are prolapsed, care is necessary to distinguish that condition from
urethral neoplasm. This can be done by observing that in prolapsus the
opening is situated either at the upper side or in the centre of the
protruding mass, whereas in abnormal growths of the urethra the meatus
surrounds the tumor or its pedicle. More than that, by making pressure
the distended vessels can be reduced in size and the prolapsed membrane
pushed up into the canal. This cannot usually be accomplished with
tumors.
PROGNOSIS.--There is no natural tendency to recovery in these
affections. If left alone they generally get worse. Recovery under
treatment depends upon the location of the dilatation and the duration
of the trouble. The conditions upon which an unfavorable prognosis is
to be based are--bladder complications, inflammation or ulceration near
the neck of the bladder, great varicosity of the veins, and fatty
degeneration of the muscular tissue. In the absence of all these
complications a complete recovery may be expected. In all cases great
relief can be secured by treatment and the patient guarded from getting
worse.
TREATMENT.--In the management of all forms of urethral dilatation
attention should be given to any inflammation of the mucous membrane
that may exist, employing the usual treatment. When there is a relaxed
and prolapsed condition of the mucous membrane, astringents should be
used. Tannic acid or alum will answer well. When these fail, the
redundant membrane should be retrenched, either by touching it with the
thermo-cautery or excising a portion with the scissors. In employing
the cautery for this purpose the long pointed tip of the instrument
should be used, and, having protected one side of the urethra with the
speculum, cauterize a narrow strip of the membrane parallel to the axis
of the canal. Two or more of these cauterizations may be made at points
equidistant on the circumference of the urethra. By operating in this
way pieces of normal membrane are left between the portions cauterized,
which prevents stricture from occurring after healing--a misfortune
which is sure to follow if the mucous membrane is destroyed by
cauterization all around.
In excising the prolapsed portion I prefer to remove one or more
V-shaped portions on opposite sides and bring the edges together by
sutures. This is preferable to clipping off the whole of the protruding
mass, because the cicatrices left are less likely to give after
trouble.
When the dilatation is caused by varicose veins it may be well to
follow the example of Gustave Simon. He exposed the vessels by cutting
through the vaginal wall, ligated the largest, and arrested the
hemorrhage from the smaller ones by applying liquor ferri perchloridi.
He repeated this operation several times on the same patient, who
experienced little or no inconvenience from the proceeding and made a
good recovery.
Dilatation of the lower third of the urethra is usually secondary to
some other trouble, as I have already stated; and all that is necessary
{360} to do for such cases is to remove the cause and treat any
inflammation that may exist. The dilatation will then disappear; and if
it does not, but little if any trouble will be caused by it.
The treatment of dilatation of the upper third consists simply in
supporting the parts. This can be effectually done by using the pessary
already recommended for the relief of prolapsus of the bladder. It may
be necessary to have the instrument so formed as to bring the pressure
where it is required. This is done by placing the pessary in position
and observing what change of form, if any, is necessary, and then
directing the instrument-maker to make the alteration. If the parts are
well supported in this way, recovery will follow unless atrophy of the
muscular wall has previously taken place. Even then the patient can be
kept comfortable by wearing the pessary. If there is urethritis
present, it may be necessary to remove that before using the pessary;
otherwise the pressure of the instrument may cause pain and aggravate
the inflammation.
In dilatation of the middle third Bozeman has proposed to make an
opening into the most dependent part of the urethra through the vaginal
wall, and maintaining it until all inflammation has been relieved, and
then closing the opening by the usual plastic operation. By this means
the urethra is perfectly drained of urine and the products of
inflammation which accumulated there before. This, with appropriate
cleansing and topical applications, soon restores the mucous membrane
to its normal condition, and the removal of the redundant tissue during
the operation of closing the opening effectually cures the whole
trouble. This treatment is admirably adapted to marked cases of long
standing, and should be employed. By using the thermo-cautery to make
the opening the operation is easily performed. In recent cases of less
magnitude I have obtained satisfactory results by dilating the lower
part of the urethra and supporting the dilated portion either with a
pessary or a tampon of marine lint. This permits the urethra to keep
itself empty, and then, by frequently washing it out and applying such
remedies as will cure the urethritis, recovery will sometimes follow.
Dislocations of the Urethra.
This is one of the affections most frequently met with in practice. I
have found very few cases recorded in medical literature. This neglect
of the subject by authors is perhaps due to the fact that in many cases
of displacement of the urethra the bladder is also dislocated, and the
whole trouble is described under the head of vesicocele or cystocele.
Now, it is true that displacement of the two occurs together, but
either may take place alone.
The extent of displacement varies exceedingly, but I shall describe
only the partial and the complete. A clear comprehension of these two
degrees will cover all intermediate forms. In partial displacement
downward the upper two-thirds of the urethra are prolapsed, so that the
direction of that portion of the canal is backward, instead of curving
upward, as in the normal condition. In complete prolapsus the urethra
runs from the meatus (which is in its normal position) backward, and
rests upon the {361} perineum, or in extreme cases, accompanied with
prolapsus of the bladder and uterus, its direction is backward and
downward, the position of the vesical end of the urethra being below
the level of the meatus. In this degree of displacement the urethra and
bladder can be seen presenting at the vulva or lying between the labia
minora. The urethra is usually shortened considerably when the
prolapsus is marked.
ETIOLOGY.--Utero-gestation and delivery are the most important causes
of this affection. In the advanced months of pregnancy I have observed
that while the bladder rose above the pubes the urethra was pushed
slightly downward by the settling of the enlarged uterus into the
pelvis. In such cases when labor occurs the head of the child
dislocates the urethra still more by pushing it still farther down.
This process I have often watched in forceps delivery. When there is a
partial prolapsus of the urethra existing before labor, the urethra and
anterior vaginal wall are forced down before the advancing head, and
that, too, while the attendant is making counter-pressure to prevent
it. The displacement produced in this way is often restored during
convalescence if proper care be taken to push the parts back into place
and the patient is kept at rest until the tissues regain their
tonicity. But in many cases the trouble is overlooked, and by
permitting the patient to get up and be on her feet while there is
still prolapsus it will slowly increase until the dislocation is
complete. This will surely be the case if there is any loss of
perineum. Indeed, rupture of the perineum is an accident which permits
the urethra to descend from its place. The perineum supports the
vaginal walls, which in turn support the urethra; and if it be lost,
even in part, the vaginal walls become relaxed, or perhaps never regain
their tonicity after delivery, and, settling down more and more, carry
the urethra with them.
SYMPTOMATOLOGY.--The symptoms arising from displacement of the urethra
are much the same as those found in dilatation and other urethral
diseases. I need not, therefore, repeat them in detail. Suffice it to
say that in dislocation of the upper portion of the canal there is, in
addition to frequent urination, a partial loss of control of the
bladder. Under the extra pressure of coughing, for example, the urine
will escape. This loss of control does not exist, as a rule, in
complete displacement. On the contrary, there is usually difficult
urination, which requires increased voluntary efforts to empty the
bladder. In all degrees of displacement the symptoms are increased in
the erect position, and are markedly relieved on the patient's lying
down.
DIAGNOSIS.--An examination of the vagina, either by touch or speculum,
will reveal the downward projection of part or all of the urethra,
which will show that there is either dilatation or prolapsus. The
change in the direction of the canal will be shown by passing the
sound, and dilatation can be excluded by observing that the urethra
grasps the instrument firmly at all points. In dislocation of the upper
two-thirds of the urethra the sound passes in the normal direction, but
is arrested at a half or three-quarters of an inch from the meatus; but
by pushing up the vaginal wall and the urethra the sound will then pass
into the bladder. When the prolapsus is complete the instrument passes
in easily, but takes a downward and backward direction.
PROGNOSIS.--Uncomplicated displacement of the urethra can be remedied
in the great majority of cases. By placing the parts in proper {362}
position, and holding them there, the relaxed tissues will usually
contract sufficiently to support themselves. Should they fail to do so,
the patient can at least be made comfortable by wearing some supporter.
TREATMENT.--When the displacement of the urethra is caused by any other
trouble, such as defective perineum or prolapsus uteri, then these
things should first be attended to. Should there be urethritis, that
also should receive appropriate treatment. But the chief indication is
to retain the urethra in place; and this can be easily accomplished by
using the pessary which has been recommended for supporting the
prolapsed bladder. Prolapsus of the upper part of the urethra can be
relieved in this way quite satisfactorily. When the whole urethra is
displaced, this pessary, while it supports the upper part, will still
permit the middle portion of the urethra to settle down. This
difficulty may be overcome by making the anterior portion of the
pessary long enough to engage in the introitus vulvæ, and in that way
keep the whole canal where it should be. Should this cause the patient
much discomfort, a tampon of marine lint should be used to keep the
parts in position until some restoration of the parts is obtained, and
then the pessary will complete the treatment.
Prolapsus or Inversion of the Urethral Mucous Membrane.
The prolapse may be limited to one side or extend all around the canal.
The size and extent of the protrusion vary considerably. If the meatus
is of full size, the prolapsed portion will usually preserve its
natural color for a time; but after a little, from chafing when wet
with urine, and especially if not kept clean, it will become red and
oedematous. When the meatus is small these changes occur sooner and in
a more marked degree, because the prolapsed portion is partially
strangulated. The longer the membrane remains exposed the more
sensitive it becomes, and the frequency of urination and pain attending
it increase. It also becomes very tender and painful to the touch. In
marked cases the ordinary movements of the body irritate the parts, and
in that way render walking painful.
These are symptoms that closely resemble those of irritable growths at
the meatus urinarius, and, so far as history is concerned, it is not
easy to make a differential diagnosis. To do this it is necessary to
make a local examination. The physical signs and the points in the
diagnosis between this affection and other diseases have been given
briefly but sufficiently under the head of Dilatations of the Urethra,
and need not be repeated here.
The causes of prolapsus of the urethral mucous membrane are numerous,
but those that are best known are long-continued congestion of the
membrane, urethral and cystic irritation causing frequent urination and
vesical tenesmus. Chlorotic and greatly debilitated women are said to
be predisposed to it, as also old prostitutes. The few cases that I
have seen were in women over fifty years of age, and all of them were
weak, nervous patients who had suffered from some organic disease or
functional derangement of the urinary organs.
PROGNOSIS.--This disease does not yield promptly to mild treatment,
{363} unless it is seen early in its progress; and if it does yield to
mild, soothing, and astringent applications, it is liable to return.
But in case there is no other disease present that tends to keep it up,
it can usually be cured by surgical means.
TREATMENT.--When a case is first seen it is well to remove any
inflammation or other complicating conditions. The prolapsed membrane
should be replaced, and the patient kept quiet in bed to favor the
retention of the parts in situ. Astringents, such as tannic acid, alum,
or persulphate of iron in a weak solution, should also be used. Should
these fail, the prolapsed portion of the membrane should be removed.
The methods of doing this (by excision and the thermo-cautery) have
already been described.
Stricture of the Urethra.
PATHOLOGY.--Obstruction of the urethra by narrowing of its calibre is a
much less common affection in the female than in the male. Still, it
occurs sufficiently often to demand attention. There are some facts in
the pathology of urethral stricture peculiar to women which we will
first notice. Passing over congenital narrowing of the urethra by
simply saying that such a malformation has been known, we find that
stricture is developed in the female, as in the male, by the deposit of
inflammatory products beneath the mucous membrane, which by gradual
contraction constricts the canal. Ulceration of the membrane in a
marked degree produces the same results. The inflammation and
ulceration which end in the formation of stricture are usually specific
in character, but the same may follow from the too free use of caustics
and injuries during childbirth. Stricture may also be produced by bands
of scar-tissue formed in the anterior vaginal wall and stretching
across the urethra. Contraction of the whole canal occasionally occurs
in cases of vesico-vaginal fistula of long standing. There the
narrowing is simply the result of disuse. The form of stricture that
most frequently comes under observation is a contraction of the meatus
urinarius, produced in many cases by the too liberal use of caustics in
the treatment of abnormal growths at the lower end of the urethra, or
from vulvitis. This form of stricture is the least troublesome and is
easily relieved. When due to the results of former urethritis or
peri-urethritis, the walls of the urethra are thickened and indurated
at the point of the stricture, and there is usually subacute
urethritis, sometimes ulceration. In those cases where the calibre of
the canal is diminished by cicatrices of the vaginal walls, and in
general contraction of the urethra in vesico-vaginal fistula of long
standing, the mucous membrane may be perfectly normal.
SYMPTOMATOLOGY.--Frequent and difficult urination are the chief
troubles caused by stricture of the urethra. The stream becomes
smaller, and may be twisted or flat, but this is rarely observed.
Patients, as a rule, only notice that they require to urinate more
frequently, and that they have to make more voluntary efforts to empty
the bladder than were necessary before. In almost all cases of
stricture the subject has at some previous time suffered an injury at
childbirth, urethritis, or something to which the origin of the
stricture can be traced. The previous {364} history of cases in which
stricture is suspected will aid in settling the diagnosis and etiology.
DIAGNOSIS.--A digital examination by the vagina will reveal thickening
and induration if the stricture is due to that cause. Cicatrices of the
vaginal wall compressing the urethra can be detected in the same way.
The use of the sound will determine the location of the stricture and
the extent to which the canal is contracted. When the stricture is at
the meatus it can be found with facility; but when it is located higher
up the largest sound that can be introduced without force should be
passed up to the point of stricture. This will localize it; then by
using a sound that will pass through it the extent of the constriction
will thus be ascertained.
The affections which are liable to be mistaken for stricture are
retention of urine or difficult urination from pressure on the urethra
by the displaced gravid uterus, pelvic tumors, and dislocations of the
urethra. The former can be excluded by a vaginal examination, and the
latter can also be detected by the sound, used as directed while
discussing the diagnosis of the dilatations.
PROGNOSIS.--Stricture of the urethra usually yields very promptly to
treatment, so that the prognosis is good. The only exceptions are where
the stricture has existed in a marked degree long enough to cause
dilatation of the ureters and disease of the kidneys. Chronic cystitis
or urethritis, occurring as a result of the stricture or coincident
with it, may so complicate matters as to make recovery slow or even
impossible. In cases where the whole urethra is contracted because of
the existence of a vesico-vaginal fistula of long standing, it is
extremely difficult to restore the tissues of the urethral walls to
their normal state.
TREATMENT.--The treatment of stricture will depend upon its location
and cause. If it is situated at the meatus, it can be divided by the
urethrotome or forcibly stretched with the dilator. When due to bands
of scar-tissue in the vagina, they should be divided at several points
and the urethra dilated by repeatedly passing the sound. When it is
owing to deposition of the products of inflammation in the submucous
tissue, forcible and rapid dilatation, as practised on the male
subject, will answer well if the proper cases are selected for this
form of treatment. Dilatation should be made carefully, with a view to
breaking up the constricting tissue without lacerating the mucous
membrane. To do this it is not necessary to dilate the urethra to any
great extent. As soon as the stricture has given way dilatation should
be suspended.
Incising the stricture from within outward, according to the method
commended by surgeons for the cure of stricture in the male, will no
doubt answer a good purpose. In fact, I am inclined to believe that
this plan of treating this affection is the best, but my own experience
with this operation on the female urethra is not sufficient to warrant
my speaking positively.
In contraction of the whole urethra arising from disuse in cases of
vesico-vaginal fistula gradual dilatation with graduated sounds answers
very well. This should be attended to before closing the opening in the
bladder. In all cases attention should be given to any inflammation
that may accompany the stricture or follow the treatment. It is well
also to keep such patients under observation, and pass the sound from
time to {365} time to see if there is any tendency of the stricture to
return. The brilliant results obtained in the treatment of stricture in
the male with electrolysis by Robert Newman should warrant a more
extended trial of this method.
Stricture at the Junction of the Urethra and Bladder.
This form or location of stricture is, so far as I know, peculiar to
women, and its influence on the function of the bladder has not been
clearly pointed out. In fact, no distinction has been made between the
pathology or clinical history of stricture at the upper end of the
urethra and elsewhere in the canal. At least, I am not aware that
writers on this subject have mentioned this form of stricture. My own
observations have been limited, but sufficient, I think, to warrant me
in saying that stricture does occur at the junction of the bladder and
urethra, and that it behaves differently from ordinary stricture at
other parts of the canal.
The causes are the same which give rise to stricture elsewhere; hence
nothing requires to be said on this point. The point of most importance
is the fact that stricture at this part of the urethra will cause
difficult urination out of proportion to the extent of the narrowing of
the canal. Contraction of the canal in a slight degree will cause great
difficulty in urination, and frequently retention. This is contrary to
the history of stricture of the urethra at other points. In such cases
there is no retention of urine until the stricture closes the canal, or
very nearly so; but I have seen retention in cases of stricture at the
neck of the bladder while a medium-sized catheter could be passed with
ease, thus showing that the narrowing of the canal was not alone the
cause of the deranged function. It is possible that the original
stricture causes spasmodic contraction, or in some way disturbs the
normal action of that portion of the canal which performs the function
of a sphincter vesicæ.
The symptoms presented in this form of stricture are difficult
urination and in some cases complete retention. I have also noticed, in
one case, that there was a frequent desire to urinate, but that was
accounted for by a slight catarrh of the bladder. These symptoms are
such as occur in other conditions, such as atrophy and paralysis of the
bladder, obstruction of the urethra from tumors, calculi, the pressure
of the displaced uterus, and prolapsus of the bladder.
In this form of stricture there are thickening and induration of the
neck of the bladder, which may be detected by digital examination of
the vagina. The sound will also reveal a narrowing of the canal at the
vesical neck, but the contraction may not be marked. Our main reliance
must be placed upon the exclusion of all other conditions which can
produce the same symptoms. Pressure upon the urethra and prolapsus of
the bladder can be excluded by an examination of the pelvic organs, and
the use of the sound will show anything like complete obstruction of
the canal.
Having excluded the possible existence of either of these conditions,
the only two affections which are to be confounded with this form of
stricture are atrophy and paralysis of the bladder. To distinguish
these from the stricture, the catheter should be passed when the
bladder is well {366} distended, and the character of the flow of urine
watched, when it will be observed that in stricture the urine comes
away with the usual force. The bladder contracts normally and with its
natural vigor, and sends the urine out in a well-sustained stream
through the catheter, if there is only stricture. On the other hand, in
paralysis and atrophy the stream is slow and without force--so much so
that voluntary effort or the pressure of the hand on the abdomen is
sometimes necessary to empty the bladder. This is especially so when
the catheter is used while the patient is in the recumbent position.
Finally, the diagnosis may be confirmed by testing the dilatability of
the urethra. This can be done by passing a dilator along the urethra
and gently testing the resistance of the walls of the canal. There is a
slight yielding at all points except at the stricture, where a decided
resistance is met.