CHAPTER XXV THE DIAGNOSIS OF DISEASES OF THE URETERS (Part 1)

CHAPTER XXV THE DIAGNOSIS OF DISEASES OF THE URETERS Anomalies, p. 486: Double ureter, p. 486. Abnormal situation of ureteral orifice, p. 486. Cystic dilatation of an occluded ureter, p. 487. Ureteritis, p. 488. Stricture of the ureter, p. 489. Ureteral calculus, p. 490. Prolapse of the ureteral mucosa into the bladder, p. 491. Ureteral Fistulse, p. 492: Uretero-uterine, p. 492. Uretero-vaginal, p. 492. Uretero-vesical, p. 492. Uretero-intestinal, p. 493. New growths of the ureter, p. 493. The anatomy and physiology of the ureters and the methods of examination will be found described in Chapter VIIL, page 104. ANOMALIES Anomalies of the ureter are rare. One ureter has been found wanting, just as one kidney is sometimes absent. It is the rule that extreme degrees of ureteral malformations are associated with non- viable fetuses. Double ureter is the anomaly most frequently observed. The duplication may start at the kidney from two separate pelves and then unite at some point below to form one canal to the bladder, or it may continue double and enter the bladder by two orifices, one behind the other. Cases are reported in which a double ureter was found on each side in the same patient. The anomaly has little if any clinical importance and is discovered in the course of cystos- copy, during operations on the kidney, or at autopsies. Abnormal Situation of Ureteral Orifice.— The ureteral orifice has been found in one of the following situations: the vagina, the urethra, near the external meatus, and under the prepuce of the clitoris. The patient suffers from persistent leakage of urine, but at the same time empties her bladder at regular intervals. The importance of finding out whether the abnormally placed ureteral orifice is the only outlet of a ureter or a supernumerary orifice is apparent. 485 ANOMALIES 487 The history of incontinence existing from birth in a virgin is a presumption in favor of abnormal congenital implantation, al- though the other causes of incontinence of urine (see Chapter X., page 154) must be investigated. If, on the other hand, the inconti- nence dates from a difficult labor, or the patient has been subjected to some operative interference, the probability is that an abnormal situation of a ureteral orifice has been artificially induced. If the orifice should be under the prepuce of the clitoris, drying the vulva with cotton and watching it will soon determine the source of the urine. If the orifice is in the urethra the urethra must be inspected through its entire length most carefully with a cystoscope in order to find the opening. If in the vagina, the vagina is dried with cotton after a speculum has been introduced, and search is made for the ureteral orifice. By placing a light packing of dry absorbent cotton in the vagina and removing it, one may fix approximately the situation of the opening by the situation of the spot of urine on the cotton. Does the wet cotton smell of urine? A fine probe may be used as a searcher. The bladder is injected with milk and water or aniline-blue solution to rule out this viscus as a source of the escaping urine. If none of the colored fluid escapes into the vagina the opening found in the vagina is a ureteral orifice. Cys- toscopy is now performed and search made for both ureteral orifices in the bladder. If only one is found the inference is that the opening in the vagina is of the opposite ureter. A sterile ureteral catheter is passed into it and the catheter palpated by rectal examination. If two orifices are found in the bladder a ureteral catheter is passed into each and an attempt made to touch one of them with the tip of a probe introduced into the orifice in the vagina, thus determining a supernumerary orifice, and also on which side of the body, and with which kidney it is connected. Cystic dilatation of an occluded ureter has been reported. In this anomaly the lower end of the ureter has failed to communicate with the bladder or with any other part of the genital tract. The reported cases have been in adults. In one instance the ureter ended in a cyst that was mistaken for a cyst of the vagina. Uterine anomalies are apt to accompany the blind ending of a ureter; sometimes the ureter may end without dilatation. In either event the corresponding kidney is the seat of hydronephrosis or it is atrophied. 488 DISEASES OF THE URETERS In all ureteral diseases as well as in cases of suspected nephritis the physician must watch each ureteral orifice separately and note the character of urine issuing from it, whether clear, turbid, or bloody, the force with which the urine is ejected, and the rate of frequency of the spurts. It will be found that in the case of a diseased kidney of diminished functional capacity the rate of spurting from the ureteral orifice will be much diminished — perhaps only once in two minutes — while the orifice from the sound kidney spurts urine every twenty seconds. Where the kidney is atrophic there may be no discharge of urine from the ureter on that side. URETERITIS Inflammation of the ureter arises from extension of inflammation downward from the kidney, upward from the bladder, from some cause in the ureter itself — as from a calculus in the ureter — or from inflammation in the cellular tissue surrounding the ureter, — periureteritis, so-called. As a rule the disease is due to the tubercle bacillus, to the gonococcus, or to the colon bacillus, except in the cases of stone in the ureter; and ureteritis is secondary to disease of the kidney or bladder, therefore its symptoms are often over- shadowed by the symptoms of those diseases. Pain in one groin extending up to the kidney on the same side, with frequent and painful micturition and pus in the urine, are the symptoms of ureteritis. The diagnosis is established by the symptoms and by the physical examination. Palpation of the base of the bladder and the lateral vaginal fornix will detect a tender, thickened cord cours- ing toward the posterior pelvis. This cord may be traced a little farther by rectal palpation. An acutely inflamed ureter is very sensitive. The abdominal course of the ureter may be palpated in patients who are not too fat by finding the promontory of the sacrum, and rolling the abdominal wall over a point situated two fingers' breadth to one side, for at this point the ureter crosses the brim of the true pelvis. If the ureter is inflamed at this point the patient will experience pain when it is pressed against the under- lying bone. Through the cystoscope the orifice of an inflamed ureter will generally be found in a puffy and swollen mons situated in an area of injected mucosa, and cloudy urine may be seen to issue from it. STRICTURE 489 STRICTURE OF THE URETER Stricture or obstruction of the caliber of the ureter is much more common in women than in men. It may be due to (a) pressure from without, to (6) a foreign body in the canal, or to (c) localized contractions or narrowing of the lumen caused by inflammatory action or to valve formation in the walls of the ureter itself, a. Some of the causes of obstruction of the ureter from without are : — Ovarian and uterine tumors, cancerous infiltration of the broad ligaments, thickened bladder walls, and tumors of the bladder. b. The bodies that may obstruct the canal of the ureter are: a calculus, a blood clot, or an echinococcus cyst. c. The affections of the ureteral walls are ; ureteritis, valve formation in the ureteral wall, cancer of the ureter, and gumma of the ureter. The situation of obstruction is almost always in the pelvic portion of the ureter, rarely in the upper end near the pelvis of the kidney. Certain diseases of those mentioned are apt to cause obstruction of both ureters. They are: cancer of the cervix extending into the bases of the broad ligaments, thickened bladder walls from *any cause, and subperitoneal fibroid tumors. In other cases the obstruction is apt to be unilateral. The symptoms depend on whether the obstruction is of sudden or of gradual occurrence. In the former case there is pain in the course of the ureter; in the latter, there may be no symptoms at all. If the obstruction depends on ureteritis the symptoms will be those of ureteritis. Persistent pain in the course of the ureter and pus in the urine should lead to an investigation of the cause. The diagnosis is made by palpating the ureter by vagina, by rectum, and at the pelvic brim, as described in the diagnosis of ureteritis. Search should be made for tumors of the pelvis, or for exudates which may press on the ureter, remembering that it is in the pelvis that obstruction generally occurs. Catheterization of the ureter through the cystoscope will show, first, that the catheter meets a sudden check, or after meeting a less pronounced obstruction it may pass by a narrowed part of the ureter, whereupon there is an immediate flow of an ounce or more of urine. Perhaps the catheter will be seized at the stricture and resist withdrawal. 490 DISEASES OF THE URETERS In introducing a metal catheter into the ureter for searching purposes it is well to have the patient in the dorsal position, so that after the catheter is in place its further course may be guided by the finger in the rectum. In using the gum-elastic or renal catheter the examination is begun with the patient in the knee-chest position. After the catheter has been introduced the patient is lowered to the dorsal position and a bladder catheter passed to let the air out of the bladder. The point where the stricture is situated is noted by withdrawing the catheter until the eye has become engaged in the stricture. At this point the flow of urine stops. Measure from the outer end of the catheter to the meatus urinarius. After the catheter is out the difference between this measurement and the total length of the catheter is the distance of the upper part of the stricture from the meatus. To determine the distance of the stricture from the bladder, subtract from the last measurement the distance from the meatus to the ureteral orifice, as measured by the ureteral searcher passed through the cystoscope. Graduated whalebone bougies have been used to determine the situation and size of strictures of the ureter by various investigators. I have had the best results with the Kelly gum-elastic renal catheters which contain stylets. URETERAL CALCULUS A calculus is much more often found in the renal pelvis or in the bladder than in the ureter. If the calculus has been lodged in the ureter for any considerable length of time it is apt to have a spindle shape. The calculus forms in the pelvis of the kidney and works down into the ureter; it may be about an inch (2.5 centimeters) long and »a quarter of an inch (5 millimeters) in diameter, but smaller ones are most often seen. A calculus five inches (12.5 centi- meters) long has been observed. Calculi generally lodge just below the pelvis of the kidney, at the pelvic brim, and in the pelvic floor. Severe pain in the course of the ureter, — often accompanied by chills and rigors, rapid pulse, and prostration, — is characteristic of the lodgment of a stone in the ureter. Paroxysms of pain come on intermittently at variable intervals as long as the stone is in the ureter. If the stone moves downward by irregular gradations PROLAPSE OF THE URETERAL MUCOSA 491 its movement may be traced by the appearance of blood in the urine. The stone, damming up the urine, causes hydroureter and by forming a ball valve in some cases permits the intermittent discharge of large quantities of urine. In the course of time the kidney is damaged by the back pressure of urine, by infection, or by both. The diagnosis is established by the symptoms, by palpation, and by catheterizing the ureters. A stone in the pelvic floor may be palpated by vaginal and rectal palpation and at the pelvic brim by abdominal palpation. In the upper part of the true pelvis a stone may be felt by high rectal palpation. Through the cystoscope a stone may be seen projecting from the ureteral orifice or pushing the mons into the bladder; if not, it may be touched with the metallic ureteral catheter introduced in the ureter. To detect a stone high up in the ureter Dr. Kelly uses a flexible renal catheter tipped with a light coating of dental wax, noting, after the catheter has been withdrawn, the scratch marks made by the stone on the wax. The X-rays may be used to detect the presence and situation of a ureteral calculus, a competent radiologist being employed to obtain a photograph, and also, if the calculus is in the upper portion of the ureter, an exploratory incision may be made either through the abdomen in the linea semilunaris, or extraperitoneally in the lumbar region, as for nephrectomy. If an incision is made plans should be perfected beforehand to proceed with an operation for the removal of a stone should palpation through the wound reveal its presence. PROLAPSE OF THE URETERAL MUCOSA INTO THE BLADDER Prolapse of the ureteral mucosa into the bladder has been found rarely in children and is probably congenital. It is thought to depend on stricture of the ureteral orifice causing the lower end of the ureter to project into the bladder in the form of a cystic tumor, the obstructed ureteral orifice being at some point on the circumference of the tumor. Cases of acquired prolapse of this sort have been reported and it is likely that the disease occurring in children has the same mechanism of causation. 492 DISEASES OF THE URETERS URETERAL FISTULA A ureteral fistula is an abnormal opening between the canal of the ureter and the surface of the body, or some part of the genital or alimentary tract. Ureteral fistula? are congenital, as pointed out in the consideration of anomalies, page 486, or they are produced by trauma, — most commonly as a result of a difficult labor, — from injuries in the course of operations on the pelvic contents or on abdominal tumors, or they are caused by ulceration. They involve generally the pelvic portion of the ureter. Difficult labor may cause sloughing of the uterus or vagina and the ureteral wall, leaving a permanent uretero-uterine or uretero-vaginal fistula. The ureters have been cut in the course of hysterectomy many times, — sometimes when the cause of death has been set down as exhaustion or peritonitis. In cases where the patient has survived, the urine finds its escape through the drainage tract either in the abdominal wall or in the vagina. In one of my cases the ureter discharged through the canal of the cervix uteri, a supravaginal amputation having been performed for a large fibroid. The opening healed spontaneously in the course of a few weeks. This is the issue in many cases. Sometimes, however, the fistula is permanent. A ureteral stone has been known to ulcerate through the walls of the ureter and bladder, finding its way into the latter viscus and forming a uretero-vesical fistula. In making a diagnosis of ureteral fistula it is to be remembered that in the congenital forms the opening of the ureter is generally situated low down near the external genital organs, i.e., under the prepuce of the clitoris, near the meatus urinarius, or in the lower vagina; in the acquired forms, on the other hand, the opening is more apt to be higher up near the base of the bladder, or in the vault of the vagina. The congenital fistula? have a history of loss of urine since childhood, whereas the acquired date from some operation, a difficult labor, or from some definite date. If only one ureter is involved in the fistula, the usual happening, the patient passes urine by the urethra as well as experiencing the discomfort of more or less constant leakage. If the fistula is into a vagina closed by a tight hymen the loss of urine may occur only when the patient is in the erect posture. NEW GROWTHS OF THE URETER 493 The bladder is injected with aniline blue and water, or with milk and water, and if there is a fistula involving the bladder and the uterus, or bladder and vagina, the escape of the colored fluid will be noted. If there is a fistula in the lower pelvic course of the ureter a metal ureteral catheter passed into this ureter will go an inch or two but not beyond the situation of the fistula, whereas in the sound ureter it may be pushed gently well up into the pelvis, some three inches. Uretero-intestinal fistula is apt to be the sequel of an operation, but may be congenital. If the ureter opens into the intestine infection commonly passes up the ureter to the kidney. This has been the result of artificially turning the ureters into the rectum because in this case there is no valve at the orifice to protect the ureter. The urine is generally irritating to the rectal mucosa and the patient when constipated feels a desire for defecation and passes urine without feces per anum. Cystoscopy shows only one ureteral orifice, or one orifice transmitting urine and the other functionless. NEW GROWTHS OF THE URETER Primary tumors of the ureter are rare. E. Garceau (" Renal and Ureteral Tumors," 1909) mentions fourteen cases of strictly localized primary ureteral tumors which he has analyzed, ureteral calculus being associated with two of these. The more usual forms are epithelial growths occurring in