CHAPTER XXIII THE DIAGNOSIS OF DISEASES OF THE URETHRA (Part 1)

CHAPTER XXIII THE DIAGNOSIS OF DISEASES OF THE URETHRA Anomalies, p. 444: Persistent urogenital sinus, p. 444. Hypospadias, p. 444. Partial defect of the external urethra, p. 444. Epispadias, p. 445. Atresia of the urethra, p. 445. Displacements of the urethra and alterations in form, p. 445: Upward dislocation, p. 445. Downward dislocation, p. 446: Diagnosis, p. 446; Differential diagnosis, p. 447, Urethrocele, p. 447. Suburethral abscess, p. 447, Dilatation of the urethra, p. 447, Dangers attending dilatation, p. 447, Prolapse of the urethral mucosa, p. 448. Inflammation of the Urethra, Urethritis, p. 450: Acute urethritis, p. 450. Chronic urethritis; (a) Diffuse; (b) Circumscribed, p. 451: Latent gonorrhea, p. 452. Stricture of the urethra, p. 451. New growths of the urethra, p. 453: Urethral caruncle, p. 453. Polypus of the urethra, p. 455. Primary Cancer of the urethra, p. 455. Sarcoma of the urethra, p. 456. The anatomy of the urethra and the methods of examination and the technique of endoscopy will be found in Chapter VIII., page 100. ANOMALIES The congenital defects of the urethra are: absence of the urethra, hypospadias, dilated short urethra, epispadias, and atresia. The development of the urethra and bladder is shown in the diagrams from Schroeder in Chapter XXL, page 395. Where the urethra has failed entirely to develop the bladder opens directly into the vagina, and the case may be regarded as a persistent urogenital sinus. Several of these cases have been reported in the literature, but more common are the instances of lack of develop- ment of the lower portion of the urethra. If the part lacking is the posterior urethral wall the case is one of hypospadias, and if both anterior and posterior walls are absent in the lower course of the urethra it is a case of partial defect of the external urethra. In cases of absence of the vagina the urethra is commonly found dilated and short, in some cases being of large enough caliber to admit 444 DISPLACEMENTS OF THE URETHRA 445 the penis. Many authors have assumed that the large size of the urethra in such patients is due to forcible dilatation during coitus, but as the large urethra is found in unmarried women who are the subjects of absence of the vagina — in patients who could never have been subjected to sexual intercourse — the condition of the urethra must be regarded as due to a partial persistence of the urogenital sinus. Intercourse has undoubtedly taken place through such a urethra in many instances, but we must not regard the dilatation by the penis as the primary cause of the large caliber. Epispadias is a defect of the upper wall of the urethra associated with separation of the labia minora and division of the clitoris. In extreme cases of epispadias there is also exstrophy of the bladder together with deficiency of the anterior bladder wall. The con- dition is rare, as is atresia of the urethra, which is supposed to be due to inflammatory affections late in intra-uterine life causing more or less complete occlusion of the urethral canal. There must be some avenue of escape for the urine even before birth or else the child has great distention of the abdomen from overfilled bladder, ureters, and kidneys. Partial atresia may be relieved soon after birth by passing a sound, as in the case reported by Mandl and cited by Kelly, in which a child two days old had vom- iting and convulsions until the atresia of the urethra was broken down by a sound. DISPLACEMENTS OF THE URETHRA AND ALTERATIONS IN FORM Upward Dislocation of the Urethra Upward dislocation of the urethra may occur from dragging on the bladder and the urethra in the case of large tumors and in pregnancy. It is supposed that the traction on the neck of the bladder may be the cause of frequency of urination, which some- times occurs in these cases; more often there are no symptoms at all. Rarely there is retention of urine, and the catheter, when passed, traverses a long route up behind the pubic bone. A soft rubber catheter is safer than a glass or silver one in such cases. 446 DISEASES OF THE URETHRA Downward Dislocation of the Urethra Downward dislocation of the urethra is a fairly common lesion resulting from child-birth. The entire urethra may be torn from its pubic supports, as in the case of procidentia, or only the upper portion may be freed from its fastenings. Not infrequently careful examination will reveal dislocation of the upper third of the urethra in cases where prolapse of the uterus is not present. We must suppose that in these cases the uterus and its ligaments have involuted and regained a normal state, while the sundered tissues under the pubic arch are unable to support the urethra in a normal situation. Downward dislocation of the urethra may be attended by no symptoms, or the patient may experience sudden stoppage of the urine during urination, or there may be partial incontinence. The tone of a dislocated urethra is apt to be below par, therefore such a urethra is more likely to become in- fected than is a normal one. Diagnosis. — The diagnosis is established by palpation of the urethra with a sound in its canal and a finger in the vagina, also by inspection of the vagina while the sound passes through the urethra, the patient being in the dorsal position. For this purpose employ a sound that is about three-sixteenths of an inch in diam- eter or a Kelly urethral dilator of the same caliber (4 millimeters) so that this larger sound may occupy the entire lumen of the urethra, and thus indicate the true course of the organ, and not — as would be the case with a small sound — enter a diverticulum, if present. With this sound passed so that its tip is just below the neck of the bladder, tilt the point downward and note whether the urethra is held to the os pubis or goes downward into the vagina. Next substitute a uterine sound for the dilator, bend the terminal inch of the sound to an angle of thirty degrees, and introduce it with the point downward. If the upper third of the urethra is dislocated downward the point of the sound, following the course of the displaced urethra, may be seen and felt in the vagina. In my private case records are the notes of fifteen cases of down- ward dislocation of the urethra not associated with uterine prolapse. In cases of uterine prolapse with accompanying dislocation of bladder and urethra, the course of the urethra in the prolapsed mass is mapped out with the bent sound in the urethra. DISPLACEMENTS OF THE URETHRA 447 Differential Diagnosis. — We must differentiate urethrocele, which is a pocket in the lower wall of the urethra — generally in the middle third of its course — from downward dislocation of the urethra. This is done by noting the general course of the urethra by means of a large sound or Kelly dilator passed to the neck of the bladder. Withdraw the sound and pass a bent probe through the opening in the urethral wall into the urethrocele, following the point of the probe with a finger in the vagina. Next pass a cysto- scope into the urethra and see the opening into the urethrocele, passing a probe through the cystoscope into the urethrocele to verify the diagnosis. Urine may collect in a urethrocele, decom- pose, and set up a urethritis. The urine is ejected during the act of coughing, laughing, or straining, and the patient complains of this sort of incontinence. Dislocation of the urethra downward must be differentiated from suburethral abscess, an abscess occupying the urethro- vaginal septum, varying in size from a cherry to a hen's egg. Such an abscess has a chronic course and is supposed to originate in Skene's glands, in a diverticulum from the urethral canal, or in a suppurat- ing cyst of the urethro- vaginal septum. It is the seat of pain and soreness during urination, defecation, and coitus,, the latter often being impossible of accomplishment because of the tenderness of the vagina. The abscess generally opens into the urethra by a minute opening, and pressure on it through the vaginal wall causes the sac to collapse as it is emptied. In some cases the patient experiences periodic discharges of pus from the urethra. If the cystoscope is passed up to the vesical neck and withdrawn, a few drops of pus will be seen to gush into its lumen after the tip of the cystoscope has passed the opening into the abscess. A probe passed into the opening and palpated per vaginam establishes the diagnosis. Dilatation of the Urethra. — Congenital enlargement of the urethra has been referred to in discussing the anomalies as a manifestation of the persistence of a urogenital sinus. Stricture or tumor of the urethra if situated near the meatus may cause dilatation of the urethra behind the stricture or tumor. All of the structures of the urethra are hypertrophicd during pregnancy and Skene thought that the urethra was dilated at that time. Artificial dilatation has been caused by coitus per 448 DISEASES OF THE URETHRA urethram and by introducing foreign bodies into the urethra for purposes of masturbation, and, also, dilatation of the urethra was formerly practiced by physicians for the purpose of digital ex- ploration of the bladder for suspected stone or tumors of that organ. The urethra is extremely tolerant of dilatation and bladder stones as large as an inch in diameter have been passed spontaneously through the urethra, followed by only temporary incontinence. Nevertheless, forcible dilatation of the urethra to a diameter of more than half an inch (12 millimeters) is entirely unjustifiable, because permanent incontinence is very apt to be the result. Few physicians possess a forefinger whose knuckle at the end of the first phalanx measures less than three-quarters of an inch (18 millimeters) in diameter and most forefingers are much larger. The interior of the bladder can not be palpated unless this knuckle is passed into the urethra. Examination with the little finger is inadequate, although the lower portions of the bladder may be reached with its tip. Modern methods of cystoscopy do away with the need of digital exploration and we may subscribe to Dr. Thomas Addis Emmet's vigorous statement to his students in the old days at the Woman's Hospital, that the man who dilates a woman's urethra with his ringer should be put in jail. The diagnosis of a dilated urethra is made by observing pouting of the meatus, and a distinct ridge in the vagina corresponding to the course of the urethra. By touch per vaginam the enlarged urethra may be felt as an elastic, rolled-up, membranous tube, and on introducing a large Kelly dilator into the urethra, it slips easily into the bladder. Moving the tip of a uterine sound about in the urethra we determine an enlarged canal, and by palpating the sound per vaginam we learn the thickness of the tissues of the urethro- vaginal septum. The No. 12 cystoscope passes easily, and the larger sizes of the urethral dilators introduced successively will tell of the exact diameter of the urethra. Prolapse of the Urethral Mucosa. — This rare affection consists of an eversion or turning out of the urethral mucous membrane through the meatus. For some reason the hypertrophied mucosa becomes loosened from its attachments and is extruded from the external orifice in the shape of a deep red or bluish tumor with the orifice of the urethra in its center. The extreme grade of this affection is most often found in debilitated old women and in DISPLACEMENTS OF THE URETHRA 449 young children; a moderate amount of eversion may occur in any woman who has had children. In the pronounced grades the prolapsed mucous membrane may become edematous or even gangrenous. The diagnosis is made by discovering a deep red tumor in the situation of the vestibule, that is covered everywhere with easily bleeding mucous membrane, and has a slit in its center that gives access to the bladder. If only a portion of o Fig. 183. — Prolapse of the Urethral Mucous Membrane. (Montgomery.) the circumference of the urethra is involved in the prolapse the everted mucosa may be mistaken for a polypus, a urethral caruncle, or eversion of the bladder mucosa. If the prolapsed mucous mem- brane is seized with a delicate pair of forceps and drawn down it will be found to have a broad base and will be increased in size; in the case of a polypus or caruncle drawing the tumor down will show a pedicle, and no increase in size beyond the elongation due 29 450 DISEASES OF THE URETHRA to traction. In many cases the everted mucosa may be replaced in the urethra by the use of cocaine and taxis. If the case is one of eversion of the mucosa of the bladder, the sound passed into the urethra can be made to sweep entirely around the tumor, and when passed further there is no bladder cavity to receive it. By taxis and pressure with a large-sized sound the prolapsed mucous membrane may be pushed into the bladder. Cystoscopy will show the distended bladder and the portion of the lining that had been prolapsed to be of a deep red color. INFLAMMATION OF THE URETHRA: URETHRITIS Urethritis is a common affection in women, though not so often diagnosed as in the male; " irritable bladder" and " cystitis," in the place of an exact diagnosis, often meaning urethritis. With the more general use of the endoscope we are learning more of this disease. It is most often due to the gonococcus, but may be due to an extension downward of a cystitis, to traumatism — as from injuries during childbirth or from the passage of a calculus — to urethral new growths, or to an extension upward of a vulvitis. The disease is limited to the mucous and submucous tissues, which are injected, swollen, and secrete pus; the upper and lower portions of the urethra being more often affected than the middle part. Urethritis occurs in two forms, acute urethritis, and chronic ure- thritis, the inflammatory process having a marked tendency to lurk in Skene's glands. This is true especially of the gonococcus form, which may be cured apparently, only to be lighted up anew into an acute attack when the gonococci have found fresh culture material in another individual. Acute Urethritis. — Acute urethritis begins with burning and itching in the neighborhood of the urethra, followed in one or two days by painful micturition. The body temperature may be elevated and anorexia and lack of energy may be present for a short time. The patient notices that her linen is discolored by a purulent discharge and even by blood; for there may be bleeding in the most acute stage. The local examination should be made before the patient has urinated. The dorsal position is used. A drop of pus appears in the meatus and the mucosa at the orifice URETHRITIS 451 of the urethra is injected, red, and swollen. Stroking the urethra from above downward by a ringer in the vagina, pus issues from the orifice of the urethra. If it does not come from the urethra it may be expressed from the openings of the canals of Skene's glands, which are situated one on each side in the lower portion of the labia urethrse just inside the meatus. The finger in the vagina notes increased body heat and tenderness of the urethra. In this acute stage it is just as well not to use the endoscope be- cause of the damage it must inflict on the inflamed mucosa. If it is used with the aid of a strong solution of cocaine, the mucous membrane is seen to be bright red and bleeding easily and pus issues from between the folds and from the minute glands, or there are to be seen linear ulcers two to four millimeters long and one millimeter broad, generally on the posterior wall. Great care should be exercised not to introduce the endoscope (Kelly Cysto- scope No. 8) beyond the bladder neck, for fear of infecting the bladder. Smears should be made and examined for the gonococcus. Concomitant inflammation of one or both of Bartholin's glands indicates probable gonococcus infection. Chronic Urethritis. — Chronic urethritis is the form of urethral inflammation most often seen by the gynecologist. It commonly follows acute urethritis, although the latter may have given very few symptoms and may not have been diagnosed. The disease is diffuse or circumscribed. (a) Diffuse Chronic Urethritis. — This generally follows acute urethritis. The longer the inflammatory process has existed the paler becomes the mucosa and the greater the thickening of the mucous and submucous tissues because of new formation of con- nective tissue. In the later stages of chronic urethritis the urethra is felt as a hard tube, only moderately tender to touch. The symp- toms may be nothing more than itching or burning in the region of the urethra and perhaps frequency of micturition. There is some swelling and a gelatinous and granular condition of the mucosa at the external orifice. The mucosa pouts out into the lumen of the endoscope so that the canal appears closed; it is dull red in color, granular and soft, and the lacuna?, crypts, and openings of the glands show as deeper red spots, perhaps giving exit to pus. The disease is most often met with in prostitutes. (b) Circumscribed Chronic Urethritis. — In this form one sees 452 DISEASES OF THE URETHRA through the cystoscope patches of pale, almost gray mucous mem- brane surrounded by the pale red, normal mucosa. Later the pale areas become whiter still as they represent scar tissue, and they sometimes form strictures of the urethra. When