DIAGNOSIS - SPASMODIC STRICTURE.
The diagnosis of spasmodic stricture is usually comparatively simple, particularly in those cases in which retention comes on slid denly. It is obvious that the sudden occurrence of retention in a case of organic stricture, or other obstructive lesion of the genitourinary tract, in which the stream of urine has been previously only moder ately lessened in size, must depend upon some complicating condi tion—either inflammation and congestion at the site of the organic lesion, spasmodic contraction of the cut-off muscle, or both condi tions in combination. A certain degree of inflammation or conges tion is to be inferred in every case of spasmodic retention of urine and requires due consideration; the predominating element of spasm is, however, the principal feature.
As a rule, in cases of sudden retention of this kind there is a history of some one or more of the exciting causes which have been enumerated.
In determining the dependence of retention of urine upon spasm, it is necessary to remember that in by far the majority of cases there is some organic foundation for the condition. When, in the course of treatment for organic stricture of small calibre, retention suddenly occurs, the predominating condition is usually congestion or inflam mation. The occurrence of acute urethritis during the course of marked organic stricture is apt to superinduce sudden retention. The condition in these cases—although a spasmodic element exists— is mainly congestion and inflammation at the site of the stricture, which produces sufficient swelling to completely close it for the time being. Urethritis produced by the introduction of instruments brings about retention in the same way. Cases of stricture of large calibre, in which there is little or no obstruction to the passage of urine, may suddenly develop retention from spasm. It is doubtful
whether congestion or inflammation alone could produce closure of the canal in such cases.
It is sometimes difficult to determine, during instrumentation of the canal, how much of the obstruction to the passage of instruments is due to organic contraction, and how much to spasm. For exam ple, after an instrument has passed a stricture of large calibre in the penile portion of the urethra, or an inflamed and irritable meatus, it will be found to be obstructed in many cases as it enters the mem branous region. A steel instrument is less likely to be obstructed than a soft bulbous one, and the spasm is more likely to yield to steady and gentle pressure against it with the point of the sound than to a soft bulb. If there be organic contraction in slight degree at the bulbo-membranous junction, a steel instrument small enough to pass the stricture in the anterior portion of the canal will, in all probability, slip by and fail to detect it. A large bulbous instrument will usually fail to pass altogether, but if a small bulbous Bougie be introduced, it will be found that the spasm of the surrounding mus cles, although insufficient to obstruct the passage of the instrument into the bladder, will at the same time contract the stricture in such a manner that the shoulder of the instrument impinges upon it as it is withdrawn. The peculiar feel imparted to the boogie, and the sudden snap produced by the passage of its shoulder through the organic contraction, will determine the exact nature of the case.
There are some exceptional cases of chronic spasmodic stricture in which the real condition can be demonstrated only by the subtrac tion of all sources of direct or reflex irritation, after which the sup posed organic stricture will disappear.