Selection of—The various forms of treatment which have been recommended for stricture are the following: 1. Caustics.
2. Continuous dilatation.
3. Gradual dilatation.
4. Dilating urethrotomy, or a combination of section and rupture.
5. Divulsion or rupture.
6. Internal urethrotomy.
7. External perineal section or urethrotomy with a guide.
8. External perineal section without a guide.
9. Electrolysis.
10. Subcutaneous section.
11. Excision, with or without a plastic operation.
The treatment of stricture by caustics is a relic of surgical bar barism, and is hardly worthy of serious attention. The objects for which it was originally recommended were (1) the destruction of the stricture, and (2) diminution of the sensibility of the mucous membrane for the purpose of allaying irritability and spasm of the canal. The substance used was generally caustic potash. Whatever the results may have been, as far as restoring temporarily the calibre of the canal was concerned, the inevitable consequence of such atro cious surgery must necessarily have been the substitution of a chemical stricture for an ordinary organic one. As is well known, stricture due to actual destruction of tissue is the most severe form with which we are called upon to deal. All the other methods of treat ment which have been enumerated have their advocates at the present day—either as a. matter of routine or a range of treatment from which to make a selection—and may under proper circumstances be prac tised with advantage in different cases. The selection of the method is necessarily—within certain limits—a matter of choice on the part of the individual surgeon. The various legitimate methods will receive special consideration after their applicability to the various forms of stricture has been outlined.
Of the various methods enumerated, there are but two which in the opinion of the author require serious consideration, these being dilatation, continuous or systematic, and urethrotomy, internal and external.
For practical purposes the surgical treatment of urethral stricture may be divided into that of To a certain extent the treatment of each particular case is modified by the calibre of the contraction; for example, in tight strictures which it seems advisable to treat by sounds, metallic instruments should not be used until a moderate amount of dilatation has been attained. The treatment is further modified by the occurrence of
complications, such as false passages, retention of urine, severe cystitis and pericystitis, infiltration of urine and abscess, fistulae, enlarged prostate, etc.
Stricture of the Meatus.—This demands division by the knife ir respective of the cause of the stricture. In the of a patho logical condition of the urethra, any meatus which prevents the in troduction of an instrument of sufficient size to distend the remainder of the canal to its extremest capacity, should be considered as strict ured. The incision should always be made in a downward direction, and if care be taken to divide all strictured bands behind the ex ternal orifice with the belly of the knife, a sufficiently large meatus can always be obtained without the production of deformity. The after-treatment of meatotomy consists in dilatation every second day until healing has taken place.
Stricture of the Penile Urethra.—Strictures in the penile portion of the urethra when recent and soft may yield to dilatation. Strictures of large calibre, the foundation of which is a normal, or at least a congenital, point of relative inelasticity of the canal, are not likely to yield to dilatation. The author believes that his experience justi fies him in asserting that in by far the larger proportion of cases of penile strictures the gleety discharge characteristic of such conditions usually continues—perhaps with acute exacerbations—until the ure thra has been put completely at rest and the source of irritation re moved by urethrotomy. If the penile stricture be very tight, pre liminary dilatation is usually preferable to an extensive primary ure throtomy. Strictures of the penile portion of ,the canal are quite likely to be multiple. When such strictures are irritable, as they are likely to be, very slight causes are sufficient to produce a urethritis, the severity of which depends upon the degree of irritation. The pres ence of reflex symptoms referable to the prostate, bladder, or kidney invariably demands urethrotomy.