STRICTURES OF THE URETHRA.
Strictures of the urethra may be of traumatic origin, as when produced by external accident, with or without laceration, or by the introduction of foreign bodies, or the minor injuries inflicted during their extraction. Deep traumatic stricture is the result of serious injuries to the perineum. The common type of urethral stricture is the consequence of one or more attacks of gonorrhea, which, not having been promptly cured, has merged into so-called gleet, and this into these inevitable consequences, with more or less infiltration of the peri-urethral tissues, and subsequent encroachment upon the caliber of the urethra, either by irregular new tissue formations or well-marked annular constriction. In addition to the above conditions there is also known a spasmodic stricture, due to involuntary contraction of the muscular fibers encircling the urethra, and of the deeper perineal muscles which concern it. Otis held that such urethral spasm is a frequent accompaniment of a contracted meatus, and taught that the best method to deal with it is by first enlarging the meatus, as may be easily done with a simple bistoury, under local cocaine anesthesia (meatotomy), and the subsequent passage of instruments of proper size.
To persistent and well-marked contraction of the urethra is given the term organic stricture, and such a stricture is generally the consequence of injury or disease, whereas purely spasmodic stricture, mentioned above, is a not infrequent occurrence in perfectly chaste individuals.
Organic stricture may be single or multiple, of large or small caliber, or even impassable and impermeable—that is, from before backward—so that even while urine may leak through, drop by drop, from behind it seems impossible to introduce an instrument from the front. In aggravated cases three or four inches of the urethral canal may be involved in lesions of this kind, which constitute a formidable condition for satisfactory treatment. The ordinary non-traumatic organic strictures are all in front of the prostate and more common near the meatus. The size of a stricture is determined either by the urethrometer devised by Otis, or, more simply, by determining the diameter of the bulbous bougie which may be made to easily slip through it, the latter being the common method. These instruments are indicated by numbers, which refer to the millimeters in circumference of the bulb; thus No. 27 implies that the bulb has a circumference of 27 Mm. The bulbous instrument is far better for examination than the sound, since it indicates the exact depth as well as the length of the strictured passage, and gives a better idea of its density or resilience. (See [Figs. 671] and [672].)
The indications of stricture are difficulty in micturition, even to the degree of impossibility, persistence of gleety discharge, and slowness or impossibility of ejaculation, while sometimes cicatricial tissue can be felt from the outside.
The strictured urethral canal should be restored to normal dimensions at the earliest practicable moment. This may be effected through gradual dilatation with a conical steel sound, passed at intervals of two or three days, or rapidly, by the improved instrument of Otis known as the dilating urethrotome, which, being passed through the stricture, has its blades expanded by a mechanism at the handle, while the stricture when it is stretched is divided by the working of a concealed blade. The Otis instrument is illustrated in [Fig. 673].
A meatus too small to admit a suitable instrument should be incised to the necessary degree.
Gradual dilatation may be employed in the milder cases, and has been combined with a method of electrolysis, in which I have little faith. No matter which method be adopted, the patient should be impressed with the force of the old adage, “Once a stricture always a stricture,” and should be warned that the occasional passage of an instrument is necessary for a long period, and that while he may be taught the procedure he should not neglect it. This is true alike of every method of treatment.
Fig. 671
