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stretched sufficiently, as indicated by the number on the calibrator (usually about 12 millimeters), the instrument is withdrawn, and the speculum of corresponding number, armed with the obturator, is introduced; the obturator is then removed.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.