DISPLACEMENT OF THE URETHRA.
There are in general four forms of displacement of the urethra : (1) Displacement upward; (2) Moderate downward displacement. (3) Complete displacement of the whole urethra downward; (4) Pro lapse of the mucous membrane of the urethra at the external orifice.
Upward displacement is seen in association with pelvic tumors, more particularly large myomata lifting the uterus up into the ab dominal cavity, and pulling along with it both bladder and urethra. In these cases the urethra may be so drawn up and flattened by com pression between the tumor and the symphysis as to make the pas sage of the catheter both difficult and dangerous. A similar difficulty is often experienced in catheterizing during labor, when the head of the child is well engaged in the pelvis. I know of an instance in which the doctor, not appreciating this difference in the di rection of the urethra in the parturient woman, in his efforts to draw off the urine before performing a Caesarean section, perfo rated the posterior wall of the urethra with the catheter and even forced the latter into the child's head several times, bring ing away some of the brain in the eye of the instrument. The opera tion was not performed, and the woman passed a dead child with several small holes iu its head.
This displacement will be relieved when the tu mor has been removed, letting the bladder and urethra down to their nor mal relations within the pelvis.
A. moderate downward displacement is found associated with a de scensus uteri and a dropping of the anterior vaginal wall and the formation of a cvstocele.
Complete downward displacement of the urethra occurs commonly with a prolapsus uteri. The direction of the urethra in these cases is at right angles to its former position. Owing to this extreme dis placement, which removes the urethra from the line of effective iutra abdominal pressure, as well as from its relation to the diverticulum of the bladder, the difficulty of emptying the bladder in prolapse is very great and considerable urine is almost always left behind.
This difficulty is corrected by the appropriate operation for the prolapsus, restoring the organs to their normal position.
Prolapse of the mucous membrane of the urethra is a disease more common at the extremes of life.. It has thus been noticed in little children a few months or a few years old, and in women of from forty-five to sixty years of age and over.
In the case of women it is usually an eversion of that part of the mucous membrane lying adjacent to the external orifice. It forms in these cases an intensely red, highly vascular tumor, in the centre or to one side of which the urethral canal is found. In one case ob served by Bagot in a woman aged thirty-two, the extruded part be came gangrenous and sloughed off.
In little children, on the contrary, the relaxation of the mucous membrane and the eversion take place from within outward. The tumor appears at the external orifice and may project an inch or more beyond it, being swollen, deep-red or bluish-red, sometimes bathed in pus. It has been noticed as a sequence of severe coughing in whooping-cough, or straining at stool in diarrhoea, and following the injury produced by rape. Weak, anmnic, and scrofulous children are most liable to it.
The treatment should not be by galvano-cautery, on account of the danger of contraction and stricture of the urethra, and it is of no use to replace the tumor, for it will invariably be reproduced. The treatment which has been adopted with the most success has been the union of the neck of the tumor with the margin of the urethra on all sides, by interrupted fine silk sutures. Care must be taken to pass the suture before cutting away the tumor, lest the severed mucous membrane retract within the urethra and bleed indefinitely before it can be secured again. It is best to leave a catheter in the bladder for two or three days.
Variations in Calibre.
Variations in calibre of three kinds are found in the urethra : (1) stricture; (2) general dilatation; (3) partial dilatation.