A man who takes a 30 French sound smoothly and easily, so that the instru-
ment is nowhere grasped and more or less firmly held, does not require a
cutting operation, though one part of his urethra may easily be stretched to
40 and another only to 30. The commonest poiut of physiological narrowing
in the urethra is the meatus urinarius, or in the next half inch of the canal.
If markedly contracted, such a meatus may cause the persistence of a urethral
discharge, and will certainly prevent the passage of a full-sized sound, one of
the most valuable means of treating chronic anterior urethritis, whether due to
stricture or not. Thus, in certain cases the division of such a meatus up to a
Fig. 224. — Sound with Benique Curve. This instrument is very useful ii
certain cases where a sound of ordinary curve does not readily pass. (Wat-
son and Cunningham.)
reasonable size — i. e., somewhere short of hypospadias — may be a valuable
curative measure.
It often happens that a patient presents himself with symptoms of a prob-
able stricture. A sound passes as far as the bulbo-membranous junction, and
is there arrested. The surgeon should not decide too hastily that the patient
has a tight stricture at that point. It may be only the resistance offered by
spasm of the compressor urethrse muscle, to be overcome by patient and very
STRICTURE OF THE URETHRA
673
gentle pressure; or the beak "I the instrumenl may have caught againsl the
triangular ligament, owing t<» ;i dilated bulbous portion, and must be lifted
over ilic ligamentous wall before ii will enter tli<- membranous portion of the
urethra. Sometimes a large instrumenl will pass this j •< > i i > t with ease, while
a small one will catch every time. It" an instrument of the ordinary curve
cannol be made to pass, a sound with the Benique curve will sometimes enter
with ease.
When a patient presents himself with a perfectly definite history of stric-
ture, such that the surgeon decides upon operative treatment, and more espe-
cially if the patient gives a history of urethral chills and fever following former
instrumentation, it will be safer to make the exacl diagnosis of the situation
and size of the stricture while the patienl is under a general anesthetic, and
to operate then and there.
Free and complete division of the scar tissue constituting a stricture offers
thf besl and usually the only hope of permanenl cure. A partially divided
O—
s»*
O
FL-SpaM,
Fia. 225. — Bougies X Boui.e for the Detection of Stricture ofthe Urethra. Below is a diagram
showing the relations of the shoulder of the instrument to the posterior face of a stricture. (Watson
and Cunningham.)
stricture recontracts at once, and the patient is but little better off than though
no operation had been dene. The surgeon may know that the stricture is
completely severed from the fact that, when the Otis urethrotome is u-n\, the
instrument may be turned up several sixes larger without resistance on the
part of the tissues. Further, a full-sized sound may he introduced readily
into the bladder, and will no longer be gripped by the urethral wall. Tf this
result cannot he attained the stricture will require the passage of sounds at
regular intervals, probably for the remainder of the patient's life. When the
entire urethra is converted into a leathery, inelastic tube, no operation can
effect a cure. Strictures of the penile urethra can usually he cured by ure-
throtomy: tight strictures at or near the bulbo-membranous junction, only
rarely. When, after operation, a stricture i< going to recontract, the surgeon
can readily detect such a tendency within a month, if not before the end of
that period.
674
DISEASES OF THE URETHRA
Instruments Useful in the Diagnosis of Stricture of the Urethra.
— The instruments useful in the diagnosis of stricture of the urethra are a set
of conical steel sounds, sizes 10 to 40 French ; a few steel sounds with the
Benique curve, the medium sizes, 18 to 30 French. For the detection of
stricture some surgeons prefer blunt sounds — i. e., of the same size to the point
of the beak. Conical sounds made with a double taper possess the advantage
that the meatus is not distended when the beak has passed into the deeper
portions of the canal. Extreme distention of the meatus is very painful.
A set of bulbous bougies (Bougies-a-boule), made with a rather abrupt
shoulder, sizes 5 to 40 French. These may be of steel or of woven material.
A set of olive-tipped silk bougies, best weighted with fine shot; sizes, from
the smallest made up to 20 French.
Filiforms, both silk and whalebone.
An Otis urethrometer.
A metal scale plate, giving the English and French diameters ; one straight
edge of this plate graduated in inches, the opposite one in centimeters.
The best soft instruments — namely, those made of woven silk, coated with
varnish — are made in France. They will stand moderate boiling a few times,
but if often boiled they become rough or cracked, and must be thrown away.
The shoulders of bulbous bougies should be made quite abrupt, since these
give a more decided jump when pushed or drawn through a stricture. Those
of varnished silk are more flexible than those made of metal, and the former
£kS-
El*.
Fig. 226. — Olivary Bougies. The upper figure is of a better shape than that below. In the latter,
the tip is too blunt and the part behind the tip increases too rapidly in size. (Watson and Cunning-
ham.)
are less likely to injure the urethra ; on the other hand, they are soon destroyed
by boiling.
Whalebone filiforms are very useful in finding the channel through a nar-
row stricture. They have a rounded tip, and are tapered for an inch or two
up to the full size of the shaft. They are usually about three millimeters in
diameter. They are made in two lengths — one foot and two feet. The latter
are valuable as guides, when threaded through the tip of a so-called tunneled
sound. It is of advantage to have the extreme tips of some of the filiforms
bent into a curve, or twisted into a spiral, or angulated ; this can be accom-
plished by dipping the tip in hot water, when it may be bent into any desired
shape. One or other of these forms may be made to engage in the channel
STRICTURE OF I HE URETHRA 07.",
of a tighl Btricture. When using fili forms, their passage i- facilitated by fill-
ing the urethra with warm oil. It the instrumenl catches in n fold of mucous
membrane, a pocket, ;i false passage, or :cj;iiii-t the face of the Btricture, it
should be withdrawn a Little, rotated, and again advanced during the rotation.
A very useful measure is to till the urethra with whalebone filifonns, seeking
t<» advance firsl one and then an _
other. Some of them will stick ^n ^
nt different levels, engaging in the
lacunae, pockets, etc., and finally .
one will engage in the stricture
itself, ;im<I may be pushed <m into ■—
the bladder. " Patience, persever-
ance, and sweet oil," as the prov- ,, _
1 Fio.227. — Whalebone Filiformb, Bejti attheihTips
erli says, will accomplish much. into Several Shapes fob i i m N'ak-
. . row and Tortuous Strictures. (Watson and
I here are very tew Strictures SO Cunningham.)
tight and so tortuous that they
cannot finally be passed in this manner. When, after patient effort, the surgeon
succeeds in getting a filiform through a had stricture, let him leave it in situ
until he operates. He may thus save himself much time. The orifice of a
stricture may also be located through the endoscope.
Woven silk bougies are useful in examining and treating deep strictures
of a caliber up to L5 to 20 French. When using metal instruments of a size
less than 15 French, the risk of wounding the urethra, when the stricture i-
at or near the bulho-membranous junction, is considerable. As elsewhere
stated, the shaft and handle of a curved sound form the long arm of a lever
held by the surgeon, and force applied here is greatly magnified in the beak
constituting the short arm, and this may readily he made to damage the
urethra and create a false passage. If slender steel instruments are used at
all, this fact must he borne in mind, and extreme gentleness only is permissi-
ble in their manipulation.
The urethrometer of < m i-
V5i ^ w is a very valuable instru-
wi». incut tor the dcicct ion 01
Fig. 228.— The Ons Urethrometer, strictures of large caliber
in the anterior urethra.
Tt consists of a slender straight steel shaft, at one end of which is a fusiform
enlargement covered with a thin rubber cap. This bulbous portion may he
enlarged to any desired extent by turning a milled head on the handle. A
dial and indicator show to what size the instrument is expanded. The shaft
is graduated in inches and half inches, so that the distance of the stricture
from the meatus can he seen at a glance. When (dosed, the hull) measures
10 French. It may he expanded to 45 French. It possesses the advantages
that it may be introduced through a narrow meatus, and that with it the en-
tire length of the anterior urethra nun- he calibrated in a few moments. Tts
676 DISEASES OF THE URETHRA
disadvantages are that the rubber covering of the expanding portion cannot
be made very smooth, so that it tends to catch in the urethra, and may in
careless hands give the impression of a decided narrowing where none exists.
It is also more irritating than a metal or silk instrument. The method of its
use is as follows : The instrument is introduced through the meatus closed, and
is passed as far as the bulbo-membranous junction. It is not intended to be
passed through the triangular ligament. The bulb is screwed up until the
patient has a sense of fullness in the perineum. This indicates that the nor-
mal distensibility of the bulbous urethra has been reached. It will rarely
vary much, when no stricture is present at that point, from the size formu-
lated by Otis. The instrument is then slowly withdrawn ; when an obstruction
is reached the bulbous part is screwed down until it passes, again enlarged,
and drawn forward. In this way the caliber of the entire anterior urethra
may be measured and points of stricture located. The following facts should
be borne in mind : (1) The bulbous portion is usually wider than the remainder
of the canal, or at least more distensible. (2) A decided narrowing is often
present at the peno-scrotal angle, 3 to 3^ inches from the meatus. (3) The
meatus is usually narrower than any other part of the canal.
J7 Ig ii ii 13 32 11
O O O O O o o
23 24 25
1Q
9 8
7 6
5 4; 3 2 1
O
o o
o o
O O o o
26
27
28
29 30
i<S<S6<56(36600 00
40 39 38 37 36 35 3* 33 32 31
'OOOOOOOOOO
^"^ 3Q7XBTC SCALE. Ms 15
Fig. 229. — Scale Plate for Determining the Size of Urethral Instruments. This is the French
scale, the one in common use. The others are superfluous. (Watson and Cunningham.)
When beginning the examination of a case of supposed stricture of the
urethra, several preliminary data are sought for. If the patient has a poste-
rior urethritis, such that both portions of his urine are purulent, a sound
introduced into his bladder is likely to make him much worse. If he has
had former attacks of epididymitis, as evidenced by a firm nodule or a firm
thickening palpable in the lower part of the epididymis, the introduction
of a sound into the bladder may be the exciting cause of another attack.
Palpation of the urethra sometimes permits one to feel that the urethra
is no longer a soft, elastic tube, but has become hard and leathery, sometimes
uneven and nodular. To palpate the penile urethra, the penis is grasped be-
tween the forefinger and thumb of the left hand just behind the glans, drawn
up, and put upon the stretch. The urethra is then palpated between the fore-
finger and thumb of the right hand, each portion being picked up in turn from
before backward. In marked cases of penile stricture, notable loss of elasticity
of the entire canal is often perceptible when the penis is put upon the stretch.
STRICTURE OF THE DRE1 llk.\ 077
The instrumental examination may be preceded by washing out tin- an-
terior urethra with normal salt solution. I prefer to omit the use of cocain
in examining for stricture. It causes a contraction of the blood vessels. The
entire penis shrinks and feels harder. The elasticity of the urethra is dimin-
ished ; as ;i result, a stricture will feci narrower than it really is. Moreover,
the sensitiveness of the differenl parts of the urethra is not withoul diagnostic
interest.
The patienl should lie upon his back, his head supported, his naked body
exposed from sternum to knees. The pelvis should be a1 right angles to the
spine. The thighs should be slightly and equally abducted. The glans penis
should be cleansed with soap and water, and then with a weak solution of
bichlorid of mercury, [f the meatus is markedly contracted the urethrometer
may be introduced at once; if not, a sound as large as will pass without un-
duly stretching the meatus is lubricated, and introduced with due gentleness,
according to the rules elsewhere given tor catheterization. Either a blunt or
cmiical sound may he used, according to the preference of the surgeon. When
an obstruction is met, no force should he ]\>cd ; the instrument should he with-
drawn and a smaller one substituted, until one is found which passes easily.
When a sound is passed through a stricture, left for a moment in situ, and
then withdrawn, a distinct sense of resistance is felt quite different from the
entire want of such resistance exhibited by a normal canal. The stricture
tissue grasps the sound quite firmly and opposes its withdrawal. The sensation
is perhaps even more distinct when a flexible woven bougie is used. If no such
grasping is felt when a good-sized instrument is used, there is no stricture.
A more accurate method of determining the size and situation of strictures
is by the use .of bullions bougies. They can seldom be used satisfactorily be-
yond the bulbous portion. As large a one
as will pass the meatus is introduced until
an obstruction is met. Tt is withdrawn,
and its distance from the meatus measured
on the shaft with a ruler. A smaller bulb
is then passed, until a size is reached which
goes through. Upon attempting to with-
draw the bulb, some resistance is felt. The
, ... .. ,, . xl . Fiq. 230. — Soft-Rubber Catheti r s. u i d
shaft Ol the instrument is then grasped in Inches, Useful in Determining the
i , .t .â– i ii , i , , l , " Urethral Li mom, oh Urinari Dis-
between the linger and thumb at the meat- TANCB » Undeb Mxn , conditions.
us, and the instrument slowly withdrawn.
As it emerges from the grasp of the stricture a distinct jump may be felt.
The instrument is again passed beyond the stricture, and withdrawn until
resistance is felt. The shaft is again grasped at the meatus and the instru-
ment removed from the urethra. The distance from the meatus to the -boul-
der of the bulb is measured. The difference between this and the former
measurement indicates the length of the stricture, as well as its situation.
These measurements are recorded. Thus the entire penile urethra to the end
678 DISEASES OF THE URETHRA
of the bulbous portion is gone over, and all anterior strictures located and cali-
brated. These measurements are essential for the proper performance of in-
ternal urethrotomy with the Otis urethrotome. Strictures at and beyond the
bulbous portion are frequently narrow. They are then safely explored with
woven silk bougies, or with silk or whalebone filiforms. I am not in favor
of the use of steel instruments attached to a soft guide for the diagnostic
exploration of stricture. The temptation to use too large an instrument and
too much force is very great. Laceration of the urethra and septic absorption
are not improbable results.
It should be borne in mind that an obstruction deeper than six and one half
inches — or, broadly, in the prostatic urethra — is not due to stricture, but to
some other cause ; most often to prostatic enlargement in the elderly, possibly
to tumor, stone, or to a cicatricial prostate following abscess. Exploration of
stricture should be followed by antiseptic irrigation of the urethra. If instru-
ments have been introduced beyond the triangular ligament the bladder should
also be irrigated.
In regard to the treatment of strictures, I believe that if stricture does not
respond readily to gradual, intermittent dilatation, it should be cut. If prop-
erly cut, a large proportion of anterior strictures and a small proportion of
deep strictures will be cured.
CHAPTER XX XIV
THE PENIS
CONGENITAL ANOMALIES
The most frequent congenita] anomalies of the urethra — namely, hypospa-
dias and epispadias — have been elsewhere described. (See Urethra.) Other
congenita] deformities of the penis are rare. A very few cases of congenital
absence of the penis have been reported. In some of these the testes and
Bcrotum have been nearly normal. The development of the urethra has al-
ways been defective. In some instances it lias opened into the rectum, a con-
dition resembling the normal arrangemenl of the cloaca in birds. In others
the urethra has opened in the perineum, the scrotum being cleft ; in these cases
the testes are often undeveloped, and may be undescended. The sex of these
individuals may be hard to determine, since, if male-, they are often of a
feminine appearance.
Harris 1 found wlial lie regarded as a certain means of differentiating the
sex — namely, in the female the upper border of the pubic hair forms a nearly
horizontal line across the hypogastrinm, while in males it is prolonged upward
in a curved line, or extends in a point to the umbilicus.
Though this is doubtless the rule, there are many exceptions. Statistics
were collected upon this point by Lombroso and Ardn.- They found that the
hair upon the pubes grew according to the male type, among women, in five
per cent of normal women and female thieves and in fifteen per cent id' pros-
titutes — !'•'!! cases examined.
A lew cases of rudimentary penis have been recorded. In these the penis
lay buried in the scrotum, or beneath the skin id' the pubes.
Double Penis. — This is a rare deformity. In some of the reported cases the
two organs lay closely side by side. The urethral opening was near the sym
physis, and led into a single bladder. In two or more cases the two organs
were entirely separated. Two bladders existed. In one case, that of Smith, 8
the patient could urinate from either Madder at will. A stone was removed
from one of the bladders. In another case urine came from only one of the
penes. The testicles lay in two separate sacs.
These anomalies possess hnt little surgical interest. In the cases where the
i Harris. Lancet, 1894, ii, 634. ""The Female Criminal," C. Lombroso, p. 326.
3 "Trans. Med. and C'hir., Faculty of Maryland, " April, 1878
670
680 THE PENIS
penis lies buried beneath the skin of the scrotum or pubes, it should be liber-
ated and covered with integument by a suitable plastic operation.
Phimosis. — Inability to retract the foreskin behind the glans is known as
phimosis. The condition may be congenital or acquired. In the congenital
form the orifice of the prepuce is so narrow that it does not permit the passage
of the glans. The prepuce is often notably redundant. A slight narrowness
of the preputial orifice is the rule in newborn infants. During the early years
of life repeated retractions of the foreskin for purposes of cleanliness usually
overcome the difficulty. If not retracted the accumulated smegma may give
rise to marked irritation, leading to the formation of adhesions between glans
and prepuce, or to the formation of preputial calculi, or to incrustations of
the glans with calcareous material. Attacks of inflammation occur, leading
to further cicatricial contraction of the preputial orifice.
Symptoms Produced by Phimosis. — If the preputial orifice is very small,
dysuria results. The prepuce balloons up during urination and the urine is
delivered through the narrow orifice in a fine stream. The prepuce may thus
be dilated to a sac as large, in some cases, as a hen's egg. If an acute inflam-
mation of the prepuce occurs, there may be complete retention. These children
may be rendered seriously ill. They are predisposed to hernia from straining,
and also, it is said, to hydrocele. As the result of the irritation they pull at
the foreskin and readily learn to masturbate. Nocturnal enuresis is a common
symptom. Priapism, prolapse of the rectum, frequent and painful urination,
even cystitis- — that is to say, symptoms closely simulating stone in the bladder —
may be produced. In some cases there are marked nervous symptoms — irrita-
bility, sleeplessness, frequent crying, etc. If the condition remains unrelieved
until adult life, the sexual functions may be interfered with. In advanced
life, phimotic men are predisposed to cancer of the penis. When a phimotic
individual acquires gonorrhea, chancroid, or chancre, the condition of the fore-
skin often invites serious complications.
Acquired Phimosis. — Inflammatory processes of the foreskin — balanitis,
chancroid, chancre, and gonorrhea — may produce phimosis as the result of
cicatricial contraction, or produce acute inflammatory phimosis, which may
be transient or become permanent. In the acute cases an exact diagnosis may
be impossible until the glans is uncovered by incision of the foreskin. In-
cision or circumcision are undesirable in chancroid and gonorrhea. In the for-
mer the wound is nearly sure to become chancroidal, and in the latter the local
treatment of the urethra may be interfered with ; still, in many instances it is
better to expose the glans at all costs, since a destructive process may be going on
beneath the tight foreskin which will cause serious loss of substance if unchecked.
Deformity of the Frenum. — The frenum may be so short that when the penis
is erect the glans is pulled upon and bent downward. Erections may even be
slightly painful ; coitus may be notably so. The frenum may be torn during
the act, and bleed quite freely. In these cases division of the frenum may
be required.
i.virkii'.s 01 i m: PENIS 681
INJURIES OF THE PENIS
Contusions of the Penis. Superficial «-«»iitti~i-.«i— of the penis are attended
by marked swelling and ecchymosis, owing to the targe size of the subcutaneous
vein- ;tn<! the loose quality of the tissues. The flaccid j .< n i - may rarely be
seriously contused by blunl violence, as in falls upon the pubes or run
accidents. The condition rarely requires operative treatment, unless the ure-
thra <»r the corpora cavernosa arc torn.
Rupture of the Corpora Cavernosa, So-called Fracture of the Penis. — The
injury occurs during erection, as from n violenl movemenl during coitus or
when the organ is seized and sharply benl by the hand. A similar injury
may be caused by blows <>r falls upon the rigid member. The urethra may
also In' ruptured. The rupture of the corpus cavernosum i- usually a hori-
zontal tear in the tunica albuginea, and may he situated at any poinl from
jusl behind the glans to just below the pubes. The cavernous tissue i- rent
more or less deeply, [mmediate palpation before the penis swells may detect
a sii]cii< in the corpus cavernosum.
Symptoms. — The symptoms arc pain ami tenderness, followed by rapid
swelling ;in<l ecchymosis. The penis may swell to enormous size. It" the
corpus spongiosum and urethra arc also torn, there will lie bleeding from the
meatus. There is often retention of urine. In some of the cases a large hema-
toma forms, and may require immediate incision and evacuation of the clots.
The rent in the fibrous investment of the corpus cavernosum should be care-
fully sutured. Tt is probable that a better functional result would be thus
obtained than by conservative treatment. If nol operated upon, the blood will
in some eases be absorbed; in other cases a large hematoma may remain for
a long time, ami may finally become infected ami suppurate. If the urethra
is also torn, the patient may have retention. In other cases he will urinate,
with resulting urinary extravasation. Incision ami suture of the torn urethra,
with perineal drainage, are the safest procedure in these cases.
As the result of rupture of the corpus cavernosum some of the cavernous
tissue is destroyed, ami its place i- taken by scar tissue. A nodular cicatrix