A Text-book of Diseases of Women

by Charles B. Penrose

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.