CHAPTER LII. AFFECTIONS OF THE BLADDER AND URETHRA. For LITERATURE, see Chapter LI. MALFORMATIONS OF THE BLADDER AND URETHRA. THESE Comparatively rare malformations are easily understood on consideration of the development of the organ. The bladder is the part of the allantois included by the abdominal plates of the embryo (figs. 311 to 315); the upper portion of the posterior wall of the urethra is formed by Müller's ducts, while the lower is formed by an invagination from the genito-urinary sinus. The developmental defects are therefore the following: (1) Total absence of urethra ; (2) Defect of external portion of urethra-hypospadias; (4) Atresia of the urethra (in malformed fœtuses); (5) Extroversion of the bladder from deficient closure of the embryonic abdominal plates. We would here only note the rarity of these conditions, and refer the practitioner to Skene or Winckel for details. DISEASES OF THE URETHRA. Of these the most important are Displacements, Neoplasms, Urethritis, Dilatation, and Stricture. Displacements of the urethra will be easily understood by reference to those of the bladder. Neoplasms of the Urethra; Urethral caruncle. The urethra is liable to be invaded by papillomata, polypi, sarcomata, carcinomata, and vascular growths (angiomata). Of these last, the most common is the well known Urethral Caruncle. Pathology. This is a vascular excrescence varying in size from a pin head to a strawberry; it consists of dilated capillaries in connective tissue, the whole being covered with squamous epithelium. Physical signs. A cherry-red tumour, exquisitely tender and vascular, is seen at the urethral orifice (fig. 355). Symptoms. These are pain on micturition or even retention of urine, pain on coitus. Treatment. Place the Caruncle at urethral orifice (a) and, in addition, neuromata in surrounding mucous membrane -see page 510 (Sir J. Y. Simpson). patient under chloroform in the lithotomy posture, and destroy the growth by Paquelin's cautery at a dull heat. If bleeding occurs, do not treat it lightly; plug the vagina, bringing the half of the last strips of lint over the urethral orifice and fixing with a perineal band. As regards the other neoplasms, papillomata are painless, sarcomata very rare and their nature settled microscopically, while carcinomata appear as hard peri-urethral tubercles which break down (Skene). In regard to treatment, they may be removed by the curette, or by small loop-snares when high up. We may also have inflammatory changes in Skene's 'tubules' (v. p. 29). Urethritis. Acute urethritis is usually part of a gonorrhoea. When pus is secreted, the urethra can be felt swollen and tender; the pus can be squeezed out of the urethral orifice by pressure from above downwards; on passage of the catheter, pain is felt in the urethra although no cystitis be found. Treatment. Give diluent drinks so as to increase the flow of urine. Copaiba may be given in the form of the well-known Nesbitt's specific : Iodoform bougies may be passed in, and counter-irritation applied in the shape of the tincture of iodine over the anterior vaginal wall. Dilatation and Stricture of the Urethra. The urethra may be unusually dilated, a condition rarely met with; in some cases the dilatation has been caused by coitus, as in malformations of the vagina (v. p. 232). The dilatation may be local or general. When it is general, the cautery may be used to burn a vertical furrow, the rest of the urethra being guarded by a speculum. Stricture of the urethra is a rare condition and readily yields to dilatation by bougies or to incision. DISEASES OF THE BLADDER. Of the diseases of the bladder we shall here consider Displacements, Neoplasms, Stone in the bladder, and Cystitis. Vesico-vaginal fistula will be considered in a separate chapter (Chap. LIII.). DISPLACEMENTS OF THE BLADDER. The female bladder when empty lies between the pubis and usually to one or other side. It is never exactly central. From its loose attachment to the pubis, it is pre-eminently displaceable. (1) It is drawn up during labour; and (2) is displaced upwards by retroversion of the gravid uterus, pelvic ovarian or fibroid tumours, and pelvic hæmatocele. (3) It may be adherent to the anterior surface of an abdominal ovarian or fibroid tumour, and may thus be cut into on abdominal section. (4) It is displaced downwards in prolapsus uteri, cystocele, and in the so-called elongation of the supra-vaginal portion of the cervix. (5) In pathological anteflexion of the uterus, the bladder is drawn back and fixed; its systole is thus interfered with, which explains some cases of so-called hysterical retention of urine. From this mobility it follows that the height of its fundus above the symphysis gives no indication of the amount of urine in the bladder. Cystocele. By this we understand a pouching of the posterior wall of the bladder downwards and backwards; the uterus and summit of the bladder are in normal position. Many a case, regarded as cystocele, is really part of a prolapsus uteri ; on the other hand, the so-called "senile prolapsus uteri " is really a cystocele; at the menopause the cicatrisation of the vaginal walls chiefly affects the posterior one, and thus the bladder tends to bulge outwards at the vaginal orifice. The diagnosis is easily made by the Bimanual and use of the sound. The treatment consists in the use of a ring pessary with diaphragm (fig. 328) or such a one as is seen at fig. 331. Should these fail, the vagina may be packed with oakum or a raw surface (as shown at fig. 339) may be made and stitches applied. NEOPLASMS OF THE BLADDER. Pathological anatomy. We may have mucous, fibroid or fibromyomatous polypi. There may also be sarcomatous or carcinomatous disease of the bladder wall, as well as so-called tubercle. The carcinomatous condition is not unfrequent, and is termed by some "villous cancer." It is most common at the trigone, and is held by some authorities not to be malignant. The bladder may be secondarily affected in carcinoma uteri (v. p. 429). Symptoms. These are disturbance of micturition, with bloody and phosphatic urine. Physical signs. The passage of the index finger into the bladder will show the position, shape, and other characters of the growth. Treatment. This will vary according to the position, nature, and pediculation or non-pediculation of the growth. Thus it may be twisted off by narrow polypus forceps, snared by a loop of fine catgut, or removed by incision into the posterior wall of the bladder and use of the galvano-cautery or curette (v. Stone). CYSTITIS. Nature. An acute or chronic inflammatory affection of the mucous membrane of the bladder. Pathological anatomy. In the acute catarrhal form, we have congestion of the vessels and loss of epithelium; in the chronic catarrhal form, the congestion is duller and there is marked rugosity of the lining of the bladder. The submucous and even the muscular tissues also become affected. The mucous membrane may be ulcerated and the muscular tissue exposed. The inflammatory process may extend deeper, to the muscular tissue (interstitial cystitis) or to the peritoneum (pericystitis). Occasionally, though rarely, we may have diphtheritic inflammation. In advanced cases, the patient is usually septicemic and there is often hydro-nephrosis. In some cases of prolonged retention the mucous membrane may slough off and be passed per urethram, but may be regenerated. Etiology. The causes are as follows:-Gonorrhea; latent gonorrhoa; exposure to cold; injury from coitus; prolonged parturition; introduction of septic matter by catheter or bougie; prolonged retention of urine. Symptoms. In acute cystitis the patient has very frequent and painful micturition. In chronic cystitis also, there is frequent micturition but accompanied with less intense pain; there are, further, shooting pains with secondary phenomena-septic, vascular and nervous. Physical signs. (a) Acute cystitis. The urine has a low specific gravity, an acid reaction; the colour is little altered, and mucus is present in excess. On vaginal examination, pain is not felt when pressure is made on the posterior vaginal wall but is felt severely when the anterior wall is touched. (b) Chronic cystitis. The urine has a low specific gravity, is usually alkaline, and is often offensive; it contains pus, epithelium, phosphates and bacteria; albumen, derived from the pus, is present. The vaginal examination gives the same results as in acute cystitis. If the finger be passed through the urethra (v. p. 563), the roughened condition of the lining membrane is felt; crystals of phosphate and marked rugosities can also be detected. Prognosis. In both acute and chronic cystitis, the prognosis is not good; the treatment is difficult, and in bad chronic cases the patient's strength sometimes becomes exhausted and septicemia may cause death. Treatment. (a.) Acute cystitis. Put patient on milk diet, and give Friedrichshall or Carlsbad water freely. Diluent drinks may be taken ad libitum. The following prescription is useful. B Potassa Bicarbonatis Tincturae Hyoscyami Infusum Buchu vel Pareirae vel Uvæ Ursi ad Sig. Tablespoonful thrice daily 3 iss. 3i. 3 vj. |