XXII. 
CASE OF URETHRO-RECTAL FISTULA. 
By F. Tildf.n Brown, M.D. 
E. J. F., male, twenty-seven, U. S. Admitted to the 
Presbyterian Hospital August 15, 1894. Discharged, cured, 
September 30th. Family history negative. 
Personal Previous History.—Several attacks of gonorrhoea. 
The last was three years before the occurrence of a prostatic 
abscess, which the patient attributed to severe compression 
of the penis and urethra during an emission. Prostatotomy 
was followed by a small urinary fistula. Extravasation of 
urine and pus followed and required additional incisions. A 
week later the right seminal vesicle was removed as a dan- 
gerous septic focus. These operations as well as five subse- 
quent ones were performed in San Francisco. 
Five months later, August 2, 1892, he had the first opera- 
tion for the cure of his fistula. Severe bleeding and abscess 
formation defeated the effort. 
On March 15, 1893, he had the second operation which 
was apparently ruined the same night by faulty catheteri- 
zation. 
The third operation was made more promising by having 
had established supra-pubic drainage, but during the third 
week, while still in bed, the old fistula opened. 
On June 1, 1893, a fourth operation was done employing 
supra-pubic drainage and extensive perineal flaps. Four 
days later the sutures parted. He had now a more extensive 
fistula than ever before. On October 15, 1893, a fifth opera- 
tion was performed on the same principles as the last, i.e., 
a plastic augmented by supra-pubic drainage ; there was but 
a most temporary occlusion of the fistula. Two months 
later he left the hospital, the supra-pubic wound closed and 
all urine issuing through the anus. He came east in July, 
Reprinted from the Presbyterian Hospital Reports, vol. i., January, 1896. 184 
CASE OF URETHRO-RECTAL FISTULA. 
1894, and entered the Presbyterian Hospital August 15th. 
He was apparently and confessedly addicted to morphine. 
Three weeks were devoted to correcting this excess, and to a 
study of the conditions presented by the fistula, bladder, ure- 
thra, and urine. The rectal aperture of the fistula was just 
within the internal sphincter. It admitted the tip of the 
index finger into the prostatic urethra. The tonicity of the 
sphincter vesicse internus was sufficient to often retain 
two or three ounces of urine. When this began to escape 
into the prostatic urethra he would voluntarily empty his 
bladder into the rectum, whence it issued at once through 
the anus, the muscles and tissues of which had been im- 
paired by previous lesions incidental to disease and former 
operations. Two moderate strictures of the urethra existed ; 
these were divided, and the canal healed at a uniform calibre 
of 32 French. Ten days later an operation for the cure of 
the fistula was performed. A perineal incision leading into 
the membranous urethra was made. Through this the right 
forefinger was passed to the prostatic urethra while the 
left forefinger in the rectum came in contact with it anddis- 
closed very thin tissues surrounding the fistulous track, so 
attenuated as to offer little hope of successful holding of 
sutures. 
With the author’s short wire rectal speculum distending 
the anus and rectum, and one finger in the prostatic urethra, 
the thin margin of the opening was trimmed with curved 
scissors, then with four sutures of silkworm-gut passed from 
the rectal side, but under guidance of sight, and the finger 
in the urethra, the opening was closed. Now a flap of rectal 
mucous membrane an inch in width and an inch and three- 
quarters in length was dissected up and brought down over 
the silkworm sutures where it was secured with silk, to form 
at least a temporary shield. A rubber perineal catheter was 
passed to the bladder and retained by the author’s tube 
holder. Defaecation was prevented for nine days. The pa- 
tient was confined to bed for two weeks. The perineal tube 
was worn for three weeks. At no time after the operation 
was there any escape of urine through the fistula. The pa- 
tient made a complete recovery and returned to California 
two months later, passing all his urine voluntarily by the 
urethra from the meatus.