URINARY SYSTEM, SURGICAL DISEASES OF (CoNnsuEn).
Diseases of the Urethra.
Anomalies of the Urethra.—The roof of the urethra may be absent, epispadias; or the floor may be deficient, hypospadias. The condition of epispadia is associated with exstrophy of the bladder. These conditions arc not infrequent, hypo spadia, however, being the more com mon.
Congenital narrowing or occlusion of the urethra and entire absence of the canal are of such rare occurrence that their consideration is almost superfluous. Narrowing, or atresia, should be treated in the same manner as acquired strict ures in the same situation. Occlusion is most often due to a thin membrane, which may be broken through with a bougie. If firmer and of greater extent, it may be divided by means of an ap propriate knife, or by external incision, either with or without suprapubic cys totomy, and retrograde catheterism, ac cording to the situation and extent of the obstruction.
Injuries of the Urethra.—Wounds of the urethra may be produced from with out or within. Punctured wounds from without will probably require a perma nent rubber catheter for some days and the ordinary treatment of the ex ternal wound. Full-sized urethral bou gics should be passed at intervals subse quently to prevent undue contraction of the scar.
External lacerated wounds, involving the urethra, require a permanent cath eter. The urethra should be united over this with fine catgut sutures if pos sible. The external wound should be al lowed to heal by granulation usually. Exceptionally, clean wounds in favor able condition may be closed by primary suture. Careful suturing of the urethra will do much to prevent the formation of a troublesome stricture. At the end of a week or ten days the catheter may be removed, after which a steel bougie of appropriate size should be introduced at regular intervals.
Injuries of the urethra produced from within, usually false passages caused by attempts at passing metal instruments in cases of stricture, require antiseptic irri gations of the urethra, and the internal administrations of urinary antiseptics.
Rupture of the Urethra.
This occurs chiefly either behind an old tight stricture or from a fall in which the patient alights astride some sharp object, such as the edge of a board or a rail. Rupture of the urethra from fract ure of the pubic bones, from "breaking" chordee, and from other forms of injury is of less frequent occurrence.
Symptoms.—The cases due to stricture must be considered separately from those due to the other causes mentioned. Usually a small, painful swelling will appear at some point along the course of the urethra. This may remain localized, forming an abscess, or it may give rise to a rapidly-spreading cellulitis, accom panied by the usual signs of inflamma tion. Urine will be passed with diffi culty and in a very small stream or there may be complete retention. Upon in quiry it will be found that the stream of ,urine has been gradually diminishing in size, and that it has been passed with increasing difficulty.
Rupture of the urethra from alighting astride a sharp object or from fracture or even disjunction of the pubes takes place in the membranous portion. Those cases due to the irrational prac tice of breaking of the penis for the sup posed cure of chordcc and to other rare forms of trauma occur in the pendulous urethra.
Pain, hwmorrhage, and retention of urine are the common symptoms in these cases. Swelling and ecchymosis may or may not be present, depending at first upon the nature of the accident and later upon whether there is extravasation of urine or not. The pain is usually not severe. Bleeding from rupture in the pendulous urethra always appears at the meatus. That which takes place from injuries to the membranous urethra may also appear at the meatus or flow back into the bladder and give rise to hrema turia. Retention of urine may be com plete from the moment of the accident and dependent upon an extensive lacer ation, or after some hours, as a result of swelling and blood-clot. If the case is not seen early, and a permanent catheter introduced, extravasation of urine will probably occur at the point of the rupt ure, and with a rapidly-spreading cellu litis.