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Stricture of the Female Urethra
THE JOURNAL OF UROLOGY
Vol. 66, No. 2, August 1951 Printed in U.S.A.
STRICTURE OF THE FEMALE URETHRA DORSEY BRANNAN
My attention has recently been focused on the subject of stricture of the female urethra because of a fatality resulting from this lesion (case 1). I believe that a condition which can ultimately lead to death and which as it appears, has not been particularly emphasized in urologic literature, merits some comment. Another fatal case was reported in the German literature in 1920 by Heinrichsdorff: A woman aged 65 acquired an injury to the urethra during labor with a resulting urethrovaginal fistula. A severe stricture gradually developed over a period of years which ultimately led to the patient's death. She presented clinically the picture of sepsis and coma (uremia?) and died 3 days after admission to the hospital. The urinary bladder was found dilated as vvell as the ureters and renal pelves, with abscesses in the kidneys and also extensive infection of the entire urinary system and associated general sepsis. Wynne, in his important contribution in 1927, referred to an article by Thompson in the English literature, who referred to another obvious fatal case of urethral stricture in the female. The report briefly described a museum specimen in the possession of the Royal College of Surgeons of Edinburg, of a 30 year old woman with strictured urethra, secondary changes in the bladder, and extravasation of urine. The death was prior to 1885. In my own experience, at least one death has occurred in a stubborn middle aged man as a result of chronic urethral stricture and the associated secondary infection and uremia. Severe lesions of this kind are much better known in men than in women. If the facts were known, no doubt other women have neglected themselves and died similar deaths secondary to urethral stricture. The literature on this subject remains rather sparse and only the more recent works were available to the writer. A good discussion of the earlier papers may be obtained in the writings of Stevens, Wynne, Pugh, and Anderson. Suffice it to record here that the Frenchman Lisfranc in 1824 first called attention to the condition of stricture in the female urethra. The first case description was credited to Earl of London in 1828. Then followed papers by Civiale in 1850 and by Newman in 1875. Hermann reviewed the literature on the subject in 1886 and contributed 6 cases of his own to the 23 cases already reported. Vander Werken and Skene published accounts of the disorder in 1887 and the former again in 1890 according to the above authors. In 1892, Otis was observant enough to devise special methods of diagnosis and treatment for slight degrees of stricture. Kelly and Burnam, in 1914, treated the subject as a rare condition and much of their material was based on the observations of others. They noted however that gonorrhea and obstetrical injuries were the important factors in etiology. Once the stricture had developed, they wrote, cystitis was very apt to follow. Their methods of treatment, aside from dilation of the urethra, seem strange today. 242
All are agreed that relatiYely little was accomplished on the subject before 1922, -when SteYens published his first paper in California. Ile concluded Hrnt
8tricture of the urethra ,rn8 a common ailment in women which responded very ,mil to adequate treatment. He also pointed out that treatment of the lesion ,ms prophylaxi8 more important disorders in the upper urinary 8Y8tem. Gonorrhea, he regarded as the prime factor in the cause of the disease. In 1924, and again in 1927, Pugh wrote two interesting essays on the subject. In the first paper he gave case reports to prove his points, while in 1927 he discussed the subject in a more academic manner. His conclusions were essentially that stricture of the female urethra -was a common condition, caused primarily by chronic gonorrhea, producing various urinary symptoms, and best treated (with good results) by dilation of the urethra. Cheetham, in presented 3 cases to emphasize the three main factors in etiology; namely, infection, which ,ms generally gonorrheal, and trauma, both obstetrical and operntiYe. He treated his patients by dilation of the urethra. Wynne, in 1927, discussed the matter of stricture of the female urethra, paying special attention to the anatomy of the urethra, age groups, and the location 2end size of the strictures. His 47 cases ranged in age from 19 to 70 years. He noted that gonorrhea and obstetrical trauma were about equal in causing strictures m about 20 per cent each, and that senility was a factor in 10 per cent of his cases. He also found several that were secondary to syphilis. In 1928, Anderson summarized his results with GO cases. He emphasized the inflammatory origin of 8,5 per and 10 per cent he regarded as rec1ulting from obstetrical injmies. He concluded that the lesion was common and responded vrnll to dilations of the methra. King, in 1931, wrote an interesting article on the 8ubject of strictme of the female urethra revie11·ing all available literature and reporting 4 cases of his own. His first case wa::, a very remarkable one showing chronic dilation of the bladder with traheculations. King also observed trabeculations of the bladder in his fourth case with changes of the trigone in hoth, but tended to minimize secondary pathology in the kidneys resulting from obstruction in the urethra. More recently, in Sinclair described 13 cases of stricture, some of which pathologic changes above the bladder. were complicated Hinman's classical book on urology gave a resume of the anatomy and physiology of the female urethra, and in another section he ga-ve a short discussion of stricture; all ,·ery concise and to the point. Lmrnley and Kirn·in presented the subject adequately in their t,ni Yolume ,rnrk on urology, and they believe that the site of the stricture in the fomalc may be very often palpated. Herman had a good discussion of the subject for a textbook, emph11sizing gonorrhea and other infections of the urethra as causes of stricture as ,rnll a8 trauma. He adyised dilations of the urethra as treatment. Everett's treatment of the subject in hi:o gynecological and obstetrical urology dcseryes special mention. He pointed out the divergent views concerning the occurrence of stricture in the female urethra, based on different concepts ar-; to what constitutes a stricture. His ideas of etiology, symptoms, diagnosis and
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treatment conformed very much to those of the other authors referred to in this paper. Everett believes that most strictures occur in the distal part of the urethra. Boyd has emphasized the occurrence of congenital stricture or stenosis of the female urethra which manifested itself in younger people, with location of the lesion at or near the meatus. Stevens also discussed congenital stricture in his paper of 1936. The author has no first hand knowledge of this particular lesion. It appears that stricture of the female urethra constituted a much more common and more important lesion than many think it to be, and it may be easily overlooked or ignored or confused ,Yith something else. Cheetham as well as Stevens believed that 10 per cent to 35 per cent of women ,yith chronic vesical symptoms have stricture of variable degrees of the urethra as the basis for their symptoms. In 1949 Powell and Powell, using caliber 20F as criterion for the diagnosis, in a study of 603 cases of urethral lesion, found 43 per cent due to stricture. Stricture of the urethra of inflammatory and traumatic origins undoubtedly constitutes the commonest cause of obstruction in the adult female urethra today. Other less common causes of urethral stricture also include such thingE as peri-urethral abscesses, certain hypertrophic senile changes in the urethra, perhaps caruncles, associated inflammatory or traumatic changes in some cases of urethrovaginal fistula, and other conditions as diverticula, and so on. HO\\' commonly chancroidal, syphilitic, and tuberculous lesions caused stricture was difficult to evaluate. The granulomatous venereal lesions of the female genital organs have also been given as a cause of stricture, particularly among ~egroes. Congenital stenosis of the female urethra also occurs. Hypertrophy of glandular tissue at the vesical orifice produced urethral obstruction very much as does an adenomatous prostate gland in men, and the writer has observed one case. While such things as tumors or grnwths should be classified as urethral obstructions, they belong in a category other than stricture. The results and effects of any type of urethral obstruction, however, remain essentially the same. The vast majority of the cases reported earlier were undoubtedly due to inflammatory reactions incidental to gonorrheal infection in the urethra. Stevens, Pugh, and Anderson, as well as others, considered gonorrhea the prime etiological factor and this point of view seems logical and correct. In more recent years, however, it seems doubtful if this thesis remains, because of the ,videspread use of effective chemotherapeutic drugs in the destruction of the gonococcus and other pathologic micro-organisms which may localize in and about the urethra. Gonorrhea has become definitely less frequent during the past few years, but severe gonorrhea remains as a very specific cause of chronic urethritis and associated stricture formation in both sexes. By the same reasoning inflammatory urethral strictures in both sexes should become less common in the future, by the use of very effective drugs. Very little was recorded about the actual microscopic pathology of the lesions in the urethra for obvious reasons. It was generally accepted, however, in the severe chronic cases of gonorrhea of the urethra wherein there was destruction
246 of epithelium and ulceration and involvement of the submucosa and muscular layers, that, in healing, more or less scarring occurred depending upon many factors. Contraction of the scar tissue and encroachment on the lumen of the urethra resulted in stricture formation ·with more or less residual chronic urethritis remaining. Foci of chronic infection in the peri-urethral ducts, and in the ,;mall urethral glands or in the glandlike recesseB and bet1Yeen the folds of the mucosa, constituted, in all probability, factors in the production of the narrm,·ing of the urnthral lumen. kind of infection in the urethra which produced ulceration could result in the production of stricture, but nonspecific infections of this grade were certainly not common in women today. Trauma was also an important factor in the production of stricture of the female urethra. The ,,-riter refers particularly to obstetrical trauma, either natural or artificially induced by instrumentation at deliveries, as ,vell as the trauma associated with operative procedures on the female genitalia. Severe pressure of the oncoming head against the symphysis pubis contusing or crushing the urethra, or producing isehcmia and a resulting small slough, ,vas probably the mechanism irrn)lved in cases of normal deliveries with ensuing stricture formation. The repeated trauma of Yigorous coitus has been mentioned as a cause by certain authors. Other types of direct trauma, partim1larly accidental, to thr, urethra could also produce stricture. In most of the cases reported belmY, it seemed that trauma, either obstetrical or operative, or both, played the main role in initiating the disorder. Secondary infection \Yas present in some, but when it occurred in time relationship with the trauma was, of course, impossible to determine. Chemical injuries of the urethra resulting in stricture formation have been observed by Anderson. He referred particularly to the overzealous use of concentrated chemicals in the urethra in an effort to cure gonorrhea. The ::mme distressing condition has been observed in men where its occurrence has undoubtedly heen more frequent. The ,niter recalls 1 case years ago in Yrhich the urethra and bladder of a woman \\·ere almost completely destroyed by the application of phenol. Some strictures were reported by some as hard and dense while others \\'ere reported as soft and delicate and easily destroyed, and that has been my experience as well. It can be assumed on the basis of the long history in the cases of hard or dense stricture that the condition ,ms one of long standing perhaps with recurrent injuries of seYeral deliveries, either spontaneous or with forceps, or following repeated pelvic operations by the yaginal approach, or by repeated or very severe infections perhap;, (cases 2, 3, and 4). Gi-:en a urethral injury from any of several causes, the healing process may be complicated ,vith infection, excessive scar formation ,vith contracture, and ultimate stricture. The strictures may be annular or longitudinal, involving relatively long or short portions of the urethral wall, or mostly the meatus. A certain degree of chronic urethritis remains associated \\·ith the stricture. The female urethra i::; regarded as analogous to the deep or posterior urethra
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in the male. It has two para-urethral ducts and a variable number of small glands or gland-like recesses in the mucosa and beneath. The epithelium of the distal portion partakes of the squamous variety and as one approaches the bladder the cells become transitional in type and like those of the trigone and bladder. The urethral mucosa forms numerous longitudinal folds. It has submucosal and muscular coats, as well as a poorly developed corpus spongosium between. The urethra ranges in diameter from 8 to 12 mm. with its narrowest portion at the roeatus. Hinman writes that the urethra varies in length from 2.5 to 5 cm. but the average is probably 3.5 to 4 cm. The normal female urethra will easily take 26F instrument and many 28F without difficulty. The normal urethra stretches very easily, and has a gentle curve (Hinman) beneath the symphysis pubis according to all teaching with which the writer is acquainted. In 1937, however, Stevens and Smith, on the basis of x-ray examinations, insisted that the female urethra was straight, and not curved. Their reproduced x-ray films were very convincing. After repeated deliveries the writer believes that the urethra may lose certain of its nulliparous or virginal features. Narrowing of the urethra to 20F or less, in the opinion of most authors, constituted mild stricture, and these patients should be so treated. Theoretically, if the narrowing were only slight, producing a lumen of 22F or 24F, this would still be a stricture. In the cases reported below the urethra was definitely less than 20F and ranging about 18F and less. In case 1, the writer has no clear idea of the size of the urethra except that it was unusually small. The presence or absence of stricture can be determined very easily by observing resistance to catheterization with a small soft rubber catheter or more properly by the use of a bougie. In the more severe cases a bougie or ordinary catheter (16 or 18F) cannot be passed, and in mild cases one should feel the hang of the bougie on withdrawing it. Wynne, in 1927, measured the urethra in 33 cases and found several 2 mm. and less in diameter as well as several others of 3-4 mm. Unfortunately, he gave no data concerning the secondary pathologic changes that occurred above the level of the urethra. In location of the stricture he found that the majority were in the anterior third and about the meatus, while a few involved the entire urethra. The symptomatology of this group of cases varies somewhat, as a rule, between relatively narrow limits. Most of these women complained of burning or discomfort in the urethra and bladder on urination with more or less frequencv of urination. The frequency, however, in the milder cases often completelv disappeared at night. Urgency of urination and actual pain and tenseness d0veloped in some cases. A very few noted straining at voiding and others slowness to empty the bladder which may amount to slight straining. An occasional prtient observed hematuria of variable degree. Retention of urine was definitely a late symptom judging by the literature and personal observations and not very frequently observed. This was probably also true of dribbling and incontenance. Hysterical retention of urine may also occur (case 6).
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The severity of the symptoms also very definitely depends upon the stage of the disorder and the type of secondary infection and other conditions which may develop in the bladder or above. Fever may change the clinical picture, and general malaise with headache etc., and pain or aching in the pelvis and about the kidneys may develop. If the vesical symptoms are not appreciated by a proper history and if the physical examination is not carefully made, the illness may be misjudged and the disorder missed and be regarded as something else. The patient's state of nervousness can also be a misleading factor (case 6). In the fatal case reported below the patient was in uremia at the time of the first observation and it developed steadily in spite of treatment. (Uremia was probably a factor in the fatal case reported by Heinrichsdorff.) Uremia, of course, may be expected in one of either sex with severe chronic urinary obstruction, especially at the vesical orifice or below, wherein both kidneys become involved.
FIG. 1. Case 6. Trabeculated urinary bladder demonstrated by the excretion of intravenous diadrast in 30 minutes.
It was also interesting to note that in some of these patients the illness, often regarded as more or less obscure, often ran a course of years. Chronicity -was characteristic of stricture of the female urethra. There were periods of time when the symptoms seemed to clear and this probably can be related to subsiding infection in the bladder and urethra which undoubtedly occurred. When an acute episode of infection developed as it appeared to do, the more acute type of symptoms arose. Among the younger women the symptoms seemed to be of shorter duration because they generally sought professional advice early in the course of their illness. Physical findings in these cases deserve special consideration. Externally one may observe nothing abnormal and the urethra and anterior vaginal wall may not be unusual in appearance. The presence of thickening along the course of the urethra was impossible to establish in my cases, and there was one with a very dense stricture (case 4). Certain writers however insisted that they could feel the strictured area with the finger in the vagina. Very often these women would complain of discomfort and a desire to void in palpating the base of the
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urinary bladder or the urethra. It has been my experience, and as found in most of the literature, very little that was positive by physical examination could be found until one passed a catheter or bougie or used other special methods of diagnosis. In some traumatic cases, the meatus may be definitely narrowed or otherwise obscured (cases 2 and 4). The more marked secondary changes, as dilation of the bladder with retention of urine observed in case 1, have not been described by others except by King. Residual urine of ordinary amounts not comparable to retention of urine, seems likely to have been a feature, but the writer has not observed it nor can references be given. Muscle spasm and pain in the lower abdomen and in the loins all depended on various degrees of infection in the kidneys and bladder, and back pressure and the like in the late cases. Uremia also occurred in the advanced and neglected cases (case 1). The urine presented variable findings. In some of the milder cases the catheterized urine showed relatively little that was unusual and this point has been mentioned by Cheetham and Everett. In most of the moderately severe cases however, the urine gave evidence of infection such as turbidity, traces of albumin and variable numbers of cells, leukocytes, mostly; but then at times erythrocytes may have been present. In these urines, bacteria of one sort or another were generally found. The writer believes that the character of the urine may change as an episode of acute infection subsides or clears up, as in the milder cases, especially following treatment with one of the more effective chemotherapeutic drugs. The histories in some of the mild cases also indicated perhaps that the infection may have cleared up at times without treatment, but it may have again recurred when local conditions changed. In cases of severe obstruction with residual urine, medication to destroy infection was of no avail until the obstruction was relieved and.this stands as an important principle in treatment .. Cystoscopically, interesting conditions may be observed. The vesical orifice was found negative in the few cases examined by the writer but the trigone was almost always hyperemic with occasional hemorrhagic points and sometimes edematous. In cases 3, 4, and 6 the bladder presented trabeculations indicating hypertrophy from overwork in expelling the urine against the resistance of the stricture. Similar findings were recorded by those authors who took the trouble to pass a cystoscope, particularly Sinclair and King. Evidence of various degrees of cystitis has been found which was the origin of the hematuria. The urethra has been examined by some with suitable instruments and whitish scars at the sites of the stricture have been described (case 6). Of course, other mild to marked secondary changes become obvious and may occur in the upper urinary system if the lesion is of long standing and severe enough. Some of these features were observed by Sinclair and published in 1926, King in 1931, and others, and by the author. Determination of renal function, urography, bacteriological studies, blood chemistry, etc., were all obvious enough, necessary, and indicated to complete the case study. There w11s general agreement in the treatment of these cases, which consisted primarily of graded dilations of the urethra and measures aimed at clearing up
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the active infection in the urinary system, ,Yhich was generally in the bladder. Dilation in the seYere and dense strictures must be made under anesthesia of one kind or another-especialy caudal or pentothal. In the milder cases the author has simply drained the bladder and inserted 20-25 cc of 3 per cent solution of as preparation for dilatiom;. The dilatiom; must, of course, be repeated at fairly frequent intervals in most cases, while in the more severe ca::;es the treatment::; may he performed enry third or fourth day for a longer period. Dilation::; must be kept up until all signs of stricture and the associated urethritis disappear and may drag out over a considerable period of time in some cases. Recurrences are to be expected especially in the eases of severe strictures, and if treatment has been Irrigations of the bladder -with warm boracic or permanganate or other solutions also gave relief and helped to clear up the cystitis. The use of chemotherapeutic drugs, as indicated, ahm stood as considerable aid, and these measures ,rnre \"ery important. A large intake of fluids was an essential part of thr trnatmcni in those cases, particularly, with active infection. It has been the experience of the author that the ordinary case of nrc1thra.l stricture in ,rnmen responded readily to treatment and if care ,ni,s exercised in relieving pain, the patients ,rnuld cooperate. At this point the writer ,viRhes to emphasize that it does no harm, and perhap8 much good, to pass nrethrnl sounds in those ,vomen with apparently simple or urethriti;; gs they clear up, because of the possibility of stricture. clearing up the nidus of the infection in the urethra, the veRical infection will probably not recur. Cystitis can seldom be regarded as a primary diseasP. t~rethral sounds for use in the female urethra are urgently needed. Insofar a::; the author is m,-are, there are no sounds made for the female urethra. One must depend upon Hager uterine dilators or the sounds for men with their marked cun,e. A set of sounds from 8F to 28F for use in ,rnmen and children seems Yery et-lsential indeed, yet the writer has not been able up to thit:1 time to interest any manufacturer of instruments in this project. If the female urethra is essr:ntially straight and not cuffed as ,rn formerly thought, the u:se of the sounds for the male nrethra can do harm or at leaRt produce more pain during treatment than may be justified. The sonncfa should be not more than 1G em. in length and with only the slightest curve, ABSTRACTS OF C,\S1'JS
Case 1. Mrs. S. aged l, July 1948. Diagnosis: Severe stricture of the urethra 11·ith chronic retention of urine; acute and chronic anemia; uremia and death. Yesical c,n,~~.+n,m for a long period of time. During the past few 'Weeks the patient had marked difficulty in voiding, with frequency and passing only small amounts of urine and with constant desire to void. She had been for many She had also lost considerable ,rnight and strength during the year. The patient was a nurse 25 years ago. She was the mother of two children, but details of deliveries were not obtained. Examination shmrnd an extrPmely emaciated weak and listless ,vhite woman
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who was also pale and dehydrated. Temperature lO0F, pulse 110, blood pressure 120/40. The abdomen presented dilation of the urinary bladder which almost reached the umbilicus. Pelvic examination was negative. Catheterization was performed with 14F catheter after the nurse had failed in the first attempt. The urine was pale and turbid, showing albumin and staphylococci. Urethral dilations were performed with 14, 16, 18 and 20F sounds and a Foley retention catheter was inserted. The bladder was gradually decompressed. Blood: Red blood cells 3,370,000; white blood cells 14,100, hemoglobin 60 per cent. Nonprotein nitrogen 120 mg., uric acid 7.6 mg., creatinine 6.25 mg. The patient did not respond well to treatment consisting essentially of 4 liters of fluids daily, two blood transfusions early in the course of hospitalization, catheter drainage of the bladder and irrigations of the same, as well as penicillin in large doses and general measures. At no time did her daily blood pressure exceed 130 systolic. Phenolsulfonphthalein excretion was zero in 4 hours. She ran a febrile course and was typically uremic during the most of the 14 days in the hospital. She died of. uremia and sepsis with associated terminal acidosis (CO 2 21 per cent, nonprotein nitrogen 129).
It is difficult to conceive of a properly trained nurse as this patient and her husband insisted that she was, allowing herself to get into such a deplorable state. The diagnosis of stricture of the urethra was very clear and the several irreversible secondary pathologic changes, sufficient to cause death followed as a result of the severe and long standing chronic obstruction in the urethra. We have no idea as to the underlying cause of the stricture in this case.
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Case 2. Mrs. B. B., aged 27, June 1930. Diagnosis: Stricture of the urethra and chronic cystitis. Six years before examination the patient first noted painless hematuria associated with frequency of urination. The hematuria recurred once just before she came under observations. In the interval she had had various episodes of vesical symptoms. She had been pregnant 5 times, two of which terminated prematurely and were followed by curettements. Examination revealed a poorly nourished white woman, whose urethral meatus appeared small. Other details of the examination were negative. Catheterization was performed with difficulty using a 18F catheter. The urine was infected and contained albumin. Phenolsulfonphthalein excretion was 60 per cent in 2 hours. Cystoscopy under caudal anesthesia revealed the presence of a fairly dense urethral stricture just inside the meatus. The urethra was dilated to 24F before the cystoscope could be passed. The bladder revealed slight edema and injection of the trigone only. The urethra was dilated several times at 5 to 10 day intervals reaching 26 and 28F as the treatment progressed. All symptoms disappeared and the urine cleared up. Permanganate irrigations of the bladder followed each of the dilations. Her general condition improved during the 3 years she was under observation. No recurrences of the urethral disorders observed.
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This is a rather typical case of stricture of the distal part of the urethra in a multipara. We have no clear indication of the etiology of the stricture, but the possibility of trauma on the urethra from the three full term deliveries, and that perhaps from the curettements, may have caused the stricture. Case 3. Mrs. A. F., aged 58, September 1948. Diagnosis: Stricture of the urethra and associated recurrent cystitis and acute pyelonephritis; chronic anemia and poor nutrition. The patient had been acutely ill several days before admission to the hospital with pain and discomfort in the bladder and urethra, frequency of urination with urgency and burning, as well as chills and fever. She also stated that she had had similar but less severe episodes as far back as 20 years. Generally the attacks cleared or almost cleared without medication in a few days or couple of weeks. She had been pregnant 5 times, two of which terminated normally, while three ended in abortions or miscarriage. She had been curetted following each of the three imperfect pregnancies. Examination revealed a poorly nourished, acutely ill and anemic patient with temperature of 102F. There was pain about the left kidney. Catheterization with small catheter was performed by the nurse; no difficulty recorded. The urine showed albumin and pus. The acute infection was treated by a large fluid intake and penicillin and it subsided in a few days. N onprotein nitrogen 28 mg. Red blood cells 3,560,000; white blood cells 5,600; hemoglobin 70. An excretory urogram was negative. Cystoscopy was performed when she was afebrile. An unsuspected stricture of the urethra was found, moderate in extent and fairly dense, involving the central part of the urethra. Bleeding occurred following the passage of the cystoscope as well as the occurrence of pain locally. The bladder was slightly hyperemic and slightly trabeculated. One blood transfusion was given. The patient was treated by urethral dilations on several occasions up to 28F. All vesical symptoms disappeared and she voided a normal stream of urine. The patient's general condition improved.
The patient probably sustained an injury or injuries to her urethra as a result of the three curettements of the uterus. Secondary infections in the bladder then occurred and cleared up it seems, to recur again and again. She probably had acute left pyelonephritis at the time of admission to the hospital, all secondary to obstruction in the urethra. Case 4. Mrs. S. M., aged 54, March 19, 1949. Diagnosis: Stricture of the urethra, chronic recurrent cystitis and operative scarring of the perineum and vagina. Some weeks before observation the patient noticed considerable hematuria, smarting and burning on urination. The bleeding ceased, but the other symptoms persisted. She also had to strain a little to void. She had had previous episodes of vesical symptoms but never hematuria. The first episode of difficulties with the bladder occurred 7 to 8 years ago and about 2 years following perinea! and vaginal operations. Six full term pregnancies had occurred.
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Examination showed considerable scarring in the posterior vaginal wall and perineum and less so in the anterior vaginal wall. The vagina was narrow and scarred. The urethral meatus appeared to be small. An excretory urogram was negative. Catheterization by the nurse using a 14 or 16F catheter revealed clear and uninfected urine. A cystoscope could not be passed until the urethra was dilated, which caused pain and slight bleeding. The dense stricture was located in the central part of the urethra as well as at the meatus. The bladder showed hyperemia of the trigone with evidence of tiny hemorrhages as well as trabeculations. The patient had her urethra dilated under butyn anesthesia at weekly intervals for 6 weeks. The sounds were gradually worked up to 26 and 28F. The patient experienced great relief and voided a full stream without difficulties. No recurrences have been recorded to this date.
It seems to the writer that we have a fairly clear case of stricture of the urethra directly related to probable trauma and infection of a perineal and vaginal operation. There may also have been an obstetrical injury but we have no conclusive evidence. The hematuria ,vas probably secondary to the recurrent cystitis. Case 5. Mrs. D. K. H., aged 25, February~March 1950. Diagnosis: Stricture of the urethra. Bladder irritation, recurrent in nature, had troubled the patient for 2 years, beginning shortly after her marriage. The cystitis had been treated with sulfa drugs, but recurrences developed 8 to 10 times in the 2 year period lasting a few days to two weeks an episode. The symptoms were mainly frequency and burning. Examination showed a healthy young white woman. Pelvic and abdominal examination were negative. Catheterization was performed with an 18F catheter and the same size bougie was the only one that would pass, definitely demonstrating a stricture. Urine was uninfected and clear. Treatment consisted of graded dilations of the urethra on 7 different occasions under butyn anesthesia. The first time a 24F sound was passed a very little blood appeared at the meatus. Her symptoms disappeared after the third or fourth treatment and she has been well since, voiding a full stream of urine.
A simple case of stricture of the urethra showing as one of cystitis which had often cleared up with chemotherapy only to recur again and again. The underlying cause of the stricture was not apparent. (The writer has records of other similar mild cases.) Case 6. Mrs. K. E. C., aged 40, an hysterical white woman with stricture of the urethra, whose history was too complicated to record. She had been treated for recurrent cystitis elsewhere and the stricture was overlooked. One of the remarkable features about the case was the extent of trabeculations of the bladder from urethral obstruction, as shown in the excretory urogram (fig. 1) and at cystoscopy. She also exhibited whitish scarring in the urethra at the site
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of the stricture when examined with the panendoscope. The vesical orifice was normal. CONCLUSIONS
Stricture of the female urethra must be regarded as common and important hut often an unrecognized lesion in those ·with vesic:al and urethral symptoms. There are two main causes of stricture of the female urethra today; first, traumatic: arising from obstetrical and surgical injuries to the urethra, and second, inflammatory following gonorrheal urethritis. A_dequate treatment, particularly graded dilations, gives good results. In long standing cases of urinary obstruction due to stricture of the urethra, mild to marked secondary pathologic changes develop in the urinary system. Death has occurred from sepsis and uremia arising secondarily from such a seemingly slight lesion as stricture of the female urethra. The third case" of death incidental to strict.me of the urethra in the female is report.eel.
8t., REFERENCES AKDERSON, A. E.: Northwest. Med., 27: 520, 1928. BOYD, M. L.: J. A. M.A., 92: 2154, 1929. CHEE"l'HAM, ,J. G.: Northwest. Med., 26: 539, 1927. EVERETT, H. S.: Gynecological and Obstetrical Urology. Baltimore: Williams and Wilkins, Hl47. H1cINRICHSDORFF: Zentralbl. f. Gynak. 44: 1081, 1920. (Abstract prepared by W. F. Prior Co. Hagerstown, _Md.) HINMAN, F.: Principles and Practices of Urology. Philadelphia: W. B. Saunders Co., 1935. HEm-LAN, L.: Practice of Urology. Philadelphia: W. B. Saunders Co, 1938. KING, M. W.: Am ..J. Surg., 13: 251, 1931. KJ,n,LY, H. A. AND BURNHAM, C. J:i'.: Diseases of the Kidneys, Ureters and Bladder. J\:ew York: Appleton, l\l14. LowsLEY, 0. S. AND Krnwrn, T. J.: Clinical Urology. Baltimore: William and Wilkins, 1944. Pow1cLL, N. B. and POWELL, E. B.: J. Urol., 61: 557, 1949. PuGH, W. S.: Ann. 79: 770, 1924. Purrn, W. S.: J. A. M. 87: 1790, 1926. Srnc1,Arn, D. A .. Urol. Cut. Rev., 50: 389, 1946. S rEVENs, W. E.: Calf. St. J. Med., 20: 51, 1922. STIDVJDNS, w. E. J. A. l\I. 106: 89, 1936. STrnVENs, W. B. AND S:mTH, S. : J. Urol., 37: 194, 1937. WYNNE, H. M. K.: Surg. Gynec. & Obst., 34: 208, 1927. 0
Vol. 66, No. 2, August 1951 Printed in U.S.A.
STRICTURE OF THE FEMALE URETHRA DORSEY BRANNAN
My attention has recently been focused on the subject of stricture of the female urethra because of a fatality resulting from this lesion (case 1). I believe that a condition which can ultimately lead to death and which as it appears, has not been particularly emphasized in urologic literature, merits some comment. Another fatal case was reported in the German literature in 1920 by Heinrichsdorff: A woman aged 65 acquired an injury to the urethra during labor with a resulting urethrovaginal fistula. A severe stricture gradually developed over a period of years which ultimately led to the patient's death. She presented clinically the picture of sepsis and coma (uremia?) and died 3 days after admission to the hospital. The urinary bladder was found dilated as vvell as the ureters and renal pelves, with abscesses in the kidneys and also extensive infection of the entire urinary system and associated general sepsis. Wynne, in his important contribution in 1927, referred to an article by Thompson in the English literature, who referred to another obvious fatal case of urethral stricture in the female. The report briefly described a museum specimen in the possession of the Royal College of Surgeons of Edinburg, of a 30 year old woman with strictured urethra, secondary changes in the bladder, and extravasation of urine. The death was prior to 1885. In my own experience, at least one death has occurred in a stubborn middle aged man as a result of chronic urethral stricture and the associated secondary infection and uremia. Severe lesions of this kind are much better known in men than in women. If the facts were known, no doubt other women have neglected themselves and died similar deaths secondary to urethral stricture. The literature on this subject remains rather sparse and only the more recent works were available to the writer. A good discussion of the earlier papers may be obtained in the writings of Stevens, Wynne, Pugh, and Anderson. Suffice it to record here that the Frenchman Lisfranc in 1824 first called attention to the condition of stricture in the female urethra. The first case description was credited to Earl of London in 1828. Then followed papers by Civiale in 1850 and by Newman in 1875. Hermann reviewed the literature on the subject in 1886 and contributed 6 cases of his own to the 23 cases already reported. Vander Werken and Skene published accounts of the disorder in 1887 and the former again in 1890 according to the above authors. In 1892, Otis was observant enough to devise special methods of diagnosis and treatment for slight degrees of stricture. Kelly and Burnam, in 1914, treated the subject as a rare condition and much of their material was based on the observations of others. They noted however that gonorrhea and obstetrical injuries were the important factors in etiology. Once the stricture had developed, they wrote, cystitis was very apt to follow. Their methods of treatment, aside from dilation of the urethra, seem strange today. 242
All are agreed that relatiYely little was accomplished on the subject before 1922, -when SteYens published his first paper in California. Ile concluded Hrnt
8tricture of the urethra ,rn8 a common ailment in women which responded very ,mil to adequate treatment. He also pointed out that treatment of the lesion ,ms prophylaxi8 more important disorders in the upper urinary 8Y8tem. Gonorrhea, he regarded as the prime factor in the cause of the disease. In 1924, and again in 1927, Pugh wrote two interesting essays on the subject. In the first paper he gave case reports to prove his points, while in 1927 he discussed the subject in a more academic manner. His conclusions were essentially that stricture of the female urethra -was a common condition, caused primarily by chronic gonorrhea, producing various urinary symptoms, and best treated (with good results) by dilation of the urethra. Cheetham, in presented 3 cases to emphasize the three main factors in etiology; namely, infection, which ,ms generally gonorrheal, and trauma, both obstetrical and operntiYe. He treated his patients by dilation of the urethra. Wynne, in 1927, discussed the matter of stricture of the female urethra, paying special attention to the anatomy of the urethra, age groups, and the location 2end size of the strictures. His 47 cases ranged in age from 19 to 70 years. He noted that gonorrhea and obstetrical trauma were about equal in causing strictures m about 20 per cent each, and that senility was a factor in 10 per cent of his cases. He also found several that were secondary to syphilis. In 1928, Anderson summarized his results with GO cases. He emphasized the inflammatory origin of 8,5 per and 10 per cent he regarded as rec1ulting from obstetrical injmies. He concluded that the lesion was common and responded vrnll to dilations of the methra. King, in 1931, wrote an interesting article on the 8ubject of strictme of the female urethra revie11·ing all available literature and reporting 4 cases of his own. His first case wa::, a very remarkable one showing chronic dilation of the bladder with traheculations. King also observed trabeculations of the bladder in his fourth case with changes of the trigone in hoth, but tended to minimize secondary pathology in the kidneys resulting from obstruction in the urethra. More recently, in Sinclair described 13 cases of stricture, some of which pathologic changes above the bladder. were complicated Hinman's classical book on urology gave a resume of the anatomy and physiology of the female urethra, and in another section he ga-ve a short discussion of stricture; all ,·ery concise and to the point. Lmrnley and Kirn·in presented the subject adequately in their t,ni Yolume ,rnrk on urology, and they believe that the site of the stricture in the fomalc may be very often palpated. Herman had a good discussion of the subject for a textbook, emph11sizing gonorrhea and other infections of the urethra as causes of stricture as ,rnll a8 trauma. He adyised dilations of the urethra as treatment. Everett's treatment of the subject in hi:o gynecological and obstetrical urology dcseryes special mention. He pointed out the divergent views concerning the occurrence of stricture in the female urethra, based on different concepts ar-; to what constitutes a stricture. His ideas of etiology, symptoms, diagnosis and
I
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treatment conformed very much to those of the other authors referred to in this paper. Everett believes that most strictures occur in the distal part of the urethra. Boyd has emphasized the occurrence of congenital stricture or stenosis of the female urethra which manifested itself in younger people, with location of the lesion at or near the meatus. Stevens also discussed congenital stricture in his paper of 1936. The author has no first hand knowledge of this particular lesion. It appears that stricture of the female urethra constituted a much more common and more important lesion than many think it to be, and it may be easily overlooked or ignored or confused ,Yith something else. Cheetham as well as Stevens believed that 10 per cent to 35 per cent of women ,yith chronic vesical symptoms have stricture of variable degrees of the urethra as the basis for their symptoms. In 1949 Powell and Powell, using caliber 20F as criterion for the diagnosis, in a study of 603 cases of urethral lesion, found 43 per cent due to stricture. Stricture of the urethra of inflammatory and traumatic origins undoubtedly constitutes the commonest cause of obstruction in the adult female urethra today. Other less common causes of urethral stricture also include such thingE as peri-urethral abscesses, certain hypertrophic senile changes in the urethra, perhaps caruncles, associated inflammatory or traumatic changes in some cases of urethrovaginal fistula, and other conditions as diverticula, and so on. HO\\' commonly chancroidal, syphilitic, and tuberculous lesions caused stricture was difficult to evaluate. The granulomatous venereal lesions of the female genital organs have also been given as a cause of stricture, particularly among ~egroes. Congenital stenosis of the female urethra also occurs. Hypertrophy of glandular tissue at the vesical orifice produced urethral obstruction very much as does an adenomatous prostate gland in men, and the writer has observed one case. While such things as tumors or grnwths should be classified as urethral obstructions, they belong in a category other than stricture. The results and effects of any type of urethral obstruction, however, remain essentially the same. The vast majority of the cases reported earlier were undoubtedly due to inflammatory reactions incidental to gonorrheal infection in the urethra. Stevens, Pugh, and Anderson, as well as others, considered gonorrhea the prime etiological factor and this point of view seems logical and correct. In more recent years, however, it seems doubtful if this thesis remains, because of the ,videspread use of effective chemotherapeutic drugs in the destruction of the gonococcus and other pathologic micro-organisms which may localize in and about the urethra. Gonorrhea has become definitely less frequent during the past few years, but severe gonorrhea remains as a very specific cause of chronic urethritis and associated stricture formation in both sexes. By the same reasoning inflammatory urethral strictures in both sexes should become less common in the future, by the use of very effective drugs. Very little was recorded about the actual microscopic pathology of the lesions in the urethra for obvious reasons. It was generally accepted, however, in the severe chronic cases of gonorrhea of the urethra wherein there was destruction
246 of epithelium and ulceration and involvement of the submucosa and muscular layers, that, in healing, more or less scarring occurred depending upon many factors. Contraction of the scar tissue and encroachment on the lumen of the urethra resulted in stricture formation ·with more or less residual chronic urethritis remaining. Foci of chronic infection in the peri-urethral ducts, and in the ,;mall urethral glands or in the glandlike recesseB and bet1Yeen the folds of the mucosa, constituted, in all probability, factors in the production of the narrm,·ing of the urnthral lumen. kind of infection in the urethra which produced ulceration could result in the production of stricture, but nonspecific infections of this grade were certainly not common in women today. Trauma was also an important factor in the production of stricture of the female urethra. The ,,-riter refers particularly to obstetrical trauma, either natural or artificially induced by instrumentation at deliveries, as ,vell as the trauma associated with operative procedures on the female genitalia. Severe pressure of the oncoming head against the symphysis pubis contusing or crushing the urethra, or producing isehcmia and a resulting small slough, ,vas probably the mechanism irrn)lved in cases of normal deliveries with ensuing stricture formation. The repeated trauma of Yigorous coitus has been mentioned as a cause by certain authors. Other types of direct trauma, partim1larly accidental, to thr, urethra could also produce stricture. In most of the cases reported belmY, it seemed that trauma, either obstetrical or operative, or both, played the main role in initiating the disorder. Secondary infection \Yas present in some, but when it occurred in time relationship with the trauma was, of course, impossible to determine. Chemical injuries of the urethra resulting in stricture formation have been observed by Anderson. He referred particularly to the overzealous use of concentrated chemicals in the urethra in an effort to cure gonorrhea. The ::mme distressing condition has been observed in men where its occurrence has undoubtedly heen more frequent. The ,niter recalls 1 case years ago in Yrhich the urethra and bladder of a woman \\·ere almost completely destroyed by the application of phenol. Some strictures were reported by some as hard and dense while others \\'ere reported as soft and delicate and easily destroyed, and that has been my experience as well. It can be assumed on the basis of the long history in the cases of hard or dense stricture that the condition ,ms one of long standing perhaps with recurrent injuries of seYeral deliveries, either spontaneous or with forceps, or following repeated pelvic operations by the yaginal approach, or by repeated or very severe infections perhap;, (cases 2, 3, and 4). Gi-:en a urethral injury from any of several causes, the healing process may be complicated ,vith infection, excessive scar formation ,vith contracture, and ultimate stricture. The strictures may be annular or longitudinal, involving relatively long or short portions of the urethral wall, or mostly the meatus. A certain degree of chronic urethritis remains associated \\·ith the stricture. The female urethra i::; regarded as analogous to the deep or posterior urethra
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in the male. It has two para-urethral ducts and a variable number of small glands or gland-like recesses in the mucosa and beneath. The epithelium of the distal portion partakes of the squamous variety and as one approaches the bladder the cells become transitional in type and like those of the trigone and bladder. The urethral mucosa forms numerous longitudinal folds. It has submucosal and muscular coats, as well as a poorly developed corpus spongosium between. The urethra ranges in diameter from 8 to 12 mm. with its narrowest portion at the roeatus. Hinman writes that the urethra varies in length from 2.5 to 5 cm. but the average is probably 3.5 to 4 cm. The normal female urethra will easily take 26F instrument and many 28F without difficulty. The normal urethra stretches very easily, and has a gentle curve (Hinman) beneath the symphysis pubis according to all teaching with which the writer is acquainted. In 1937, however, Stevens and Smith, on the basis of x-ray examinations, insisted that the female urethra was straight, and not curved. Their reproduced x-ray films were very convincing. After repeated deliveries the writer believes that the urethra may lose certain of its nulliparous or virginal features. Narrowing of the urethra to 20F or less, in the opinion of most authors, constituted mild stricture, and these patients should be so treated. Theoretically, if the narrowing were only slight, producing a lumen of 22F or 24F, this would still be a stricture. In the cases reported below the urethra was definitely less than 20F and ranging about 18F and less. In case 1, the writer has no clear idea of the size of the urethra except that it was unusually small. The presence or absence of stricture can be determined very easily by observing resistance to catheterization with a small soft rubber catheter or more properly by the use of a bougie. In the more severe cases a bougie or ordinary catheter (16 or 18F) cannot be passed, and in mild cases one should feel the hang of the bougie on withdrawing it. Wynne, in 1927, measured the urethra in 33 cases and found several 2 mm. and less in diameter as well as several others of 3-4 mm. Unfortunately, he gave no data concerning the secondary pathologic changes that occurred above the level of the urethra. In location of the stricture he found that the majority were in the anterior third and about the meatus, while a few involved the entire urethra. The symptomatology of this group of cases varies somewhat, as a rule, between relatively narrow limits. Most of these women complained of burning or discomfort in the urethra and bladder on urination with more or less frequencv of urination. The frequency, however, in the milder cases often completelv disappeared at night. Urgency of urination and actual pain and tenseness d0veloped in some cases. A very few noted straining at voiding and others slowness to empty the bladder which may amount to slight straining. An occasional prtient observed hematuria of variable degree. Retention of urine was definitely a late symptom judging by the literature and personal observations and not very frequently observed. This was probably also true of dribbling and incontenance. Hysterical retention of urine may also occur (case 6).
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The severity of the symptoms also very definitely depends upon the stage of the disorder and the type of secondary infection and other conditions which may develop in the bladder or above. Fever may change the clinical picture, and general malaise with headache etc., and pain or aching in the pelvis and about the kidneys may develop. If the vesical symptoms are not appreciated by a proper history and if the physical examination is not carefully made, the illness may be misjudged and the disorder missed and be regarded as something else. The patient's state of nervousness can also be a misleading factor (case 6). In the fatal case reported below the patient was in uremia at the time of the first observation and it developed steadily in spite of treatment. (Uremia was probably a factor in the fatal case reported by Heinrichsdorff.) Uremia, of course, may be expected in one of either sex with severe chronic urinary obstruction, especially at the vesical orifice or below, wherein both kidneys become involved.
FIG. 1. Case 6. Trabeculated urinary bladder demonstrated by the excretion of intravenous diadrast in 30 minutes.
It was also interesting to note that in some of these patients the illness, often regarded as more or less obscure, often ran a course of years. Chronicity -was characteristic of stricture of the female urethra. There were periods of time when the symptoms seemed to clear and this probably can be related to subsiding infection in the bladder and urethra which undoubtedly occurred. When an acute episode of infection developed as it appeared to do, the more acute type of symptoms arose. Among the younger women the symptoms seemed to be of shorter duration because they generally sought professional advice early in the course of their illness. Physical findings in these cases deserve special consideration. Externally one may observe nothing abnormal and the urethra and anterior vaginal wall may not be unusual in appearance. The presence of thickening along the course of the urethra was impossible to establish in my cases, and there was one with a very dense stricture (case 4). Certain writers however insisted that they could feel the strictured area with the finger in the vagina. Very often these women would complain of discomfort and a desire to void in palpating the base of the
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urinary bladder or the urethra. It has been my experience, and as found in most of the literature, very little that was positive by physical examination could be found until one passed a catheter or bougie or used other special methods of diagnosis. In some traumatic cases, the meatus may be definitely narrowed or otherwise obscured (cases 2 and 4). The more marked secondary changes, as dilation of the bladder with retention of urine observed in case 1, have not been described by others except by King. Residual urine of ordinary amounts not comparable to retention of urine, seems likely to have been a feature, but the writer has not observed it nor can references be given. Muscle spasm and pain in the lower abdomen and in the loins all depended on various degrees of infection in the kidneys and bladder, and back pressure and the like in the late cases. Uremia also occurred in the advanced and neglected cases (case 1). The urine presented variable findings. In some of the milder cases the catheterized urine showed relatively little that was unusual and this point has been mentioned by Cheetham and Everett. In most of the moderately severe cases however, the urine gave evidence of infection such as turbidity, traces of albumin and variable numbers of cells, leukocytes, mostly; but then at times erythrocytes may have been present. In these urines, bacteria of one sort or another were generally found. The writer believes that the character of the urine may change as an episode of acute infection subsides or clears up, as in the milder cases, especially following treatment with one of the more effective chemotherapeutic drugs. The histories in some of the mild cases also indicated perhaps that the infection may have cleared up at times without treatment, but it may have again recurred when local conditions changed. In cases of severe obstruction with residual urine, medication to destroy infection was of no avail until the obstruction was relieved and.this stands as an important principle in treatment .. Cystoscopically, interesting conditions may be observed. The vesical orifice was found negative in the few cases examined by the writer but the trigone was almost always hyperemic with occasional hemorrhagic points and sometimes edematous. In cases 3, 4, and 6 the bladder presented trabeculations indicating hypertrophy from overwork in expelling the urine against the resistance of the stricture. Similar findings were recorded by those authors who took the trouble to pass a cystoscope, particularly Sinclair and King. Evidence of various degrees of cystitis has been found which was the origin of the hematuria. The urethra has been examined by some with suitable instruments and whitish scars at the sites of the stricture have been described (case 6). Of course, other mild to marked secondary changes become obvious and may occur in the upper urinary system if the lesion is of long standing and severe enough. Some of these features were observed by Sinclair and published in 1926, King in 1931, and others, and by the author. Determination of renal function, urography, bacteriological studies, blood chemistry, etc., were all obvious enough, necessary, and indicated to complete the case study. There w11s general agreement in the treatment of these cases, which consisted primarily of graded dilations of the urethra and measures aimed at clearing up
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the active infection in the urinary system, ,Yhich was generally in the bladder. Dilation in the seYere and dense strictures must be made under anesthesia of one kind or another-especialy caudal or pentothal. In the milder cases the author has simply drained the bladder and inserted 20-25 cc of 3 per cent solution of as preparation for dilatiom;. The dilatiom; must, of course, be repeated at fairly frequent intervals in most cases, while in the more severe ca::;es the treatment::; may he performed enry third or fourth day for a longer period. Dilation::; must be kept up until all signs of stricture and the associated urethritis disappear and may drag out over a considerable period of time in some cases. Recurrences are to be expected especially in the eases of severe strictures, and if treatment has been Irrigations of the bladder -with warm boracic or permanganate or other solutions also gave relief and helped to clear up the cystitis. The use of chemotherapeutic drugs, as indicated, ahm stood as considerable aid, and these measures ,rnre \"ery important. A large intake of fluids was an essential part of thr trnatmcni in those cases, particularly, with active infection. It has been the experience of the author that the ordinary case of nrc1thra.l stricture in ,rnmen responded readily to treatment and if care ,ni,s exercised in relieving pain, the patients ,rnuld cooperate. At this point the writer ,viRhes to emphasize that it does no harm, and perhap8 much good, to pass nrethrnl sounds in those ,vomen with apparently simple or urethriti;; gs they clear up, because of the possibility of stricture. clearing up the nidus of the infection in the urethra, the veRical infection will probably not recur. Cystitis can seldom be regarded as a primary diseasP. t~rethral sounds for use in the female urethra are urgently needed. Insofar a::; the author is m,-are, there are no sounds made for the female urethra. One must depend upon Hager uterine dilators or the sounds for men with their marked cun,e. A set of sounds from 8F to 28F for use in ,rnmen and children seems Yery et-lsential indeed, yet the writer has not been able up to thit:1 time to interest any manufacturer of instruments in this project. If the female urethra is essr:ntially straight and not cuffed as ,rn formerly thought, the u:se of the sounds for the male nrethra can do harm or at leaRt produce more pain during treatment than may be justified. The sonncfa should be not more than 1G em. in length and with only the slightest curve, ABSTRACTS OF C,\S1'JS
Case 1. Mrs. S. aged l, July 1948. Diagnosis: Severe stricture of the urethra 11·ith chronic retention of urine; acute and chronic anemia; uremia and death. Yesical c,n,~~.+n,m for a long period of time. During the past few 'Weeks the patient had marked difficulty in voiding, with frequency and passing only small amounts of urine and with constant desire to void. She had been for many She had also lost considerable ,rnight and strength during the year. The patient was a nurse 25 years ago. She was the mother of two children, but details of deliveries were not obtained. Examination shmrnd an extrPmely emaciated weak and listless ,vhite woman
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who was also pale and dehydrated. Temperature lO0F, pulse 110, blood pressure 120/40. The abdomen presented dilation of the urinary bladder which almost reached the umbilicus. Pelvic examination was negative. Catheterization was performed with 14F catheter after the nurse had failed in the first attempt. The urine was pale and turbid, showing albumin and staphylococci. Urethral dilations were performed with 14, 16, 18 and 20F sounds and a Foley retention catheter was inserted. The bladder was gradually decompressed. Blood: Red blood cells 3,370,000; white blood cells 14,100, hemoglobin 60 per cent. Nonprotein nitrogen 120 mg., uric acid 7.6 mg., creatinine 6.25 mg. The patient did not respond well to treatment consisting essentially of 4 liters of fluids daily, two blood transfusions early in the course of hospitalization, catheter drainage of the bladder and irrigations of the same, as well as penicillin in large doses and general measures. At no time did her daily blood pressure exceed 130 systolic. Phenolsulfonphthalein excretion was zero in 4 hours. She ran a febrile course and was typically uremic during the most of the 14 days in the hospital. She died of. uremia and sepsis with associated terminal acidosis (CO 2 21 per cent, nonprotein nitrogen 129).
It is difficult to conceive of a properly trained nurse as this patient and her husband insisted that she was, allowing herself to get into such a deplorable state. The diagnosis of stricture of the urethra was very clear and the several irreversible secondary pathologic changes, sufficient to cause death followed as a result of the severe and long standing chronic obstruction in the urethra. We have no idea as to the underlying cause of the stricture in this case.
r
Case 2. Mrs. B. B., aged 27, June 1930. Diagnosis: Stricture of the urethra and chronic cystitis. Six years before examination the patient first noted painless hematuria associated with frequency of urination. The hematuria recurred once just before she came under observations. In the interval she had had various episodes of vesical symptoms. She had been pregnant 5 times, two of which terminated prematurely and were followed by curettements. Examination revealed a poorly nourished white woman, whose urethral meatus appeared small. Other details of the examination were negative. Catheterization was performed with difficulty using a 18F catheter. The urine was infected and contained albumin. Phenolsulfonphthalein excretion was 60 per cent in 2 hours. Cystoscopy under caudal anesthesia revealed the presence of a fairly dense urethral stricture just inside the meatus. The urethra was dilated to 24F before the cystoscope could be passed. The bladder revealed slight edema and injection of the trigone only. The urethra was dilated several times at 5 to 10 day intervals reaching 26 and 28F as the treatment progressed. All symptoms disappeared and the urine cleared up. Permanganate irrigations of the bladder followed each of the dilations. Her general condition improved during the 3 years she was under observation. No recurrences of the urethral disorders observed.
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This is a rather typical case of stricture of the distal part of the urethra in a multipara. We have no clear indication of the etiology of the stricture, but the possibility of trauma on the urethra from the three full term deliveries, and that perhaps from the curettements, may have caused the stricture. Case 3. Mrs. A. F., aged 58, September 1948. Diagnosis: Stricture of the urethra and associated recurrent cystitis and acute pyelonephritis; chronic anemia and poor nutrition. The patient had been acutely ill several days before admission to the hospital with pain and discomfort in the bladder and urethra, frequency of urination with urgency and burning, as well as chills and fever. She also stated that she had had similar but less severe episodes as far back as 20 years. Generally the attacks cleared or almost cleared without medication in a few days or couple of weeks. She had been pregnant 5 times, two of which terminated normally, while three ended in abortions or miscarriage. She had been curetted following each of the three imperfect pregnancies. Examination revealed a poorly nourished, acutely ill and anemic patient with temperature of 102F. There was pain about the left kidney. Catheterization with small catheter was performed by the nurse; no difficulty recorded. The urine showed albumin and pus. The acute infection was treated by a large fluid intake and penicillin and it subsided in a few days. N onprotein nitrogen 28 mg. Red blood cells 3,560,000; white blood cells 5,600; hemoglobin 70. An excretory urogram was negative. Cystoscopy was performed when she was afebrile. An unsuspected stricture of the urethra was found, moderate in extent and fairly dense, involving the central part of the urethra. Bleeding occurred following the passage of the cystoscope as well as the occurrence of pain locally. The bladder was slightly hyperemic and slightly trabeculated. One blood transfusion was given. The patient was treated by urethral dilations on several occasions up to 28F. All vesical symptoms disappeared and she voided a normal stream of urine. The patient's general condition improved.
The patient probably sustained an injury or injuries to her urethra as a result of the three curettements of the uterus. Secondary infections in the bladder then occurred and cleared up it seems, to recur again and again. She probably had acute left pyelonephritis at the time of admission to the hospital, all secondary to obstruction in the urethra. Case 4. Mrs. S. M., aged 54, March 19, 1949. Diagnosis: Stricture of the urethra, chronic recurrent cystitis and operative scarring of the perineum and vagina. Some weeks before observation the patient noticed considerable hematuria, smarting and burning on urination. The bleeding ceased, but the other symptoms persisted. She also had to strain a little to void. She had had previous episodes of vesical symptoms but never hematuria. The first episode of difficulties with the bladder occurred 7 to 8 years ago and about 2 years following perinea! and vaginal operations. Six full term pregnancies had occurred.
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Examination showed considerable scarring in the posterior vaginal wall and perineum and less so in the anterior vaginal wall. The vagina was narrow and scarred. The urethral meatus appeared to be small. An excretory urogram was negative. Catheterization by the nurse using a 14 or 16F catheter revealed clear and uninfected urine. A cystoscope could not be passed until the urethra was dilated, which caused pain and slight bleeding. The dense stricture was located in the central part of the urethra as well as at the meatus. The bladder showed hyperemia of the trigone with evidence of tiny hemorrhages as well as trabeculations. The patient had her urethra dilated under butyn anesthesia at weekly intervals for 6 weeks. The sounds were gradually worked up to 26 and 28F. The patient experienced great relief and voided a full stream without difficulties. No recurrences have been recorded to this date.
It seems to the writer that we have a fairly clear case of stricture of the urethra directly related to probable trauma and infection of a perineal and vaginal operation. There may also have been an obstetrical injury but we have no conclusive evidence. The hematuria ,vas probably secondary to the recurrent cystitis. Case 5. Mrs. D. K. H., aged 25, February~March 1950. Diagnosis: Stricture of the urethra. Bladder irritation, recurrent in nature, had troubled the patient for 2 years, beginning shortly after her marriage. The cystitis had been treated with sulfa drugs, but recurrences developed 8 to 10 times in the 2 year period lasting a few days to two weeks an episode. The symptoms were mainly frequency and burning. Examination showed a healthy young white woman. Pelvic and abdominal examination were negative. Catheterization was performed with an 18F catheter and the same size bougie was the only one that would pass, definitely demonstrating a stricture. Urine was uninfected and clear. Treatment consisted of graded dilations of the urethra on 7 different occasions under butyn anesthesia. The first time a 24F sound was passed a very little blood appeared at the meatus. Her symptoms disappeared after the third or fourth treatment and she has been well since, voiding a full stream of urine.
A simple case of stricture of the urethra showing as one of cystitis which had often cleared up with chemotherapy only to recur again and again. The underlying cause of the stricture was not apparent. (The writer has records of other similar mild cases.) Case 6. Mrs. K. E. C., aged 40, an hysterical white woman with stricture of the urethra, whose history was too complicated to record. She had been treated for recurrent cystitis elsewhere and the stricture was overlooked. One of the remarkable features about the case was the extent of trabeculations of the bladder from urethral obstruction, as shown in the excretory urogram (fig. 1) and at cystoscopy. She also exhibited whitish scarring in the urethra at the site
STHICTURE OF FEMALI, URI,THRA
2.53
of the stricture when examined with the panendoscope. The vesical orifice was normal. CONCLUSIONS
Stricture of the female urethra must be regarded as common and important hut often an unrecognized lesion in those ·with vesic:al and urethral symptoms. There are two main causes of stricture of the female urethra today; first, traumatic: arising from obstetrical and surgical injuries to the urethra, and second, inflammatory following gonorrheal urethritis. A_dequate treatment, particularly graded dilations, gives good results. In long standing cases of urinary obstruction due to stricture of the urethra, mild to marked secondary pathologic changes develop in the urinary system. Death has occurred from sepsis and uremia arising secondarily from such a seemingly slight lesion as stricture of the female urethra. The third case" of death incidental to strict.me of the urethra in the female is report.eel.
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