A hot bath and a full opiate before resorting to the use of the catheter should he administered: sometimes the patient will be able to pass his urine in the bath.
After the failure of these the patient should be put to bed, and a No. or 2 gum-elastic instrument without a stilet should be passed down to the stricture, if necessary under chloroform anaesthesia, and with patience and gentleness it may he coaxed through. After the opening up of the anterior portion of the stricture the writer has often succeeded in passing through a No. or a No. o. Where these fail a No. z silver catheter may be tried, but in inexperienced and rough hands this is a dangerous instrument, as every hospital house surgeon knows. When the bladder is entered and the urine drawn off, the instrument should be tied in, and the greater the difficulty experienced in passing it, the more reason is there for tying in the catheter, so as to avoid further irritation when the bladder again fills. After a few days a larger instrument may be passed and tied in, and the routine treatment for stricture may be then commenced.
It will frequently happen that no hollow instrument will pass through a stricture. Before resorting to aspiration or operative measures trial should be made of filiform bougies of various shapes, bent, curved, angled, etc. If one of these can be coaxed through the narrows and tied in it will allow of the slow discharge of urine by its side. At the same time general treatment, such as an opiate, aperient, hot bath, and other measures are adopted. The patient after relieving himself temporarily from time to time will ultimately empty the bladder. Should the filiform bougie be also a guide to an internal urethrotome, it may next day be used for the introduction of this instrument and internal urethrotomy performed.
Where the bladder cannot be relieved by the urethral route, it may be punctured with the aspirator needle above the pubes, or a suprapubic opening may be made by a long curved trochar and canula, which may be retained for a few days or the operation of Cock or Wheelhouse may be performed. (See under Stricture of the Urethra, Urinary Fistula, etc.) If the retention is caused by a small impacted calculus this should be removed by suitable forceps, or if too close to the bladder, a gum-elastic or silver catheter may be gently worked past it, when steps can afterwards be undertaken for its removal. Where the gentlest possible trial of the forceps fails, there is nothing left but to cut down in the middle line upon the calculus; where the blocking is situated in the penile urethra it is best to manipulate the stone backwards into the membraneous urethra, from which it can be extracted by a median perinea] incision. Where this
fails the penile urethra should he freely divided with a sharp knife, and when the stone is extracted the lips of the urethral wound should be neatly stitched over a soft catheter, which should then be left in situ for a few days.
The so-called spasmodic stricture has generally an organic basis, there being nearly always some slight structural narrowing on which the spasm is grafted. It yields to the hot bath and opium, or to the passage of a fair-sized catheter. The retention caused by reflex spasm following operations yields easily to the passage of a full-sized rubber instrument, and this is true also of the retention from atony of the bladder and spinal paralysis, and of the form of retention occurring after a large dose of morphia or in fevers.
Where swelling or inflammation of the urethra, as in gonorrhoea, is the cause of retention, a very hot bath and a warm urethral injection of dis tilled water, or a drachm of cocaine solution (5 per cent.), with a smart Saline purge, and if necessary leeching the anterior portion of the perineum, may be tried, after which a rectal injection of 3o mins. of Laudanum or the introduction of a Morphia suppository may be resorted to. In un yielding cases a medium-sized soft rubber catheter may he introduced under chloroform anaesthesia.
Hysterical retention should not be relieved by the catheter till a hot bath or cold douche and other antihysterical remedies have been tried, as the patient rapidly acquires the habit of desiring the catheter through loss of power over the expulsive mechanism. But where a gravid or a displaced uterus containing a fibroid tumour exists a male gum-elastic catheter should be passed through the urethra till the bladder is reached before attempting reduction of the displaced uterus.
Where retention is caused by clotting of blood in the bladder, as from a villous or malignant growth or tuberculosis of the cavity wall, the best procedure is to open the bladder above the pubes, wash the organ out thoroughly and drain. In desperate bladder hemorrhage associated with greatly enlarged prostate it may be necessary to remove the prostate without waiting for the arrest of the bleeding. As a rule it will be advisable to wait for the arrest of the hemorrhage before resorting to an attempt to remove the cause. In villous growths in the female bladder causing retention from large clots, the best procedure is to dilate the urethra rapidly and reach the bleeding surface, which may be then operated on by galvano-cautery or strong Perchloride of Iron solution. The treatment of these cases will depend on the result of a cystoscopic examination of the bladder.