URINARY FISTULA.
This may be a sequel to the last-mentioned condition; more frequently it follows as a result of old gonorrhoeal stricture, impacted calculi, prostatic abscess, etc. The primary condition which causes the obstruc tion to the flow of urine must be the obvious aim of all treatment.
Only one sinus about the scrotum or perineum may exist, whilst as many as fifty openings have been seen studded over the same region and extending into the rectum and above the groins. The treatment will, therefore, necessarily vary considerably.
A simple fistula, opening at the one extremity into the urethra and at the other into the perineal region, will be found, in the great majority of cases, to be secondary to a stricture of long standing. Such a fistulous opening will as a rule heal as soon as the urethra] stricture is properly dilated. Under the heading of Stricture of the Urethra the various plans of dealing with the primary affection have been detailed, and need not be here repeated. As a rule it will be wise to begin with solid metal bougies, passed eYery two or three days, till the fullest size which the urethra is capable of taking is reached.
When the anterior end of the stricture is very narrow the continuous process of dilatation will have to be commenced with filiform bougies till a small catheter can be manipulated into the bladder, after which it may be retained for 24 to 4S hours before a larger instrument is similarly tied in for a time. When a No. 6 English is reached the interrupted method may then be commenced.
Should the fistula fail to heal after the dilatation of the stricture, the cause of failure is always due to an escape of urine during micturition, which keeps the track green and prevents healing. The plan of injecting irritants or caustics along the fistulous track in such cases is bad practice, though still advised by some surgeons. The best procedure by far is to teach the patient to pass a large-sized soft instrument, and caution him not to attempt to make water without its aid, or a catheter may he tied in for a day or two. Even before haying a motion from the bowels he should immediately pass his catheter, and draw off every drop of urine. In this way all trickling of urine along the fistulous track is completely prevented, and in a short time complete closure results. This method will also be found to be efficacious in those cases of urinary fistula caused by prostatic abscesses.
When two, three, or four openings lead direct from the perineum into the urethra without much induration or any diyerticula, success may follow the above line of treatment. When, however, the tracks of the
fistulT are in connection with regions riddled by small abscesses, the perineum should be opened by a free external incision made over a Syme's staff for perineal section, and all indurated tissue freely removed, the fistulous tracks scraped by a sharp curette, and packed with strips of lodoform gauze. Fenwick advocates free excision of every track or burrow right up to the urethra, and suture of the raw surfaces thus ro:4 URINARY FISTULA—URTICAR1A, OR NETTLE RASH produced. Scrotal fistula should be treated also in this manner. A Penile fistula usually results from sloughing of the urethra, caused by the impaction of a calculus; hence there is generally much loss of substance. The fistulous track should be freely incised, the edges pared, and the urethroplastic operation of Clark or Nelaton or the more elaborate transplanting method mentioned in the last article may be resorted to.
When the stricture is impassable by any instrument introduced along the urethra, the treatment so successful in simple cases cannot, of course, he pursued. There is nothing left in such cases for the surgeon but to cut down upon the seat of stricture by perineal section, and by the 13outonniCre operation the urethra may he divided upon a Wheelhouse's straight grooved steel staff. In some cases Cock's operation may be performed, and the urethra divided behind the stricture in its membranous portion. Wheelhouse's operation is the best for most cases, and it is described along with the other methods under Stricture of the Urethra.
In dealing with some cases of fistula it may be necessary to open the bladder above the pubes, and by the method known as " retrograde catheterisation " to introduce into the urethra a catheter from above, as in the operation for dealing with a ruptured urethra.
In some cases after performing external urethrotomy the impermeable stricture may be completely excised or resected, and the divided ends of the urethra carefully sutured together over a full-sized catheter tied in the passage. This is facilitated by placing the patient in the extreme lithotomy position with the hips about eight inches above the level of the shoulders, and having the urethral tissues stained by the use of methylene blue given internally beforehand and immediately before operation in jected into the urethra.