—Inflammation frequently extends beyond the anatomical confines of the urethra, and produces a degree of infiltration which is often well marked and disastrous. The site of such a lesion is marked by a nodule, more or less tender, which may subsequently break down into an abscess. The pus from these abscesses will usually escape into the urethra. Sometimes it burrows into the tissues of the corpus spongiosum, or travels even farther, and produces locally extensive destruction of tissue, with its possibility of urinary infiltration as a sequel, and all the septic disturbances which can be imagined as resulting therefrom. Thus fistulas often follow abscess formation, and these may be succeeded by phlebitis of the peri-urethral and prostatic plexuses, extensive destruction or multiple abscesses, or even gangrene and pyemia. Peri-urethritis is the essential factor in the production of strictures of the urethra, which constitute an exceedingly common condition.
While urethral stricture is a common result of gonorrhea it constitutes by itself a special lesion. (See chapter on the [Genito-urinary Tract].) These peri-urethral infiltrations may occur in irregular patches, so variously placed as to encroach upon the urethra at different points without completely surrounding it, or they may form tubular lesions by which very serious annular constriction is produced. The degree of infiltration is, to some extent, a measure of the violence of the inflammation and of the virulence of the infection. This is true, however, only up to a certain point. One object of properly directed treatment should be to guard against the deep extension of a gonorrheal infection, in order to limit the tendency to the formation of stricture.
Between the folds of the triangular ligament are situated two racemose follicles known as Cowper’s glands. These occasionally become infected in the same way as the anterior follicles of the urethra and give rise to a painful swelling in the perineum, which gives most discomfort to the patient in the sitting posture. This condition is known as Cowperitis. It may proceed to abscess formation, in which case incision in the perineum should be made for its relief.
Prostatitis.
—The prostate consists of a collection of follicles embedded in a mass of involuntary muscle fiber. The largest of these follicles is known as the utricle, or, under the old anatomical name, uterus masculinus. These are liable to invasion when the infection has reached the deep urethra. The reaction which follows in this tissue after such invasion gives rise to prostatitis and causes much pain and general reaction. The prostate, being embedded within a fibrous capsule, cannot expand easily when it becomes inflamed, and the pressure thus made not only causes intense pain, but will also obstruct the urethra and occasion great difficulty in urination, sometimes retention of urine. In proportion to the other disturbance will be the general reaction, and fever may run high, with early expressions of septic intoxication or of septicemia. The prostate becomes tender, and pain is felt not only in the pelvic region, but in the back and in the thighs, as well as along the urethra. Prostatic abscess is a frequent sequel to this condition; it sometimes evacuates spontaneously into the urethra, or bursts through the capsule and burrows along the structures in the perineum and lower pelvis; occasionally it empties into the rectum. Intensity of symptoms should give rise to a suspicion of prostatic abscess, and a perineal incision should be made early and the abscess evacuated. Occasionally these abscesses present toward the rectum, when they should be tapped or incised through the bowel.
From the prostatic urethra inflammation may extend on one side or both along the vas deferens to the seminal vesicles. The production in this way of a vesiculitis is made known by the reference of pain to the rectum and by the appearance of blood, sometimes with pus, in the seminal discharge. By a digital examination of the rectum the enlarged and tender vesicles can be recognized above the prostate.
When the deep urethra has become seriously involved the condition of the patient is unpromising. Belfield calls attention to the triple function of the deep urethra, in that the impulse to urinate originates therein, that it is a sphincter for the bladder, and that it is intimately concerned with the sexual act. When it is disturbed by gonorrheal infection all of these functions are disturbed, the most serious symptoms being increased desire to urinate, amounting to almost constant vesical tenesmus; marked difficulty in expulsion of urine, which may increase to complete retention, and frequent bloody emissions, with chordee. The pain, the heat, and the sense of tension in the perineum and in the parts around it are distressing, as well as pain during and after urination, which is usually referred to the end of the urethra. The last few drops of urine will often be bloody.
Cystitis.
—Cystitis is the not infrequent result of the further migration of the infectious process from the deep urethra to the bladder. The process is usually acute and serves to further complicate the case and to harass the patient. Except in the nature of the exciting causes cystitis differs but little from the other varieties to be considered in their appropriate place (q. v.). Cystitis of gonorrheal origin is likely to travel along the ureters and lead to involvement of the kidneys. Ascending infection is most commonly of gonorrheal origin. In proportion to the extent and rapidity with which the disease travels upward the case is marked by expressions of septic intoxication and infection, such as chills, fever, pain in the loins, along the ureters, and in the testicles. The kidneys may become enlarged. A more minute appreciation of the condition of affairs can be obtained by microscopic examination of the urine. In proportion as the kidney is involved, there is a preponderance of albumin, i. e., more than pus alone would produce. One of the numerous ways in which gonorrhea kills its victims is by the production of a pyelonephritis of the type known as “surgical kidney.”