PATHOLOGY.—Obstruction of the urethra by narrowing of its calibre is a much less common affection in the female than in the male. Still, it occurs sufficiently often to demand attention. There are some facts in the pathology of urethral stricture peculiar to women which we will first notice. Passing over congenital narrowing of the urethra by simply saying that such a malformation has been known, we find that stricture is developed in the female, as in the male, by the deposit of inflammatory products beneath the mucous membrane, which by gradual contraction constricts the canal. Ulceration of the membrane in a marked degree produces the same results. The inflammation and ulceration which end in the formation of stricture are usually specific in character, but the same may follow from the too free use of caustics and injuries during childbirth. Stricture may also be produced by bands of scar-tissue formed in the anterior vaginal wall and stretching across the urethra. Contraction of the whole canal occasionally occurs in cases of vesico-vaginal fistula of long standing. There the narrowing is simply the result of disuse. The form of stricture that most frequently comes under observation is a contraction of the meatus urinarius, produced in many cases by the too liberal use of caustics in the treatment of abnormal growths at the lower end of the urethra, or from vulvitis. This form of stricture is the least troublesome and is easily relieved. When due to the results of former urethritis or peri-urethritis, the walls of the urethra are thickened and indurated at the point of the stricture, and there is usually subacute urethritis, sometimes ulceration. In those cases where the calibre of the canal is diminished by cicatrices of the vaginal walls, and in general contraction of the urethra in vesico-vaginal fistula of long standing, the mucous membrane may be perfectly normal.
SYMPTOMATOLOGY.—Frequent and difficult urination are the chief troubles caused by stricture of the urethra. The stream becomes smaller, and may be twisted or flat, but this is rarely observed. Patients, as a rule, only notice that they require to urinate more frequently, and that they have to make more voluntary efforts to empty the bladder than were necessary before. In almost all cases of stricture the subject has at some previous time suffered an injury at childbirth, urethritis, or something to which the origin of the stricture can be traced. The previous history of cases in which stricture is suspected will aid in settling the diagnosis and etiology.
DIAGNOSIS.—A digital examination by the vagina will reveal thickening and induration if the stricture is due to that cause. Cicatrices of the vaginal wall compressing the urethra can be detected in the same way. The use of the sound will determine the location of the stricture and the extent to which the canal is contracted. When the stricture is at the meatus it can be found with facility; but when it is located higher up the largest sound that can be introduced without force should be passed up to the point of stricture. This will localize it; then by using a sound that will pass through it the extent of the constriction will thus be ascertained.
The affections which are liable to be mistaken for stricture are retention of urine or difficult urination from pressure on the urethra by the displaced gravid uterus, pelvic tumors, and dislocations of the urethra. The former can be excluded by a vaginal examination, and the latter can also be detected by the sound, used as directed while discussing the diagnosis of the dilatations.
PROGNOSIS.—Stricture of the urethra usually yields very promptly to treatment, so that the prognosis is good. The only exceptions are where the stricture has existed in a marked degree long enough to cause dilatation of the ureters and disease of the kidneys. Chronic cystitis or urethritis, occurring as a result of the stricture or coincident with it, may so complicate matters as to make recovery slow or even impossible. In cases where the whole urethra is contracted because of the existence of a vesico-vaginal fistula of long standing, it is extremely difficult to restore the tissues of the urethral walls to their normal state.
TREATMENT.—The treatment of stricture will depend upon its location and cause. If it is situated at the meatus, it can be divided by the urethrotome or forcibly stretched with the dilator. When due to bands of scar-tissue in the vagina, they should be divided at several points and the urethra dilated by repeatedly passing the sound. When it is owing to deposition of the products of inflammation in the submucous tissue, forcible and rapid dilatation, as practised on the male subject, will answer well if the proper cases are selected for this form of treatment. Dilatation should be made carefully, with a view to breaking up the constricting tissue without lacerating the mucous membrane. To do this it is not necessary to dilate the urethra to any great extent. As soon as the stricture has given way dilatation should be suspended.
Incising the stricture from within outward, according to the method commended by surgeons for the cure of stricture in the male, will no doubt answer a good purpose. In fact, I am inclined to believe that this plan of treating this affection is the best, but my own experience with this operation on the female urethra is not sufficient to warrant my speaking positively.
In contraction of the whole urethra arising from disuse in cases of vesico-vaginal fistula gradual dilatation with graduated sounds answers very well. This should be attended to before closing the opening in the bladder. In all cases attention should be given to any inflammation that may accompany the stricture or follow the treatment. It is well also to keep such patients under observation, and pass the sound from time to time to see if there is any tendency of the stricture to return. The brilliant results obtained in the treatment of stricture in the male with electrolysis by Robert Newman should warrant a more extended trial of this method.
Stricture at the Junction of the Urethra and Bladder.
This form or location of stricture is, so far as I know, peculiar to women, and its influence on the function of the bladder has not been clearly pointed out. In fact, no distinction has been made between the pathology or clinical history of stricture at the upper end of the urethra and elsewhere in the canal. At least, I am not aware that writers on this subject have mentioned this form of stricture. My own observations have been limited, but sufficient, I think, to warrant me in saying that stricture does occur at the junction of the bladder and urethra, and that it behaves differently from ordinary stricture at other parts of the canal.