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Stricture of the Urethra with Calculi in Scrotal Sinuses
STRICTURE OF THE URETHRA WITH CALCULI IN SCROTAL SINUSES J . M. VENABLE From the Urological Service, R . B. Green Hospital, San Antonio, Texas Received for publication August 4, 1927
The excessive calculus formation in the following case of stricture of the urethra justifies this report. Case no. 2918. Mexican man, aged forty-seven years, entered the hospital April 6, 1927, complaining of very difficult urination and stones in his scrotum. The following is as near an exact a history as could be obtained: Gonorrhea in 1903, duration six months. In 1918 first noticed his urinary stream getting small with increasing dysuria until complete retention in November, 1918. He was in Mexico at this time and repeated attempts at catheterization failed. Apparently he had a rupture of his urethra with extravasation into his scrotum and sinus formation. According to the patient no urine has since passed through the anterior urethra but has all passed through the scrotal sinuses. Three years later calculi began to pass through the sinuses. Patient states that he has passed 30 or 40 calculi some as large as the end of his thumb. For two weeks prior to coming to the hospital he has passed no calculi and consequently had increasing difficulty in passing any urine at all. · Physical examination unimportant except for the genitalia. General physical condition was excellent. The scrotum was five times the natural size, with extensive scar formation and multiple sinuses exuding pus and urine. It was almost entirely filled with calculi which could be felt grating upon one another. Both testicles could be felt situated posterior and lateral to the mass of stones and were apparently normal. A probe in the urethra grated upon calculi at the peno-scrotal junction, filiforms could not be passed. The prostate was not enlarged but irregularly indurated. X-ray was negative except for the shadows filling the scrotum. Urinalysis normal except for a moderate number of pus cells. 671
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J. M. VENABLE
Wassermann negative. Operation, April, 1927. Ether anesthesia. Incision was made over the scrotal septum, edges dissected back and the sinuses with their contents were removed en bloc after a long and tedious dissection. Neither tunica vaginalis was opened. The urethra where the sinuses began was about two centimeters in diameter with markedly thickened walls and contained two large and one small calculus. The urethra was incised, stones removed, strictures located and cut, and a large catheter (24 Fr.) passed from meatus to bladder. An attempt was made to close the urethra over the catheter with plain catgut. Superficial tissues and skin closed with silkworm. One drain in the lower angle of the incision. In the mass that was removed there were 67 calculi varying in size from a small pea to 2.5 cm. The catheter did not drain well and was removed on the fifth day with the patient passing most of his urine through a fistula at the site of the drain. A 24 Fr. sound could be passed with little difficulty. After about five weeks there seemed to be little likelihood of the fistula closing, so a second operation to close the urethra was attempted. Operation, June 1, 1927. Ether anesthesia. The former skin incision was resected with a large flap of scar tissue that would interfere with proper healing. The urethra was easily exposed and presented an opening about 2 cm. long. The edges of this opening were freshened and the second fistulous tract excised. The urethral opening was closed with chromic No. 1 interrupted. The subcutaneous tissue was closed over this with chromic, and the skin edges were approximated with silkworm. No drainage. Following this operation the patient voided normally and there was no leakage through the wound. He was discharged from the hospital June 24, 1927, with instructions to return to the Outpatient clinic for urethral dilation.
The excessive calculus formation in the following case of stricture of the urethra justifies this report. Case no. 2918. Mexican man, aged forty-seven years, entered the hospital April 6, 1927, complaining of very difficult urination and stones in his scrotum. The following is as near an exact a history as could be obtained: Gonorrhea in 1903, duration six months. In 1918 first noticed his urinary stream getting small with increasing dysuria until complete retention in November, 1918. He was in Mexico at this time and repeated attempts at catheterization failed. Apparently he had a rupture of his urethra with extravasation into his scrotum and sinus formation. According to the patient no urine has since passed through the anterior urethra but has all passed through the scrotal sinuses. Three years later calculi began to pass through the sinuses. Patient states that he has passed 30 or 40 calculi some as large as the end of his thumb. For two weeks prior to coming to the hospital he has passed no calculi and consequently had increasing difficulty in passing any urine at all. · Physical examination unimportant except for the genitalia. General physical condition was excellent. The scrotum was five times the natural size, with extensive scar formation and multiple sinuses exuding pus and urine. It was almost entirely filled with calculi which could be felt grating upon one another. Both testicles could be felt situated posterior and lateral to the mass of stones and were apparently normal. A probe in the urethra grated upon calculi at the peno-scrotal junction, filiforms could not be passed. The prostate was not enlarged but irregularly indurated. X-ray was negative except for the shadows filling the scrotum. Urinalysis normal except for a moderate number of pus cells. 671
672
J. M. VENABLE
Wassermann negative. Operation, April, 1927. Ether anesthesia. Incision was made over the scrotal septum, edges dissected back and the sinuses with their contents were removed en bloc after a long and tedious dissection. Neither tunica vaginalis was opened. The urethra where the sinuses began was about two centimeters in diameter with markedly thickened walls and contained two large and one small calculus. The urethra was incised, stones removed, strictures located and cut, and a large catheter (24 Fr.) passed from meatus to bladder. An attempt was made to close the urethra over the catheter with plain catgut. Superficial tissues and skin closed with silkworm. One drain in the lower angle of the incision. In the mass that was removed there were 67 calculi varying in size from a small pea to 2.5 cm. The catheter did not drain well and was removed on the fifth day with the patient passing most of his urine through a fistula at the site of the drain. A 24 Fr. sound could be passed with little difficulty. After about five weeks there seemed to be little likelihood of the fistula closing, so a second operation to close the urethra was attempted. Operation, June 1, 1927. Ether anesthesia. The former skin incision was resected with a large flap of scar tissue that would interfere with proper healing. The urethra was easily exposed and presented an opening about 2 cm. long. The edges of this opening were freshened and the second fistulous tract excised. The urethral opening was closed with chromic No. 1 interrupted. The subcutaneous tissue was closed over this with chromic, and the skin edges were approximated with silkworm. No drainage. Following this operation the patient voided normally and there was no leakage through the wound. He was discharged from the hospital June 24, 1927, with instructions to return to the Outpatient clinic for urethral dilation.