It will be well to put the patient upon a urinary antiseptic, such as 5 grs. Urotropine twice daily, though the most rigid sterilisation of all instruments must he invariably seen to. The patient should pass water a few minutes before the introduction of the dilating instrument.
The surgeon's first step is to locate the site of the stricture by passing a large sound down to the constricted part ; he then tries one size of bougie after another till he finds an instrument which will just pass through the stricture with slight difficulty. This should be withdrawn before its presence excites spasm and the dilatation postponed for 4 or 5 days. Upon the second and subsequent seances the same and the next larger size of bougie are introduced, till at twice a week intervals the dilatation is effected so as to admit the largest solid sound. say No. i6 E. Some surgeons insist upon the importance of leaving the last instrument used on each occasion in situ for several minutes. Force, in the ordinary sense of the term, is never justifiable, and the young surgeon is very liable to be dissatisfied with the slow progress which always gives the best:results in the long-run.
The best lubricant in the writer's experience is the K.V. Jelly or the B.F. Glycerin. Boracis, which is a strong. unirritating antiseptic, and does not injure the coating of soft instruments. Sterilised Vaseline, Olive or Castor Oil, to which 5 per cent. Carbolic Acid or 2 per cent. Oil of Eucalyptus has been added, is usually employed.
The length of the intervals between the sittings is to be regulated by the amount of dilatation accomplished without bleeding, and by the toler ance of the urethra. Every third day till headway is made, then every seventh day is a safe rule, but whenever bleeding is provoked the next dilatation must be postponed. In the case of a stricture which contracts rapidly, it may he safely attacked twice a week.
The sittings should be continued till a No. r6 English instrument can he easily passed. To stop at a No. 12 is a mistake, as inevitable shrinkage soon follows. It is the non-obser•ance of this rule which leads to failure in the hands of most men. Though the stricture cannot he regarded as cured in the great majority of cases, nevertheless, by dilating the urethra up to its fullest capacity, the very best results are obtainable, and in some cases no narrowing may be detected for years.
The patient should be taught to pass at least a No.r 2 English gum-elastic bougie every month for 3 or 4 months, then even- 3 or 6 months, returning once a year to have the largest (No. r6) size introduced by the surgeon.
In very narrow strictures there may be great difficulty in passing any instrument at first, and in such cases a rigid metal or a whalebone bougie should never he employed owing to the danger of making a false passage, especially in the neighbourhood of the triangular ligament. When an ordinary fine bougie cannot be coaxed through the constriction, one or two manoeuvres may be resorted to. Thus the patient may be made to pass water and whilst the urine is flowing a very fine instrument may be slipped through the stricture. When this fails the urethra may be injected with sterilised oil, and one filiform bougie after another should be passed as far down the canal as possible till every pouch or false passage has been blocked, after which sometimes a very fine instrument may be slipped through the stricture. It will be necessary in such a case to tie the bougie i.. sitn, and have the patient put to bed. Micturition in such cases will take place alongside the bougie, and in 24 hours a larger instrument may be introduced. After the first opening up of the narrow passage by either of these means the method of interrupted dilatation may be resumed.
These narrow strictures are very liable to contract speedily, and in many instances, when the treatment by the slow or interrupted method of dilatation has appeared to be progressing satisfactorily, the superadded element of spasm appears on the scene and taxes the surgeon's patience severely. The routine practice of the writer when dealing with such cases was to start dilatation by the continuous method about to he described, and as soon as the stricture had been opened up to admit readily a No. 6 Bougie, then to resort to the interrupted plan ; this line of procedure gives very satisfactory results.