[Reprinted from The Medical News, September 29, 1894 ] EXTERNAL PERINEAL URETHROTOMY. A Review of Nine Cases. By W. B. ROGERS, M.D., PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY AND CLINICAL SURGERY IN THE MEMPHIS HOSPITAL MEDICAL COLLEGE. Your attention is requested to-day, gentlemen, to a detailed review of the salient points in the nine cases of external perineal urethrotomy that you have witnessed at this clinic within the past few months. On the board you see diagrams of the conditions ex- isting at the time of operation in the first eight cases, in all of which stricture of the urethra existed. The ninth operation was exploratory in a case of cystitis, which proved irremediable. It is hoped that you have kept careful notes of these cases and that you will follow me closely. I do not feel that any apology for this re- view need be made. The importance of the subject warrants its frequent presentation. Collectively these cases present nearly every condi- tion for which you will be called on to do the operation of external perineal urethrotomy and nearly every local complication you will likely encounter in a lifetime-prac- tice in this department of surgery ; therefore, I trust this review will neither prove uninteresting nor unprofit- able. The operation was imperative as a life-saving measure in at least four instances, and sooner or later the same condition would have been reached in four others. Of 2 the evident relief afforded in all but one case you can testify. The ninth case was exploratory upon the bladder. In no case was there hemorrhage of any consequence. In none was there a history of traumatism to the urethra to account for the stricture ; hence the contractions were attributed to admitted gonorrhea. External perineal urethrotomy is done for various purposes, namely: To facilitate the use of instruments within the bladder in the removal of tumors, calculi, and foreign bodies introduced from without; to facilitate the use of instruments in operations on the prostate gland and removal of'prostatic calculi; for the removal of calculi engaged in the urethral canal; for the relief of stricture of the membranous urethra; to insure drainage, as well as free escape of urine, in cases of a urethra ruptured traumatically or otherwise, as well as to divert the urine and give rest to the anterior urethra after operations thereon ; to give a more direct course to the bladder for the introduction of the catheter in cases of retention from enlarged prostate ; lastly, as a part of the operation for securing drainage and consequent rest to a chronically inflamed bladder. When preparatory treatment can be instituted do not fail to thoroughly cleanse the alimentary canal, prefer- ably by the use of calomel and soda. Always examine the urine for tube-casts. Sometimes they admonish not to operate; again, when operation is imperative, they modify the prognosis. If the urine is hyperacid give an alkali; if alkaline from decomposition in the bladder, benzoic acid is serviceable, five grains every four hours. For scanty urine give lemonade in abundahce. Before doing any cutting or dilating in the urethra never fail to thoroughly irrigate the canal and all pus-infected surfaces when they can be reached, and never fail to repeat the irrigation (in- cluding the bladder) after doing an external perineal 3 urethrotomy. Always retain a catheter in the bladder to prevent contact of urine when this is of bad quality. Quinin, either as preventive or curative of rigors fol- lowing manipulations or operations on the urethra, has proved a masterly failure in my experience. If the patient is bilious and comes from a malarial climate, quinin, with mercury, is indicated, because shock often brings on a malarial chill, but for rigors per se and re- curring, no benefit follows from the administration of quinin. Opium hypodermatically does more to prevent rigors than all else in the way of drugs. Protect the cut or dilated surfaces from contact with urine. Correct abnormal conditions of the urine before operating, and if there be no kidney-complications, rigors will not be of serious import. Lastly, a sound, full size, under anes- thesia, local or general, should be introduced between the third and the fifth day after the operation, and rein- troduced at intervals of from three to six days, until the wound has healed, and its use continued at proper inter- vals so long as there is any tendency to recontraction when the operation has been undertaken for the relief of stricture. Case I. October i, 1893. Impassable urethral stric- ture; urinary scrotal abscess- Robert S., a white, thirty- two years old, presented a temperature of 103°, a pulse of 140, and a history of fever, and an average of three rigors to the twenty-four hours for the previous ten days. The secretions were all bad. The bowels were constipated. The scrotum was immensely swollen, and red, and fluc- tuation was distinct at its base. The urine escaped by driblets continually, but by forced effort the bladder could be nearly emptied. The first indication was the evacuation of the scrotal abscess. On incision a quan- tity of pus and decomposing urine escaped. No effort was made to enter the bladder through the urethra, as the urine was now easily voided through the scrotal opening. A urinary fistula was therefore completed. 4 Cathartics were prescribed, and on the next morning our patient was free from fever and quite comfortable. Ten days elapsed before you again saw him. His general condition had meanwhile much improved, and time had allowed the local condition to mend. Much of the inflammatory thickening had disappeared, but the parts were not in good condition for operation, and yet an evening rise of temperature warned that the bladder needed relief. Fig. i. Accordingly, exploration of the urethra was made. You will recall that there existed a stricture, as indicated in Fig. i, which failed to admit even the filiform guide. Just behind the stricture was the opening in the urethra, and it was by this channel that the urine came origin- ally into the scrbtal abscess-cavity, now a fistula. You will recall how much difficulty was encountered in pass- ing a probe through the fistula, to the urethra, in through this opening, and on down the rugged cicatricial peri- neal region. However, the probe was finally located in 5 the membranous urethra, after first being introduced and then withdrawn from several sinuses which honey- combed the perineum. The section was made on the probe as a guide, and after washing out the bladder, the urethra was followed forward to the meatus, the urethro- tome introduced, and all contractions cut, so that a No. 32 F. sound passed the entire length of the canal. The hemorrhage was slight. A catheter was placed in the urethra and bladder, and retained for a few days. The patient made an excellent recovery; the fistula healed, and a No. 29 sound passed easily. Let me remind you that this is the patient whom I found in almost the same condition, and whom I afforded the same relief by ex- ternal perineal urethrotomy eight years before. The case should teach you the same lesson that I hope he has learned, not to neglect the use of the sound after operations for stricture. The dribbling of urine resulted from an over-filled bladder, which, with the aid of the abdominal muscles, could be partially emptied, but some urine was always left, called residual urine. The fever resulted from the infiltration of the scrotum when first presented ; later on the residual urine by decomposition caused the evening rise of temperature. When there is an acute inflammation, with pus and putrid urine in the tissues, you will often find, after evacuating the focus of infection, that a little delay will afford a better field- tissue to work in, and consequently a better result. Case II. October 7, 1893. Multiple stricture, with fistula and infiltration of urine.-Andrew Y., fifty-eight years of age, was referred to the clinic by Dr. Wright, of Mississippi, with a history of long-standing urethral obstruction, which, on examination, was found to be due to three narrowings, as shown in the accompanying dia- gram (Fig. 2). There was active inflammation of all the tissues surrounding that portion of the canal contained within the scrotum. Six fistulae were discharging pus through the scrotum and at the base of the penis. 6 Nearly all the urine was voided through these fistulae. The general condition of the patient was miserably bad. It was with much care and patience that a filiform guide was passed into the bladder, and, over this, Rogers' tunnelled urethrotome, aided by a little firm pressure, was guided past the membranous portion of the Fig. 2. canal; then the bulb was formed, and the contractions cut to full size as the instrument was withdrawn. The deep stricture was cut in the floor of the canal, and the instrument was then reversed so as to cut the penile contractions in the roof. A staff was readily passed into the bladder, and on this the perineal urethra was laid open its full length from without. The various fistulae were explored with a grooved director and laid open, so that thorough drainage was secured for these pus-infil- trated parts. The bladder was then emptied of a pint of foul urine and thoroughly irrigated. Examination of the bladder with the finger through the dilated prostatic urethra failed to disclose a calculus. That no urine might come in contact with the newly-cut surfaces until granulations were well established, a soft-rubber catheter 7 about the size of the urethra was now passed into the bladder, but before this was done a double silk ligature was passed through the wall of the catheter (avoiding encroaching on its caliber), about three or three-and-a- half inches from its point; then when the catheter was passed the ligature was found lying in the wound. A piece of gauze, folded to a size to fill the wound, was packed into it, and tied to the catheter by means of a ligature. This tampon of gauze served two purposes. It kept the catheter from escaping from the bladder, and it also checked the hemorrhage. The usual dressings of gauze and cotton, and a T-bandage were now applied, and the patient was put to bed. External perineal urethrotomy was not only the safest procedure in the treatment of the deep stricture, but it was indicated to give rest to the anterior portion of the canal surrounded by fistulous tracks; besides, a thor- ough digital exploration of the bladder in such cases is highly satisfactory, and often reveals the presence of unsuspected foreign bodies. Hemorrhage was but slight, and the patient made an excellent recovery. Sounds were reintroduced at proper intervals, and the patient returned to the clinic for dila- tation up to March 8th, when all of the fistulse had healed. A No. 30 F. sound could now be passed. There still existed much peri-urethral induration. Case III. November ig, f8gj. Cystitis; multiple stricture; foreign body in bladder.-H. W., thirty-six years old, who was sent to the clinic by Dr. Branch, had suffered more or less with cystitis for five years, and had had a stricture for about the same length of time. His suffering had become intense, and urine was passed every few moments. Examination of the urethra re- vealed several contractions, as shown in the accompany- ing diagram (Fig. 3). External perineal urethrotomy was determined upon, because of the number and the small caliber of the strictures. Free escape of urine 8 through a perineal incision is safer than allowing the fluid to pass over multiple urethral incisions. Moreover, the contractions were very resistant to the sound, argu- ing against treatment by gradual dilatation. A small staff was passed and the perineal urethra laid open from without. My finger was passed into the bladder and a foreign body felt. With forceps three segments of a Fig. 3. soft-rubber catheter, as you see here, averaging an inch each in length, were extracted. They are encrusted with phosphates precipitated from the urine. Here you have an example of a foreign body acting as a nucleus to a stone, and this case ought to re-impress upon you the advisability of putting your finger in the bladder whenever this is practicable. The urethra was cleared of all contractions. The patient, on coming from the anesthesia, recalled the time two years before when he lost the piece of catheter, but had forgotten to tell us before operating. He made an excellent recovery. Case IV. November 22, 1893. Cystitis ; multiple stricture.-H. R., thirty-nine years old, suffered intensely with chronic cystitis. His symptoms began many months before, and had gradually grown worse, finally necessi- tating the act of urination every twenty minutes. The stream was very small. Examination with bulbous sounds located two penile contractions of the caliber 9 as shown in the appended diagram (Fig. 4), while the membranous urethra here was so narrowed that it was impassable to instruments. Treatment by gradual dila- tation was contra-indicated by reason of the impassability of the stricture and the urgency of the symptoms. The bladder loudly demanded rest. A small staff was passed just into the membranous urethra. It was firmly pressed against the stricture and then reversed, its point being thrown toward the perineum, after Fleuhrer's practice, and the canal was opened by an incision through the perineum. Thus we were at the distal extremity of the membranous structure. The lips of the wound in the urethra were seized with forceps and held apart, and then with much teasing the small probe was passed along the tortuous and narrow canal into the bladder. Along the side of the probe a grooved director was forced until a drop of urine appeared, showing that the Fig. 4. bladder was reached. The probe was withdrawn and the floor of the membranous urethra laid open upon the director. Internal urethrotomy on the two anterior strictures gave easy admission to a No. 32 F. sound. On January 4th the patient was dismissed, after passing in your presence a No. 32 F. sound. Case V. December zp, 1893. Two penile strictures ; 10 multiple urinary fistulce.-G. G., forty-five years old, pre- sented two pronounced urethral narrowings, as shown here in the accompanying diagram (Fig. 5). The pos- terior one involved the bulbous portion of the canal, and was so small in caliber that the urethra behind it, from the pressure of urine forced by the inflamed bladder, had Fig. 5. given way. The urine first gave rise to the formation of an abscess, and later found vent through the three fistulous openings, as shown. All of the urine escaped through the fistulas at the time the man was presented. His condition was bad in the extreme. Fever, pain, emaciation, constant and slow poisoning from the pres- ence of pus in the scrotal tissues, together with cystitis, promised an early death. In this case internal urethrot- omy alone might have been done and relief possibly obtained, but I greatly prefer doing the perineal opera- tion from without in'such cases, in addition to the internal penile urethrotomy. The posterior outlet affords rest to the inflamed anterior segment of the urethra, and you get more rapid improvement, both local and general; and this case truly exemplified such teaching. 11 The external perineal urethrotomy was done, and the bladder explored and irrigated. The patient steadily improved during the eight weeks of his attendance here, but, like most of this class of patients, as soon as the fistula had healed and he was getting along well he gave up treatment. The probability is that we shall see him here again next year in the same condition. Case VI. January g, 1894. Multiple stricture ; Jout urinaryJistulce.-G. R., thirty years old, had had repeated attacks of gonorrhea, which had resulted in numerous contractions of the urethra, as shown in the appended diagram (Fig. 6), which shows four pronounced stric- Fig. 6. tures, ranging from a caliber of No. 20 down to No. 12 F. You will recall that the first step was an internal urethrotomy on the anterior urethra, cutting everything to size No. 30. Next, the point of a small staff was engaged in the membranous urethra; then the instru- ment was reversed so that the convexity was directed toward the pubis and the point bulged in the perineum. 12 This is a procedure suggested and practised by Fleuhrer, and is worth remembering. It has frequently done me good service. With the point of the staff pressing to- ward the perineum the opening was easily made. The membranous urethra was laid open its full length. A No. 30 F. sound was passed. A catheter was then intro- duced and retained in the urethra by the means described in the report of Case II. Through this catheter the bladder was thoroughly irrigated ; and the patient was sent to bed. On February 1 sounds Nos. 30 and 32 were passed. The patient left the hospital, but returned frequently for the introduction of the sound, and is doing well. All of the fistulas have healed. Case VII. February 20, 1894. Two strictures with fistula ; operation without a guide.-O. W., thirty years old, gave a history of repeated attacks of urethritis. He Fig. 7. passed water with much difficulty. There were two strictures, with two fistulous openings, as shown in the accompanying diagram (Fig. 7). The perineum was inflamed, hardened, and infiltrated with pus. Every 13 effort to pass a filiform guide into the bladder failed, and an incision was made through the perineum without a guide. The case was rendered especially difficult by reason of the condition of the perineum already de- scribed. No anatomic landmarks in the soft tissues were left, and reliance had to be placed on the sense of touch, aided by a good light. The perineum was carefully incised, keeping line by line well in the middle, with the left index finger guiding until the corded urethra was located, exposed, and seized with a tenaculum. The canal was then opened, and the small probe passed into the bladder; then this small director, on which the stricture was divided. The prostatic urethra was dilated, and the finger explored the bladder. Internal urethrotomy was next performed at this point, as indicated by the stricture, and a No. 32 F. sound was passed the full length of the canal. The sinuses were laid open. A soft rubber catheter was introduced and retained in the urethra for three days in the manner described In the report of Case II. On March 8th the patient was doing well, and a No. 30 F. sound was passed. Case VIII. Multiple impassable strictures; external perineal urethrotomy without a guide.-G. B., thirty - eight years old, a white man, gave history of repeated attacks of gonorrhea. A stricture was known to have been in existence for several years. When the man pre- sented himself he passed a pin-hole stream of urine with much pain, and was having fever every evening. The urine was voided with pain every half-hour, both by day and by night. You will recall that under anesthesia every effort was made to pass an instrument into the bladder, but without success. The filiform guide, even, failed to enter. The appended diagram (Fig. 8) shows the location of the various contractions and the cali- ber of each. The guide would not enter the perineal urethra. There was no peri-urethral collection of pus, 14 no false passages to mislead. The perineum was in its normal condition. External perineal urethrotomy was done without a guide. You will further recall that very little trouble was experienced in finding the urethra just anterior to the prostate gland, where, as I have shown you on the diagram, this dilated condition existed. Upon opening the urethra in this dilated part, the next step was to explore the bladder with the finger, and allow me to again recommend that you do not fail in these cases to do this. No stone was found. The canal was then traced forward, the urethrotome freely used, and a full- sized sound passed. After ten days the patient was up and left the hospital, able to pass a No. 30 F. sound. Fig. 8. You will rarely find a case suitable for external peri- neal urethrotomy without a guide presenting so ana- tomically clear a perineum ; and the ease of performance of the operation in this case should not mislead you to consider it a trivial procedure. A correct understanding of the anatomy was all that was needed in this instance, but do not forget which presented such a con- trast to this. The pouch-like condition of the urethra is said by Cocke to exist in all cases of impassable stricture of the membranous urethra. The mechanism of the formation of this pouch I have more than once explained to you. 15 Case IX. February io, 1894. Chronic cystitis.-Wm, McD., a white man, twenty-three years old, had been for twelve or more years a sufferer with cystitis, the origin of which he could not explain, never having had any venereal disease. Aside from the bladder-complaint his general health was excellent. His left hip-joint was ankylosed and the limb was a little shortened in conse- quence of an arthritis in early childhood. The call to urinate was almost constant, and had to be complied with every half-hour during the day, and his getting up at night, urinating and returning to bed, had become so nearly automatic, that though for years he arose a score of times each night, his health had suffered little or none. He was able to attend regularly to his work as cashier in a retail store. His urine had never contained blood, but frequently was clouded with pus. There was not much pain in the act of urination, though much discom- fort was caused by an effort to retain more than a few ounces. The patient had been under observation for some months. At no time had I found tube-casts or epithelium in the urine pointing to a kidney-complica- tion. There was, however, an abundance of pus, and the urine was either neutral or alkaline in reaction. At times the urethra showed inflamed patches when viewed through the endoscope. There was no urethral nar- rowing. Each introduction of an instrument into the deep urethra, whether cocainized or not, caused dizzi- ness and, if persisted in, fainting. I had failed after repeated explorations to find any stone. Medicinal therapeutics had been appealed to, but had signally failed to afford any relief. Irrigation of the bladder had not afforded benefit, and I found that the bladder would not retain more than three ounces of warm solution. An effort was made to overcome the contracted bladded by hot-water injections, but I was unable to increase its holding-capacity. Having ex- hausted all of these resources for relief, I determined on 16 digital exploration of the bladder. The viscus was not susceptible of dilatation, so that suprapubic cystotomy was not practicable. A subpubic route was thus forced upon us. The ankylosed hip caused but little incon- venience in performing external perineal urethrotomy. With my left forefinger introduced into the bladder I found the walls of the viscus (as felt between the finger within the cavity and the right hand pressing down above the pubis) hypertrophied to at least an inch in thickness. The vesical cavity was divided into two compartments, so to speak, by a slight transverse nar- rowing, while the surfaces felt very rugged and ulcer- ated. As nearly as I can describe the condition, it resembled the inner surface of a hide newly taken from a beef by a novice at skinning. I could easily explore the entire surface within, and found neither tumor, pocket, nor calculus. The case was one of chronic inflammation of the bladder; the question of causation was obscure and of no interest now, because we had before us the effect of prolonged inflammation, a thickened, hyper- trophied bladder, not amenable to any treatment. The neck of the bladder was forcibly dilated, and paralyzed temporarily. At the end of a week the patient was up, with the wound nearly closed, and able to retain urine for an hour and a half at a time. After four weeks the bladder had resumed its former half-hour regularity o action. The patient was fitted with a rubber urinal for use day and night. In this case you saw a condition that needed treatment -one like many that you will encounter in practice, whose cause you cannot remove, because you cannot locate it, and, in fact, ah original cause often ceases to act, leaving behind it a morbid condition, which some- times is one that we cannot remedy.