Students often confuse not only terms but conditions, and it is necessary to be accurate in teaching regarding these subjects. Suppression of urine is purely a matter of cessation of renal function, and has nothing to do with the bladder. Retention of urine, on the other hand, has nothing to do with the kidneys, but is purely a bladder affair. It may be due to spasm of the bladder outlet, or to its obstruction by calculi, other foreign body, or by prostatic enlargement, or it may be a consequence of paralysis of bladder muscle. Such retention is the inevitable consequence of fracture of the spine, since paraplegia is to be expected in such cases, and the condition is to be atoned for by careful and regular catheterization. Retention, again, is occasionally seen in hysterical patients. It furnishes the distressing and sometimes permanent or even fatal consequences of prostatic enlargement in old men. No matter how produced, it must be relieved, for urine tends to accumulate and to distend the bladder, which will finally burst unless the difficulty be sufficiently overcome so that urine may in some way escape. Distention of the bladder under these circumstances is recognized by the formation of a rapidly increasing tumor, which finally rises to the level of the umbilicus, fluctuates, and is accompanied or not by pain according to the nature of the cause of retention. In paralytic cases there will be little or no pain. In obstructive cases it will be agonizing.
By natural efforts final rupture of the bladder is usually prevented, as after a certain degree of distention has been attained urine begins to escape drop by drop. This is simply an expression of an overflow, and is not to be confused with incontinence in the proper sense of the term. It may be spoken of as stillicidium, due to retention. The young and indifferent practitioner may mistake this escape of urine for incontinence, which would be a most serious error. Under any circumstances, when such a condition may possibly occur, the lower abdomen should be palpated, when the presence of a distended bladder should be instantly recognized. The first indication is for its prompt relief by the use of the catheter, while the necessary catheterization should be done with the usual precautions. When the passage of an ordinary instrument is made difficult or impossible the cause of the retention is usually thereby revealed, and may be shown to be so serious as to necessitate further operative procedures.
When the bladder is distended and no catheter can be introduced it is advisable to aspirate, the aspirating needle being introduced through the sterilized skin just above the pubis, its point directed toward the centre of the mass formed by the distended bladder. Repeated aspiration may be necessary, and it has been suggested to make more or less permanent use of such a tube or hollow needle. At present no surgeon would continue this as a permanent measure, but simply as a temporary relief, even if repetition be necessary, until more radical procedure can be carried out. Whether this be the removal of a foreign body or calculus, or of an enlarged prostate, it is indicated just the same, the only exception to this statement being those cases already too seriously involved to justify more than perineal section (cystotomy for drainage). Retention of urine, then, is always a preventable condition, and its continuance is inexcusable.
Incontinence implies a paralytic condition, usually of the expulsive muscles, but sometimes of the sphincter apparatus in either sex, by which urinary control is lost and urine escapes involuntarily. It may be a temporary and occasional phenomenon, occurring under the influence of strong excitement or during sleep, especially in children, or it may be due to spinal disease or traumatisms, with paralysis of the lower segments of the cord and nerves given off from them. When originating in the latter way it is usually a hopeless condition, but nocturnal incontinence of children, or even of adults, or that due to hysterical or other neurotic conditions, may usually be benefited. For this purpose the surgeon should search for the cause from which the reflex proceeds. This may be extreme acidity of urine, the irritation of a tight prepuce in either sex, the presence of worms, intestinal disturbances, or any one of a great number of possible causes of disturbance of nerve control. Some of them permit of surgical relief; others require simpler measures. Children thus suffering should be given no fluid late in the evening, but should be made to empty the bladder before retiring, and perhaps be aroused once or twice through the night for the same purpose. In all cases the urine should be examined and hyperacidity overcome. All forms of genital excitement should be obviated. In the adolescent and in adults thus annoyed, and in the insane, it has been shown to be of great benefit to make a few intraspinal injections of sterile salt solution, as for local anesthetic purposes, a little cerebrospinal fluid being first withdrawn, and then from 2 to 10 or 15 Cc. of the solution being introduced. This seems to have been empirically suggested by a French surgeon, but has been found of value by Valentine and others, including the writer.
The above forms of incontinence are to be distinguished from intense irritability of the bladder, with frequent calls to empty it, which accompany many such conditions as cystitis, tuberculosis, tumors, calculi, and the like. This is the extreme irritability of local disease rather than true incontinence. But there is also a form, in women, characterized by falling away of the urethra and neck of the bladder from the pubis, due usually to injuries received during parturition, with consequent sacculation or dilatation of the urethra and formation of a cystocele. (Dudley.) This may also be associated with other results of perineal laceration. Here loss of urine is not constant, but occasional or frequent. For its treatment the following methods have been suggested: the injection of paraffin; partial torsion of the urethra (Gersuny), i. e., a partial dissection of the urethra and revolution upon its own axis, with subsequent suture, by which incontinence may be overcome, but at the possible risk of sloughing. Finally, Dudley has proposed the method of advancement of the urethra. He makes a horseshoe denudation, between the meatus and the clitoris, down on either side of the urethra, and nearly its entire length. Its anterior end is then loosened sufficiently so that the meatus can be drawn forward and secured below the clitoris by two sutures. The balance of the wound is then closed, the effect of the operation being to replace and retain the urethra and prevent its sagging. Other surgical treatment, as for cystocele, laceration, etc., may be added as needed.
CYSTITIS.
The condition of true cystitis arises invariably either from the irritation of a foreign body or the presence of bacteria; the former need not necessarily be large, and minute and irritating crystals are often sufficient to produce at least some of its features. Sooner or later, however, the germ element enters, and from that time on cystitis is a bacterial infection. Furthermore this infection is usually secondary, rarely if ever primary, and may come from without or within. Thus it may be the consequence of the introduction of unclean instruments; is a very frequent consequence of gonorrhea, including all forms of urethritis; or may be the result of local tuberculous processes or those travelling downward from the kidneys; or, again, of more general toxic or septic conditions, such as typhoid and other infectious fevers. Certain conditions predispose, such as the presence of calculi or the occurrence of traumatism. Again, a bladder weakened by overdistention or paralysis, as in cases of spinal injury, loses its natural resisting power and succumbs to infection abnormally easily. It should be emphasized that the absolutely healthy bladder wall is resistant to all germ activity, but this resistance is easily lost or modified in the presence of disease, either close by or distant. A bladder whose normal shape has been greatly changed by enlargement of the prostate is again rendered not only unhealthy, but incapable of acting normally. It becomes, therefore, easily infected, and cystitis is a frequent accompaniment of prostatic hypertrophy.
Fig. 651
Internal appearance of bladder in some cases of inveterate cystitis; mucosa sacculated by columns of hypertrophied tissue. (Launois.)