The local treatment is carried out by injections into the urethra, which must be made with a syringe, preferably of hard rubber, with a blunt tip and without a nozzle, or by a douche bag connected with a soft catheter, all of which should be kept constantly sterilized. During the first days of an attack, when only the anterior part of the urethra is affected, treatment can be made more readily and effectively with a small “P” syringe, and at this time only 15 to 20 Cc. of fluid will be required, which should be held in the urethra for some time. When irrigation is decided upon a douche should be employed. Accurate directions should be given the patient as to how to make the injections, and he should be cautioned to first empty the bladder before using the syringe. The patient’s comfort may be increased by injections of water up to a temperature of 115° F. Antiseptics, i. e., potassium permanganate, boric acid, or one of the new preparations of the silver salts, may be added to the water. The parts may be advantageously immersed in hot water at intervals during the day, and for fifteen or twenty minutes at a time. There are many ways of conducting local treatment in these cases. Those mentioned below have given the best results in the practice of the writer.
A very satisfactory method would be to commence the local treatment with the use of hot water, as above, every two to six hours, and to follow it with a small injection of an emulsion of bismuth subnitrate, with sufficient cocaine and a little morphine to blunt sensibility and diminish tenderness and pain. The following formula, which may be varied, will accomplish this purpose: Morphine sulphate 0.3, cocaine muriate 2, bismuth subnitrate 20, cherry-laurel water 150, mucilage of acacia 50.
The injection should be retained for a few moments and no effort made to expel it. The bismuth salt is not only antiseptic, but is soothing, slightly astringent, and non-irritating.
Belfield has recommended the use of the yellow hydrastia muriate in connection with protargol. His formula is as follows: Yellow hydrastia muriate 2.50, protargol 1.50, glycerin 15, water 500. After using this for a few days the proportion of protargol may be doubled. Of this preparation 15 to 20 Cc. should be injected several times a day. The silver salts are the least irritating of all the stronger and more reliable antiseptics, and drug manufacturers are putting upon the market at frequent intervals new preparations for which much is claimed. Among the latest of these is argyrol, a combination of silver with albumen (vitellin), in such form as to make it antiseptic and non-irritating. In solution it is of a dark mahogany color and stains whatever it comes in contact with; these stains, however, are readily washed out. Argyrol in solutions of 2 to 5 per cent. strength has proved reliable, and if such a solution be retained in the urethra for five minutes at a time a pronounced effect may be made upon the disease. It is my custom to alternate the use of the bismuth formula with a solution of argyrol as above, and in this way give the greatest relief in the shortest time. It has been demonstrated that under the influence of this preparation all gonococci which are reached by it are destroyed; therefore the earlier it is employed the better. Before using either of these formulas the anterior urethra should be washed with hot water or with hot normal salt solution. No harm need be feared should either of the above injections reach the deep urethra, and the effort should be to make them reach at least as deeply as the disease has gone.
When the discharge has reached what Finger has called “the mucous terminal stage,” then the argyrol may be used two or three times a day only, and one of the following solutions substituted for it part of the time: Zinc sulphate 0.75, bismuth subnitrate 8, colorless liquor hydrastis 15, cherry-laurel water 60. Of this solution 10 Cc. may be used three or four times a day.
Belfield strongly recommends the use at this time of a solution of muriate of berberine, in strength of ¹⁄₂ to 1 per cent., or the yellow hydrastia muriate in about the same strength. He also recommends zinc chloride 0.25, zinc iodide 0.50, water 500. Either of the above salts may be added to this.
When nothing remains of the discharge but the so-called “morning” or “military drop,” and the urine is almost clear, argyrol solution at night and one of the above formulas once or twice through the day will be sufficient. This, in brief, is a description of how a case of urethritis may be satisfactorily treated.
The systematic use of potassium permanganate solutions was introduced by Janet, and has been enthusiastically described and prescribed by Valentine. The treatment is more complicated and less satisfactory than that advised above.
With deep extension of the disease and its added symptoms of tenesmus, pain local and referred, etc., the limit of the injection should be extended and the entire urethra should now be treated. The bladder being empty, the patient should make a strong effort to empty it again at the moment when fluid is being injected into the urethra; the compressor muscle being thus relaxed, the fluid passes into the deep urethra. It will take a little practice to enable him to do this, but when once learned the procedure is simple, and those who cannot accomplish it in the standing position will succeed if they lie down before making the attempt. In this way the entire urethra may be traversed.
In the treatment of deep urethritis it is not necessary to change the formulas or drugs above advised.