STRICTURE OF THE MALE URETHRA MAJOR THOMAS W.
LIEUT. COL. JOHN H. HARRISON AND CAPT. BURDETTE E. TRICHEL MEDICAL CORPS, ARMY OF THE UNITED STATES
T is the purpose of this communication to present an anaIysis of eighty-seven cases of urethra1 strictures treated in an Army Genera1 Hospital overseas in a period of twenty-two months; 1077 cases of urethritis were treated during the same period. A description of the symptoms, signs, diagnosis, treatment and disposition of urethra1 strictures wiI1 be given. Stricture of the urethra is the most insidious and at the same time the most common Iate complication of gonorrhea. Trauma is a more serious but less common cause of stricture. Inflammatory stricture is usuaIIy acquired in earIy life but often does not become manifest for years. When this is the case, there is an accompanying infection of the mid and upper urinary tract which is proportionate to the severity of the urethra1 obstruction. EarIy recognition of the presence of a stricture permits the institution of appropriate measures to prevent constriction and obstruction of the urethra. The treatment, though primariIy paIIiative and not curative, may obviate subsequent pathoIogic changes in the mid and upper urinary tract. AI1 of the patients were in the third and fourth decades of Iife, except three in the fifth and three in the sixth decade. There were seventy-six patients who previousIy had gonorrhea, four had sustained severe trauma to the urethra, one had a congenita1 structure, and six denied any history to expIain the presence of the Iesion. Fifty-nine of the patients who had had gonorrhea had been treated with suIfonamides for their infection and seventeen had not had any of these agents. None had received peniciIIin and onIy three had been I43
treated with fever therapy. There were forty-nine white and thirty-eight negro soIdiers in the group. The presenting symptoms of our patients are shown in TabIe I. TABLE I Chronic urethral discharge.. Chronic urethra1 discharge and obstructive tams....................................... Obstructive symptoms alone. Acute urethral discharge due to gonococcus. No symptoms due to stricture.. . .
23 I2 14 6
Thirty-two patients compIained of urethra1 discharge of Iong duration and usuaIIy manifested as a “morning drop.” This discharge varied from a thin watery ffuid containing epitheIia1 ceIIs and a few Ieucocytes to a mucopuruIent ffuid Ioaded with Ieucocytes. Twenty-three patients had a chronic urethra1 discharge and aIso compIained of a weak, smaI1, hesitant urinary stream. TweIve patients had the Iatter symptoms without noticeabIe urethra1 discharge. Acute gonorrhea1 urethritis was present in fourteen patients who aIso had stricture of the urethra. This was the second attack of gonorrhea for these patients. There were six patients who had no symptoms and in whom the diagnosis of stricture was made when cystoscopy was attempted for other reasons. The Iapse of time between the origina gonorrhea and the diagnosis of stricture varied from one to twenty-seven years, with the majority evenIy divided between one and tweIve years. OnIy ten patients were aware that they possessed a stricture before their current hospitaIization. One patient with a known stricture of twenty years’ duration entered the hospita1 with acute urinary retention. His temperature was I03OF. and he pre-
sented the signs and symptoms of severe urinary tract infection. This was the onIy patient of our series who was admitted in a critica condition. There was one patient admitted here six weeks after a buIIdozer turned over on him and fractured his peIvis and ruptured his urethra. A suprapubic. cystotomy had been performed at the time of injury, but no attempt had been made to restore the continuity of the urethra. The foIIowing outIine is adhered to in the investigation of patients with stricture of the urethra: I. History. CarefuI attention is given to the duration of symptoms, especiaIIy to any history of antecedent upper urinary tract infection. It is aIs of paramount importance to discover how incapacitating the disease has been in reIation to the type of miIitary duty the patient has been performing. If the urethral discharge is present it is important to inquire into recent sexua1 exposures. 2. Physical Examination. A compIete physical examination is made which incIudes paIpation of the urethra, testicIes, epididymes, prostate and semina1 vesicIes. 3. Observation of the Patient during the Act of Urination. The importance of this simple test -is often overIooked, and deserves particuIar emphasis. Not onIy does it demonstrate the force and caIibre of the urinary stream but it is an aid in foIIowing the subsequent course of the patient under treatment. 4. Urinalysis. Frequent examination of the &ine is essentia1. 5. Renal Function. EvaIuation of renal function is made by using the phenolsuIphonephthaIein excretion test, the concentration test, and the non-protein nitrogen content of the bIood. 6. Calibration of tbe Urethra. This is accomplished by passing curved stee1 sounds, woven or stee1 bougie a bouIes or woven bougies. If acute urethritis or prostatitis is present, caIibration is postponed unti1 the infection has subsided. In manv_I instances there is chronic ure-
thritis which is kept active by a stricture. In such cases gentIe caIibration is performed to determine if a stricture is the underlying factor. 7. Volume of Residual Urine. Where possibIe a smaI1 soft rubber catheter is passed after the patient has voided to estabIish the amount of. retained urine. If the stricture is impermeabIe, paIpation of the bladder reveaIs the degree of distention. 8. Smears and Cultures. Smears are made of any urethral discharge and of the prostatic and vesicuIar secretion. Cultures are Iikewise made upon both chocoIate agar and bIood agar. g. Cysto-uretbroscopy. The use of an instrument with fore-obIique vision gives direct VisuaIization of the stricture; the entire urethra and bIadder can be examined if the Iumen of the stricture permits the instrument to pass. It is most usefu1 in visuaIizing the stricture and any exudate or uIceration of the urethra. IO. Cysto-urethrography. The urethrogram provides accurate information concerning the caIibre and contour of the stricture.’ A cystogram is usuaIIy made at the same time by first fiIIing the bIadder with the opaque soIution which is instiIIed through the urethra without using a cathkter. Ten per cent skiodan or sodium iodide soIution gives satisfactory contrast, and fiIms are made in both anteroposterior and obIique positions. An accurate idea of vesical function can be obtained by making a roentgenographic exposure during the act of micturition in the Iateral obIique position. I I. Pyelograpby. Excretory urograms are made when there is no significant diminution of renaI function. Therapy of urethra1 stricture may be divided into a consideration of treatment of the stricture itself and that of the accompanying infection of the upper, mid and Iower urinary tract. In civi1 Iife urethra1 strictures are treated as a ruIe in the offxce or out-patient department except in the most severe cases, and the patient
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can carry out his daiIy business whiIe his stricture is diIated at intervaIs over a Iong period of time. In the Army, however, a patient is usuaIIy treated in the hospita1 unti1 ready for miIitary duty. In addition, when the individua1 patient with stricture is evaIuated it must be decided whether he wiI1 be abIe to perform fuI1 or Iimited miIitary duty overseas, or whether he shouId be evacuated to the United States. If the stricture is readiIy amenabIe to instrumenta diIatation, as manifested by easy passage of curved sounds to a caIibre of 24 or 26 French scaIe without bIeeding, no further hospitaIization is required. The patient is returned .to duty with instructions to have his unit medica officer continue with caIibration every one or two months. This type of patient required two to three weeks’ hospitaIization as the diIatations are done at six to seven-day intervaIs. In the technic of urethral instrumentation we instiI1 a semi-fluid mixture of $$ per cent nupercaine soIution or 4 per cent boric acid soIution and a steriIe water-soIubIe surgica1 Iubricant before passing urethra1 instruments. This acts as an exceIIent hydrostatic diIator and insures compIete Iubrication. Fifty-six of our patients were treated in the above Fifty-four of these strictures manner. were I 2 to 14 cm. from the meatus and two were 5 to 8 cm. from the meatus. The strictures that can be treated in this manner are the most favorable type and have a minimum of urinary infection. SuIfathiazoIe is administered for three days prior to diIatation and for severa days thereafter. Internal urethrotomy is a vaIuabIe procedure to increase quickIy the caIibre of a stricture in selected cases. Our criteria for the use of this operation are as foIIows: (I) The stricture is not impermeabIe. (2) The stricture is Iocated in the anterior urethra, i.e., within the peniIe or buIbous urethra. (3) The stricture is not amenabIe to diIatation due to: (a) tortuous Iumen, (6) associated bIeeding from the adjacent urethra dista1 to the stricture, and (c)
American Journal of Surgery
ineIasticity of the stricture due to dense scar tissue. (4) The stricture is of smaI1 caIibre, i.e., Iess than 18 French scaIe. The operation is done under spina or cauda1 anesthesia, and the Maisonneuve type of urethrotome is used. After the stricture is cut, further diIatation is carried out by the passage of curved stee1 sounds. A soft rubber catheter, 20 or 22 French, is then Ieft in the urethra for not more than three days. WhiIe the catheter is in place, suIfathiazoIe 1.0 Gm. four times a day is given. On the seventh or eighth postoperative day, diIatation of the urethra is started and is continued at weekIy intervaIs unti1 the caIibre remains constant and the wound in the urethra has heaIed. About one month of postoperative hospitaIization is necessary for these patients. When they return to duty they are instructed to have urethra1 caiibrations at intervals of one to two months. There is very IittIe bIeeding at the time of the interna urethrotomy, which is in accord with the fact that most urethra1 bIeeding foIIowing instrumentation for stricture comes from the adjacent mucosa. The stricture is reIativeIy avascular. Patients who have undergone interna urethrotomy have amazingIy IittIe discomfort and a11 notice a marked improvement in their urinary stream when the catheter is removed. InternaI urethrotomy was the tregtment of choice for twenty-six of our eighty-seven patients. Three of these strictures were 5 to 8 cm. from the meatus, and twenty-three were 12 to 14 cm. from the meatus. The type of stricture that meets the criteria for interna urethrotomy is severe and on instrumentation alone a proIonged period of hospitaIization is required. The vaIue of internal urethrotomy lies in the fact that simpIe incision of dense scar tissue is Iess traumatic to the urethra than diIatation accompIished by repeated passage of stee1 sounds. ExternaI urethrotomy was the procedure of choice in four patients. The indication for the operation was the presence of an impermeable stricture caus-
American JCWWI of Surgery
ing urinary retention. Three of these patients had post-inff ammatory strictures of Iong duration, associated upper urinary tract infection and diminished renaI function. One of them entered criticaIIy III with acute urinary retention and a prostatic abscess. The drainage of the infection and the relief of the bIadder obstruction were accompIished by perinea1 section. CaIibration of the urethra was started eight to ten days after the operation. However, because of the severity of the stricture and the effect of Iongstanding stasis, these patients couId not be sent to duty. The fourth external urethrotomy was performed upon a soIdier who six weeks previousIy had suffered a ruptured membranous urethra and a fractured peIvis. A suprapubic cystotomy had been performed at the time of injury, and at the time of admission to this hospita1 he had an impermeabIe stricture and was on suprapubic drainage. An externa1 urethrotomy was performed and a seton was passed through the urethra to the bIadder at the time of operation; diIatation was then carried out using the seton as a guide. It is not in the province of this articIe to discuss the management of rupture of the urethra, severa aspects of which have been stressed eIsewhere by one of the authors.2 The best resuIts in the treatment of rupture of the buIbous urethra have been obtained by immediate externa1 urethrotomy, whereas the operative management of rupture of the membranous or prostatic urethra consists of combined suprapubic and perinea1 approach. Furthermore, the stricture resuIting from trauma caIIs for a Iong period of observation and calibration as the scar tends to be more dense than that foIlowing inff ammation aIone. As a coroIIary to treatment of stricture of the urethra, it is important to stress that no urethra1 instrumentation shouId be performed if there is a co-existing acute infection of the urethra, prostate, semina1 vesicIes or epididymes. In addition, gentIe instrumentation is essential as much harm wiI1 be done if the operator is rough.
It aIso must be stressed that a stricture is composed of scar tissue which wiI1 aIways be present, so that any operative procedure must not be regarded as a cure, but as a means to permit dilatation of the stricture in order to obtain a urethra1 caIibre that is compatibIe with norma urinary function. The compIications of instrumentation of urethra1 strictures are transient bacteremia or so-caIIed “urethra1 fever,” peri-urethral abscess, urethra1 fistuIa, extravasation of urine, and acute epididymitis, prostatitis The onIy compIicaand pyeIonephritis. tions that we encountered were in two patients who developed acute pyeIonephritis, one after internal and one after externa1 urethrotomy. The criteria for the return of the soIdier with urethral stricture to fuI1 miIitary duty are as foIIows: (I) The patient is asymptomatic, (2) The urinary stream is free and of good calibre. (3) There is no upper urinary tract infection or impaired renal function. (4) There is no active urethritis, prostato-vesiculitis or epididymitis. (5) The urine sediment is free of ceIIs and casts. (6) The caIibre of the stricture is at Ieast a 22 French and of such nature that a curved sound can be easiIy passed. If the patient does not meet the above requirements, he cannot be properIy cared for in the fieId. Seventy-one of our patients were returned to fuI1 duty. Six patients were returned to the United States because of the stricture and associated upper urinary tract infection. Ten patients were returned to the United States because of other diseases and not because of their urethral strictures. The four patients who underwent externa1 urethrotomy and one patient who underwent interna urethrotomy were among those returned home because of stricture. One patient who aIso had benign hypertrophy of the prostate was not treated but evacuated home, because it was not thought justified to start treatment overseas because of the Iong hospitalization and eventua1 disposition.
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SUMMARY I. Eighty-seven cases of urethral stricture in which the patients were treated at a Genera1 HospitaI overseas are reviewed. 2. The majority (seventy-six) of the strictures were a seque1 to gonorrhea; four were post-traumatic, one was congenita1, and in six the history was noncontributory as to cause. 3. Chronic urethra1 discharge and diffk cuIty in urination were the main presenting symptoms. However, fourteen had acute gonorrhea. 4. The uroIogic investigation of urethra1 stricture is outIined with emphasis on the vaIue of (I) observation of the patient with stricture during the act of micturition, (2) cysto-urethroscopy and (3) urethrography.
5, The treatment and indications for the type of treatment are outIined. 6. Fifty-six patients were treated by urethra1 diIatation; twenty-six patients had interna urethrotomy, and four had externa1 urethrotomy. One patient received no instrumenta treatment. 7. Seventy-one patients were returned to fuI1 miIitary duty; six were returned to the United States because of urethra1 stricture and its compIications, and ten were evacuated home because of reasons other than urethra1 stricture. REFERENCES I. PRATHER,G. C. Urethrograms in urethra1 strictures. J. Ural., 49: 487, 1943. 2. HARRISON, J. H. The treatment of rupture of the
urethra, especiaIIy when accompanying fracture of the peIvic bones. Surg., Gynec. ti Ok., 72: 662-631, 1941.