2. Much rarer than dilatation of the urethra is narrowing, stenosis et strictura urethrie in women.
The causes are chiefly three; and they mark the three forms of the malady. First we have lesions of the urethro-vaginal septum, followed by cicatrization; they are seen chiefly after severe labors. Cicatricial bands are found at the vaginal entrance. Thus in Scanzoni's case (1858) there was a urethral stricture 4 to 5 lines from the meatus, which could be felt with the finger, as a cartilaginous prominence along the line of the urethra; it had been caused by a gangrenous colpitis after a forceps delivery. In Gayet's case an analogous injury caused a circular stricture at the ostium vaginm, and there was so much callous tissue under the arch of the pubis, that the urethra was almost entirely closed. Ledetsch reports a similar ease.
A tumor in the urethral wall is a much rarer cause. These may be phlebectasies, polypi, vascular or fibrous tumors.' They only obstruct the lumen when small, causing dilatation where they are more developed.
A still more rare cause of stricture of the female urethra is a urethral chancre. Scanzoni found such a one in a prostitute 5 lines from the meatus; it caused. a stricture so close that only with difficulty could a crow-quill-sized sound be introduced into the bladder. Similar to this is the case of V elpeau and one of Larcher's (in his other three cases the cause was unknown.) Lewin found among 612 women treated at the Berlin Charit6 for pseudo-syphilis, 6 with urethral ulcerations, and 5 with ulcerations of the urethra and of the labia pudenda. Boucher found in a case that had long suffered from leucorrhcea and ulceration of the os uteri (though the record does not say whether she was specifically infected or not), two hardened and strictured places near the anterior mouth of the urethra, which could only be passed by the minute olive of a small bougie with considerable pain.
Stenoses of the urethra itself occur with chronic vesico-vaginal fistulae. The passage is often so narrow as hardly to admit the smallest-sized bougies. Very lately I examined two patients with lesions of this kind.
The vesico-vaginal fistulas resulted in both cases from operative confine ments, and the callous urethro-vaginal stenosis was such that only with the greatest of difficulty could a very fine sound be introduced.
Compression of the urethia in retroflexion of the uterus, by present ing parts during delivery, by limmatocolpos or Inematometra, etc., need not detain us; their results mainly affect the bladder, and will be con sidered under that he,ad.
Like the causes, the symptoms of urethral strictures and stenoses are very various. Those due to vesico-vaginal fistulae, simply render cathe terization difficult Those caused by cicatricial tissue obstruct urination; the stream becomes smaller, the bladder can only be emptied by a con siderable exertion of the abdominal muscles, and finally the urine can only be voided in drops, and retention may occur. It is well known that in the female also hypertrophy of the bladder occurs under these circum stances. Scanzoni lays stress upon the deleterious influence exercised by hypertrophy of the bladder, following stricture upon the neighboring organs, the uterus and the vagina; he has often noticed descent of the anterior vaginal wall in consequence of it.
If we made a thorough examination of every patient that comes to us complaining of difficulty of urination; if we carefully examined the meatus and palpated the urethra from the vaginal, and then introduced a catheter, following its advance with our finger in the vagina; it would be almost impossible to mistake stricture of the urethra for any other condition. The urine should then be carefully examined, since vesical catarrh and irritation may not only cause frequent desire to urination and dripping, but may hinder the entrance of a catheter by reflex contrac tions of the urethra and bladder. It must of course not be forgotten to examine per vaginam for a urethral tumor before passing the catheter, and if it is present, to push it if possible to one side during the operation.