GENERAL DILATATION OF THE URETHRA Relaxation of the urethra as a whole is most frequently observed in cases where coitus has taken place per urethram, or where the urethra has been dilated by the finger for the examination of the blad der, or for the extraction of a stone. Cases of relaxation due to the latter cause are fortunately becoming rare, and ought never to occur.
Relaxation due to coitus per urethram is found in cases of mal formation of the external genitals interfering with coitus per vagi nam, as in the case of imperforate hymen, or absence of the vagina. I saw an extreme case of relaxation of this form in one of my cases, in which the urethra lay inside the vaginal orifice behind the symphysis pubis, and below it were two small orifices divided by the septum; it was a case of double vagina, so placed as not to be infringed upon by any large body introduced from without.
Another class of cases is that in which atresia has been acquired through inflammatory affections following childbirth; thus in the patient figured in the text, a black woman, the vagina was closed clown to a fine fistulous orifice about the size of a hair. The only trace of the vagina left below the atresia was a little pocket. Above was a large hDematokolpos and hmmatometra. The urethra was so relaxed that in examining the patient the index finger passed at once into the bladder without the examiner being conscious of the abnor mal condition. When the patient was two fingers could easily be carried into the bladder.
The symptoms produced by this condition are variable. Where the urethra has been broken down by an examination or by dragging out a stone, persistent incontinence may be the result, the patient having no power to control the flow of urine, which dribbles contin ually over her person. In relaxations from coitus, strange to say, the patients are not usually troubled with incontinence, being able to hold the urine two or three hours. But it usually escapes when the woman laughs or during the strain of sudden lifting.
the relaxation is due to coitus, it will be best not to touch it unless the vaginal canal can be restored. In the case of the black woman above referred to, the urethra was relieved of its abnormal function by an operation establishing the integrity of the vaginal canal. The case of relaxed urethra with double vagina was re
lieved by a plastic operation bringing the lower margin of the urethra farther forward, and by cutting away the septum between the two halves of the vagina, substituting a single larger for two smaller func tionally useless canals.
Where the incontinence is due to manual or instrumental break ing down of the canal, Schultze has recommended an operation to re store the urethra with the neck of the bladder to its normal calibre, by first splitting the vaginal mucosa over the urethra and then draw ing out the excess of the dilated canal and cutting it off with sharp scissors, uniting the raw surfaces again by suture.
Winckel treated a case by excision of a piece of the anterior vagi nal wall 8 cm. (3 in.) long, and from 1 to 1+ cm. (- to in.) in breadth, beginning at the very margin of the urethra. The wounded surface thus exposed was closed with twelve silkworm-gut sutures. He did this at first without removing any of the mucous membrane, and the improvement was but moderate. At a second operation a piece 2+ cm. long by 1+ cm. broad was excised, including a piece of the mucous membrane of the urethra from 4 to 5 mm. in breadth, as recom mended by Frank in Cologne, in the Centralblattliir Gyniikologie, No. 9, 1882. The result this time was so good that the patient was able to bold 500 c.c. of urine and was completely relieved of the trouble.
Pawlik cured a case of incontinence, remaining after the closure of a large vesico-vaginal fistula, by excising a wedge-shaped piece on one side of the urethra extending a short distance up into the vagina. The wound was brought together by sutures, and after it had thoroughly healed a similar operation was performed upon the opposite side. The result of both operations was to pull the urethra out flat by tension on its two sides and to produce a distinct bend in the urethral canal. (Wiener medizinische Wochenschrift, 1883, Nos. 25 and 26.) Schatz has been able to relieve incontinence by the use of funnel shaped pessaries placed within the vagina.
A similar result has been obtained by a glass ball pressing the neck of the bladder against the symphysis pubis.