The Various Forms And Positions Of Strictures And Other Obstructions Of The Urethra False Passages Enlargements And Deformities Of The Prostate


Sources: Surgical Anatomy

Impediments to the passage of the urine through the urethra may arise

from different causes, such as the impaction of a small calculus in the

canal, or any morbid growth (a polypus, &c.) being situated therein, or

from an abscess which, though forming externally to the urethra, may

press upon this tube so as either to obstruct it partially, by bending

one of its sides towards the other, or completely, by surrounding the

canal on all sides. These causes of obstruction may happen in any part

of the urethra, but there are two others (the prostatic and the

spasmodic) which are, owing to anatomical circumstances, necessarily

confined to the posterior two-thirds of the urethra. The portion of the

urethra surrounded by the prostate can alone be obstructed by this body

when it has become irregularly enlarged, while the spasmodic stricture

can only happen to the membranous portion of the urethra, and to an inch

or two of the canal anterior to the bulb, these being the parts which

are embraced by muscular structures. The urethra itself not being

muscular, cannot give rise to the spasmodic form of stricture. But that

kind of obstruction which is common to all parts of the urethra, and

which is dependent, as well upon the structures of which the canal is

uniformly composed, as upon the circumstance that inflammation may

attack these in any situation and produce the same effect, is the

permanent or organic stricture. Of this disease the forms are as various

as the situations are, for as certainly as it may reasonably be supposed

that the plastic lymph, effused in an inflamed state of the urethra from

any cause, does not give rise to stricture of any special or particular

form, exclusive of all others; so as certainly may it be inferred that,

in a structurally uniform canal, inflammation points to no one

particular place of it, whereat by preference to establish the organic

stricture. The membranous part of the canal is, however, mentioned as

being the situation most prone to the disease; but I have little doubt,

nevertheless, that owing to general rules of this kind being taken for

granted, upon imposing authority, many more serious evils (false

passages, &c.) have been effected by catheterism than existed previous

to the performance of this operation.[Footnote]



[Footnote: Home describes "a natural constriction of the urethra,

directly behind the bulb, which is probably formed with a power of

contraction to prevent," &c. This is the part which he says is "most

liable to the disease of stricture." (Strictures of the Urethra.) Now,

if anyone, even among the acute observing microscopists, can discern the

structure to which Home alludes, he will certainly prove this anatomist

to be a marked exception amongst those who, for the enforcement of any

doctrine, can see any thing or phenomenon they wish to see. And, if

Hunter were as the mirror from which Home's mind was reflected, then the

observation must be imputed to the Great Original. Upon the question,

however, as to which is the most frequent seat of stricture, I find that

both these anatomists do not agree, Hunter stating that its usual seat

is just in front of the bulb, while Home regrets, as it were, to be

obliged to differ from "his immortal friend," and avers its seat to be

an infinitesimal degree behind the bulb. Sir A. Cooper again, though

arguing that the most usual situation of stricture is that mentioned by

Hunter, names, as next in order of frequency, strictures of the

membranous and prostatic parts of the urethra. Does it not appear

strange now, how questions of this import should have occupied so much

of the serious attention of our great predecessors, and of those, too,

who at the present time form the vanguard of the ranks of science? Upon

what circumstance, either anatomical or pathological, can one part of

the urethra be more liable to the organic stricture than another?]



Figs. 1 and 2, Plate 59.--In these figures are presented seven forms of

organic stricture occurring, in different parts of the urethra. In a,

Fig. 1, the mucous membrane is thrown into a sharp circular fold, in the

centre of which the canal, appears much contracted; a section of this

stricture appears in b, Fig. 2. In b, Fig. 1, the canal is contracted

laterally by a prominent fold of the mucous membrane at the opposite

side. In c, Fig. 1, an organized band of lymph is stretched across the

canal; this stricture is seen in section in c, Fig. 2. In e, Fig. 1, a

stellate band of organized lymph, attached by pedicles to three sides of

the urethra, divides the canal into three passages. In d, Fig. 1, the

canal is seen to be much contracted towards the left side by a

crescentic fold of the lining membrane projecting from the right. In f,

the canal appears contracted by a circular membrane, perforated in the

centre; a section of which is seen at a, Fig. 2. The form of the organic

stricture varies therefore according to the three following

circumstances:--1st. When lymph becomes effused within the canal upon

the surface of the lining mucous membrane, and contracts adhesions

across the canal. 2ndly. When lymph is effused external to the lining

membrane, and projects this inwards, thereby narrowing the diameter of

the canal. 3rdly. When the outer and inner walls of a part of the

urethra are involved in the effused organizable matter, and on

contracting towards each other, encroach at the same time upon the area

of the canal. This latter state presents the form, which is known as the

old callous tough stricture, extending in many instances for an inch or

more along the canal. In cases where the urethra becomes obstructed by

tough bands of substance, c e, which cross the canal directly, the

points of flexible catheters, especially if these be of slender shape,

are apt to be bent upon the resisting part, and on pressure being

continued, the operator may be led to suppose that the instrument

traverses the stricture, while it is most probably perforating the wall

of the urethra. But in those cases where the diameter of the canal is

circularly contracted, the stricture generally presents a conical

depression in front, which, receiving the point of the instrument,

allows this to enter the central passage unerringly. A stricture formed

by a crescentic septum, such as is seen in b d, Fig. 1, offers a more

effectual obstacle to the passage of a catheter than the circular septum

like a f.





















Fig. 3, Plate 59.--In this there are seen three separate strictures, a,

b, c, situated in the urethra, anterior to the bulb. In some cases there

are many more strictures (even to the number of six or seven) situated

in various parts of the urethra; and it is observed that when one

stricture exists, other slight tightnesses in different parts of the

canal frequently attend it. (Hunter.) When several strictures occur in

various parts of the urethra, they may occasion as much difficulty in

passing an instrument as if the whole canal between the extreme

constrictions were uniformly narrowed.












Fig. 4, Plate 59.--In this the canal is constricted at the point a,

midway between the bulb and glans. A false passage has been made under

the urethra by an instrument which passed out of the canal at the point

f, anterior to the stricture a, and re-entered the canal at the point c,

anterior to the bulb. When a false passage of this kind happens to be

made, it will become a permanent outlet for the urine, so long as the

stricture remains. For it can be of no avail that we avoid re-opening

the anterior perforation by the catheter, so long as the urine prevented

from flowing by the natural canal enters the posterior perforation.

Measures should be at once taken to remove the stricture.










Fig. 5, Plate 59.--The stricture a appears midway between the bulb and

glans, the area of the passage through the stricture being sufficient

only to admit a bristle to pass. It would seem almost impossible to pass

a catheter through a stricture so close as this, unless by a laceration

of the part, combined with dilatation.












Fig. 6, Plate 59.--Two instruments, a, b, have made false passages

beneath the mucous membrane, in a case where no stricture at all

existed. The resistance which the instruments encountered in passing out

of the canal having been mistaken, no doubt, for that of passing through

a close stricture.












Fig. 7, Plate 59.--A bougie, b b, is seen to perforate the urethra

anterior to the stricture c, situated an inch behind the glans, and

after traversing the substance of the right corpus cavernosum d, for its

whole length, re-enters the neck of the bladder through the body of the

prostate.










Fig. 8, Plate 59.--A bougie, c c, appears tearing and passing beneath

the lining membrane, d d, of the prostatic urethra. It is remarked that

the origin of a false passage is in general anterior to the stricture.

It may, however, occur at any part of the canal in which no stricture

exists, if the hand that impels the instrument be not guided by a true

knowledge of the form of the urethra; and perhaps the accident happening

from this cause is the more general rule of the two.












Fig. 9, Plate 59.--Two strictures are represented here, the one, e,

close to the bulb d, the other, f, an inch anterior to this part. In the

prostate, a b, are seen irregularly shaped abscess pits, communicating

with each other, and projecting upwards the floor of this body to such a

degree, that the prostatic canal appears nearly obliterated.










Fig. 10, Plate 59.--Two bougies, d e, are seen to enter the upper wall

of the urethra, c, anterior to the prostate, a b. This accident happens

when the handle of a rigid instrument is depressed too soon, with the

object of raising its point over the enlarged third lobe of the

prostate.










Fig. 11, Plate 59.--Two instruments appear transfixing the prostate, of

which body the three lobes, a, b, c, are much enlarged. The instrument d

perforates the third lobe, a; while the instrument e penetrates the

right lobe, c, and the third lobe, a. This accident occurs when

instruments not possessing the proper prostatic bend are forcibly pushed

forwards against the resistance at the neck of the bladder.












Fig. 12, Plate 59.--In this case an instrument, d d, after passing

beneath part of the lining membrane, e e, anterior to the bulb,

penetrates b, the right lobe of the prostate. A second instrument, c c,

penetrates the left lobe. A third smaller instrument, f f, is seen to

pass out of the urethra anterior to the prostate, and after transfixing

the right vesicula seminalis external to the neck of the bladder, enters

this viscus at a point behind the prostate. The resistance which the two

larger instruments met with in penetrating the prostate, made it seem,

perhaps, that a tight stricture existed in this situation, to match

which the smaller instrument, f f, was afterwards passed in the course

marked out.










Figs. 1 to 5, Plate 60, represent a series of prostates, in which the

third lobe gradually increases in size. In Fig. 1, which shows the

healthy state of the neck of the bladder, unmarked by the prominent

lines which are said to bound the space named "trigone vesical," or by

those which indicate the position of the "muscles of the ureters," the

third lobe does not exist. In Fig. 2 it appears as the uvula vesicae, a.

In Fig. 3 the part a is increased, and under the name now of third lobe

is seen to contract and bend upwards the prostatic canal. In Fig. 4 the

effect which the growth of the lobe, a, produces upon the form of the

neck of the bladder becomes more marked, and the part presenting

perforations, e e, produced by instruments, indicates that by its shape

it became an obstacle to the egress of the urine as well as to the

entrance of instruments. A calculus of irregular form is seen to lodge

behind the third lobe, and to be out of the reach of the point of a

sound, supposing this to enter the bladder over the apex of the lobe. In

Fig. 5 the three lobes are enlarged, but the third is most so, and while

standing on a narrow pedicle attached to the floor of the prostate,

completely blocks up the neck of the bladder. [Footnote]






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[Footnote: On comparing this series of figures, it must appear that the

third lobe of the prostate is the product of diseased action, in so far

at least as an unnatural hypertrophy of a part may be so designated. It

is not proper to the bladder in the healthy state of this organ, and

where it does manifest itself by increase it performs no healthy

function in the economy. When Home, therefore, described this part as a

new fact in anatomy, he had in reality as little reason for so doing as

he would have had in naming any other tumour, a thing unknown to normal

anatomy. Langenbeck (Neue Bibl. b. i. p. 360) denies its existence in

the healthy state. Cruveilhier (Anat. Pathog. liv. xxvii.) deems it

incorrect to reckon a third lobe as proper to the healthy bladder.]





Fig. 6, Plate 60.--The prostatic canal is bent upwards by the enlarged

third lobe to such a degree as to form a right angle with the membranous

part of the canal. A bougie is seen to perforate the third lobe, and

this is the most frequent mode in which, under such circumstances, and

with instruments of the usual imperfect form, access may be gained to

the bladder for the relief of retention of urine. "The new passage may

in every respect be as efficient as one formed by puncture or incision

in any other way." (Fergusson.)










Fig. 7, Plate 60.--The three lobes of the prostate, a, b, c, are equally

enlarged. The prostatic canal is consequently much contracted and

distorted, so that an instrument on being passed into the bladder has

made a false passage through the third lobe. When a catheter is

suspected to have entered the bladder by perforating the prostate, the

instrument should be retained in the newly made passage till such time

as this has assumed the cylindrical form of the instrument. If this be

done, the new passage will be the more likely to become permanent. It is

ascertained that all false passages and fistulae by which the urine

escapes, become after a time lined with a membrane similar to that of

the urethra. (Stafford.)












Fig. 8, Plate 60.--The three lobes, a, b, c, of the prostate are

irregularly enlarged. The third lobe, a a, projecting from below,

distorts the prostatic canal upwards and to the right side.












Fig. 9, Plate 60.--The right lobe, a c c, of the prostate appears

hollowed out so as to form the sac of an abscess which, by its

projection behind, pressed upon the forepart of the rectum, and by its

projection in front, contracted the area of the prostatic canal, and

thereby caused an obstruction in this part. Not unfrequently when a

catheter is passed along the urethra, for the relief of a retention of

urine caused by the swell of an abscess in this situation, the sac

becomes penetrated by the instrument, and, instead of urine, pus flows.

The sac of a prostatic abscess frequently opens of its own accord into

the neighbouring part of the urethra, and when this occurs it becomes

necessary to retain a catheter in the neck of the bladder, so as to

prevent the urine entering the sac.












Fig. 10, Plate 60.--The prostate presents four lobes of equal size, and

all projecting largely around the neck of the bladder. The prostatic

canal is almost completely obstructed, and an instrument has made a

false passage through the lobe a.












Fig. 11, Plate 60.--The third lobe of the prostate is viewed in section,

and shows the track of the false passage made by the catheter, d,

through it, from its apex to its base. The proper canal is bent upwards

from its usual position, which is that at present marked by the

instrument in the false passage.










Fig. 12, Plate 60.--The prostatic lobes are uniformly enlarged, and

cause the corresponding part of the urethra to be uniformly contracted,

so as closely to embrace the catheter, d d, occupying it, and to offer

considerable resistance to the passage of the instrument.












Fig. 13, Plate 60.--The prostate, bc, is considerably enlarged

anteriorly, b, in consequence of which the prostatic canal appears more

horizontal even than natural. The catheter, d, occupying the canal lies

nearly straight. The lower wall, c, of the prostate is much diminished

in thickness. A nipple-shaped process, a, is seen to be attached by a

pedicle to the back of the upper part, b, of the prostate, and to act

like a stopper to the neck of the bladder. The body a being moveable, it

will be perceived how, while the bladder is distended with urine, the

pressure from above may block up the neck of the organ with this part,

and thus cause complete retention, which, on the introduction of a

catheter, becomes readily relieved by the instrument pushing the

obstructing body aside.






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