<Callout type="important" title="Important Rule">Always perform a careful search for gonococcus in chronic cases.</Callout> The speculum is passed through such cicatricial areas they show decreased elasticity and tear easily, causing bleeding. The chronic inflammation may be limited to the region of Skene's glands. In this case there will be reddening about the orifices of the ducts of the glands and pressure through the vagina will express a drop of pus or turbid serum from the gland. The discharge is apt to be thin and serous in the chronic cases, and gonococci are few. Careful search for this organism should be made. Skene's glands are among the chief lurking places of latent gonorrhea, the other most frequent situations being the cervical canal and Bartholin's glands. If the gonococcus can be isolated from the discharge from either of the latter organs, even though it is absent in the urethral discharge, the inference is that gonorrhea infection of the urethra is present also. Several microscopic examinations should be made from the discharges from each of the three situations before pronouncing that gonorrhea is absent.<Callout type="risk" title="Risk of Misdiagnosis">Several microscopic examinations are crucial to avoid misdiagnosing gonorrhea.</Callout> <Callout type="tip" title="Tip for Careful Examination">Use a conical calibrator to measure the urethral meatus, which should be over 6 millimeters in adults.</Callout> STRicture OF THE URETHRA Van de Warker as long ago as 1887 called attention to the frequency and importance of strictures of large caliber in women. My own experience has taught me that such strictures are relatively frequent and are found by the physician who does a good deal of cystoscopic work. In my private records are the notes of nine cases that I have seen, and Pasteau (quoted by Knorr) saw twelve cases and had collected one hundred and twelve from the literature. Strictures are caused by chronic gonorrheal urethritis, by injuries of the urethra during labor, by cicatricial contracture of the anterior vaginal wall, due to a slough, or very rarely to cicatrization of a chancre, or carcinoma of the urethra. Stricture at the meatus sometimes results from kraurosis vulva?. The symptoms of stricture are : painful and difficult micturition, the urine being passed in a small stream. A small meatus is very commonly met with in women and is diagnosed by passing the conical calibrator. Any measurement in the adult under 6 millimeters must be classed as small. A stricture is detected by passing the graduated urethral dilators and noting the situation and size of the point of resistance. Through the cystoscope one sees irregular rolling-in of the mucosa and asymmetry, the strictured portion being whiter than the surrounding mucosa, non-elastic, and bleeding if stretched.<Callout type="warning" title="Warning for Painful Micturition">Painful micturition can indicate a stricture; seek medical attention promptly.</Callout> NEW GROWTHS OF THE URETHRA 453 The new growths observed as occurring in the urethra are caruncle, polypi, cancer, and sarcoma. Urethral Caruncle. — Urethral caruncle is the term used to denote a highly vascular tumor which projects from the urinary meatus. It is a common affection. Lange has described three forms according to their pathology; (a) granuloma, (b) papillary angioma, and (c) telangiectatic non-papillary mucous polyp. a. The granuloma is characterized by infiltration of round cells and abundant capillaries, and is the result of a gonorrheal lesion of the urethra, b. Papillary angioma is a highly vascular mucous polyp. It has a covering of pavement epithelium with nipple-like elevations, and is invaded by connective-tissue elements, c. The telangiectatic variety is characterized by an abundance of thin-walled capillaries, these being so dilated often as to give the tissue a cavernous character; they may even contain cysts. This tumor has no papillae. All three varieties are found with equal frequency in middle life, the granuloma is more often found in young women between twenty and forty, and the papilloma variety in women over forty. As a rule, urethral caruncle is observed late in the childbearing period of life, although it may be found at any age from childhood to old age. The symptoms are excessive pain on urination and sensitivity of the vulva, even to the slightest touch, also frequency of micturition and derangement of the nervous system. Patients may hold their urine for long periods of time to avoid the pain experienced on passing it. Pains, which we may call sympathetic, radiate in all directions from the pelvis, just as in vaginismus. One of my patients complained of a spasmodic drawing up of one thigh so that when she walked one leg seemed shorter than the other. Physical examination showed no difference in the length of the limbs and no abnormality in the locomotor apparatus. The symptom was entirely done away with by the removal of the caruncle. Coitus is painful or impossible. The patient with a caruncle is apt to be morose, depressed, anxious, or even hysterical. The diagnosis is established by the appearances. On separating Fig. 184. — Urethral Caruncle. (Montgomery.) the labia one sees a brilliant red growth projecting from the meatus. It may look like a cock's comb or a very small raspberry and varies in size from a BB shot to a cherry, — large ones being unusual. Its surface is generally smooth, but may be roughened like the surface of a raspberry. The growth generally springs from the posterior wall of the urethra just inside the meatus and is either pedunculated or sessile. With a few exceptions urethral caruncle <Callout type="important" title="Important Rule">is exquisitely sensitive; now and then a non-sensitive tumor is seen.</Callout> It bleeds easily, but does not, as a rule, bleed enough to soil the patient's linen, but a purulent vaginal discharge is a common accompaniment of these growths, perhaps because they are frequently of gonorrheal origin. They are of slow growth and almost always recur when removed unless every bit of tumor tissue has been taken out; but the recurrent growth is like the first, and there is no tendency to malignancy or to extension beyond the original site. A thorough diagnosis can not be made often without cocaine or an anesthetic. The meatus must be dilated with the conical calibrator and the exact situation and extent of the base of the tumor determined by the aid of the cystoscope.<Callout type="tip" title="Tip for Diagnosis">Use a cystoscope to examine the urethra thoroughly.</Callout> Polypus of the Urethra. — Certain forms of caruncle are polypi, as already stated in the consideration of caruncle. Mucous polypi situated in the middle and upper urethra are very rare. They cause few symptoms and are to be seen through the endoscope. A few cases of fibroma of the urethra have been described and one or two cases of myoma. Primary Cancer of the Urethra. — This is a rare disease, there being on record in 1903 only nine authentic cases. Secondary cancer of the urethra, on the other hand, is not so uncommon. The primary disease is a disease of older women and seems to start in the tissues about the lower urethra more often than in the urethra itself and to invade the mucous membrane late. Strictly speaking, only the form of cancer beginning in the urethral tissues should be classed as cancer of the urethra, but after the mucous membrane has been destroyed the differentiation of the primary point of origin is necessarily difficult. The disease must be differentiated from caruncle, chancre, and tuberculosis. In caruncle the tumor is soft and does not increase in size; it is situated in the urethral canal, generally on the posterior wall. In the case of primary cancer the growth is hard and is seldom seen before it has involved a wide area. The ulcer of a chancre follows a suspicious intercourse with a definite period of incubation, twenty-six days. It heals in a short time, leaving a scar. The ulceration of cancer is of long duration, it extends to the surrounding parts, and the history of infection is absent. Perhaps the Spirochseta pallida can be isolated from the discharge. In the case of a tuberculous ulcer the cheesy matter and the tubercles, characteristic of tuberculosis, may be seen by the naked eye, and there is little or no induration of the base of the ulcer as in the case of both cancer and chancre. In all doubtful cases a piece of tissue should be excised for microscopic examination.<Callout type="warning" title="Warning for Cancer Diagnosis">Cancer can mimic other conditions; always seek expert diagnosis.</Callout> Sarcoma of the Urethra. — This is a very rare disease, only four cases having been reported. Three of the cases were in women fifty years of age or older, and the fourth in a child of three. The symptoms are bleeding and the presence of a tumor in the situation of the urethra. The tumor is to be removed and examined under the microscope.<Callout type="important" title="Important Rule">Always remove and examine any suspicious growths for cancer.</Callout>
Key Takeaways
- Perform a careful search for gonococcus in chronic cases.
- Use the conical calibrator to measure urethral meatus size.
- Dilate the urethra with graduated dilators and use cystoscopy for thorough examination.
- Be aware of recurrent growths after removal of caruncles or polyps.
- Always remove and examine suspicious growths for cancer.
Practical Tips
- Regularly check for any unusual symptoms such as pain during urination, which could indicate a stricture or other urethral issues.
- Use lubricants to reduce friction and discomfort when inserting speculums or calibrators into the urethra.
- Keep detailed records of patient history and symptoms to aid in accurate diagnosis.
Warnings & Risks
- Misdiagnosis can lead to untreated conditions, so thorough examination is crucial.
- Painful micturition could indicate a serious condition like stricture; seek medical attention promptly.
- Recurrent growths after removal of caruncles or polyps are common and should be monitored closely.
Modern Application
While the techniques described in this chapter are historical, the principles of thorough examination and accurate diagnosis remain relevant. Modern tools and methods have improved diagnostic accuracy but the importance of careful observation and patient history has not changed. This knowledge still matters for understanding potential issues and ensuring proper care.
Frequently Asked Questions
Q: How can one differentiate between a urethral caruncle and cancer?
According to the chapter, in caruncles the tumor is soft and does not increase in size, while primary cancer of the urethra causes hard growths that are rarely seen before involving a wide area. Additionally, cancer ulcers have long duration and extend to surrounding parts, unlike the short-healing chancres.
Q: What is the significance of examining Skene's glands during diagnosis?
The chapter states that chronic inflammation may be limited to the region of Skene's glands. Pressure through the vagina can express a drop of pus or turbid serum from these glands, which helps in diagnosing conditions like gonorrhea.
Q: What are the symptoms of urethral strictures?
The chapter mentions that symptoms include painful and difficult micturition with urine being passed in a small stream. A small meatus is often present, diagnosed by passing the conical calibrator. Strictures can also cause irregular rolling-in of the mucosa and asymmetry when examined through a cystoscope.