the urine, and to put the bladder at rest
by relieving it from all functional action. This is a most valuable
therapeutic operation in cases of obstinate cystitis.
In performing cystotomy the anatomical relations of the ureters and
the internal orifice of the urethra must be kept in mind. It will be
remembered that the ureters terminate in the bladder at points situated
from ½ to ¾ of an inch from the median line.
[Illustration: FIG. 192.--Illustration of the position of the incision
in vaginal cystotomy, and the relations of the urethra and the ureters:
_A_, anterior vaginal column; _B_ marks the position of the internal
urinary meatus; _C_ and _D_ mark the orifices of the ureters. The
distance from _C_ to _D_ varies from 1 to 1½ inches. _C_, _B_, _D_ is
approximately an equilateral triangle.]
The course of the urethra is indicated by the anterior vaginal column,
which is a single or double thickening of mucous membrane traversed by
short transverse folds or ridges. It begins near the external meatus
and extends upward for about an inch. The internal meatus may be very
approximately located by the upper end of this anterior vaginal column.
The incision into the bladder should be made in the median line above
this point.
The operation should be performed under the influence of an anesthetic.
The woman should be placed in the Sims or the dorso-sacral position.
The anterior vaginal wall should be exposed with the Sims speculum.
A sound should be passed into the bladder, and its point should be
pressed against the posterior vesical wall toward the vagina, at the
position where the incision is to be made. The incision should be
made into the bladder through the tissues fixed on the point of the
sound. The opening may then be enlarged with the knife or scissors. The
opening should be from 1 to 1½ inches in length. In order to prevent
spontaneous closure of the fistula, the mucous membrane of the bladder
should be sutured to the mucous membrane of the urethra around the
margin of the fistula.
The after-treatment consists in daily washing of the bladder with large
quantities of sterile warm water or with the boracic-acid solution. The
woman should be placed in the dorso-sacral position, and the fistulous
opening should be exposed by the Sims speculum. The water should be
introduced into the bladder through the urethra. Care must be taken to
hold the edges of the fistula open, so that there may be a free channel
of escape.
The patient should at first remain in bed. After the acute symptoms
have disappeared she may get up and the frequency of the local
treatments may be diminished. Various appliances have been introduced
for receiving the continuously escaping urine. None of them, however,
are satisfactory. They are difficult to keep clean, they cause pain,
and they are liable to become displaced. The best method is to wear a
vulvar pad of some absorbent material and to pay strict attention to
cleanliness. The progress of the case may be determined by examination
of the urine, and by examination of the vesical mucous membrane through
the fistula or through the endoscope.
The time required for cure may extend from one to six months.
When the vesical membrane has been restored to a normal condition the
fistula may be readily closed.
=Vesical Calculus.=--Stone in the bladder is less common among women
than among men. This fact is probably due to the greater size and
dilatability of the female urethra, on account of which small calculi
may readily pass out.
The symptoms and methods of diagnosis of vesical calculus are similar
to those in the male. The stone may often be palpated by bimanual
examination.
_Treatment._--Small stones uncomplicated with cystitis may be crushed
and removed through the urethra. Large stones should be removed by
cystotomy. Whenever cystitis is present, it is advisable to perform
cystotomy and to make a permanent fistula until the cystitis is cured,
when the opening may be readily closed.