STRICTURE OF THE URETHRA.
Strictures of the urethra are usually circular or tubular and result from an antecedent gonorrhoea. Stricture may also result from trauma. I have seen one case of carcinoma in which the urethra was narrowed throughout its length by a longitudinal infiltration parallel to the canal. Marked narrowing of the urethra is also not uncommonly observed when carcinoma involves the urethro-vaginal septum.
Van • de Warker lays great stress upon strictures of the urethra of larger calibre, comparing them to these strictures in the male. In deed he thinks they are more frequent than in the male, and result either from gonorrhoea or from trauma in childbirth. They are more rare in young women. These strictures are not to be detected by an ordinary sound. The best way to detect their presence is by passing an olive-pointed bougie which trips over the ring of the stricture as it is withdrawn.
The diagnosis of stricture of small calibre is often made accident ally in the difficulty experienced by the first attempt to catheterize the patient. In one of my cases, in which I performed a cholecystotomy, I was able only with difficulty to introduce a catheter 2 mm. in diam eter through a stricture which lay immediately behind the meatus. In another case suffering from extensive ulceration of the external genitals and elephantiasis, the lower part of the urethra was con verted into a rigid tubular canal.
Upon introducing the speculum the contracted lumen of the stric tured urethra is seen closing over in front of the orifice of the speculum, which cannot be pushed any farther in without undue force.
Treatment.—This consists in dilatation by graduated bougies, which is usually not difficult, on account of the shortness of the canal making the stricture easily accessible. The best dilators are slightly sigmoid in shape, the sizes increasing a half-millimeter each time from 3 mm. up to 12 mm. At one treatment sufficient dilatation, from 2 to 5 or 6 mm., can be obtained to allow the urine to pass readily. At the subsequent treatments, the dilatation can be carried up to 8 or 10 mm., at which point it must be maintained.
For the first thorough examination it is best to give anesthesia, and afterward to continue the dilatations under cocaine.
It is important to keep these cases under observation a long time, because a stricture which has been dilated shows a persistent ten dency to contract again. In one of my cases I had a dilator made the size of one of my No. 8 endoscopes, that is, 8 mm. in diameter, and taught the patient to pass it herself. I saw her a year later and learned that by using the dilator at intervals she had had no fur ther difficulty.
Where the injury to the anterior part of the urethra is extensive and associated with a large amount of cicatricial tissue, it will be better to buttonhole the urethra behind the stricture, by incising the ure thro-vaginal septum, taking care not to touch the neck of the bladder by keeping as far anterior to it as the stricture permits, and attaching the mucous membrane of the urethra on all sides to the mucous mem brane of the vagina.