STRICTURE OF THE URETHRA.
Spasmodic stricture of the urethra occurs at some period in nearly all cases of neglected organic narrowing, the element of superadded spasm suddenly showing itself by the production of retention of urine. Simple spasmodic stricture is caused by some reflex contraction of the constrictor urethra muscle, usually the result. of an inflammatory state of the lining membrane about the prostatic part, though the seat of the spasm is the compressor urethrae muscle lying between the layers of the triangular liga ment.
The immediate treatment resolves itself into that of the resulting retention and the routine should be the administration of a hot bath ; when this fails a large, soft rubber or well-lubricated gum elastic catheter, about No. to (English), should be passed and the bladder emptied. In very sensitive patients the preliminary injection of a few drops of a 5 to to per cent. Cocaine solution may be employed; a 1- gr. Morphia suppository may be administered if the retention symptoms are not urgent, and often this will dispense with the use of the catheter. After the relief of the bladder distension, the cause of the spasm—gonorrhceal urethritis, fissure of the anus, urethral calculus, etc.—will require attention.
Congestive stricture is closely allied to the above, and is usually the result of a gonorrhoeal inflammation of the posterior urethra. The treatment is to be carried out on the same lines, by long immersion in a hot bath, the injection of Cocaine with Adrenalin solution, Morphia by the rectum, and when a large soft rubber catheter fails to pass, the bladder may be aspirated above the pubes.
Organic or cicatricial stricture in the great majority of cases can be best treated by the method of— Intermittent or Slow instruments are used, and it need hardly be insisted upon that, in the absence of retention of urine, catheters should not be employed. Differences of opinion exist as to the preference to be given to soft or to solid metal bougies, some surgeons insisting upon the routine employment of one kind to the exclusion of the other. It will be safe to adopt, under ordinary circumstances, the follow
ing practice, especially if the operator has not much experience—i.e., to begin with soft gum-elastic bougies from the filiform size up to No. 6 F.., and always to use metal ones for wider strictures.
There is a considerable danger in passing small metal instruments except by the most experienced. Heavy, solid bougies for all sizes of stricture are better in skilled hands than gum-elastic instruments for interrupted dilatation, though it will be safer to begin with the latter in narrow strictures.
Any of the modern short-curved, conical metal bougies may be em ployed, hut the old-fashioned, highly polished bellied sounds of Sir Henry Thompson are the best. The actual dilatation should be produced by the shaft and not by the point of the instrument. The point should he of such a size that it will readily enter the stricture, the thicker part following and causing the dilatation. Tortuous strictures cannot be safely treated with rigid instruments till after partial dilatation by pliable ones.
Having placed the patient in the best possible condition of health, and having his bowels cleared out (and a warm bath given in some cases), he is sent to bed a few hours earlier than usual, and the treatment may be inaugurated. This latter precaution is a wise one if the operator has not had any previous experience of the patient's power of tolerating urethral interference. It will he well to begin the treatment after he has got warmed in bed, and where he can remain till next morning. In this way rigors, etc., may be prevented till the patient gets accustomed to the use of instruments. (See under Urethral Fever.) \t subsequent dilatations this will be unnecessary. It will, however, be always necessary to caution the patient against walking or other exercise, and against exposure to chills for some hours after the passage of instruments.