A Text-book of Diseases of Women

by Charles B. Penrose

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.