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Stricture of the female urethra
STRICTURE
OF THE FEMALE URETHRA* W. KING, M.D., P.A.C.S.
M.
CLEVELAND,
M
Y
interest in this subject was aroused ten years ago by a case I saw diagnosed as a pus tube
instead
of as a distended
stricture
of the urethra,
bladder, and this
was made in spite of the fact of the departments
of the
due to a diagnosis
that
in each
dispensary
patient attended for months, her complaint was diffIcuIty in voiding. The purpose of this paper is: I. To present the 4 cases I have amined,
treated
and
came under observation,
foIIowed
since
the chief
exthey
and to review the
169 articIes anaIyzed, together with the discussion of this subject in the various Systems of Surgery, GynecoIogy, Obstetrics and UroIogy. 2. To anaIyze the etioIogica1 factors of stricture, and to show that gonorrhea is the most common cause, and that carcinoma is a more frequent cause than is generaIIy considered. 3. To urge that no case shouId be reported as a congenita1 stricture, unIess it fuIfIIIs Young’s requirements. 4. To stress the fact that no examination of the femaIe peIvis is compIete without a urethra1 examination. 5. To urge a compIete study of these cases by cystoscopy, functiona tests, and x-ray in order to determine the pathoIogica1 changes, if any, that foIIow. BartheImey, in 1550, reported the first case of stricture of the female urethra, a congenita1 type, in which the urethra was compIeteIy cIosed, and the urine passed through the umbilicus. Lisfrance in 1824 and CiviaIe in 1850, brought this subject more forcibIy to the attention of the medica profession. The most carefu1 work has been contributed by Herman, who reported 23 cases in 1886; Hamon in 1901; ViIfroy in 1911; Wynne, 40 cases in 1922; * Submitted
OHIO
Pugh, 68 cases in 1926; and Gorowitz, 17 cases just recently. For the compIeteness of this paper, I wouId Iike to present briefly the anatomy of the femaIe urethra. It is 3.5 cm. Iong, and 7.5 mm. in diameter, and pursues a course downward and forward under the symphysis pubis. The mucous membrane is stratified epitheIium, except near the bIadder where it becomes a transitiona type. Many smaI1 mucous gIands Iined with coIumnar epitheIium dot the anterior portion, and Skene’s gIands empty into it at or near its externa1 orifice. The muscuIar Iayer consists of inner circuIar and outer IongitudinaI fibers. The externa1 Iayer is fibrous tissue. Imbert and Soubeyran say that the femaIe urethra represents embryoIogicaIIy that part of the femaIe urethra which is never invoIved by gonorrhea; therefore, the gonococcus can never be a cause of stricture here. Most authors, however, state it is the most common cause, espeWynne, ciaIIy KIeinwachter, Herman, Pugh, Stevens and Bagot who cIaims that one-third of the cases are so caused, but that the stricture does not appear for from five to eight years after the acute onset. Pugh cIaims that 90 per cent of his cases were due to gonorrhea. From the case reports in the Iiterature, this is we11 borne out as foIIows: gonorrhea, 12 I times; carcinoma, 50; obstetrica1, trauma, 38; traumatic, 19; syphiIis, 17; non-specific infection, I 5 ; congenita1, 13 ; seniIe thickening, 12; poIyps, 9; spasmodic type, 5; caIcuIus and infection, 4; gonorrhea and Iues, 4; uIcers, 4; chancroid, 4; benign tumors, 3; eIectroIysis, 2; postoperative, 2; lupus, 2; kraurosis vuIvae, 2; typhoid, 2; and one each of the foIIowing conditions, typhus fever, fissure, masturbatuberculosis, burn, scarlet fever, tion,
for publication 25’
November
14, 1930.
232
American
Journal
of Surgrry
King-Urethra1
diphtheria, keloid, sarcoma and melanosarcoma. To these I would add 4 cases, whose etioIogy couId not be proved bacterioIogicalIy, but cIinicaIly seemed certain; chancroid I from gonorrhea, I from associated with gonorrhea, I from a luetic uIcer and gonorrhea, and I from nonspecific infection associated with caIcuIi. Contrary to KIeinwachter’s opinion that tumors rareIy cause stricture, and if they do onIy in the beginning, about 50 per cent of the reported cases produced stricture, and most of these in the Iast six months of the disease. It is interesting to note that onIy I case was reported as due to tubercuIosis, which is about as infrequent as for the maIe, according to Young. Some question is raised by the author reIative to the cIassification of the foIIowing 2 cases reported as congenita1 strictures, as they do not f&I Young’s requirements: nameIy that the history of diffIcuIty in voiding shouId begin from birth, and that there ought to be hypertrophy and diIatation of the bIadder, ureters, and kidney peIves. One patient having pyeIonephritis yet showing a negative specific history, stated that her troubIe began in ad& life. The other, a woman of thirty, who had a pearIy-white diaphragm in the urethra with a centraI perforation, gave a history of diffIcuIty of onIy two years’ duration, and a combined infection of gonorrhea and syphihs. Some authors cIaim that a pearly-white membrane with a centraI perforation aIways indicates a congenita1 stricture. This is not true, because Iast year I saw such a membrane in a maIe urethra where a stricture, due to gonorrhea, had been diIated three years before. I cannot agree with Boyd when he interprets a11 chiIdren’s urethras which wil1 not admit a French No. 20, as congenita1 because in the treatment of strictures, genitaI infection in children many urethras wiI1 not admit over a No. 16 catheter. I do not believe that these so-caIIed soft strictures, reaIIy edema of the mucosa, shouId be cIassified as true strictures, because if the edema subsides, the troubIe
Stricture disappears without resort t3 dilation. Every one has seen cases where retention has foIIowed an aIcohoIic spree, or a severe chiIIing from a long ride in the winter, or after sitting through a footbaI1 game. Just recentIy I saw a man thirty-eight years oId who having drunk profusely the night before, had retention, due to congestion. Interesting, too, but differing considerably from the maIe is the Iocation reported most frequentIy invoIved by the stricture: anterior third, 86; middle third, 18; posterior third, 12; entire urethra, 12. There were a few cases of muItipIe stricture reported. These were not incIuded in the figures, nor were those due to carcinoma, which usualIy invoIved the whoIe cana1. One cannot draw any accurate con&sions as to the period of Iife when these strictures, due to inff ammatory processes, begin, because the age was stated onIy in I 37 of the 43 I cases recorded. However, it wouId appear that most occur during middIe life. On the contrary, a rather accurate period can be estabhshed for those caused by maIignancy, since the age was reported in 42 of the 48 cases, as is easiIy seen in the foIIowing chart: Age under I year
Inflammatory
____ 3
0
2
0
31 36 29 17 II
2 7 4 18
1-10 IO-20
20-30 30-40 40-50 5040 60-70 70-80
~ MaIignancy
0
0
10 1
The size of these strictures can be stated onIy with reIative accuracy because of the many types of instruments used; but reducing those given to a singIe scaIe, we have approximateIy the foIIowing from the Iiterature which shows that the filiform or near fiIiform is the most common. 3 ~1-26 French bougie. 16-20............................. 11~-15............................. 6-IO............................. Filiform-5 French. FiIiform.
3 8 14 42 70
NEW SERIES VOL. XIII,
No. 2
King-Urethra1
Pugh states that if a French No. 16 or smaIIer cannot pass, it constitutes a stricture, especiaIIy if symptoms of difflc&y in voiding and frequency are present. LeroueIIe says some strictures wiII aIIow onIy a French No. 20 to pass. Bugbee and Cheetham cIassify a condition aIIowing French 22 or smaIIer, a stricture. Stevens caIIs everything that permits a French 26 to pass, one, if any bladder symptoms are present and reports 173 such cases out of 234 patients examined for bIadder troubIe, aIthough he states that onIy 56 had rea1 symptoms. On the other hand Herman measured 55 norma cases where onIy a French No. 17 couId be passed. Bugbee reports 692 cases in IOOO of patients compIaining of frequency, Cheetham 16 3 in 3000 gynecoIogy in 100, WinkeI admissions, Fischer 4 in 4000, Hamonic 12 in 5000. These strictures varying from a thin membrane to a bridge of tissue, may cause very serious compIications. It is interesting to note that in the avaiIabIe Iiterature, no case of femaIe urethra1 fistuIa is recorded, except one reported by WincheI due to an uIcerating carcinomatous stricture. Young states that damage to the bIadder, ureters or kidneys is rare in strictures of the urethra because if the bIadder empties at aI1, it usuaIIy does so compIeteIy. There was no damage to the ureters or kidneys in one of my cases even when for severa years, there was constant retention in the bIadder of over 300 C.C. On the other hand Kreutzmann94 states that a considerabIe number of cases where urethra1 obstruction was present for some time, showed a diIation of the ureters and kidney peIves. This he beIieves is due to hypertrophy of the bIadder muscIes causing constricting bands about the Iower ureters. Autopsy reports of various cases have shown enlarged, thickened, and trabecuIated bIadders; diIation and hypertrophy of ureters and kidney peIves; enIarged and thick-waIIed kidneys. According to Heinricksdorff a puruIent cysto-UreteropyeIonephritis was present in 2 cases of stricture foIIowing a cicitricia1
Stricture
American Journal of Surgery
253
contraction of vesicovagina1 fistuIas caused by chiidbirth trauma. Tuckermann in 1899 reported a congenita1 stricture in a gir1 five years of age whose autopsy report showed the bIadder distended to the umbiIicus, the waIIs very thick, and a very smaI1 cavity in the fundus of the bIadder fuI1 of pus from which a staphyIococcus was cuItured, both ureters irreguIarIy diIated, and both renaI peIves markedIy enIarged. Stevens cIaims that 54.5 per cent of uretera strictures have urethra1 strictures and in 46.1 per cent of urethra1 strictures he founduretera1 strictures. Hunner according to Stevens found that 85 per cent of his uretera stricture cases had urethra1 strictures. On the whoIe, only a comparativeIy few compIications were reported because reIativeIy few autopsies were performed and onIy a record of 6 cystoscopies which were performed by Cheetham. No renaI functiona tests or pyeIograms were reported. The symptoms in the femaIe are the same as in the maIe: frequency, pain, burning, passing of smaI1 amounts of urine, diffIcuIty in starting the stream, straining during voiding, increase in emptying time of the bIadder, constant desire, urgency, dribbIing and diminution in the size of the stream down to a fine spray or compIete retention. Uremic and toxic symptoms such as headaches, drowsiness, depression, irritabiIity and nausea occur. Fatigue, Iack of ambition, abdomina1 discomfort and weakness are compIained of. Stanton and Cheetham report renaI coIic symptoms due to urethra1 strictures. The duration of symptoms varied from a few weeks to twenty-six years. In cases due to non-maIignant causes, the symptoms most often reported in order of frequency are: diffIcuIty in voiding, frequency, pain and dribbIing; whereas in those due to maIignancy the symptoms are bIeeding, frequency, difficuIty in voiding, retention, pain and burning. Treatment varied according to the cause from the simpIest procedure of diIation to the radica1 operation. In that due to maIig-
254
AmericanJournnld
King-Urethral
Surgery
nancy excision of the urethra often with a portion of the bladder was performed in 30 of the 48 cases whereas radium and x-ray were used onIy in 4. In non-maIignant strictures gradua1 diIation was performed seventy-eight times, interna urethrotomy in 3 I, &prapubic cystotomy and retrograde diIation in 2 cases and raDid diIation, trochar, gaIvanism and eIectroIysis in a few. I want to report 4 cases of stricture of the femaIe urethra I have seen since 1920 in a dispensary service of two hospitaIs, one for two years, the other for eight years. .d
I
CASE I. N. M., coIored, aged forty-one, was seen March, 1922, compIaining of pain in the lower abdomen, of burning, smarting and frequency of urination, of painfu1 and diff&It urination, of sIowness in starting the stream, of a very smaI1 stream, of inabiIity to hold her urine, and of a feeIing that she never emptied her bladder. She further compIained of nausea, headache, drowsiness, loss of ambition, inabiIity to work, of convulsive seizures, a11 of which had been present for one and one-half years. She gave a history of antiIeutic and antigonorrhea1 treatment since the appearance of a sore about the urethra and a discharge in 1917. Wassermann reaction 4 pIus. She had one chiId seventeen years old. Examination reveaIed a soft, tender mass in the Iower abdomen reachin’g haIf-way up to the umbilicus. The cervix presenting a IittIe discharge was in mid-position. The mass feIt covered the uterus both anteriorIy and IateraIIy. The urethral orifice was a dispraced depression, the result of scarring about the site of an oId ulceration. It would not admit a No. IO F. catheter. Therefore, I had her void whiIe on the tabIe to see if the urine did pass through the depressed pIace, and she passed a fine spray-Iike stream. The depression was fiIIed with fiIiforms and one jumped through a smaI1 opening under the bridge of tissue that overIapped the orifice. A No. 12 meta foIIower was attached and forced through removing 350 C.C. of urine. The supposed pus tube disappeared. The urethra was dilated periodicaIIy unti1 April 3, 1922, when a cystoscopic examination showed congestion and trabecuIations about the trigone and posterior waI1 of the bIadder. Catheters were passed UninterruptedIy to the kidney pelves. Each held IO C.C. Indigo carmine
Stricture functiona test was performed, 5 C.C. intravenously. The appearance time was four minutes. After coIIection for ten minutes the right kidney secretion was norma and 25 per cent more than the Ieft kidney. Phthalein test was 55 per cent in two hours. CASE II. C. S., coIored, twenty-eight years oId, presented herseIf on Jan. 20, 1927, compIaining of pain in the Iower right abdomen, of frequency of urination, 0ccasionaIIy every five minutes, of diffIcuIt voiding over a period of six years, of nycturia four to five times. She had been married for twelve years and had one child that died at six months of age. She had had Ieucorrhea for two years and biIatera1 Bartholin gIand abscesses, urethra1 polyps and a cicatricia1 scarring from a chancroid, which produced a stricture of the urethra. Wassermann test was negative and no gonococci were found. Both gIands were excised and severa poIyps ~4 in. long were removed from the urethral orifice. A stricture fiIiform in size which was situated 46 in. within the urethra, was dilated. Cystoscopic examination was done and pyeIograms made on February 7. The bladcier mucosa was somewhat congested but had no trabecuIations. Number 6 catheters were passed UninterruptedIy to the kidney pelves. Indigo carmine test was normaI. Both kidney specimens contained a trace of aIbumin, WBC, RBC and B. coIi. PyeIograms showed the right kidney enIarged but no change in either pelvis except that the major caIyces showed a IittIe unusua1 branching. There was no evidence of caIcuIi.
CASE III. F. B. coIored, aged forty-seven, came in complaining of nycturia, some diffIcuIty in voiding, frequency and a vagina1 discharge. She had had an operation for fibroid uterus and pus tubes fifteen years ago. Prior to this she had had two spontaneous miscarriages. The cervica1 smear showed no gonococci. Wassermann test was positive. The urethra would onIy admit a No. IO F. diIator but was easily diIated as the stricture was formed by an induration of the waI1 in the anterior third of the urethra. B. coli was cuItured from the bIadder urine. She refused cystoscopy, so diIation of the stricture and antiIuetic treatment only were done. This stricture, I believe, was due to gonorrhea as there was no evidence of any ulceration or scars.
CASE IV. This woman,
M. McA.,
seventy-
NEW SERIES VOL.XIII, No. 2
King-Urethra1
three years oId, coIored, was seen in Oct., 1928, compIaining of bIood in the urine for six months, of bIadder troubIe for thirty years, of frequency, often every fifteen minutes, of passing smaI1 amounts of urine, of dysuria, of diffIcuIty in voiding, of a smaI1 stream, of urgency, of nycturia four to five times, of passing sand and pebbIes for the Iast three days. She had cramping pains in the kidney regions, radiation to the Iower back, groin, and to the anterior surface of the thighs. There was no venerea1 history, but she and many of her family gave a history of tubercuIosis. Examination revealed tenderness over both kidneys and bladder. The urethra1 orifice was smaI1 and the cana rope-Iike to palpation throughout its entire Iength. The ureters were not feIt bimanuaIIy. There was no vaginal discharge. The uterus and adnexa were small and Iocated normaIIy. The stricture was diIated from a No. 12 F. to 26 and cystoscopic examination showed much congestion of the bIadder mucosa, and many Iarge trabecuIations behind the trigone. A smaI1 white stone was removed. The uretera orifices were very prominent and congested. A No. 5 catheter couId not be passed over 2 cm. into the right ureter. A fXiform was passed and then a No. 4 catheter. Only a Miform couId be passed into the Ieft ureter. Catheters met an obstruction 3 cm. within. Specimens coIIected were bIood-tinged. Indigo carmine, 5 C.C. injected intravenousIy, appeared from the right kidney in five minutes and from the Ieft kidney in eight minutes. CoIIection for
Stricture
American Journd of Surgery
255
a ten-minute
period was about 60 per cent from the right and 40 per cent from the Ieft kidney. X-rays showed the right kidney peIvis norma and the Ieft sIightIy enIarged. No caIcuIi were present. CuItures showed a staphyIococcus in the bIadder specimen but no growth from either kidney. Further treatment consisted of urethra1 diIation and bIadder irrigations. The ureters were diIated to a No. 8 F. .and the urethra to a No. 28 F. In concIusio,n, it seemed to me severa important facts couId be deduced from a11 these case reports. I. That gonorrhea is the most frequent cause of stricture of the femaIe urethra. 2. That carcinoma is a far greater cause of stricture than is generaIIy supposed. 3. That a11 strictures reported as congenita1 shouId fuIfiI1 Young’s ruIe. 4. That diIation and hypertrophy of the ureters and kidney pelves are not frequentIy associated with stricture of the urethra with the exception of the congenita1 tY Pe. 5. That
a11 cases shouId be compIeteIy studied by cystoscopic functiona tests, and x-rays taken to determine a11 the accompanying pathoIogica1 changes. 6. That the so-caIIed soft stricture shouId not be cIassified as a stricture.
7. That the femaIe urethra be overIooked in examination.
shouId
not
BIBLIOGRAPHY
I. ASTROP. A case of stricture of the fernate urethra. Virginia M. Semi-Month., 13: 494, 1908-9. 2. ALLWOOD. Three impermeable strictures of urethra. Brit. M. J., 2: 173, 1901. 3. BERNHART, F. X. Tertiare Lues und Striktureen der weibhchen Urethra. Miincben. med. Wcbnscbr., 72: 1547, 1925. 4. BERTNER, E. W. Reconstruction of the female urethra. Med. Rec. u Ann., 20: 88, 1926. 5. BAGOT, W. S. Stricture of the urethra in women. Med. News, 66: 426, 1895. 6. BANZET. Retrbissement de I’uretre chez Ia femme, probabIement d’origine congenitaIe. Ass. franc. d’urol. Proc.-verb. 1902. Par. 6: 227, 1903. 7. BOGOLYUBOFF, V. SIuchai trbvmaticheskoi strikturi uretri u dievochki 6 liet. (Traumatic stricture of the urethra in a gir1 six years oId.) Med. Obozr. Mask., 69: 910-12, 1908. 8. BARNES, F. Stricture of the urethra in the femaIe. Provincial M. J., Leicester, 9: 720, 1892.
9. BRIDGES, W. 0. Stricture of the urethra in the female, and refIex neurosis from urethra1 stricture in the maIe. Med. Rec., 41: 516, 1892. IO. BOYD, M. Strictures of the urethral meatus in the female. J. A.M. A., J. 92: 2154, 1929. II. BUGBEE, H. U. and WOLLSTEIN, M. SurgicaI pathoIogy of the urinary tract in infants. J. A. M. A. 83: 1887-94. 1924. 12. CLARK, J. G. Urethra1 stricture in women. Progr. Med. Pbila., 2: 240, 1923. 13. CARDERO, M. Apuntes acerca de aIgunos hechos de uretroestenosis en Ia mujer. Gac. mid. de Mexico, 27: 377-382, 1892. 14. CURLING, T. B. Stricture of the femaIe urethra, caused by injury in chiIdbirth; cured by dilatation. Lancet, I: 188, 1861. 15. CECIL, A. B. Unique type of obstruction. J. Ural., 2: 379, 1918. [For Remainder of BibIiography see Author’s Reprints.]
OF THE FEMALE URETHRA* W. KING, M.D., P.A.C.S.
M.
CLEVELAND,
M
Y
interest in this subject was aroused ten years ago by a case I saw diagnosed as a pus tube
instead
of as a distended
stricture
of the urethra,
bladder, and this
was made in spite of the fact of the departments
of the
due to a diagnosis
that
in each
dispensary
patient attended for months, her complaint was diffIcuIty in voiding. The purpose of this paper is: I. To present the 4 cases I have amined,
treated
and
came under observation,
foIIowed
since
the chief
exthey
and to review the
169 articIes anaIyzed, together with the discussion of this subject in the various Systems of Surgery, GynecoIogy, Obstetrics and UroIogy. 2. To anaIyze the etioIogica1 factors of stricture, and to show that gonorrhea is the most common cause, and that carcinoma is a more frequent cause than is generaIIy considered. 3. To urge that no case shouId be reported as a congenita1 stricture, unIess it fuIfIIIs Young’s requirements. 4. To stress the fact that no examination of the femaIe peIvis is compIete without a urethra1 examination. 5. To urge a compIete study of these cases by cystoscopy, functiona tests, and x-ray in order to determine the pathoIogica1 changes, if any, that foIIow. BartheImey, in 1550, reported the first case of stricture of the female urethra, a congenita1 type, in which the urethra was compIeteIy cIosed, and the urine passed through the umbilicus. Lisfrance in 1824 and CiviaIe in 1850, brought this subject more forcibIy to the attention of the medica profession. The most carefu1 work has been contributed by Herman, who reported 23 cases in 1886; Hamon in 1901; ViIfroy in 1911; Wynne, 40 cases in 1922; * Submitted
OHIO
Pugh, 68 cases in 1926; and Gorowitz, 17 cases just recently. For the compIeteness of this paper, I wouId Iike to present briefly the anatomy of the femaIe urethra. It is 3.5 cm. Iong, and 7.5 mm. in diameter, and pursues a course downward and forward under the symphysis pubis. The mucous membrane is stratified epitheIium, except near the bIadder where it becomes a transitiona type. Many smaI1 mucous gIands Iined with coIumnar epitheIium dot the anterior portion, and Skene’s gIands empty into it at or near its externa1 orifice. The muscuIar Iayer consists of inner circuIar and outer IongitudinaI fibers. The externa1 Iayer is fibrous tissue. Imbert and Soubeyran say that the femaIe urethra represents embryoIogicaIIy that part of the femaIe urethra which is never invoIved by gonorrhea; therefore, the gonococcus can never be a cause of stricture here. Most authors, however, state it is the most common cause, espeWynne, ciaIIy KIeinwachter, Herman, Pugh, Stevens and Bagot who cIaims that one-third of the cases are so caused, but that the stricture does not appear for from five to eight years after the acute onset. Pugh cIaims that 90 per cent of his cases were due to gonorrhea. From the case reports in the Iiterature, this is we11 borne out as foIIows: gonorrhea, 12 I times; carcinoma, 50; obstetrica1, trauma, 38; traumatic, 19; syphiIis, 17; non-specific infection, I 5 ; congenita1, 13 ; seniIe thickening, 12; poIyps, 9; spasmodic type, 5; caIcuIus and infection, 4; gonorrhea and Iues, 4; uIcers, 4; chancroid, 4; benign tumors, 3; eIectroIysis, 2; postoperative, 2; lupus, 2; kraurosis vuIvae, 2; typhoid, 2; and one each of the foIIowing conditions, typhus fever, fissure, masturbatuberculosis, burn, scarlet fever, tion,
for publication 25’
November
14, 1930.
232
American
Journal
of Surgrry
King-Urethra1
diphtheria, keloid, sarcoma and melanosarcoma. To these I would add 4 cases, whose etioIogy couId not be proved bacterioIogicalIy, but cIinicaIly seemed certain; chancroid I from gonorrhea, I from associated with gonorrhea, I from a luetic uIcer and gonorrhea, and I from nonspecific infection associated with caIcuIi. Contrary to KIeinwachter’s opinion that tumors rareIy cause stricture, and if they do onIy in the beginning, about 50 per cent of the reported cases produced stricture, and most of these in the Iast six months of the disease. It is interesting to note that onIy I case was reported as due to tubercuIosis, which is about as infrequent as for the maIe, according to Young. Some question is raised by the author reIative to the cIassification of the foIIowing 2 cases reported as congenita1 strictures, as they do not f&I Young’s requirements: nameIy that the history of diffIcuIty in voiding shouId begin from birth, and that there ought to be hypertrophy and diIatation of the bIadder, ureters, and kidney peIves. One patient having pyeIonephritis yet showing a negative specific history, stated that her troubIe began in ad& life. The other, a woman of thirty, who had a pearIy-white diaphragm in the urethra with a centraI perforation, gave a history of diffIcuIty of onIy two years’ duration, and a combined infection of gonorrhea and syphihs. Some authors cIaim that a pearly-white membrane with a centraI perforation aIways indicates a congenita1 stricture. This is not true, because Iast year I saw such a membrane in a maIe urethra where a stricture, due to gonorrhea, had been diIated three years before. I cannot agree with Boyd when he interprets a11 chiIdren’s urethras which wil1 not admit a French No. 20, as congenita1 because in the treatment of strictures, genitaI infection in children many urethras wiI1 not admit over a No. 16 catheter. I do not believe that these so-caIIed soft strictures, reaIIy edema of the mucosa, shouId be cIassified as true strictures, because if the edema subsides, the troubIe
Stricture disappears without resort t3 dilation. Every one has seen cases where retention has foIIowed an aIcohoIic spree, or a severe chiIIing from a long ride in the winter, or after sitting through a footbaI1 game. Just recentIy I saw a man thirty-eight years oId who having drunk profusely the night before, had retention, due to congestion. Interesting, too, but differing considerably from the maIe is the Iocation reported most frequentIy invoIved by the stricture: anterior third, 86; middle third, 18; posterior third, 12; entire urethra, 12. There were a few cases of muItipIe stricture reported. These were not incIuded in the figures, nor were those due to carcinoma, which usualIy invoIved the whoIe cana1. One cannot draw any accurate con&sions as to the period of Iife when these strictures, due to inff ammatory processes, begin, because the age was stated onIy in I 37 of the 43 I cases recorded. However, it wouId appear that most occur during middIe life. On the contrary, a rather accurate period can be estabhshed for those caused by maIignancy, since the age was reported in 42 of the 48 cases, as is easiIy seen in the foIIowing chart: Age under I year
Inflammatory
____ 3
0
2
0
31 36 29 17 II
2 7 4 18
1-10 IO-20
20-30 30-40 40-50 5040 60-70 70-80
~ MaIignancy
0
0
10 1
The size of these strictures can be stated onIy with reIative accuracy because of the many types of instruments used; but reducing those given to a singIe scaIe, we have approximateIy the foIIowing from the Iiterature which shows that the filiform or near fiIiform is the most common. 3 ~1-26 French bougie. 16-20............................. 11~-15............................. 6-IO............................. Filiform-5 French. FiIiform.
3 8 14 42 70
NEW SERIES VOL. XIII,
No. 2
King-Urethra1
Pugh states that if a French No. 16 or smaIIer cannot pass, it constitutes a stricture, especiaIIy if symptoms of difflc&y in voiding and frequency are present. LeroueIIe says some strictures wiII aIIow onIy a French No. 20 to pass. Bugbee and Cheetham cIassify a condition aIIowing French 22 or smaIIer, a stricture. Stevens caIIs everything that permits a French 26 to pass, one, if any bladder symptoms are present and reports 173 such cases out of 234 patients examined for bIadder troubIe, aIthough he states that onIy 56 had rea1 symptoms. On the other hand Herman measured 55 norma cases where onIy a French No. 17 couId be passed. Bugbee reports 692 cases in IOOO of patients compIaining of frequency, Cheetham 16 3 in 3000 gynecoIogy in 100, WinkeI admissions, Fischer 4 in 4000, Hamonic 12 in 5000. These strictures varying from a thin membrane to a bridge of tissue, may cause very serious compIications. It is interesting to note that in the avaiIabIe Iiterature, no case of femaIe urethra1 fistuIa is recorded, except one reported by WincheI due to an uIcerating carcinomatous stricture. Young states that damage to the bIadder, ureters or kidneys is rare in strictures of the urethra because if the bIadder empties at aI1, it usuaIIy does so compIeteIy. There was no damage to the ureters or kidneys in one of my cases even when for severa years, there was constant retention in the bIadder of over 300 C.C. On the other hand Kreutzmann94 states that a considerabIe number of cases where urethra1 obstruction was present for some time, showed a diIation of the ureters and kidney peIves. This he beIieves is due to hypertrophy of the bIadder muscIes causing constricting bands about the Iower ureters. Autopsy reports of various cases have shown enlarged, thickened, and trabecuIated bIadders; diIation and hypertrophy of ureters and kidney peIves; enIarged and thick-waIIed kidneys. According to Heinricksdorff a puruIent cysto-UreteropyeIonephritis was present in 2 cases of stricture foIIowing a cicitricia1
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253
contraction of vesicovagina1 fistuIas caused by chiidbirth trauma. Tuckermann in 1899 reported a congenita1 stricture in a gir1 five years of age whose autopsy report showed the bIadder distended to the umbiIicus, the waIIs very thick, and a very smaI1 cavity in the fundus of the bIadder fuI1 of pus from which a staphyIococcus was cuItured, both ureters irreguIarIy diIated, and both renaI peIves markedIy enIarged. Stevens cIaims that 54.5 per cent of uretera strictures have urethra1 strictures and in 46.1 per cent of urethra1 strictures he founduretera1 strictures. Hunner according to Stevens found that 85 per cent of his uretera stricture cases had urethra1 strictures. On the whoIe, only a comparativeIy few compIications were reported because reIativeIy few autopsies were performed and onIy a record of 6 cystoscopies which were performed by Cheetham. No renaI functiona tests or pyeIograms were reported. The symptoms in the femaIe are the same as in the maIe: frequency, pain, burning, passing of smaI1 amounts of urine, diffIcuIty in starting the stream, straining during voiding, increase in emptying time of the bIadder, constant desire, urgency, dribbIing and diminution in the size of the stream down to a fine spray or compIete retention. Uremic and toxic symptoms such as headaches, drowsiness, depression, irritabiIity and nausea occur. Fatigue, Iack of ambition, abdomina1 discomfort and weakness are compIained of. Stanton and Cheetham report renaI coIic symptoms due to urethra1 strictures. The duration of symptoms varied from a few weeks to twenty-six years. In cases due to non-maIignant causes, the symptoms most often reported in order of frequency are: diffIcuIty in voiding, frequency, pain and dribbIing; whereas in those due to maIignancy the symptoms are bIeeding, frequency, difficuIty in voiding, retention, pain and burning. Treatment varied according to the cause from the simpIest procedure of diIation to the radica1 operation. In that due to maIig-
254
AmericanJournnld
King-Urethral
Surgery
nancy excision of the urethra often with a portion of the bladder was performed in 30 of the 48 cases whereas radium and x-ray were used onIy in 4. In non-maIignant strictures gradua1 diIation was performed seventy-eight times, interna urethrotomy in 3 I, &prapubic cystotomy and retrograde diIation in 2 cases and raDid diIation, trochar, gaIvanism and eIectroIysis in a few. I want to report 4 cases of stricture of the femaIe urethra I have seen since 1920 in a dispensary service of two hospitaIs, one for two years, the other for eight years. .d
I
CASE I. N. M., coIored, aged forty-one, was seen March, 1922, compIaining of pain in the lower abdomen, of burning, smarting and frequency of urination, of painfu1 and diff&It urination, of sIowness in starting the stream, of a very smaI1 stream, of inabiIity to hold her urine, and of a feeIing that she never emptied her bladder. She further compIained of nausea, headache, drowsiness, loss of ambition, inabiIity to work, of convulsive seizures, a11 of which had been present for one and one-half years. She gave a history of antiIeutic and antigonorrhea1 treatment since the appearance of a sore about the urethra and a discharge in 1917. Wassermann reaction 4 pIus. She had one chiId seventeen years old. Examination reveaIed a soft, tender mass in the Iower abdomen reachin’g haIf-way up to the umbilicus. The cervix presenting a IittIe discharge was in mid-position. The mass feIt covered the uterus both anteriorIy and IateraIIy. The urethral orifice was a dispraced depression, the result of scarring about the site of an oId ulceration. It would not admit a No. IO F. catheter. Therefore, I had her void whiIe on the tabIe to see if the urine did pass through the depressed pIace, and she passed a fine spray-Iike stream. The depression was fiIIed with fiIiforms and one jumped through a smaI1 opening under the bridge of tissue that overIapped the orifice. A No. 12 meta foIIower was attached and forced through removing 350 C.C. of urine. The supposed pus tube disappeared. The urethra was dilated periodicaIIy unti1 April 3, 1922, when a cystoscopic examination showed congestion and trabecuIations about the trigone and posterior waI1 of the bIadder. Catheters were passed UninterruptedIy to the kidney pelves. Each held IO C.C. Indigo carmine
Stricture functiona test was performed, 5 C.C. intravenously. The appearance time was four minutes. After coIIection for ten minutes the right kidney secretion was norma and 25 per cent more than the Ieft kidney. Phthalein test was 55 per cent in two hours. CASE II. C. S., coIored, twenty-eight years oId, presented herseIf on Jan. 20, 1927, compIaining of pain in the Iower right abdomen, of frequency of urination, 0ccasionaIIy every five minutes, of diffIcuIt voiding over a period of six years, of nycturia four to five times. She had been married for twelve years and had one child that died at six months of age. She had had Ieucorrhea for two years and biIatera1 Bartholin gIand abscesses, urethra1 polyps and a cicatricia1 scarring from a chancroid, which produced a stricture of the urethra. Wassermann test was negative and no gonococci were found. Both gIands were excised and severa poIyps ~4 in. long were removed from the urethral orifice. A stricture fiIiform in size which was situated 46 in. within the urethra, was dilated. Cystoscopic examination was done and pyeIograms made on February 7. The bladcier mucosa was somewhat congested but had no trabecuIations. Number 6 catheters were passed UninterruptedIy to the kidney pelves. Indigo carmine test was normaI. Both kidney specimens contained a trace of aIbumin, WBC, RBC and B. coIi. PyeIograms showed the right kidney enIarged but no change in either pelvis except that the major caIyces showed a IittIe unusua1 branching. There was no evidence of caIcuIi.
CASE III. F. B. coIored, aged forty-seven, came in complaining of nycturia, some diffIcuIty in voiding, frequency and a vagina1 discharge. She had had an operation for fibroid uterus and pus tubes fifteen years ago. Prior to this she had had two spontaneous miscarriages. The cervica1 smear showed no gonococci. Wassermann test was positive. The urethra would onIy admit a No. IO F. diIator but was easily diIated as the stricture was formed by an induration of the waI1 in the anterior third of the urethra. B. coli was cuItured from the bIadder urine. She refused cystoscopy, so diIation of the stricture and antiIuetic treatment only were done. This stricture, I believe, was due to gonorrhea as there was no evidence of any ulceration or scars.
CASE IV. This woman,
M. McA.,
seventy-
NEW SERIES VOL.XIII, No. 2
King-Urethra1
three years oId, coIored, was seen in Oct., 1928, compIaining of bIood in the urine for six months, of bIadder troubIe for thirty years, of frequency, often every fifteen minutes, of passing smaI1 amounts of urine, of dysuria, of diffIcuIty in voiding, of a smaI1 stream, of urgency, of nycturia four to five times, of passing sand and pebbIes for the Iast three days. She had cramping pains in the kidney regions, radiation to the Iower back, groin, and to the anterior surface of the thighs. There was no venerea1 history, but she and many of her family gave a history of tubercuIosis. Examination revealed tenderness over both kidneys and bladder. The urethra1 orifice was smaI1 and the cana rope-Iike to palpation throughout its entire Iength. The ureters were not feIt bimanuaIIy. There was no vaginal discharge. The uterus and adnexa were small and Iocated normaIIy. The stricture was diIated from a No. 12 F. to 26 and cystoscopic examination showed much congestion of the bIadder mucosa, and many Iarge trabecuIations behind the trigone. A smaI1 white stone was removed. The uretera orifices were very prominent and congested. A No. 5 catheter couId not be passed over 2 cm. into the right ureter. A fXiform was passed and then a No. 4 catheter. Only a Miform couId be passed into the Ieft ureter. Catheters met an obstruction 3 cm. within. Specimens coIIected were bIood-tinged. Indigo carmine, 5 C.C. injected intravenousIy, appeared from the right kidney in five minutes and from the Ieft kidney in eight minutes. CoIIection for
Stricture
American Journd of Surgery
255
a ten-minute
period was about 60 per cent from the right and 40 per cent from the Ieft kidney. X-rays showed the right kidney peIvis norma and the Ieft sIightIy enIarged. No caIcuIi were present. CuItures showed a staphyIococcus in the bIadder specimen but no growth from either kidney. Further treatment consisted of urethra1 diIation and bIadder irrigations. The ureters were diIated to a No. 8 F. .and the urethra to a No. 28 F. In concIusio,n, it seemed to me severa important facts couId be deduced from a11 these case reports. I. That gonorrhea is the most frequent cause of stricture of the femaIe urethra. 2. That carcinoma is a far greater cause of stricture than is generaIIy supposed. 3. That a11 strictures reported as congenita1 shouId fuIfiI1 Young’s ruIe. 4. That diIation and hypertrophy of the ureters and kidney pelves are not frequentIy associated with stricture of the urethra with the exception of the congenita1 tY Pe. 5. That
a11 cases shouId be compIeteIy studied by cystoscopic functiona tests, and x-rays taken to determine a11 the accompanying pathoIogica1 changes. 6. That the so-caIIed soft stricture shouId not be cIassified as a stricture.
7. That the femaIe urethra be overIooked in examination.
shouId
not
BIBLIOGRAPHY
I. ASTROP. A case of stricture of the fernate urethra. Virginia M. Semi-Month., 13: 494, 1908-9. 2. ALLWOOD. Three impermeable strictures of urethra. Brit. M. J., 2: 173, 1901. 3. BERNHART, F. X. Tertiare Lues und Striktureen der weibhchen Urethra. Miincben. med. Wcbnscbr., 72: 1547, 1925. 4. BERTNER, E. W. Reconstruction of the female urethra. Med. Rec. u Ann., 20: 88, 1926. 5. BAGOT, W. S. Stricture of the urethra in women. Med. News, 66: 426, 1895. 6. BANZET. Retrbissement de I’uretre chez Ia femme, probabIement d’origine congenitaIe. Ass. franc. d’urol. Proc.-verb. 1902. Par. 6: 227, 1903. 7. BOGOLYUBOFF, V. SIuchai trbvmaticheskoi strikturi uretri u dievochki 6 liet. (Traumatic stricture of the urethra in a gir1 six years oId.) Med. Obozr. Mask., 69: 910-12, 1908. 8. BARNES, F. Stricture of the urethra in the femaIe. Provincial M. J., Leicester, 9: 720, 1892.
9. BRIDGES, W. 0. Stricture of the urethra in the female, and refIex neurosis from urethra1 stricture in the maIe. Med. Rec., 41: 516, 1892. IO. BOYD, M. Strictures of the urethral meatus in the female. J. A.M. A., J. 92: 2154, 1929. II. BUGBEE, H. U. and WOLLSTEIN, M. SurgicaI pathoIogy of the urinary tract in infants. J. A. M. A. 83: 1887-94. 1924. 12. CLARK, J. G. Urethra1 stricture in women. Progr. Med. Pbila., 2: 240, 1923. 13. CARDERO, M. Apuntes acerca de aIgunos hechos de uretroestenosis en Ia mujer. Gac. mid. de Mexico, 27: 377-382, 1892. 14. CURLING, T. B. Stricture of the femaIe urethra, caused by injury in chiIdbirth; cured by dilatation. Lancet, I: 188, 1861. 15. CECIL, A. B. Unique type of obstruction. J. Ural., 2: 379, 1918. [For Remainder of BibIiography see Author’s Reprints.]