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Urinary Tract Disturbances Referable to Cervicitis1
URINARY TRACT DISTURBANCES REFERABLE TO CERVICITIS 1 0. A. NELSON Seattle, Washington
Every urologist has had women patients with urinary disturbances that were perplexing as to the cause of the symptoms. Therefore, if it can be established that cervicitis will frequently cause vesical and urethral disturbances, we shall. be in a. better position to relieve many of the women now suffering from that condition. We do not, however, intend to convey the idea that all vesical symptoms in women are brought on by cervidtis. During the last few years several papers have appeared that deal with infection of the cervix in relation to diseases and symptoms of the urinary tract, but only a few have discussed the treatment of cervicitis. There is no unanimity of opinion on the subject among either the gynecologists or the urologists. Although most gynecologists agree that cervicitis can cause symptoms and disease of the urinary tract, they are at variance as to the best method to eradicate cervical infection. The urologists and gynecologists the world over are greatly indebted To Winsbury-White, Mackenzie, Parks, Howard, Leopold, and Sturmdorf, and others in establishing the relationship between cervidtis and disturbances of the urinary tract, and the part played by the lymphatics in extension of infection. Harold, Ewert, and Maryan recently wrote an excellent clinical paper on cervidtis in relation to urinary symptoms. However, these last mentioned authors and Winsbury-White rely on cauterization to eradicate the cervical infection. Cauterization has been unsatisfactory in many of the patients in our series. On the other hand, in many instances, the Sturmdorf type operation brought about prompt and permanent relief of the urinary symptoms. Nearly two decades ago Sturmdorf, and more recently Richard O'Shea, of Seattle, have called attention to the importance of complete eradication of cervical infection when that condition was causing disturbance. During the last 6 years we have watched with keen interest the two schools on treatment of cervicitis: (1) those who cauterize all types of cervicitis, and (2) those who do sharp-edge dissections when complete 'Read at the annual meeting of the American Urological Association, Minneapolis, Minn,, July 1, 1937. 361
362
0. A. NELSON
removal of all the infected tissue requires going deeply into the cervix and near the internal os. We shall relate the clinical result as we have seen it by each method of treatment. This paper is based on a review of 87 cases in our private practice. The patients who had disease or conditions other than cervicitis that could account for their urinary symptoms were excluded, even though they had a severe degree of cervicitis. Some interesting facts were revealed by the study and follow-up of these case records. Their history brought out that although cervicitis may begin in childhood, the condition usually follows instrumentation of the cervix or vagina, gonococcic infection, child-birth, or abortion. A tri-symptom complex was frequently present; these were: (1) frequency of urination, (2) backache, and (3) leukorrhea. All of these 87 women had frequency of urination when they reported for examination. This high incidence of urinary symptoms in this group is, of course, to be accounted for by the fact that they came for urological examination. Of this group, 72 women gave a history of low backache which was usually periodic and had its onset after the time of the cervical infection. Leukorrheal discharge had been present at some time or another, either constantly or periodically in 68 of this group of 87. In all of these women urethroscopic examination showed a variable degree of granular urethritis, and in many inflammatory villi were projecting from the urethral mucosa. Trigonitis was present in 33 women. The catheterized urine showed no pus or bacteria in 58. A variable degree of pyogenic infection was present in the remaining 29 women; 19 had infections of the upper urinary tract, and 14 had pyelectasis and caliectasis with urethral dilatation; 3 of the group had renal calculi. Cultural methods were not used for isolation of the organisms; consequently, no attempt was made to study the type of organisms other than to rule out tubercle bacilli by staining. Except for the findings in the uterine cervix, pelvic examination and recording of such findings were not carried out in detail, for women with evidence of uterine or adnexal disease were either returned to their · physician, or referred for gynecological examination. At times it was difficult to decide whether cervical infection were responsible for the vesical symptoms, and in many instances gynecological consultation was a hindrance rather than a help in reaching a correct diagnosis. This was particularly true when the practitioner had already cauterized the cervix, but with continuing evidence of infection. Furthermore, in
URINARY TRACT DISTURBANCES AND CERVICITIS
363
many instances the evidence of infection was much more pronounced in the operative specimen than was apparent to inspection or palpation before the incision was made. We often felt the need of a method or technique, by aspiration or otherwise, to facilitate the making of a definite diagnosis by biopsy from the deeper portions of the cervical tissue. Four women in this group had had interposition operations for the relief of cystocele and vesical symptoms. The uterus with an infected cervix had been antiflexed and placed under the bladder for support; their symptoms had increased after the operation, and were not influenced by any treatment to the urethra and bladder, such as urethral dilatation, injection, or instillation. Examination of the blood showed a definite secondary anemia with hemoglobin values below 65 per cent in 4 women; all of these 4 had had long standing pyelonephritis. In general the diagnosis of cervicitis as an etiological factor in urinary disturbances in this group was based on the finding of evidence of cervical infection, and the absence of findings that indicated the presence of renal tuberculosis, interstitial cystitis, nephritis, diabetes, lesion of the central nervous system or of the abdominal or pelvic organs. Our reason for discussing the treatment of cervicitis is that we have found in many instances after our making the diagnosis of cervicitis as the cause of urinary disturbances, the physician who sent the patient to us or gynecologist cauterized the cervix without relief to the patient. On the other hand, the Sturin.dorf type of gynoplasty usually brought about permanent relief. We noticed also that young women were more likely to get prompt and complete relief than were the older ones. In all instances in this group, failure to relieve the urinary symptoms and backache by a Sturmdorf operation was in women over 45 years of age and who had had the infection for many years. Furthermore, we were by clinical evidence and result led to believe that when there is a severe degree of parametritis, operative procedures limited to the cervix are likely to fail to bring about the desired results. The clinical results from the two types of treatment were in this group quite definite; 43 of the group of 87 women had had, before coming to us, cauterization of the cervix without permanent relief of the vesical symptoms; 36 women have, since they were first examined by us, had their cervix coned out by the Sturmdorf technique; 20 of this group had had one or more cervical cauterizations before the Sturmdorf operation; 8 of the 36 women who have had Sturmdorf operations were not relieved
364
0. A. NELSON
of their vesical symptoms. Failures might be accounted for by incorrect diagnosis, the presence of undiscovered infection about the vulva or pelvis, or incomplete removal of the infected cervical tissue. Two of the 8 who were not relieved have since had hysterectomies, as they were not relieved by the Sturmdorf operation and had definite evidence of parametritis. Hysterectomy brought about complete relief of the urinary symptoms. These 2 cases are mentioned to bring out the fact that often the infection has extended into the parametrium and pelvic glands; consequently, operation on the cervix will not always relieve or eradicate such infection. Nevertheless, we believe that in many instances eradication of the cervical infection will be followed by the subsidence of infection in the pelvic lymphatics. Although in a few instances it was necessary to treat the urethra after the tracheloplasty, 28 of the 36 were permanently relieved by the Sturmdorf type of operation. The following case record shows that it is difficult to make a diagnosis of cervicitis by inspection and palpation, and that the diagnosis must be made by a process of elimination. Mrs. A. L. H., a housewife, aged 33 years, was first seen on October Her chief complaint was a vesical irritation. Frequent and painful urination had been periodically present since she was 9 years old. These attacks usually came on every 2 or 3 months, and would last from 1 to 3 weeks. General examination revealed nothing abnormal. A note concerning the uterine cervix made at the time of the examination is as follows: "The cervix appears to be fairly normal; but it should be reexamined." Catheterized specimens of urine taken on different days were all normal to laboratory examination. Cystoscopic examination showed no stricture of the urethra, but a grade 3 granular urethritis and a moderately severe trigonitis. Ureteral catheterization, renal function test, and pyelography revealed the upper urinary tract to be normal. As the upper urinary tract, the neuro-muscular system, and the uterus and adnexa were found to be normal, we recommended that her physician examine the cervix from time to time; and that if he found any evidence of cervicitis he should do a Sturmdorf operation. Repeated examination of the cervix revealed that at times there was considerable purulent discharge; but at no time was any marked inflammation, or cysts, seen in the cervix. On October 19, 1934, cauterization of the cervix was done, but this was followed by no relief to the patient. On January 4, 1935, the Sturmdorf operation was done by her physician. The specimen removed from the cervix showed that many of the glands were grossly infected, particularly in the mid-portion of the cervix and near the internal os. Case 1.
5, 1934.
URINARY TRACT DISTURBANCES AND CERVICITIS
365
Although there was a considerable degree of relief from her vesical symptoms, she was not entirely well. On February 6, 1935, cystoscopy showed that the granular urethritis was still present, as well as many villousprojections from the urethral mucosa. The urethra was then gradually dilated from time to time until a caliber of 33F was reached; this required five dilatations. On April 16, 1937, she declared that she had been entirely well since the last urethral dilatation. · The following case record shows an instance of pyelonephritis that could not be relieved until after eradication of cervical infection. Case 2. Mrs. F. P., housewife, aged 51 years, was seen on January 19, 1935. Her symptoms were attacks of frequent and painful urination and pain under the rib margin and back, first on one side and then on the other. The attacks of pain in the back were usually accompanied by chills and fever. The symptoms of urinary tract infection had been present for 6 years. She had recently had an attack of chills followed by fever and pain in the right side and back. A few days later the pain also came into the left side. She was so sick that she remained in the hospital 8 days. A plain film of the kidneys, ureters, and bladder showed no shadow suggestive of stone. An intravenous pyelogram showed bilateral caliectasis that was suggestive of infection rather than obstruction. Catheterized urine showed many pus cells and many gram negative bacilli; no acid fast organisms were found. The urine was acidified by ammonium chloride, and hexamethylene was given. She also received 0.2 gram of neoarsphenamine on every fifth day for four doses. She had a severe degree of laceration of the cervix with considerable infection. We advised a Sturmdorf operation on the cervix. On December 6, 1934, the cervix was cauterized. Nevertheless, she continued to have periods of bladder symptoms, but no severe attack of pyelonephritis occurred until January, 1935, when she again had severe attacks of bachache and elevation of temperature. Sturmdorf operation was done on February 6, 1935, by her own physician. An interview with the patient on September 15, 1936, revealed that she had been entirely free of her vesical symptoms. Her urine was examined on June 6, 1936, and again on September 14, 1936; at each time it was entirely normal to laboratory examination.
The following record shows that cervicitis can cause elevation of temperature. Case 3. Miss L. L., graduate nurse, aged 26 years, was first seen on February 9, 1935. Her history was frequent, urgent, and painful urination of 18 months duration. One year before coming she had many urethral dilatations
366
0. A. NELSON
with some relief of symptoms. However, 6 months before coming she had had a return of severe vesical symptoms when urethral dilation gave her no relief. During the 3 months before coming she had been in a tuberculosis sanitorium for observation, as she had an afternoon temperature which varied from 99° to 101 °. However, very competent physicians found no evidence of pulmonary lesion either by physical examination or x-ray. A general examination revealed nothing unusual except a urethral stricture of large caliber and a grade 4 cervicitis with multiple cysts. A catheterized specimen of urine was normal to laboratory examination. Cystoscopy showed granular urethritis and a moderately severe trigonitis; otherwise the interior of the bladder appeared to be normal. Renal function as measured by indigo carmine was normal from each side. A gynecologist agreed that the cervicitis was likely responsible for the vesical symptoms; but he contended that cauterization of the cervix would bring about as good a result as a Sturmdorf operation could do. On February 16, 1935, cauterization of the cervix was done by a gynecologist. On March 29, 1935, the patient reported that her bladder had been somewhat improved after the cervical cauterization, but that the vesical symptoms had returned. At this time, we emphatically stated that a Sturmdorf operation should be done. On March 30, 1935, a general surgeon did a Sturmdorf operation. Following this operation her vesical symptoms subsided within one week, and the afternoon elevation of temperature, which had been a baffling problem, also subsided and has not returned. The last communication we had from this patient was on September 20, 1936, when she stated that she had had no return of the vesical symptoms since the Sturmdorf operation. CONCLUSIONS
Experimental and clinical findings justify the conclusion that cervical infection can and often does extend to the urinary tract. When the tri-symptom complex to which we have referred is present, the clinician should suspect cervicitis to be the primary cause of such symptoms. Infection in the deep portion of the cervix will at times not be discernible to inspection or palpation. With the object in view to stop the extension of the infection from the cervix to the urinary tract, cauterization will usually fail to bring about the desired results. When properly performed for cervicitis that is causing urinary symptoms, the Sturmdorf type of operation will, in the majority of instances, bring about a permanent relief.
509 Olive Way, Seattle, Wash.
Every urologist has had women patients with urinary disturbances that were perplexing as to the cause of the symptoms. Therefore, if it can be established that cervicitis will frequently cause vesical and urethral disturbances, we shall. be in a. better position to relieve many of the women now suffering from that condition. We do not, however, intend to convey the idea that all vesical symptoms in women are brought on by cervidtis. During the last few years several papers have appeared that deal with infection of the cervix in relation to diseases and symptoms of the urinary tract, but only a few have discussed the treatment of cervicitis. There is no unanimity of opinion on the subject among either the gynecologists or the urologists. Although most gynecologists agree that cervicitis can cause symptoms and disease of the urinary tract, they are at variance as to the best method to eradicate cervical infection. The urologists and gynecologists the world over are greatly indebted To Winsbury-White, Mackenzie, Parks, Howard, Leopold, and Sturmdorf, and others in establishing the relationship between cervidtis and disturbances of the urinary tract, and the part played by the lymphatics in extension of infection. Harold, Ewert, and Maryan recently wrote an excellent clinical paper on cervidtis in relation to urinary symptoms. However, these last mentioned authors and Winsbury-White rely on cauterization to eradicate the cervical infection. Cauterization has been unsatisfactory in many of the patients in our series. On the other hand, in many instances, the Sturmdorf type operation brought about prompt and permanent relief of the urinary symptoms. Nearly two decades ago Sturmdorf, and more recently Richard O'Shea, of Seattle, have called attention to the importance of complete eradication of cervical infection when that condition was causing disturbance. During the last 6 years we have watched with keen interest the two schools on treatment of cervicitis: (1) those who cauterize all types of cervicitis, and (2) those who do sharp-edge dissections when complete 'Read at the annual meeting of the American Urological Association, Minneapolis, Minn,, July 1, 1937. 361
362
0. A. NELSON
removal of all the infected tissue requires going deeply into the cervix and near the internal os. We shall relate the clinical result as we have seen it by each method of treatment. This paper is based on a review of 87 cases in our private practice. The patients who had disease or conditions other than cervicitis that could account for their urinary symptoms were excluded, even though they had a severe degree of cervicitis. Some interesting facts were revealed by the study and follow-up of these case records. Their history brought out that although cervicitis may begin in childhood, the condition usually follows instrumentation of the cervix or vagina, gonococcic infection, child-birth, or abortion. A tri-symptom complex was frequently present; these were: (1) frequency of urination, (2) backache, and (3) leukorrhea. All of these 87 women had frequency of urination when they reported for examination. This high incidence of urinary symptoms in this group is, of course, to be accounted for by the fact that they came for urological examination. Of this group, 72 women gave a history of low backache which was usually periodic and had its onset after the time of the cervical infection. Leukorrheal discharge had been present at some time or another, either constantly or periodically in 68 of this group of 87. In all of these women urethroscopic examination showed a variable degree of granular urethritis, and in many inflammatory villi were projecting from the urethral mucosa. Trigonitis was present in 33 women. The catheterized urine showed no pus or bacteria in 58. A variable degree of pyogenic infection was present in the remaining 29 women; 19 had infections of the upper urinary tract, and 14 had pyelectasis and caliectasis with urethral dilatation; 3 of the group had renal calculi. Cultural methods were not used for isolation of the organisms; consequently, no attempt was made to study the type of organisms other than to rule out tubercle bacilli by staining. Except for the findings in the uterine cervix, pelvic examination and recording of such findings were not carried out in detail, for women with evidence of uterine or adnexal disease were either returned to their · physician, or referred for gynecological examination. At times it was difficult to decide whether cervical infection were responsible for the vesical symptoms, and in many instances gynecological consultation was a hindrance rather than a help in reaching a correct diagnosis. This was particularly true when the practitioner had already cauterized the cervix, but with continuing evidence of infection. Furthermore, in
URINARY TRACT DISTURBANCES AND CERVICITIS
363
many instances the evidence of infection was much more pronounced in the operative specimen than was apparent to inspection or palpation before the incision was made. We often felt the need of a method or technique, by aspiration or otherwise, to facilitate the making of a definite diagnosis by biopsy from the deeper portions of the cervical tissue. Four women in this group had had interposition operations for the relief of cystocele and vesical symptoms. The uterus with an infected cervix had been antiflexed and placed under the bladder for support; their symptoms had increased after the operation, and were not influenced by any treatment to the urethra and bladder, such as urethral dilatation, injection, or instillation. Examination of the blood showed a definite secondary anemia with hemoglobin values below 65 per cent in 4 women; all of these 4 had had long standing pyelonephritis. In general the diagnosis of cervicitis as an etiological factor in urinary disturbances in this group was based on the finding of evidence of cervical infection, and the absence of findings that indicated the presence of renal tuberculosis, interstitial cystitis, nephritis, diabetes, lesion of the central nervous system or of the abdominal or pelvic organs. Our reason for discussing the treatment of cervicitis is that we have found in many instances after our making the diagnosis of cervicitis as the cause of urinary disturbances, the physician who sent the patient to us or gynecologist cauterized the cervix without relief to the patient. On the other hand, the Sturin.dorf type of gynoplasty usually brought about permanent relief. We noticed also that young women were more likely to get prompt and complete relief than were the older ones. In all instances in this group, failure to relieve the urinary symptoms and backache by a Sturmdorf operation was in women over 45 years of age and who had had the infection for many years. Furthermore, we were by clinical evidence and result led to believe that when there is a severe degree of parametritis, operative procedures limited to the cervix are likely to fail to bring about the desired results. The clinical results from the two types of treatment were in this group quite definite; 43 of the group of 87 women had had, before coming to us, cauterization of the cervix without permanent relief of the vesical symptoms; 36 women have, since they were first examined by us, had their cervix coned out by the Sturmdorf technique; 20 of this group had had one or more cervical cauterizations before the Sturmdorf operation; 8 of the 36 women who have had Sturmdorf operations were not relieved
364
0. A. NELSON
of their vesical symptoms. Failures might be accounted for by incorrect diagnosis, the presence of undiscovered infection about the vulva or pelvis, or incomplete removal of the infected cervical tissue. Two of the 8 who were not relieved have since had hysterectomies, as they were not relieved by the Sturmdorf operation and had definite evidence of parametritis. Hysterectomy brought about complete relief of the urinary symptoms. These 2 cases are mentioned to bring out the fact that often the infection has extended into the parametrium and pelvic glands; consequently, operation on the cervix will not always relieve or eradicate such infection. Nevertheless, we believe that in many instances eradication of the cervical infection will be followed by the subsidence of infection in the pelvic lymphatics. Although in a few instances it was necessary to treat the urethra after the tracheloplasty, 28 of the 36 were permanently relieved by the Sturmdorf type of operation. The following case record shows that it is difficult to make a diagnosis of cervicitis by inspection and palpation, and that the diagnosis must be made by a process of elimination. Mrs. A. L. H., a housewife, aged 33 years, was first seen on October Her chief complaint was a vesical irritation. Frequent and painful urination had been periodically present since she was 9 years old. These attacks usually came on every 2 or 3 months, and would last from 1 to 3 weeks. General examination revealed nothing abnormal. A note concerning the uterine cervix made at the time of the examination is as follows: "The cervix appears to be fairly normal; but it should be reexamined." Catheterized specimens of urine taken on different days were all normal to laboratory examination. Cystoscopic examination showed no stricture of the urethra, but a grade 3 granular urethritis and a moderately severe trigonitis. Ureteral catheterization, renal function test, and pyelography revealed the upper urinary tract to be normal. As the upper urinary tract, the neuro-muscular system, and the uterus and adnexa were found to be normal, we recommended that her physician examine the cervix from time to time; and that if he found any evidence of cervicitis he should do a Sturmdorf operation. Repeated examination of the cervix revealed that at times there was considerable purulent discharge; but at no time was any marked inflammation, or cysts, seen in the cervix. On October 19, 1934, cauterization of the cervix was done, but this was followed by no relief to the patient. On January 4, 1935, the Sturmdorf operation was done by her physician. The specimen removed from the cervix showed that many of the glands were grossly infected, particularly in the mid-portion of the cervix and near the internal os. Case 1.
5, 1934.
URINARY TRACT DISTURBANCES AND CERVICITIS
365
Although there was a considerable degree of relief from her vesical symptoms, she was not entirely well. On February 6, 1935, cystoscopy showed that the granular urethritis was still present, as well as many villousprojections from the urethral mucosa. The urethra was then gradually dilated from time to time until a caliber of 33F was reached; this required five dilatations. On April 16, 1937, she declared that she had been entirely well since the last urethral dilatation. · The following case record shows an instance of pyelonephritis that could not be relieved until after eradication of cervical infection. Case 2. Mrs. F. P., housewife, aged 51 years, was seen on January 19, 1935. Her symptoms were attacks of frequent and painful urination and pain under the rib margin and back, first on one side and then on the other. The attacks of pain in the back were usually accompanied by chills and fever. The symptoms of urinary tract infection had been present for 6 years. She had recently had an attack of chills followed by fever and pain in the right side and back. A few days later the pain also came into the left side. She was so sick that she remained in the hospital 8 days. A plain film of the kidneys, ureters, and bladder showed no shadow suggestive of stone. An intravenous pyelogram showed bilateral caliectasis that was suggestive of infection rather than obstruction. Catheterized urine showed many pus cells and many gram negative bacilli; no acid fast organisms were found. The urine was acidified by ammonium chloride, and hexamethylene was given. She also received 0.2 gram of neoarsphenamine on every fifth day for four doses. She had a severe degree of laceration of the cervix with considerable infection. We advised a Sturmdorf operation on the cervix. On December 6, 1934, the cervix was cauterized. Nevertheless, she continued to have periods of bladder symptoms, but no severe attack of pyelonephritis occurred until January, 1935, when she again had severe attacks of bachache and elevation of temperature. Sturmdorf operation was done on February 6, 1935, by her own physician. An interview with the patient on September 15, 1936, revealed that she had been entirely free of her vesical symptoms. Her urine was examined on June 6, 1936, and again on September 14, 1936; at each time it was entirely normal to laboratory examination.
The following record shows that cervicitis can cause elevation of temperature. Case 3. Miss L. L., graduate nurse, aged 26 years, was first seen on February 9, 1935. Her history was frequent, urgent, and painful urination of 18 months duration. One year before coming she had many urethral dilatations
366
0. A. NELSON
with some relief of symptoms. However, 6 months before coming she had had a return of severe vesical symptoms when urethral dilation gave her no relief. During the 3 months before coming she had been in a tuberculosis sanitorium for observation, as she had an afternoon temperature which varied from 99° to 101 °. However, very competent physicians found no evidence of pulmonary lesion either by physical examination or x-ray. A general examination revealed nothing unusual except a urethral stricture of large caliber and a grade 4 cervicitis with multiple cysts. A catheterized specimen of urine was normal to laboratory examination. Cystoscopy showed granular urethritis and a moderately severe trigonitis; otherwise the interior of the bladder appeared to be normal. Renal function as measured by indigo carmine was normal from each side. A gynecologist agreed that the cervicitis was likely responsible for the vesical symptoms; but he contended that cauterization of the cervix would bring about as good a result as a Sturmdorf operation could do. On February 16, 1935, cauterization of the cervix was done by a gynecologist. On March 29, 1935, the patient reported that her bladder had been somewhat improved after the cervical cauterization, but that the vesical symptoms had returned. At this time, we emphatically stated that a Sturmdorf operation should be done. On March 30, 1935, a general surgeon did a Sturmdorf operation. Following this operation her vesical symptoms subsided within one week, and the afternoon elevation of temperature, which had been a baffling problem, also subsided and has not returned. The last communication we had from this patient was on September 20, 1936, when she stated that she had had no return of the vesical symptoms since the Sturmdorf operation. CONCLUSIONS
Experimental and clinical findings justify the conclusion that cervical infection can and often does extend to the urinary tract. When the tri-symptom complex to which we have referred is present, the clinician should suspect cervicitis to be the primary cause of such symptoms. Infection in the deep portion of the cervix will at times not be discernible to inspection or palpation. With the object in view to stop the extension of the infection from the cervix to the urinary tract, cauterization will usually fail to bring about the desired results. When properly performed for cervicitis that is causing urinary symptoms, the Sturmdorf type of operation will, in the majority of instances, bring about a permanent relief.
509 Olive Way, Seattle, Wash.