A Text-book of Diseases of Women

by Charles B. Penrose

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As the speculum is withdrawn from the bladder the internal meatus and the urethral walls may be examined as they fall together beyond the distal end of the instrument.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.