DISEASES OF THE URETHRA AND BLADDER.
Before considering in detail the diseases of the urethra and bladder, it will be necessary to describe the modern methods of examining these structures.
The examination of the urethra and bladder has been very much facilitated by the methods and instruments that have been popularized in this country by Kelly. The following apparatus is required: a female catheter; a urethral calibrator; a series of specula with obturators; a head-mirror and light or an electric headlight; long, delicate toothed forceps ([Fig. 184]); an inclined plane or several hard pillows for elevating the pelvis; small balls of absorbent cotton about the size of a pea, or strips of absorbent gauze cut 1 inch in width and about 10 inches long, for drying out the bladder.
Fig. 184.—Mouse-tooth forceps for bladder.
Fig. 185.—Urethral dilator: short lines indicate diameter in millimeters.
The urethral calibrator or dilator ([Fig. 185]) is a conical metal instrument with a maximum diameter of twenty millimeters. The diameters in millimeters of the various portions are indicated by numbers upon the instrument.
The urethral calibrator is useful for dilating the external meatus to a degree sufficient to admit the necessary speculum. The external meatus is, as a rule, the only portion of the urethra that requires dilatation. Any instrument that will pass through the meatus will pass through the rest of the canal.
Fig. 186.—Kelly’s cystoscope or vesical speculum.
The speculum ([Fig. 186]) is a cylindrical metal tube fitted with a handle on which is the number indicating the size of the instrument. There are a number of specula, varying in diameter from 5 to 20 millimeters. Each speculum is fitted with an obturator. The most useful specula are those ranging from 8 to 12 millimeters in diameter. The urethra may readily be dilated up to 12 millimeters, with little if any, external laceration. Dilatation sufficient to admit the largest instrument (20 millimeters) is always accompanied by considerable laceration of the urethral opening. Dilatation of the urethra should never be practised beyond this degree, on account of the danger of subsequent incontinence of urine.
An anesthetic is usually required for the examination, unless the woman be capable of enduring considerable pain, or has become accustomed to the procedure from previous experience. Local anesthesia of the urethra with cocaine (gr. x to ℥j) is often sufficient.
The woman is placed on the table in the lithotomy position, and the bladder is emptied with the catheter. The external meatus is then dilated to the requisite size by inserting the graduated calibrator with a general rotary movement. When the meatus has been stretched sufficiently, as indicated by the number on the calibrator (usually about 12 millimeters), the instrument is withdrawn, and the speculum of corresponding number, armed with the obturator, is introduced; the obturator is then removed.
The hips of the woman are now elevated on the pillows or the inclined plane, or the foot of the table is raised, so that the hips shall be from 10 to 20 inches above the level of the shoulders.
The examiner, armed with the head-mirror or light, is then prepared to inspect the interior of the bladder. If the mirror is used, the light (Argand burner or electric drop-light) should be held close to the pubis of the patient.
Fig. 187.—Vesical probe or applicator.
Usually a small quantity of urine remains in the bladder after catheterization, or is secreted during the preliminary procedures, and it is necessary to remove this before complete examination of the bladder can be made. This may be done by means of the small balls of absorbent cotton or the strips of gauze grasped with the long-toothed forceps and passed in through the speculum; or some form of suction apparatus may be employed, consisting of a rubber exhaust bulb and a long metal tube perforated at the distal end by small openings.
The elevated position of the hips is an essential part of this method of examination; it permits the intestines to gravitate out of the pelvis, and, as soon as the urethra is opened, the bladder becomes distended with air, so that all of its interior may be readily inspected, and applications to the surface may be directly made through the speculum. In some cases it is difficult to produce the requisite distention of the bladder by elevating the hips. This difficulty may arise in the case of very fat women. It then becomes necessary to place the patient in the knee-chest position, when the requisite distention is readily accomplished.
As the speculum is withdrawn from the bladder the internal meatus and the urethral walls may be examined as they fall together beyond the distal end of the instrument.
DISEASES OF THE URETHRA.
The female urethra is a musculo-membranous canal averaging 1¾ inches in length, and, when not stretched, about ¼ inch in diameter. The urethra is normally closed by the apposition of its walls. In the neighborhood of the external meatus it is an antero-posterior slit. In the neighborhood of the internal meatus it is a transverse slit. In the middle portion the mucous membrane is arranged in longitudinal folds, and a transverse section shows a stellate closure.
The muscular coat of the urethra contains both striped and unstriped muscular fibers.
The mucous glands of the urethra are most numerous in the region of the external meatus. Skene first described two glands that are worthy of special mention. Skene’s glands are two tubules, large enough to admit a No. 1 probe of the French scale, that lie upon the floor of the urethra immediately within the external meatus. They lie parallel to the long axis of the urethra, and in length vary from ⅜ to ¾ of an inch. They are placed beneath the mucous membrane, in the muscular coat. The orifices of the glands are on the free surface of the mucosa, immediately within the external meatus. In young women the orifices are found about ⅛ of an inch above the plane of the external meatus. If the external meatus be patulous, or if there be any prolapse or inflammation of the mucous membrane of the urethra, the orifices of Skene’s glands may be seen upon each side of the urethral orifice as soon as the labia are separated. In gonorrhea their position is often indicated by a small drop of pus exuding from the orifices. The upper ends of the glands may terminate in a number of divisions.
Urethritis.—Urethritis is much less frequent in women than in men. In the great majority of cases it is caused by gonorrhea. Aside from microscopic examination, urethritis, acute or chronic, may be considered one of the strongest evidences of gonorrheal infection that we have.
Urethritis is also rarely caused by the exanthematous diseases, irritation of concentrated urine, vaginal discharges, chemical irritants, and traumatism.
Symptoms.—The symptoms of urethritis in the acute stage of the disease are frequent and painful urination. Burning and scalding sensations are experienced along the course of the urethra during urination. Occasionally a few drops of blood escape during or after urination. As the disease progresses toward cure or passes into the chronic stage, the intensity of these symptoms diminishes, and finally they disappear.
Examination of the parts shows that the external meatus is red and swollen. The swollen mucous membrane may bulge through the opening, giving the appearance of prolapse. The orifices of Skene’s glands may be conspicuous. If the woman have not recently urinated, a drop of pus may appear at the meatus, or it may be brought into view by vaginal pressure along the course of the urethra. Pressure upon the urethra through the vagina causes pain. This is one of the best tests of inflammation of this structure. The urethra may feel hypertrophied, indurated, or cord-like to the touch. The urethral discharge should always be examined microscopically for the gonococci.
In chronic urethritis the subjective symptoms are usually absent—except, perhaps, frequency of urination. The diagnosis is made by physical examination. If the woman has not urinated for several hours, the examiner will be able to express, by vaginal pressure along the course of the urethra, a drop of muco-purulent fluid resembling the gleety discharge of the male.
The endoscope reveals the presence of congestion and inflammation of the mucous membrane.
Treatment.—In the acute or the painful stage of the disease no local applications should be made. The external genitals should be bathed several times a day with hot water, preferably by means of sitz-baths. Vaginal douches are not indicated unless the vagina be involved in the inflammation. The vaginal syringe may be the means of carrying infection higher up in the genital tract. Rest in the recumbent position, if possible, is desirable. The diet should be non-stimulating, and large quantities of diluent drinks, such as flaxseed tea, should be prescribed. The bowels should be kept loose by saline purgatives.
In the subacute or the chronic stages of the disease boracic acid (gr. x-xx three or four times a day), salol, oil of sandal-wood, cubebs, copaiba, and other drugs used for the similar condition in the male are indicated. After painful micturition has ceased, the physician may make local applications to the urethra, in case the inflammation does not subside satisfactorily without them. Such local applications are not always necessary, and they may do harm unless proper care is exercised in their administration. Asepsis and gentleness are necessary, and the applications should never be too strong or irritating.
Frequent douching of the urethra (two or three times a day if possible) with sterile hot water is often of much benefit. Skene’s reflux catheter should be used ([Fig. 188]). The shaft of this instrument is fluted or grooved to permit the return of the fluid. The catheter should be introduced as far as the internal meatus; a fountain syringe should be attached to it, and the urethra should be washed out with a quart of hot water.
After the irrigation the catheter should be withdrawn and a urethral injection of nitrate of silver (gr. j or ij to ℥j) should be administered. The injection may be given by means of a glass pipette the nozzle of which is large enough to encircle the external meatus. The nozzle should be placed over, not in, the meatus. The female urethra will hold about 15 minims of fluid; more than this should not be injected. As the condition improves the frequency of these treatments may be diminished.
Fig. 188.—Skene’s reflux catheter.
If the condition does not yield to such treatment within a few weeks, application should be made directly to the mucous membrane of the urethra through the endoscope. The urethral canal should be washed out as just described, and the endoscope should be introduced as far as the internal meatus. As it is slowly withdrawn the application should be made over the whole inner surface of the urethra by a fine applicator wrapped with cotton. Nitrate of silver (gr. v-x to ℥j) should be employed.
Sometimes it is found that the suppuration persists in Skene’s glands. A small drop of pus may be found exuding from the orifice of the gland after the rest of the urethra has been restored to a healthy condition. In such a case the gland should be split up on the urethral surface by introducing into it one blade of a fine scissors, and the tract should be carefully wiped out with pure carbolic acid or a strong solution of nitrate of silver.
In every case of urethritis of gonorrheal origin it is of the greatest importance that every trace of the disease should be eradicated before the patient gives up treatment. There is always danger of infection extending to the upper parts of the genital tract.
Stricture of the Urethra.—Stricture of the urethra in the woman, unlike the similar condition in the male, is very rare. It is caused by gonorrhea, injury at childbirth or other traumatism, and caustic applications. The stricture may exist at any part of the urethral canal. The form most usually seen is that which occurs at the external meatus, and is caused by the removal of abnormal growths with caustic or with the knife.
The symptoms of urethral stricture in women are much less marked than those in men. There is frequent and difficult urination. Occasionally there is incontinence or partial retention of urine.
If the stricture exist at the external meatus, it may be readily seen and its dimensions determined. If it exist in the upper portion of the urethral canal, it may sometimes be felt by palpation along the course of the urethra through the vagina, the position of the stricture being indicated by local thickening and induration. Its location may also be determined, as in man, by the use of the bulbous bougie or sound.
Treatment.—When the stricture is situated at the external meatus, it may be divided with the knife or forcibly stretched. When it is situated in the upper portion of the urethra, it is best treated by forcible dilatation.
Fig. 189.—Female urethral sound.
The small uterine dilator is the most convenient instrument to use. The dilatation should not extend beyond half an inch, for fear of injuring the urethral walls or producing incontinence. In order to prevent contraction, it is advisable to pass the large urethral sound (10 millimeters) at intervals of one or two days after this operation, until the patency of the urethra is ensured.
In some cases the continual subsequent use of the sound is necessary, as in stricture in the male. The woman may be readily taught the use of the instrument herself.
Prolapse of the Mucous Membrane of the Urethra.—Prolapse of the urethral mucous membrane is of unusual occurrence. Prolapse may be limited to part of the circumference of the meatus, or it may extend around the whole canal. The condition is usually found in weak, debilitated women. It may occur during childhood.
The prolapse may be caused by dilatation of the urethra and the external meatus or by the traction of a neoplasm of the urethra. It sometimes occurs after labor. It may be produced by continual vesical tenesmus, the result of cystitis, calculus, or a tumor of the bladder.
The symptoms, vesical tenesmus and dysuria, are usually present. Sometimes incontinence of urine occurs. The protruding mucous membrane may become irritated and inflamed, and cause much local pain. It has been known to slough off.
Treatment.—The treatment should be directed, in the first place, to the relief of any causative condition, such as cystitis or calculus.
Inflammation of the protruding mucous membrane should be relieved by local applications of hot water and by rest in bed. The mucous membrane should then be gently replaced within the urethra, and contraction of the canal should be promoted by the use of astringent injections of tannic acid or alum.
If the disease does not yield to this treatment, the prolapsed mucous membrane should be excised, and the edges of the mucosa should be stitched to the margin of the meatus by fine suture.
After this operation there is sometimes cicatricial contraction of the external meatus, which may readily be cured by forcible dilatation.
Vesico-urethral Fissure.—Vesico-urethral fissure is an ulcerated crack of the mucous membrane situated at the internal urinary meatus. The upper portion extends into the bladder, the lower portion is in the urethra. Skene describes it as “from ¼ to ⅜ of an inch in length, and from 1/12 to ⅙ of an inch in width at the center, but tapering off at each end. The deepest part has a yellowish-gray color, like that of an indolent ulcer, while the edges are red and actually inflamed, like those of an irritable ulcer.”
Vesico-urethral fissure is usually caused by urethritis. It may also result from injuries during confinement or from the bungling use of the catheter.
Symptoms.—There is a constant desire to urinate, and urination is followed by severe tenesmus. There is a burning pain at the neck of the bladder, increased immediately after urination. Pressure upon the internal meatus through the vagina may cause lancinating pain.
The symptoms resemble closely those of urethritis and cystitis.
Fig. 190.—Skene’s urethral endoscope.
The diagnosis of vesico-urethral fissure can be made with certainty only by seeing the fissure through the endoscope. The existence of the condition may be suspected in a woman who presents the symptoms just described, and in whom no signs of inflammation or other disease of the urethra or the bladder can be detected.
The open endoscope is not satisfactory for detecting this condition, because the fissure is hidden from view by the folds of mucous membrane at the upper end of the instrument. Skene, who has especially directed attention to vesico-urethral fissure, states that he never was able to detect the lesion until he used the form of endoscope introduced by him ([Fig. 190]), which consists of a small glass tube like the ordinary test-tube, into which is passed a mirror on a holder. The instrument is passed into the urethra, and light is thrown in by means of the concave head-mirror. By moving the small mirror in the tube, different parts of the urethral walls may be examined. The instrument opens out the folds of mucous membrane immediately above the fissure and renders it visible.
Treatment.—The cure of vesico-urethral fissure is often difficult. The lesion is exposed to continuous irritation from the urine and from the sphincteric action of the muscular fibers at the vesical neck—an action which is much increased by the tenesmus present. This constant muscular action impedes healing, as in the case of fissure of the anus. The internal urinary meatus should be dilated under anesthesia to the extent of ½ inch by means of the graduated bougies or the uterine dilator. After dilatation the woman should be kept in bed and the urine should be rendered as unirritating as possible by the use of diluent drinks and boracic acid.
If this treatment does not result in cure, a vesico-vaginal fistula should be made, so that, by carrying off the urine by this means, rest from functional activity will be furnished to the region of the vesical neck.
No effort need be made to keep the fistula open, as by the time it has closed spontaneously the fissure will have healed.
Dilatation of the Urethra.—Dilatation of the urethra producing symptoms that require treatment is unusual. It may be due to congenital defect, to spontaneous expulsion, or instrumental extraction of a calculus or tumor of the bladder, to excessive dilatation by the surgeon; and it may occasionally follow pregnancy. Skene says, “the hyperemia of the urethra which occurs in pregnancy and which tends to produce overdistention of the veins favors dilatation of the whole urethra.”
The urethra may be so dilatable that it will admit the penis—coitus having been practised in this way in a number of instances.
In dilatation of the urethra there may be continuous incontinence of urine, or the urine may escape only during acts of straining, coughing, or lifting.
The condition may be determined by the insertion of sounds or the finger.
Treatment should be directed to the cure of any inflamed condition of the urethra which may accompany dilatation, and to the use of astringent injections of tannic acid.
If incontinence of urine persists it may be necessary to perform a plastic operation, excising a portion of the anterior wall of the vagina and the posterior wall of the urethra, and closing the wound by transverse sutures.
In urethrocele the dilatation is confined to a portion of the urethra, usually the middle third. There is a sacculated condition of the posterior wall of the urethra extending into the vagina. The usual cause of this condition is traumatism during labor. The symptoms are painful and difficult micturition and partial incontinence of urine. The condition may be diagnosed by the use of the sound or the probe, which may be inserted in the sac through the urethra, when the point may be felt by a finger on the anterior vaginal wall. Sometimes the urethrocele produces a distinct bulging in the anterior wall of the vagina.
If the annoying symptoms of urethrocele continue after any accompanying inflammation of the urethra has been relieved, it may be necessary to excise the sacculated portion of the urethra by incision through the vaginal wall and close the wound by suture.
URETHRAL NEOPLASMS.
Urethral Caruncle.—The urethral caruncle is a small raspberry-like tumor situated at or just inside of the external meatus. It is composed of dilated capillaries set in a dense stroma of connective tissue and covered with mucous membrane. The tumor varies in size from a pin-head to a hickory-nut. In color it varies from a pale to a bright red. It is usually situated upon the posterior wall of the urethra. There may be two or more such· tumors around the circumference of the meatus, and occasionally they are found in the vestibule. The growth is usually sessile.
The caruncle is often erectile in character, and increases in size at the menstrual period.
The growths bleed very easily on manipulation, and are exquisitely sensitive. The urethral caruncle is the commonest neoplasm of the urethra.
Symptoms.—The most marked symptom of urethral caruncle is pain. Intense pain is experienced at micturition and upon contact with the clothing or other body. Sexual connection is sometimes rendered impossible.
There is usually more or less hemorrhage from the tumor, which may rarely be so profuse as to cause marked anemia. The general health suffers, and nervous symptoms, resulting from the pain and loss of sleep, are often present to a pronounced degree.
Treatment.—The treatment consists in the total extirpation of the growth. It should be picked up with forceps and excised with the knife or scissors. The edges of the mucous membrane should be united by sutures.
Excision should be complete or the tumor may return. In case of recurrence a second operation should be performed.
Urethral Cysts.—Small cysts are occasionally found in the course of the urethra. They may occur at any point from the internal to the external meatus. They are caused by obstruction and distention of the urethral glands. They produce no symptoms unless large enough to cause obstruction to the flow of urine. They may be seen by the endoscope or may be palpated through the vaginal wall.
The treatment consists of incision and removal of part of the cyst-wall.
Polypus.—Mucous polyp of the urethra is of very rare occurrence. The tumor generally has a delicate pedicle, and may protrude from the meatus. It is painless, and causes discomfort only by obstructing the flow of urine.
The treatment consists of removal by torsion, ligature, or excision.
Sarcoma and cancer of the urethra have rarely been observed. The phenomena are those similar to cancer in other parts of the body.
The treatment consists in thorough removal.
DISEASES OF THE BLADDER.
The urinary bladder has three coats—an outer incomplete peritoneal investment, a middle muscular coat, and an inner lining of mucous membrane.
The empty bladder is always collapsed, its walls being in apposition. A median sagittal section of the bladder and urethra shows a Y-shaped fissure lying between the symphysis pubis and the uterus, the uterus lying anteverted upon the upper surface of the bladder.
For convenience of description the bladder is divided into three parts—the corpus, or body, the fundus, or base; and the cervix, or neck.
The body of the bladder is all that portion that lies above the plane of the vesical orifices of the ureters and the center of the symphysis pubis.
The part lying below this plane is the base.
The vesical triangle, or the trigone, is that triangular area in the base of the bladder, the angles of which are marked by the vesical orifices of the ureters and the internal meatus of the urethra.
The neck of the bladder is the funnel-shaped portion where the bladder merges into the urethra.
The mucous membrane of the bladder is covered partly with squamous, partly with cylindrical epithelium. The mucous membrane is loosely attached to the muscular coat throughout the body of the bladder, so that when the organ is contracted the membrane is thrown into uneven folds. The mucous membrane is much more closely attached to the underlying structures in the region of the vesical triangle, and it here preserves a smooth surface when the bladder is collapsed.
The vesical triangle is more richly supplied with nerves than are the other portions of the bladder, and is consequently the most sensitive portion.
The vesical orifice of the ureter appears as a dimple, a small truncated cone, or a pin-hole or slit on the mucous membrane.
A transverse band or fold of mucous membrane, known as the intra-ureteral ligament, extends between the orifices of the ureters.
The dimensions of the vesical triangle are subject to individual variations. The triangle is usually equilateral, its sides varying from 1 to 1½ inches in length. The vesical orifices of the ureters are therefore situated at points lying from ½ to ¾ of an inch from the median line—a useful fact to remember in opening the bladder through the vagina.
The vascular supply of the bladder is intimately associated with that of the uterus—a fact that explains the sympathetic disturbance of the bladder in uterine disease. The interior of the normal bladder is of a dull gray-red color. When distended, as in making an endoscopic examination, the minute arteries and veins may be plainly seen upon the surface.
The pressure of the urine in the bladder may be determined by the manometer. In the erect posture the intra-vesical pressure has been found to vary from 12 to 16 inches of mercury. In the recumbent posture the pressure is reduced to from 4 to 6 inches.
Cystitis.—Cystitis, especially of the subacute or the chronic form, is a common disease in women. The pathological changes resemble those seen in inflammation of mucous membrane in other parts of the body.
In the acute stage the mucous membrane is swollen and relaxed, and of a deep-red or hyperemic appearance. Partial exfoliation takes place. The surface may be covered with thick, tenacious mucus or pus.
In the chronic stage the mucous membrane is of a muddy gray color, and may be more or less covered with a muco-purulent secretion. Ulceration, superficial or deep, may occur. The ulcer is sometimes deep and ragged and extends into the muscular wall.
In chronic cystitis we often find on the surface of the mucous membrane small localized areas of inflammation varying in size from ½ inch to 2 inches in diameter, and presenting a congested, granular, or eroded appearance, while the rest of the mucous membrane appears perfectly normal. These areas of inflammation bleed readily when touched. They are most often found in the base of the bladder, though they may occur in any part. When chronic cystitis is limited, it is usually confined to the vesical triangle.
The outer coats of the bladder may be involved in the inflammatory process, and become much thickened and hypertrophied. The ureters and the kidneys may become in time affected, through direct extension of the inflammation in the form of a ureteritis and pyelitis, or through obstruction of the vesical orifice of the ureters from inflammatory thickening. The alteration in the character of the urine is usually marked except in the mild forms of chronic inflammation. The specific gravity is low, varying from 1005 to 1018. In the chronic disease the urine is alkaline and ammoniacal. It contains blood, mucus, pus, and epithelial cells from the vesical mucosa.
Cystitis in women is usually caused by infection at catheterization. The very great improvement in the asepsis of this procedure that has taken place in recent years has in a corresponding degree diminished the frequency of cystitis.
Infection at catheterization is caused not only by the use of a dirty catheter, but by the conveyance of septic material from the external genitals or the urethra into the bladder. For this reason the nurse or the physician should never pass the catheter by touch, as was sometimes formerly taught. The parts should be exposed to view, and the external genitals, vestibule, and meatus should be cleansed.
Cystitis may also be caused by extension of urethritis; by inflammation of adjacent organs; by abnormal urine; by constitutional diseases, as the exanthemata; by injuries to the bladder and displacement of this organ; and by retention of urine.
Symptoms.—The symptoms of cystitis vary with the stage and the character of the affection. Pain, frequent urination, and tenesmus are usually present.
In the acute stages there may be an elevation of temperature. There is a feeling of fulness in the bladder, with pain in the region of this organ. The pain is increased by motion and by the erect position, which increases the intra-vesical pressure. The pain is constant, and is not relieved by evacuation of the bladder. Pressure upon the base of the bladder through the vagina causes pain. This is a useful diagnostic point. There is a frequent desire to urinate, and the passage of urine is followed by straining efforts or tenesmus. The alteration in the character of the urine has already been mentioned.
In time the general system suffers from secondary renal disease and from absorption, through the bladder, of the ingredients of decomposed urine and septic material from the mucous membrane.
The diagnosis of cystitis is easily made by proper examination. It should always be remembered that not every woman who complains of painful and frequent urination and vesical tenesmus is necessarily suffering with cystitis. These symptoms are often caused by disease of the urethra, by displacement of the uterus, which drags upon the neck of the bladder, by the pressure of a tumor, or by displacement of the bladder such as may follow laceration of the perineum.
Women may often be seen who have been treated for weeks for cystitis without avail, and who are immediately relieved of all symptoms by the replacement of a retroverted uterus or the closure of a torn perineum. These conditions may in time result in cystitis, but the disease usually disappears with the cure of the causative lesion.
It is of the first importance, therefore, for the physician to make a careful pelvic examination, and to exclude all conditions that might cause irritation of the bladder. Microscopic examination of the urine, by revealing the presence of pus and blood and the epithelial cells of the bladder, is of value in making a diagnosis. The urine for examination should be drawn with the catheter, to prevent contamination from vaginal discharges.
Examination of the urine does not, as a rule, enable one to exclude inflammation of the ureters or of the pelves of the kidneys. If there is any doubt, it may be removed by the use of the endoscope, which will reveal the true condition of the bladder-wall.
As has already been said, tenderness upon pressure through the vagina on the base of the bladder is of diagnostic value in determining the presence of cystitis. In the mild forms of chronic cystitis—those characterized by local areas of inflammation—examination of the urine may throw no light upon the condition, as the secretion of pus or mucus is very slight. The diagnosis can then be made only by means of the endoscope.
It is perhaps advisable in all cases of chronic cystitis to use the endoscope, not only to confirm the diagnosis, but to begin the treatment by making direct local applications.
Treatment.—The treatment of cystitis is general and local. Local treatment should never be used in the acute stages of the disease. Many cases recover completely without any local treatment whatever.
In acute cystitis the woman should be put to bed. The irritation of the bladder is much relieved when the intra-vesical pressure is thus diminished.
The diet should be carefully regulated, all stimulating ingredients being withdrawn. An exclusive milk diet is the best.
Saline laxatives should be administered, and continued to the point of mild purgation. One dram of Rochelle salts every two or three hours, given in half a tumblerful of soda-water, is useful for this purpose. Large quantities of diluent drinks should be given, such as flaxseed tea or Vichy water.
If the urine is acid, citrate of potassium may be administered with the diluent drinks, so that from 1 to 2 drams of the salt are taken during the day. Bicarbonate of potassium in similar doses is also useful.
When the urine becomes ammoniacal, boracic acid, in doses of 10 grains from three to six times a day, is most useful. Benzoic acid, in doses of 10 grains three or four times a day, is also valuable.
A very good method is to make a pint or a quart of flaxseed tea, to dissolve in it the requisite amount of citrate of potassium or of boracic acid (as the urine is acid or alkaline), and to administer this in divided doses during the day. This treatment, with rest in bed, should be continued as long as the vesical pain and tenesmus continue.
If the pain and tenesmus are severe, small doses of opium may be given. It is, however, not advisable to use opium unless the suffering of the woman demands it.
If the disease, as the symptoms become less acute, does not progress satisfactorily toward cure, medicines that have a more stimulating effect upon the mucous membrane should be given, such as cubebs and copaiba, oil of turpentine, oil of eucalyptus, and oil of sandalwood.
Many cases of acute cystitis, if carefully treated in this way, will recover completely without the use of local treatment. If, however, the disease does not yield to these measures, local treatment becomes necessary.
In many instances the woman first comes under treatment when the disease has reached a chronic stage; or it may be that the disease has begun subacutely, and has gradually progressed without having presented any symptoms of acute onset. Local combined with general treatment is then often advisable from the beginning.
Local treatment consists of general applications made to the whole of the interior of the bladder through the catheter; direct application, limited to the diseased portions of the mucous membrane, through the endoscope; and operation, or the formation of a vesico-vaginal fistula.
Fig. 191.—Apparatus for washing the bladder.
Washing out the bladder with sterile warm water, either pure or medicated, is often very useful. Gentleness in manipulation and asepsis should be carefully observed in this procedure, or much more harm than good may result from it. The operation, if properly performed, should never give pain to the woman.
A very simple apparatus is required, consisting of a soft-rubber catheter, of moderate size, attached to a small glass funnel by means of a rubber tube and a piece of glass tubing. The whole is about 2 feet long ([Fig. 191]).
The catheter, slightly lubricated at the point, should be gently introduced into the bladder, and the urine should be slowly withdrawn. As the urine flows into the funnel its character may be observed. The rapidity of the flow of the urine may be regulated by raising or lowering the funnel. As the last portion of the urine is withdrawn the flow should be very slow, in order to prevent injury to the vesical mucous membrane from dragging it into the eye of the catheter.
When the bladder is emptied, sterile hot water may be introduced through the funnel and the process of withdrawal repeated. The mucus, pus, or blood which had remained in the bladder after evacuating the urine may be examined as the water flows into the funnel. This process may be repeated several times if necessary to wash out the bladder. The water should be about the temperature of the body (100° F.). It is less irritating to the mucous membrane if there is dissolved in it boracic acid or common table salt, about 1 dram to the pint, though these ingredients should not be added if they act chemically on the substances subsequently used in the medicated solution.
The quantity of water introduced into the bladder may be regulated by the feelings of the patient. The distention of the bladder should never be great enough to cause pain. Usually an ounce of fluid is all that can at first be tolerated without producing pain. As improvement takes place more fluid may be introduced in the subsequent treatments.
After the bladder has been washed out in this way, applications may be made to the interior by pouring through the funnel the desired medicated solution, the most useful one being a weak solution of nitrate of silver (gr. j or ij to ℥j). This solution should be retained in the bladder for a few minutes, and should then be withdrawn.
A solution of sulphate of copper (gr. j-iv to ℥j) is also useful.
At first daily irrigation and application should be thus practised. As the case improves the intervals between the treatments should be lengthened.
This local treatment should always be combined with the general treatment already prescribed—rest in bed if possible, a milk diet, and the administration of boracic acid internally.
Application through the Endoscope.—If the endoscope is used in the first place for diagnosis in a case of chronic cystitis, much time that might otherwise be wasted in unnecessary or useless forms of treatment may be saved. The condition of the parts maybe accurately determined, and the proper form of treatment may be instituted. It may, for instance, be seen that deep ulceration is present, or that other lesions of the bladder are so extensive that the quickest plan of cure will be to proceed immediately to the formation of a vesico-vaginal fistula, without attempting to treat the disease by applications.
Applications may be readily made through the endoscope to any part of the interior of the bladder. Applications made in this way are most useful when the disease is localized. Stronger solutions may be used on the affected areas than when the application is made to the whole surface of the organ.
When the disease is limited to the vesical triangle or to local areas situated elsewhere, the inflamed spots should be touched with a solution of nitrate of silver (gr. v-xx to ℥j). Much benefit is frequently derived from one such application, in connection with the general treatment already indicated. The applications may be made every few days. The procedure causes less discomfort to the woman as she becomes accustomed to it.
Cystotomy.—In cases of ulceration of the mucous membrane, or when the disease has resisted the milder forms of treatment, it may become necessary to perform cystotomy, to furnish an opening for the continuous drain of the urine, and to put the bladder at rest by relieving it from all functional action. This is a most valuable therapeutic operation in cases of obstinate cystitis.
In performing cystotomy the anatomical relations of the ureters and the internal orifice of the urethra must be kept in mind. It will be remembered that the ureters terminate in the bladder at points situated from ½ to ¾ of an inch from the median line.
Fig. 192.—Illustration of the position of the incision in vaginal cystotomy, and the relations of the urethra and the ureters: A, anterior vaginal column; B marks the position of the internal urinary meatus; C and D mark the orifices of the ureters. The distance from C to D varies from 1 to 1½ inches. C, B, D is approximately an equilateral triangle.
The course of the urethra is indicated by the anterior vaginal column, which is a single or double thickening of mucous membrane traversed by short transverse folds or ridges. It begins near the external meatus and extends upward for about an inch. The internal meatus may be very approximately located by the upper end of this anterior vaginal column. The incision into the bladder should be made in the median line above this point.
The operation should be performed under the influence of an anesthetic. The woman should be placed in the Sims or the dorso-sacral position. The anterior vaginal wall should be exposed with the Sims speculum. A sound should be passed into the bladder, and its point should be pressed against the posterior vesical wall toward the vagina, at the position where the incision is to be made. The incision should be made into the bladder through the tissues fixed on the point of the sound. The opening may then be enlarged with the knife or scissors. The opening should be from 1 to 1½ inches in length. In order to prevent spontaneous closure of the fistula, the mucous membrane of the bladder should be sutured to the mucous membrane of the urethra around the margin of the fistula.
The after-treatment consists in daily washing of the bladder with large quantities of sterile warm water or with the boracic-acid solution. The woman should be placed in the dorso-sacral position, and the fistulous opening should be exposed by the Sims speculum. The water should be introduced into the bladder through the urethra. Care must be taken to hold the edges of the fistula open, so that there may be a free channel of escape.
The patient should at first remain in bed. After the acute symptoms have disappeared she may get up and the frequency of the local treatments may be diminished. Various appliances have been introduced for receiving the continuously escaping urine. None of them, however, are satisfactory. They are difficult to keep clean, they cause pain, and they are liable to become displaced. The best method is to wear a vulvar pad of some absorbent material and to pay strict attention to cleanliness. The progress of the case may be determined by examination of the urine, and by examination of the vesical mucous membrane through the fistula or through the endoscope.
The time required for cure may extend from one to six months.
When the vesical membrane has been restored to a normal condition the fistula may be readily closed.
Vesical Calculus.—Stone in the bladder is less common among women than among men. This fact is probably due to the greater size and dilatability of the female urethra, on account of which small calculi may readily pass out.
The symptoms and methods of diagnosis of vesical calculus are similar to those in the male. The stone may often be palpated by bimanual examination.
Treatment.—Small stones uncomplicated with cystitis may be crushed and removed through the urethra. Large stones should be removed by cystotomy. Whenever cystitis is present, it is advisable to perform cystotomy and to make a permanent fistula until the cystitis is cured, when the opening may be readily closed.