CHAPTER II. RUPTURED URETHRA; TRAUMATIC STRICTURE. SUBCUTANEOUS rupture of the urethra is usually met with in boys who have been trying to walk along the top of a fence and have fallen astride it. The urethra is driven forcibly upwards or outwards against the pubic arch and torn across just as it pierces the triangular ligament in the region of the bulb. It is also met with occasionally in crush fractures of the pelvis, when the membranous urethra may be torn across. The rupture may be partial, or complete, and when the urethra and corpus spongiosum are both torn completely, blood and urine are effused into the tissues around the corpus spongiosum. As a general rule when the rupture is in the neighbourhood of the triangular ligament the fluid comes forward beneath the fascia of Colles and upwards into the skin of the scrotum, penis and abdomen, so that the limits of the fascia become marked out by a plum-coloured "bruise." Symptoms, Diagnosis and Treatment. The history. The patient has fallen astride a fence or a beam. Bleeding urethra.-Blood is found to be dribbling from the meatus apart from micturition. If the rupture is complete micturition is usually impossible, if incomplete the urine passed contains clots. There are signs of effusion of blood in the perinæum, and if the patient has micturated there may be quite a large collection of fluid in that position, but more usually the bladder is distended with urine, and painful from retention of urine. In neglected cases a large collection of blood and urine appears in the subcutaneous tissues of the perinæum and comes forward beneath the skin of the scrotum and penis; infection is seldom long delayed and sets up a gangrenous cellulitis leading to death from septicemia. Such a patient should be placed under a general anesthetic without delay, before any attempts are made to sound him. When he is safely anæsthetised, an attempt should be made to pass a soft red rubber catheter of a size just large enough to enter the meatus. If it passes into the bladder it means that there is only a partial rupture, and there is then no need to proceed further. The catheter is tied in, and left for seven days. If it does not pass an attempt should be made to insert a round-nosed black gum-elastic catheter, and if this fails the catheter is left in the urethra as far as it will go, the patient is placed in the lithotomy position, and a median perinæal incision carried straight down till the tip of the catheter is exposed. In this way the distal end of the urethra is found. The wound is now sponged out and the hæmorrhage controlled, after which the proximal end of the urethra has to be searched for. When it is found the catheter is passed into the bladder and the torn urethra is reunited round the catheter by fine catgut sutures. The catheter is tied in and is left for seven days in situ. The perineal wound is left open to permit of free drainage. If the upper end cannot be found after a prolonged search, then it is wiser to desist and simply insert a large drainagetube into the perinæal wound, and allow the urine to drain away in that way for some days. A second operation a few days later is more likely to prove successful when the bruised and torn tissues have recovered a little. AFTER-TREATMENT. A most rebellious stricture will form at the site of the junction if immediate steps be not taken to control it. On the eighth day the catheter is removed, and a steel bougie of a corresponding calibre gently passed into the bladder. This is passed every day for three days, then once a week for a month, once a fortnight for a month, and then once a month for a year, and twice a year for the rest of life. If this treatment be not carried out a stricture forms, rapidly contracts down to a narrow gauge, and sets up back-pressure changes on bladder and kidneys. CHAPTER III. HOW TO DEAL WITH A CASE OF RETENTION OF URINE. CASES of retention of urine present themselves in three different forms: 1. Painful retention. 2. Painless retention. 1. PAINFUL RETENTION. The patient complains that he has been unable to pass any water for many hours, and is suffering great agony from attacks of cramp in the hypogastrium which come on every few minutes and last a variable time. In between the attacks he has a feeling of weight and a dull aching pain in the hypogastrium, There can seldom be any doubt of the diagnosis, and it is at once confirmed by abdominal palpation, which reveals a tense, pear-shaped cystic swelling above the pubes yielding a dull note to percussion. The younger the patient, the better the state of his general health, the more recent the cause of the retention the greater is the pain, which means still active bladder-muscle. Pain, therefore, is of good prognosis. 2. PAINLESS RETENTION. This type is seen in patients who are prostrated by a severe toxæmia, for instance in the course of typhoid fever, when the bladder-muscle becomes poisoned and relaxes completely. No pain is complained of nor is the patient in a fit enough mental state to notice that he has not been passing urine, so that the condition will be missed unless a daily note of the urine and a daily inspection of the abdomen be made in typhoid fever and similar debilitating illnesses. 3. PAINLESS INCONTINENCE. The patient complains that he cannot hold his water for more than a few minutes, but that only a small quantity is passed every time, and he has no pain. The diagnosis is easy if it be remembered that true incontinence is rare, and that incontinence is usually false or due to retention of urine with overflow. Abdominal examination reveals a large toneless bladder extending upwards almost to the umbilical level. This form is especially met with in men with nervous disorders or with enlarged prostates. 1. The distended bladder. Diagnosis. 2. The cause of the distended bladder. 1. THE DISTENDED BLADDER. This forms an elastic rounded swelling rising upwards immediately above the pubes towards the umbilicus, and yielding a dull percussion note. It usually occupies the middle line, but in chronic cases the peritoneum may become adherent to its outer surface in front so that nearly the whole organ is intra-peritoneal, and it may then lie to one side or other of the middle line, and in one case we have seen it missed because coils of gut lay in front of it. Pouches and diverticula may cause it to assume abnormal forms, rounded or conical projections being felt on one side or other, so that the shape is not always characteristic. A distended bladder is the commonest swelling met with in the hypogastric region, and has to be distinguished from the other tumours of that part, especially the pregnant uterus, uterine fibroids and ovarian cysts, and less common ones such as collections of pus, urachal cysts and growths of the cave of Retzius. In cases of doubt the passage of a catheter will settle the diagnosis. 2. THE CAUSE OF THE DISTENDED BLADDER. Common causes. In males: Stricture. Enlarged prostate. In females: Retroverted gravid uterus. Pelvic tumour. Disease of the nervous system-tabes, disseminated sclerosis, hysteria. In children: Phimosis. Impacted urethral calculus. LIST OF POSSIBLE CAUSES. A. URETHRAL OBSTRUCTION. 1. Inside the tube. -Calculi, bladder tumours, foreign bodies. 2. In the wall.-Stricture, urethritis, rupture, abscess, tumour. 3. Outside the wall.-Enlarged prostate, pelvic tumour, phimosis, ligature. B. FAULTY BLADDER-WALL. -muscular atony from over-distension. -poisons, acute specific fevers, belladonna, lead. ―nervous disease, tabes, cord lesions, brain lesions, hys teria. -reflex, after operations, etc. The cause is discovered by a routine examination to exclude all but one of these causes, note being taken of the history, the nervous system, the abdomen, the perinæum and pelvis (rectal and vaginal examination), and, finally, an examination of the urethra is carried out by means of a catheter or bougie (see pp. 278 and 387). Treatment. For purposes of treatment the cases should be divided into two groups: the acute or recent, where there are no backpressure changes, and so little danger in passing a catheter; the acute on chronic, where the cause has been of long standing and there has been time for back-pressure to affect the kidneys, so that the relief by catheter presents no little danger of setting up infection or even suppression of urine. This can often be determined at once if the cause be known, and in any case an examination of the blood-pressure will yield valuable evidence, as if it is much raised, say to 150– 200 mm. of mercury, it is very fair evidence that the kidneys are widely affected. 1. Common causes of acute retention : Acute urethritis. Retroverted gravid uterus. Impacted urethral calculus, |