Incontinence is a feature in epispadias, downward dislocation of the urethra, and in some cases of prolapse of the uterus, and in cystocele. In the latter cases, the urine may escape only when the intra-abdominal pressure is increased in laughing, coughing, sneezing, or straining.
VESICAL SYMPTOMS 155 2. General Causes. — Nocturnal enuresis is a form of incontinence found in children. Here large quantities of urine are voided, quite unconsciously, at night only, the affection being supposed to be caused by an over reflex excitability of the nervous mechanism of the bladder. Rarely a local abnormality, such as an adherent prepuce, may act as a cause.
Incontinence may be due to a disorder of the brain itself (a), or (b) to some affection of that portion of the spinal cord which puts the brain into communication with the vesical centers in the sacral segments of the cord.
(a) The conditions which inhibit conscious cerebral activity are: coma, from whatever cause, as alcohol, epilepsy, or cerebral hemorrhage; some insanities; sunstroke; shock, and the poisons of some of the infectious diseases, as diphtheria and typhoid fever.
(b) The lesions which interfere with the conduction between the brain and the vesical centres in the lower cord are: myelitis, injuries and tumors of the cord, spinal meningitis, and locomotor ataxia. If the reflexes are entirely abolished total paralysis of the bladder with retention and dribbling of urine ensues; if the paralysis is partial, there will be partial retention, with occasional voiding of urine and its involuntary escape after voluntary urination is finished. The last happening is a frequent occurrence in locomotor ataxia.
Retention of Urine (Ischuria). — The urine may be retained in the bladder and the patient unable to void it in the same diseases of the brain and spinal cord as in the case of incontinence just noted. It is a pretty constant symptom of multiple sclerosis. Retention often alternates with incontinence in cases of coma and the typhoid state. Retention is common in hysteria, and in order that overdistention of the bladder may be avoided, the physician should palpate and percuss the lower abdomen of the hysterical woman to detect a full bladder. Retention is not uncommon during late pregnancy, and, whatever the cause, may result in a lack of expelling power and atony of the bladder. Retention is to be expected in incarceration of the retroflexed pregnant uterus, and may occur, rather infrequently, in fibroids and ovarian tumors. Retention has occurred because of blocking of the urethra by a suburethral abscess, or by cancer of the urethra. Temporary retention has been caused by the occluding of the urethra by a calculus or a pedunculated tumor of the bladder, and lodgment of a stone in the ureter may produce retention by causing spasm of the sphincter vesicae.
Suppression of the Urine (Anuria). — If urine is not secreted, or if secreted does not reach the bladder, the condition is known as suppression of urine, or anuria. The catheter must be passed and the bladder found empty before anuria may be said to be present.
Anuria, a rare condition, may occur in hysteria, in uremia, during the terminal stage of chronic nephritis, in acute nephritis, or in poisoning by turpentine, lead, phosphorus, or cantharides. Suppression of urine has been noted in yellow fever, typhoid fever, and the late stages of acute yellow atrophy of the liver, and in sunstroke.
In hysterical anuria the diagnosis is established by passing the catheter and then repeating the procedure after a definite interval of time, — say two hours, when the patient does not expect it, thus obviating conscious or unconscious malingering. If both ureters are obstructed by disease within, or by pressure from without (see Chapter XXV., page 489), so that no urine reaches the bladder, the condition is known as obstructive anuria. This is a rare condition, the diagnosis being made by cystoscopy and ureteral catheterization.
<Callout type="important" title="Important">Always ensure the bladder is empty before diagnosing anuria.</Callout>
RECTAL SYMPTOMS In taking the history, certain facts pointing toward rectal disease are to be noted; among them are the occurrence of slight morning diarrhea, continuing over a long period of time and alternating with attacks of constipation, a sense of weight in the pelvis, dull pain, in the region of the sacrum, and pain or swelling of the left lower limb.
Pain. — As to pain, ask when it was first noticed, the exact situation, how long the attack usually lasts, what effect has defecation upon it, and how severe it is. The most probable cause of pain occurring over a long period of time is fissure. When of recent occurrence, pain may be due to fissure, complete fistula, blind internal fistula, or prolapsed internal piles.
<Callout type="warning" title="Warning">Pain following defecation indicates possible serious conditions such as stricture, piles, or polyps.</Callout>
FECAL SYMPTOMS 157 If the pain lasts after defecation for several hours, the probable diagnosis is fissure or blind internal fistula, or complete fistula with a large internal opening. Pain ceases after defecation in the case of stricture, but in the case of piles the pain persists as long as the piles are outside the sphincter.
Pain or itching, coming only after the patient has gone to bed, may mean external piles or eczema about the anus.
Hemorrhage. — Hemorrhage from the rectum is either (a) associated with defecation, or (b) it is independent of defecation.
(a) Bleeding internal piles and fissure cause loss of blood with the stools. When the feces passed are only smeared with a little blood, the diagnosis may be ulcer of the rectum. Profuse hemorrhage sometimes accompanies defecation in the case of internal piles, a slight hemorrhage being more usual in cases of prolapse, polyp, or villous tumor.
(b) Hemorrhage independent of defecation occurs in some cases of internal piles, cancer, and, in the case of prolapsed growths, in prolapse of the mucous membrane, in internal piles, and in polyp. Continuous hemorrhage seldom lasts more than twenty-four hours and, as a rule, hemorrhage in rectal disease is intermittent. Blood may come from the skin around the anus in the case of eczema, fissures, external piles, or tuberculosis in that region.
Rectal Discharge. — Besides blood, there may be discharged from the rectum, mucus, muco-pus, and serous fluid. An increase in the amount of the rectal mucus is found in proctitis, in internal piles, in prolapse, and in stricture with invagination of the rectum.
In the case of chronic hypertrophic proctitis the amount of mucus passed per anum, often involuntarily, is so great that the patient is forced to wear a napkin. Pus is due to an abscess which has ruptured into the bowel, or to a fistula-in-ano. Muco-pus is generally found in ulceration, whether malignant or simple.
Serous fluid is passed in cases of villous tumor, often in large quantities and involuntarily. Besides making inquiry on these points the patient's linen should be inspected.
Fecal Accumulation. — The rectum is almost always found filled with feces in cases of fissure, internal piles, eczema of the anus, and hypertrophy of the external sphincter from whatever cause. In the case of stricture of the rectum the accumulation of feces will be found above the stricture, not below. The symptoms of this condition may be nothing more than a sense of fulness in the rectum, or there may be no symptoms. Digital examination makes the diagnosis. The physician should have the probabilities in mind before making the examination.
Difficulty in Defecation. — With this condition there is present a more or less constant desire to empty the bowel, and defecation is not attended by relief. It is not the same as constipation. If the dread of going to stool is due to pain caused by the act, the probable diagnosis is fissure, or ulcer, or a partly torn off polyp, causing spasm of the sphincter. If there is a tightness of the sphincter, the muscle will be found hypertrophied and non-dilatable. If there is much pain with straining before and during defecation and disappearing entirely after defecation, leaving a sense of only partial relief, a stricture is probably present.
Character of the Feces. — Diarrhea is not a true diarrhea unless it consists of a frequent discharge of fecal matter, whether solid, semi-solid, or fluid. True diarrhea is not frequently met with in rectal disease. If the feces are passed in short pieces of small caliber, with a little mucus and blood, or pus and blood, a stricture is probably present. If there is much blood and the feces are not in small pieces, cancer is to be suspected. In prolapse or invagination of the rectum, the feces are apt to be scybalous.
Protrusion from the Anus. — This occurs in internal piles, polyp, and pedunculated tumors, including villous tumors and cancer. If the protrusion is associated with defecation, the tumor returning to the rectum spontaneously soon after, — the probable diagnosis is internal piles, a polyp with short pedicle, a moderate degree of prolapse, or a villous tumor. When the protrusion remains down for several hours, the probable diagnosis is internal piles which have become pedunculated, a polyp with long pedicle, a marked degree of prolapse, or a villous tumor, and also, if protrusion occurs on standing or straining, it is probably due to an extreme degree of any of these. The affections referred to in the preceding section will be found described at length in Chapter XXVI., pages 498, and 523-525.
COCCYGODYXIA 159 COCCYGODYNIA The term coccygodynia (from Gr. coccyx, coccix, the tail, and Sd6vrj pain) is the name given by Sir James Y. Simpson to pain in the region of the coccyx, an affection occurring almost entirely in women and generally due to injury of the coccyx during labor. Some time previous to May, 1844, Dr. J. C. Nott, of Mobile, Alabama, removed the last two coccygeal bones in a young unmarried woman for 'neuralgia of the coccyx,' due to caries of the coccyx, following injury from a fall. This is the first recorded instance of coccygodynia, which is very commonly associated with gynecological affections.
Cocc3'godynia may occur in men when due to injury, but it is extremely rare. As in Nott's case, the disease in woman may be associated with caries of the bone; this is however, rare, and the pathological appearances of the specimens removed by operation show most often disease of the joint between the first and second coccygeal bones. The three lower bones are generally ankylosed in adults so that forcing them backward, — as in labor, — or forward, as in a fall on the buttocks when the thighs are flexed, places the strain on the only movable joint, that between the first and second pieces. Besides injury to the joints the coccyx may be fractured. The etiology of the pain is obscure and some authors attribute it to rheumatism of the muscles in the neighborhood of the coccyx, others to sprains of the ligaments, and still others to some affection of Lushka's coccygeal gland, which has a rich nerve supply.
The symptoms consist of continuous pain in the region of the coccyx aggravated by sitting down and by rising from a sitting posture. A hard seat causes especially severe pain and pain is exaggerated by defecation and by coitus. Mild cases are fairly common, but severe ones are infrequent. In the bad cases there may be constant pain along the entire length of the spinal column; the patient may get up from a sitting posture by placing the palm of one hand upon the seat of the chair and the other on any convenient support, and pushing the body up by the arms as much as possible, so as to avoid contracting the muscles of the pelvic floor and the glutei. The bad cases are usually the victims of neurasthenia.
In making the diagnosis, tenderness of the coccyx to light pressure, both from the skin surface and by a finger in the rectum, is the chief feature. If there is dislocation the lower bones of the coccyx, grasped between the finger in the rectum and the thumb in the crease of the nates, may be thrown out of line with the upper bone, or bones. A fracture may be felt as a ridge on the surface of the coccyx.
Tenderness over the coccyx by both vaginal and rectal digital examination may be found in proctitis (see Chapter XXVI., page 506), therefore in establishing the diagnosis of coccygodynia this disease must be ruled out.
PRURITUS VULVJE Pruritus vulva?, or itching of the vulva, is a symptom which may be the source of a great deal of misery to its victim, and may lead to serious derangement of the health from loss of sleep and constant nervous irritation. In the severe grades it is often accompanied by evidences of impairment of the nervous system, such as frequency of micturition, indigestion, irritability of temper, and instability of disposition. It is a symptom and is undoubtedly due to a certain sort of irritation of the terminal filaments of the nerves in the skin of the vulva, but the pathology is, as yet, unknown. The causes of pruritus may be divided into: (1) irritating discharges from the vagina or bladder, (2) diseases of the vulva, and (3) neuroses.
i. Irritating discharges from the vagina are, (a) leucorrhea from chronic endometritis. Leopold holds that this is a very common cause of pruritus; also leucorrhea from vaginitis, as in gonorrhea, is a not uncommon cause of itching.
(b) The urine of diabetes is a frequent cause of pruritus. The patient complains of great thirst, drinks large quantities of water, and is hungry most of the time. Examination of the vulva shows slight redness about the orifice of the urethra, redness and perhaps induration of the labia, and excoriations from scratching. The urine has a sweetish smell and on examination is found to contain sugar. Pruritus is often the first symptom which leads to the diagnosis of diabetes.
PRURITUS VULVAE 161 ii. Diseases of the vulva causing pruritus are, first, (a) congestion of the vulva and varix of the vulva, both commonly found in pregnancy, in uterine or ovarian tumors, or in any obstruction to the venous return of the blood in the pelvis, — such as intra-abdominal pressure on the vena cava. Even the congestion of the menstrual period may be accompanied by itching.
(b) Vulvitis and kraurosis vulvae are attended by more or less pruritus, the latter, generally by intense itching.
(c) Pediculus pubis is a cause of itching. On careful inspection of the hairs of the vulva the parasites or their nits are readily seen and are destroyed by shaving the parts and anointing with a ten-per-cent solution of carbolic acid and olive oil.
(d) Thrush of the vulva is a cause of pruritus, and in little girls (e) simple uncleanliness seems to operate as a cause. (/) Eczema of the vulva is nearly always attended by severe itching.
Key Takeaways
- Incontinence can be caused by various conditions, including brain disorders and spinal cord injuries.
- Retention of urine is a common symptom in multiple sclerosis and other neurological conditions.
- Anuria should always be confirmed by catheterization to rule out urinary obstruction.
Practical Tips
- Always ensure the bladder is empty before diagnosing anuria, as overdistention can cause further complications.
- For patients with chronic conditions like diabetes or multiple sclerosis, regular monitoring of urine flow and bladder function is crucial.
- In cases of suspected internal rectal issues, digital examination should be performed carefully to avoid exacerbating symptoms.
Warnings & Risks
- Be cautious when interpreting pruritus vulvae as a symptom; it can indicate serious underlying conditions like diabetes or cancer.
- Avoid using harsh chemicals on the vulva without proper diagnosis and treatment of the cause of itching.
- In cases of suspected coccygodynia, avoid forcing the patient to sit in uncomfortable positions that may worsen pain.
Modern Application
While many of the conditions discussed in this chapter are rare or have been improved upon with modern medicine, understanding urinary and rectal symptoms remains crucial for triage during survival situations. Knowledge of these symptoms can help identify serious underlying issues early on, which is vital when medical resources may be limited.
Frequently Asked Questions
Q: What should I do if a patient has incontinence due to spinal cord injury?
For patients with incontinence due to spinal cord injuries, it's important to assess the level of injury and any associated neurological deficits. Ensure proper catheterization techniques are used to prevent urinary tract infections and bladder atony. Regular monitoring and care can help manage symptoms effectively.
Q: How can I differentiate between anuria caused by a blockage and one due to kidney failure?
Anuria from a blockage, such as urethral obstruction or urinary retention, will often be accompanied by distended bladder on palpation. Anuria from kidney failure may not show this sign but could present with other symptoms like electrolyte imbalances or fluid overload. Cystoscopy and imaging can help differentiate the causes.
Q: What are some common causes of pruritus vulvae in modern times?
Common causes of pruritus vulvae today include yeast infections, bacterial vaginosis, and allergic reactions to hygiene products. It's important to perform a thorough examination and consider the patient’s medical history before diagnosing and treating.