Symptoms.—The symptoms commonly observed by the patient are: a gleety dis charge; some increased frequency of urination; dribbling at the conclusion of the act, which is apt to require a longer time than normal and may require some voluntary effort; the stream may be much smaller in calibre than normal; and may be forked, twisted, or otherwise altered. If one or more of these phe nomena be present in a man who has had gonorrhoea, or other serious ure thral lesion, stricture may reasonably be looked for. The actual presence of this condition is determined by exploration of the urethra. For this purpose the acorn-headed bougie (bougie a boule) should be employed.
It has been found as a result of a large -number of observations that the follow ing approximate relationship exists be tween the circumference of the flaccid penis at the middle of the pendulous portion and the calibre of the urethra:— A suitable lubricant for urethral in struments is liquid vaselin or liquid al bolene containing 2 per cent. of carbolic acid, or 25-per-cent. solution of boro glyceride containing the same amount of carbolic acid.
If a bougie a boule of appropriate size can be passed into the bladder and with drawn without being arrested at any point, the calibre of the urethra must be considered normal. If a stricture is present the instrument will be arrested at the contracted area if it is distinctly smaller than the bulb of the bougie, or, if the calibre is very nearly the same as the circumference of the acorn-head, the stricture may not be detected until the instrument is withdrawn, the abrupt shoulder being especially designed to de tect contractions, when passing in this direction. It is well to begin the exami nation of a case with an instrument at least nearly equal to the normal calibre of the urethra as determined by the above table, and if it meets an obstruc tion beyond which it will not pass to try smaller and smaller sizes until one be found that will enter the bladder. Strictures will be met with so small that nothing larger than a filiform bougie will pass, and occasionally even this can not be introduced.
In urethral instrumentation, whether for diagnosis or treatment, the greatest gentleness should be used. Force is never justifiable.
Etiology. — Nothing need be added under this head to what has been said of the first two varieties of stricture. Or ganic stricture is usually the sequel of gonorrhoea. The gonococci tend to penetrate the mucous membrane and to develop in its deeper layers, thus estab lishing also a periurethritis. Further, the severity of the inflammation at one or more points causes exfoliation of the epithelium, so that there is a tendency for the urine to infiltrate the tissues. To
prevent this nature surrounds the vul nerable point with a deposit of lymph which organizes into firm, unyielding scar-tissue, and gradually contracts, in terfering with the dilatability of the urethra. The contraction is very slow; so that months and perhaps years may pass before the patient is aware of any distinct trouble in urination.
The next most frequent cause of stricture is rupture of the urethra. This usually occurs in the membranous por tion from alighting astride of some sharp object or from fractures of the pelvic bones. The resulting changes are very similar to those observed in strictures of inflammatory origin. The reparative material thrown out around the rupture is far in excess of the actual needs, and when this organizes it contracts and en croaches upon the urethra.
are treated by (1) dilatation or (2) cutting [(a) internal urethrotomy; (b) external urethrotomy]. The various other methods described are applicable to so few cases or are to he entirely condemned that they will not be mentioned here. For description of these the reader is referred to special works on this subject. It must be under stood that all of the following proced ures are to be carried out with the most rigid antiseptic detail.
DILATATION.—The method to be chosen in every case in which it is ap plicable is dilatation. It is unsuitable in: 1. Impassable strictures. 2. Those below 10 or 12 of the French scale, as it is unsafe to pass boogies below this size. 3. Strictures of the meatus and first inch and a half of the urethra, as experience has demonstrated that these will not yield to dilatation. 4. Strictures of the pendulous urethra, usually. If of recent formation and of large calibre, gradual dilatation should be tried. 5. Traumatic strictures, as a rule, are not dilatable and require division.
Dilatation may be either continuous or gradual. Continuous dilatation is suitable only in strictures below 10 or 12 French. In order to prepare for gradual dilatation in these cases a whalebone filiform should be introduced, and, if possible, two or more, and retained from twenty-four to forty-eight hours. The effect will be to soften and enlarge the calibre of the stricture. Or, having passed a filiform into the bladder, a Gouley tunneled catheter may be intro duced over this as a guide and retained. As soon as either of these methods has secured sufficient enlargement, gradual dilatation should be commenced. This form of treatment will usually be applied to strictures situated in the bulbous or membranous urethra, excepting those of traumatic origin.