The causes are the same which give rise to stricture elsewhere; hence nothing requires to be said on this point. The point of most importance is the fact that stricture at this part of the urethra will cause difficult urination out of proportion to the extent of the narrowing of the canal. Contraction of the canal in a slight degree will cause great difficulty in urination, and frequently retention. This is contrary to the history of stricture of the urethra at other points. In such cases there is no retention of urine until the stricture closes the canal, or very nearly so; but I have seen retention in cases of stricture at the neck of the bladder while a medium-sized catheter could be passed with ease, thus showing that the narrowing of the canal was not alone the cause of the deranged function. It is possible that the original stricture causes spasmodic contraction, or in some way disturbs the normal action of that portion of the canal which performs the function of a sphincter vesicæ.
The symptoms presented in this form of stricture are difficult urination and in some cases complete retention. I have also noticed, in one case, that there was a frequent desire to urinate, but that was accounted for by a slight catarrh of the bladder. These symptoms are such as occur in other conditions, such as atrophy and paralysis of the bladder, obstruction of the urethra from tumors, calculi, the pressure of the displaced uterus, and prolapsus of the bladder.
In this form of stricture there are thickening and induration of the neck of the bladder, which may be detected by digital examination of the vagina. The sound will also reveal a narrowing of the canal at the vesical neck, but the contraction may not be marked. Our main reliance must be placed upon the exclusion of all other conditions which can produce the same symptoms. Pressure upon the urethra and prolapsus of the bladder can be excluded by an examination of the pelvic organs, and the use of the sound will show anything like complete obstruction of the canal.
Having excluded the possible existence of either of these conditions, the only two affections which are to be confounded with this form of stricture are atrophy and paralysis of the bladder. To distinguish these from the stricture, the catheter should be passed when the bladder is well distended, and the character of the flow of urine watched, when it will be observed that in stricture the urine comes away with the usual force. The bladder contracts normally and with its natural vigor, and sends the urine out in a well-sustained stream through the catheter, if there is only stricture. On the other hand, in paralysis and atrophy the stream is slow and without force—so much so that voluntary effort or the pressure of the hand on the abdomen is sometimes necessary to empty the bladder. This is especially so when the catheter is used while the patient is in the recumbent position. Finally, the diagnosis may be confirmed by testing the dilatability of the urethra. This can be done by passing a dilator along the urethra and gently testing the resistance of the walls of the canal. There is a slight yielding at all points except at the stricture, where a decided resistance is met.
Regarding the management of stricture at the junction of the urethra and bladder, I am obliged to say that my experience has not yet been sufficient to enable me to speak definitely. Rapid and free dilatation is not sufficient to effect a cure; at least it has failed in one case. Division of the stricture by incision suggests itself, but I am confident that that operation would be unsatisfactory, because of the great irritation which always occurs when there is a solution of continuity at this point. My practice, therefore, has been to produce slow and gradual dilatation by the use of graduated sounds, and the application of oleate of mercury or iodine to the anterior vaginal wall at the site of the stricture. More extended observation may develop other and better methods of treatment, but for the present that is all that I have to offer on this subject.
DISEASES OF THE VAGINA AND VULVA.
BY EDWARD W. JENKS, M.D., LL.D.