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Stricture of the Urethra
STRICTURE OF THE URETHRA JOHN R. CAULK
St. Louis, Missouri
In presenting the subject of stricture of the urethra and the far reaching effects of the crippling complications, it seems fitting to preface my remarks with a few relevant facts relating to its pathology and contributory factors concerned in its formation. Stricture of the urethra was best defined by Keyes as "an abnormal constriction or loss of distensibility of that channel." Basically, it is a scar resulting as a rule from an acute inflammatory process, and much less frequently tuberculosis, syphilis, trauma, chemical irritation, and congenital malformations. By far the most frequent exciting cause is gonorrhea, which is creative of at least 90 per cent of all strictures of the urethra, both in the male and female. It is apparent that the constant impact of urine against the ever-increasing obstacle in its path leads to ulceration, erosion and proliferation of its surface and continued narrowing of the lumen of the urethra. This marks the completion of a vicious cycle of events because the chronic inflammatory process in the urethra feeds the infection and the increase in scar formation promotes continued urinary retention and sepsis. It is needless to dwell more fully on the importance of the spread of the inflammatory process to the surrounding glandular structures which leave in their wake often sacrificial scarring of the perineum. It is difficult to assess the relative importance of the factors which contribute to the occurrence of stricture and its disabling sequelae but undoubtedly, trauma, the result of injudicious treatment with irritating solutions stands preeminent. This is admirably exemplified by the occurrence of dense resilient strictures which so often prove refractory to routine treatment, in the vicinity of the external meatus. A mild chronic urethritis seldom 407
408
JOHN R. CAULK
results in urethral sclerosis but a severe urethral reaction, whether the result of invasion by a virulent strain of organism combined with low individual tissue resistance or due to trama incited by chemicals or instrumentation, is much more likely to have a urethral scar as the end result. In private practice, properly conducted, I am convinced that stricture of the urethra following an attack of gonorrhea is relatively infrequent and I can recall but few instances of its occurrence during the course of the treatment, in my private practice. Time will not permit a detailed consideration of the many ramifications of this absorbing subject. We owe a debt of gratitude to the early French school of urology which furnished us with instruments, the ingenuity of which has not been surpassed to the present day and which were the products of such outstanding figures as Civiale, Maissoneuve, Le Fort, Albarran and Guyon. The German school contribut'ed in no small way through the efforts of Oberlaender and Kollmann, particularly in the realm of pathology. The British investigators, Wheelhouse, Syme, and Sir Henry Thompson aided in soving its problems, the last having contributed the first monograph in the English language, and our own Bangs, Otis, White, and the elder Keyes furnished their fair share of the knowledge on the subject. Clinically, strictures of the urethra may develop in various segments of the canal and assume configurations upon which depends their productivity of symptoms and to a certain extent their susceptibility or resistance to treatment The two types of stricture most frequently encountered are those which occur early: the result of traumatic injury, and the type occurring as a late manifestation of gonorrhea. The incidence of traumatic stricture due to penetrating or non-penetrating wounds of the perineum rather than those caused by instrumental mishaps, remains practically stationary. The institution of rational therapy employing mild stimulating medications which have as their objective drainage, has marked a most decided decrease in the incidence of strictures of inflammatory origin. The bearing which this therapeutic regime has had in minimizing the dangers of chronicity is evidenced by the relatively rare occurrence
STRICTURE OF URETHRA
409
of periurethral abscesses, urinary extravasation, fistulous formation in well organized clinics in the present day. Far advanced lesions of the upper urinary tract in old standing cases or those in which treatment has been neglected are also less frequent but when they occur, they demand the same meticulous care in their treatment as do the obstructive uropathies resulting from prostatic enlargment. If the surgeon is to be spared the unpleasantness of a high mortality rate and regards the patient's welfare of primary importance he must handle the gonorrheic who requires surgery in the same manner as the prostatic. Gradual decompression of the chronically dilated urinary tract must be instituted at an early date and radical surgery deferred until the patient is well prepared from every standpoint. The symptoms of stricture of the urethra are dependent chiefly on the factors of irritation and obstruction which it induces to the urinary flow and the severity of the complications with which it is associated. Whether one relies on the use of bougies-a-boule or the impressions acquired by the passage of metal instruments, in the diagnosis of stricture is a matter of personal aptitude and of little moment. However, there is one particular phase of the subject which I wish to stress and that is the importance of differentiating muscle spasm from stricture formation and the importance of muscle spasm with stricture. The physiological response of smooth muscle is that it reacts by contraction to stimuli. The irritation excited by the inflammation coincident to stricture of the urethra results in a muscle spasm in its immediate vicinity, so that the impressions derived from sounding are often fallacious as regards the extent of sclerotic contraction. This status is well exemplified by the patient who voids with great difficulty or may even develop complete retention and after the passage of a fine filiform, observes the marked improvement in his urinary stream which may in in fact approach normal. It is true that this apparent benefit is only transitory and that the stricture promptly recontracts, demanding continued and persistent treatment but the disparity in symptoms and physical findings is ample proof of the profound effect of spasm, This fact explains in a great measure the difficulty in the precise calibration not only of strictures but also of
410
JOHN R. CAULK
the normal urethra. We may also advance the existence of muscle spasm associated with stricture formation in the urethra as the explanation for the clinical finding of multiplicity where the pathologist only finds a single lesion. It is important in dealing with this feature that we exercise patience and utilize every essential design in its correction rather than hurriedly subject the stricture to radical surgery. One must always be cognizant of the fiickleness of stricture and its susceptibility to the whims of muscle flirtations. The most frequent site for stricture of the urethra is the bulbomembranous junction, which in addition to being a cesspool for the inflammatory products is highly receptive to irritability and spasticity of the sphincteric muscle in its vicinity. Urethral spasms in this location are commonly designated as strictures in the hands of the novice, whereas true strictures are often misinterpreted as to their actual calibration, being regarded as filiform when they are actually of moderate calibre, the additional tightness accounted for by muscle spasm. A brief citation of 2 cases which came under my attention will perhaps illustrate quite vividly the importance of muscle spasm in one instance and the effect of urinary sepsis with its reactionary processes in the other. The first was a case of recurrent carcinoma of the prostate for which a suprapubic prostatectomy had been performed in another clinic. The patient developed a dense apparently impassable stricture involving the entire deep urethra, which after repeated attempts at dilatation under local, caudal, and general anesthesia, permitted the passage of a fine filiform and follower but just as promptly recontracted. X-ray examination revealed the presence of a large vesical calculus 2 inches in diameter, and under spinal anesthesia a large Bigelow lithotrite was readily passed, the stone crushed and evacuated at one sitting. The second case was one of stricture of the urethra complicated by a large vesical calculus and profound inflammatory involvement of the surrounding tissues practically amounting to a "penitis," in which it was possible to pass after repeated and labored attempts a fine filiform into the bladder. Following suprapubic cystotomy undertaken for the removal of the calculus,
STRICTURE OF URETHRA
411
the inflammatory reaction in the urethra and penile structures promptly subsided and it was possible to pass a No. 30 French sound with ease within one week. I believe that the dictum of J. William White "dilate if you can and cut only if you have to" is a useful guide to following the treatment of strictures. I might add that persistence in the attempts at gradual dilatation will often be rewarded where failure seems imminent. I have already stressed the necessity for gradual decompression of chronically dilated bladders with paradoxical incontinence before venturing into radical surgery. In my experience retention is often satisfactorily relieved, simply by the passage of a fine filiform into the bladder which allows the urine to trickle along its sides, and the application of heat and sedatives. Whenever the stricture is impassable the mere engagement of a filiform in the stricture may help in overcoming the urethral spasm and permit the flow of urine. In the treatment of urethral strictures of small calibre, I prefer the use of filiforms with LeFort followers to graduated bougies. I have found the stricture to respond to this combination instrument much more readily than the bougie which once it has been retracted makes difficult to impassable the insertion of a larger one. In rare instances it is permissible to relieve urinary retention by suprapubic tapping with trocar and cannula. The realization of the benefits derived from repeated and persistent gradual dilatation of urethral strictures and the tendency to absorption of inflammatory products which it induces has lead to a new conception of the rational treatment of strictures. When we bear in mind the maxim of "once a stricture always a stricture" we are cognizant of the fallacy that urethrotomy "cures stricture." In the past, external urethrotomy was the operation of choice for the adequate treatment of stricture but in this day of enlightenment it should only be reserved for those cases associate with complications which cannot be cared for by other less radical measures. Periodic supervision of urethral strictures is essential, though this may prove a difficult task particularly in the out-patient clinic type of patient and has possibly led to the phrase "about
412
JOHN R. CAULK
as dependable as a nigger with a stricture." It is difficult to predict the duration of relief of symptoms following either dilatation or surgery. I have seen tight strictures apparently relieved for several years merely by the passage of a filiform and others to recontract promptly following higher dilatations. The dense resilient scar formations near the meatus often prove the most refractive to dilatation and may require division. There seems to be very little necessity for plastic procedures upon the urethra itself for the treatment of stricture. The consensus of opinion is that perineal urethrotomy with resection of the scar, allowing the roof of the urethra to remain intact and building the soft parts around an indwelling catheter and relying on nature to take care of the plastic procedure is the operation of choice. I have seen only 1 case in which this procedure failed and that was a traumatic stricture. After five perineal operations and with suprapubic drainage, each time after the removal of the catheter the perineum was converted into a solid mass of scar tissue. Incidentally, this patient refused uretero-intestinal anastomosis but has been made comfortable and happy with a double ureterostomy. A recent analysis which I conducted of the cases of stricture and its complications occurring in my private practice and clinic will perhaps serve to illustrate in a more striking fashion the swing of the pendulum from radical surgery to the more conservative methods of treatment of urethral stricture. In a total of 1320 strictures, 45 urethrotomies have been performed, 2 internal and 43 external. Of this number only 2 internal and 8 external were performed for uncomplicated stricture, of which 5 were done prior to 1913 and 3 since. The remainder of the urethrotoies were performed for the complications associated with stricture-11 for extravasation of urine, 10 for periurethral abscess, 14 for fistulae and 8 for impermeable stricture. The surgery of stricture is the surgery of its complications, in other words, numerically, open · operation was resorted to in 3.4 per cent of strictures but in only 0.6 of 1.0 per cent was it required for simple uncomplicated stricture. In 17 instances of stricture complicated by perineal fistulous
STRICTURE OF URETHRA
413
formation an apparent cure was effected simply by curettement of the :fistulae and dilatation of the stricture. Whenever urinary extravasation complicated stricture it was promptly relieved by urethrotomy and free drainage through multiple incisions. I well recall the most pronounced case of urinary extravasation that ever came to my attention. It occurred in a patient in whom it had been progressing for four days and involved the entire abdominal wall as high as the axillae, as well as the perinea!, penile and scrotal tissues. The patient was moribund but survived 100 incisions for drainage and is living today. The mortality from stricture is low and in uncomplicated cases it is practically nil. Sudden death following instrumentation or local anesthesia is an occasional occurrence. Surgical mortality depends upon the gravity of the complications-bilateral pyelonephritis with or without calculus and urinary extravasation have been responsible for the mortality in these cases. There were five deaths, two were sudden, one following simple instrumentation, one from anesthesia preparatory to operation, both had bilateral calculous pyelonephritis. One case died of sepsis from extravasation. Two died shortly after admission to the hospital, both were "in extremis" from general sepsis and renal infection. We may summarize the salient features of the subject of stricture of the urethra in a few words. 1. Gonorrhea is the most frequent cause of stricture formation in the urethra. 2. Injudicious treatment with strong irritating medicaments predisposes to their development. 3. Appropriate treatment during the acute stage and supervision during the chronic with particular attention to the adnexa minimizes the incidence of its occurrence. 4. Latency and chronicity of infection must be combated by treatment of the vesicles and prostate. 5. Muscle spasm is apt to prove deceptive in assessing the nature of a stricture. 6. Whenever possible strictures should be dilated gradually and repeatedly. Divulsion is to be condemned.
414
JOHN R. CAULK
7. Operative procedures should usually be reserved for its complications. 8. Because of the pronounced tendency of urethral regeneration, plastic procedures except in rare instances are seldom necessary. 9. The recurrence of stricture is likely. The time is difficult to predict, hence, periodic supervision is essential. 10. The mortality of stricture is low and occurs usually m neglected cases and results from sepsis or renal disease. 723 University Club Bldg., St. Louis, Mo.
St. Louis, Missouri
In presenting the subject of stricture of the urethra and the far reaching effects of the crippling complications, it seems fitting to preface my remarks with a few relevant facts relating to its pathology and contributory factors concerned in its formation. Stricture of the urethra was best defined by Keyes as "an abnormal constriction or loss of distensibility of that channel." Basically, it is a scar resulting as a rule from an acute inflammatory process, and much less frequently tuberculosis, syphilis, trauma, chemical irritation, and congenital malformations. By far the most frequent exciting cause is gonorrhea, which is creative of at least 90 per cent of all strictures of the urethra, both in the male and female. It is apparent that the constant impact of urine against the ever-increasing obstacle in its path leads to ulceration, erosion and proliferation of its surface and continued narrowing of the lumen of the urethra. This marks the completion of a vicious cycle of events because the chronic inflammatory process in the urethra feeds the infection and the increase in scar formation promotes continued urinary retention and sepsis. It is needless to dwell more fully on the importance of the spread of the inflammatory process to the surrounding glandular structures which leave in their wake often sacrificial scarring of the perineum. It is difficult to assess the relative importance of the factors which contribute to the occurrence of stricture and its disabling sequelae but undoubtedly, trauma, the result of injudicious treatment with irritating solutions stands preeminent. This is admirably exemplified by the occurrence of dense resilient strictures which so often prove refractory to routine treatment, in the vicinity of the external meatus. A mild chronic urethritis seldom 407
408
JOHN R. CAULK
results in urethral sclerosis but a severe urethral reaction, whether the result of invasion by a virulent strain of organism combined with low individual tissue resistance or due to trama incited by chemicals or instrumentation, is much more likely to have a urethral scar as the end result. In private practice, properly conducted, I am convinced that stricture of the urethra following an attack of gonorrhea is relatively infrequent and I can recall but few instances of its occurrence during the course of the treatment, in my private practice. Time will not permit a detailed consideration of the many ramifications of this absorbing subject. We owe a debt of gratitude to the early French school of urology which furnished us with instruments, the ingenuity of which has not been surpassed to the present day and which were the products of such outstanding figures as Civiale, Maissoneuve, Le Fort, Albarran and Guyon. The German school contribut'ed in no small way through the efforts of Oberlaender and Kollmann, particularly in the realm of pathology. The British investigators, Wheelhouse, Syme, and Sir Henry Thompson aided in soving its problems, the last having contributed the first monograph in the English language, and our own Bangs, Otis, White, and the elder Keyes furnished their fair share of the knowledge on the subject. Clinically, strictures of the urethra may develop in various segments of the canal and assume configurations upon which depends their productivity of symptoms and to a certain extent their susceptibility or resistance to treatment The two types of stricture most frequently encountered are those which occur early: the result of traumatic injury, and the type occurring as a late manifestation of gonorrhea. The incidence of traumatic stricture due to penetrating or non-penetrating wounds of the perineum rather than those caused by instrumental mishaps, remains practically stationary. The institution of rational therapy employing mild stimulating medications which have as their objective drainage, has marked a most decided decrease in the incidence of strictures of inflammatory origin. The bearing which this therapeutic regime has had in minimizing the dangers of chronicity is evidenced by the relatively rare occurrence
STRICTURE OF URETHRA
409
of periurethral abscesses, urinary extravasation, fistulous formation in well organized clinics in the present day. Far advanced lesions of the upper urinary tract in old standing cases or those in which treatment has been neglected are also less frequent but when they occur, they demand the same meticulous care in their treatment as do the obstructive uropathies resulting from prostatic enlargment. If the surgeon is to be spared the unpleasantness of a high mortality rate and regards the patient's welfare of primary importance he must handle the gonorrheic who requires surgery in the same manner as the prostatic. Gradual decompression of the chronically dilated urinary tract must be instituted at an early date and radical surgery deferred until the patient is well prepared from every standpoint. The symptoms of stricture of the urethra are dependent chiefly on the factors of irritation and obstruction which it induces to the urinary flow and the severity of the complications with which it is associated. Whether one relies on the use of bougies-a-boule or the impressions acquired by the passage of metal instruments, in the diagnosis of stricture is a matter of personal aptitude and of little moment. However, there is one particular phase of the subject which I wish to stress and that is the importance of differentiating muscle spasm from stricture formation and the importance of muscle spasm with stricture. The physiological response of smooth muscle is that it reacts by contraction to stimuli. The irritation excited by the inflammation coincident to stricture of the urethra results in a muscle spasm in its immediate vicinity, so that the impressions derived from sounding are often fallacious as regards the extent of sclerotic contraction. This status is well exemplified by the patient who voids with great difficulty or may even develop complete retention and after the passage of a fine filiform, observes the marked improvement in his urinary stream which may in in fact approach normal. It is true that this apparent benefit is only transitory and that the stricture promptly recontracts, demanding continued and persistent treatment but the disparity in symptoms and physical findings is ample proof of the profound effect of spasm, This fact explains in a great measure the difficulty in the precise calibration not only of strictures but also of
410
JOHN R. CAULK
the normal urethra. We may also advance the existence of muscle spasm associated with stricture formation in the urethra as the explanation for the clinical finding of multiplicity where the pathologist only finds a single lesion. It is important in dealing with this feature that we exercise patience and utilize every essential design in its correction rather than hurriedly subject the stricture to radical surgery. One must always be cognizant of the fiickleness of stricture and its susceptibility to the whims of muscle flirtations. The most frequent site for stricture of the urethra is the bulbomembranous junction, which in addition to being a cesspool for the inflammatory products is highly receptive to irritability and spasticity of the sphincteric muscle in its vicinity. Urethral spasms in this location are commonly designated as strictures in the hands of the novice, whereas true strictures are often misinterpreted as to their actual calibration, being regarded as filiform when they are actually of moderate calibre, the additional tightness accounted for by muscle spasm. A brief citation of 2 cases which came under my attention will perhaps illustrate quite vividly the importance of muscle spasm in one instance and the effect of urinary sepsis with its reactionary processes in the other. The first was a case of recurrent carcinoma of the prostate for which a suprapubic prostatectomy had been performed in another clinic. The patient developed a dense apparently impassable stricture involving the entire deep urethra, which after repeated attempts at dilatation under local, caudal, and general anesthesia, permitted the passage of a fine filiform and follower but just as promptly recontracted. X-ray examination revealed the presence of a large vesical calculus 2 inches in diameter, and under spinal anesthesia a large Bigelow lithotrite was readily passed, the stone crushed and evacuated at one sitting. The second case was one of stricture of the urethra complicated by a large vesical calculus and profound inflammatory involvement of the surrounding tissues practically amounting to a "penitis," in which it was possible to pass after repeated and labored attempts a fine filiform into the bladder. Following suprapubic cystotomy undertaken for the removal of the calculus,
STRICTURE OF URETHRA
411
the inflammatory reaction in the urethra and penile structures promptly subsided and it was possible to pass a No. 30 French sound with ease within one week. I believe that the dictum of J. William White "dilate if you can and cut only if you have to" is a useful guide to following the treatment of strictures. I might add that persistence in the attempts at gradual dilatation will often be rewarded where failure seems imminent. I have already stressed the necessity for gradual decompression of chronically dilated bladders with paradoxical incontinence before venturing into radical surgery. In my experience retention is often satisfactorily relieved, simply by the passage of a fine filiform into the bladder which allows the urine to trickle along its sides, and the application of heat and sedatives. Whenever the stricture is impassable the mere engagement of a filiform in the stricture may help in overcoming the urethral spasm and permit the flow of urine. In the treatment of urethral strictures of small calibre, I prefer the use of filiforms with LeFort followers to graduated bougies. I have found the stricture to respond to this combination instrument much more readily than the bougie which once it has been retracted makes difficult to impassable the insertion of a larger one. In rare instances it is permissible to relieve urinary retention by suprapubic tapping with trocar and cannula. The realization of the benefits derived from repeated and persistent gradual dilatation of urethral strictures and the tendency to absorption of inflammatory products which it induces has lead to a new conception of the rational treatment of strictures. When we bear in mind the maxim of "once a stricture always a stricture" we are cognizant of the fallacy that urethrotomy "cures stricture." In the past, external urethrotomy was the operation of choice for the adequate treatment of stricture but in this day of enlightenment it should only be reserved for those cases associate with complications which cannot be cared for by other less radical measures. Periodic supervision of urethral strictures is essential, though this may prove a difficult task particularly in the out-patient clinic type of patient and has possibly led to the phrase "about
412
JOHN R. CAULK
as dependable as a nigger with a stricture." It is difficult to predict the duration of relief of symptoms following either dilatation or surgery. I have seen tight strictures apparently relieved for several years merely by the passage of a filiform and others to recontract promptly following higher dilatations. The dense resilient scar formations near the meatus often prove the most refractive to dilatation and may require division. There seems to be very little necessity for plastic procedures upon the urethra itself for the treatment of stricture. The consensus of opinion is that perineal urethrotomy with resection of the scar, allowing the roof of the urethra to remain intact and building the soft parts around an indwelling catheter and relying on nature to take care of the plastic procedure is the operation of choice. I have seen only 1 case in which this procedure failed and that was a traumatic stricture. After five perineal operations and with suprapubic drainage, each time after the removal of the catheter the perineum was converted into a solid mass of scar tissue. Incidentally, this patient refused uretero-intestinal anastomosis but has been made comfortable and happy with a double ureterostomy. A recent analysis which I conducted of the cases of stricture and its complications occurring in my private practice and clinic will perhaps serve to illustrate in a more striking fashion the swing of the pendulum from radical surgery to the more conservative methods of treatment of urethral stricture. In a total of 1320 strictures, 45 urethrotomies have been performed, 2 internal and 43 external. Of this number only 2 internal and 8 external were performed for uncomplicated stricture, of which 5 were done prior to 1913 and 3 since. The remainder of the urethrotoies were performed for the complications associated with stricture-11 for extravasation of urine, 10 for periurethral abscess, 14 for fistulae and 8 for impermeable stricture. The surgery of stricture is the surgery of its complications, in other words, numerically, open · operation was resorted to in 3.4 per cent of strictures but in only 0.6 of 1.0 per cent was it required for simple uncomplicated stricture. In 17 instances of stricture complicated by perineal fistulous
STRICTURE OF URETHRA
413
formation an apparent cure was effected simply by curettement of the :fistulae and dilatation of the stricture. Whenever urinary extravasation complicated stricture it was promptly relieved by urethrotomy and free drainage through multiple incisions. I well recall the most pronounced case of urinary extravasation that ever came to my attention. It occurred in a patient in whom it had been progressing for four days and involved the entire abdominal wall as high as the axillae, as well as the perinea!, penile and scrotal tissues. The patient was moribund but survived 100 incisions for drainage and is living today. The mortality from stricture is low and in uncomplicated cases it is practically nil. Sudden death following instrumentation or local anesthesia is an occasional occurrence. Surgical mortality depends upon the gravity of the complications-bilateral pyelonephritis with or without calculus and urinary extravasation have been responsible for the mortality in these cases. There were five deaths, two were sudden, one following simple instrumentation, one from anesthesia preparatory to operation, both had bilateral calculous pyelonephritis. One case died of sepsis from extravasation. Two died shortly after admission to the hospital, both were "in extremis" from general sepsis and renal infection. We may summarize the salient features of the subject of stricture of the urethra in a few words. 1. Gonorrhea is the most frequent cause of stricture formation in the urethra. 2. Injudicious treatment with strong irritating medicaments predisposes to their development. 3. Appropriate treatment during the acute stage and supervision during the chronic with particular attention to the adnexa minimizes the incidence of its occurrence. 4. Latency and chronicity of infection must be combated by treatment of the vesicles and prostate. 5. Muscle spasm is apt to prove deceptive in assessing the nature of a stricture. 6. Whenever possible strictures should be dilated gradually and repeatedly. Divulsion is to be condemned.
414
JOHN R. CAULK
7. Operative procedures should usually be reserved for its complications. 8. Because of the pronounced tendency of urethral regeneration, plastic procedures except in rare instances are seldom necessary. 9. The recurrence of stricture is likely. The time is difficult to predict, hence, periodic supervision is essential. 10. The mortality of stricture is low and occurs usually m neglected cases and results from sepsis or renal disease. 723 University Club Bldg., St. Louis, Mo.