The diseases of the male urethra

Introduction

It may be justly asserted that in no part of the human frame does an accurate conception of its structure and functions have so important a bearing on the proper understanding of its diseases as in the urethra, and it may be said with equal justice that in no other part of the human frame have such erroneous anatomical and pathological views been so obstinately maintained.

Until recent years the medical profession has failed to apply to the urethra the same sound reasoning, based on a knowledge of pathology, which has been applied to other parts of the body. This is partly attributable to the fact that during life the facilities for examining the urethra have been imperfect, and the opportunities for examining it after death have been neglected ; and partly to the dogmatic views on the subject which have been taught by recognized authorities, and accepted, like gospel truths, more on the faith in the infallibility of the teacher than on the exposition by these views of obscure points in urethral diseases.

With the advent of improved instruments for intra-urethral inspection, together with the general advancement in our knowledge of bacteriological and pathological subjects, a new era in urethral pathology has been ushered in and many radical advances have been made, not only in the pathology but also in the treatment of urethral diseases.

Vlll INTRODUCTION.

It will be the object of tlie writer to place before the reader the diseases of the urethra, as viewed from the modern standpoint, promising, however, that those facts relating - to the subject that are too well established to be open for discussion will be dwelt upon as briefly as is consistent with their proper elucidation.

The pathology of stricture and its relationship to gleet will be entered into, perhaps more fully than its importance would apparently justify ; but to those who are familiar with the conflicting views entertained on this subject, and the far-reaching influence which such views exert on the treatment of chronic urethritis, an apology is unnecessary.

In a work of such limited scope as the present one, it is considered advisable to confine it as closely as possible to the discussion of the acute and chronic inflammations and stricture of the urethra, leaving out the diseases of the urethra that are, on account of their rarity, unimportant. It will be necessary, however, in order to cover the ground in a satisfactory manner, to include a description of the inflammatory diseases of the important glands which communicate with the urethra, namely, Cowper's glands, the glands of the prostate, the epididymis, and the seminal vesicles.

DISEASES OP THE URETHRA.

CHAPTEK I.

THE ANATOMY OF THE MALE UKETHRA.

The urethra (Figs. 1 and 2) is that portion of the genito-urinary apparatus that has for its function the conveyance from the body of the urinary and seminal secretions. When it is in a state of quiescence, or not performing the functions stated, its canal is obliterated, and its mucous surfaces retained in apposition by the elasticity and contractility of the submucous connective and muscular tissues which surround it throughout its entire extent. At certain places the muscular tissues become more markedly developed than at others, forming distinct bands, having particular functions to perforin, and deserving of the closest attention, since a knowledge of their situation and function is essential to the understanding of many of the phenomena of urethral diseases. The vesical orifice of the urethra is surrounded by a ring of involuntary non-striated muscular fibres, the tonic contraction of which, acting as a sphincter, offers a barrier to the passage of urine from the bladder. This muscle is called the sphincter vesicae interims. Numerous longitudinal muscular fibres of the bladder pass into the substance of the prostate gland, to become continuous with its muscular structure.

These muscular fibres radiate from the vesical orifice of the urethra along' the vesical wall, and by their contraction during- the act of urination tend to open the orifice of the urethra, and are, therefore, antagonistic to the

Promon

1/1$ eusjjr penis

Pig. 1. — Sagittal Section of the Male Generative Organs (Hitzmann).

action of the sphincter vesicae internus. The two wellmarked muscular bands which form the lateral boundaries of the trigone are especially active, their contraction tending to open the vesical orifice at their prostatic termination and closing the orifice of the ureters at their

Verteco

Glans penis

OrificJcutan.

Fig. 2.— The Urethra and Bladder Opened from Above (Hitzmann).

vesical termination, thus saving- the delicate ureters and secreting- portion of the kidneys from injurious distention during the act of urination. When the bladder is distended the tension of its wall acting on the vesical orifice of the urethra overcomes the sphincteric action of the internal sphincter, and the urine leaks into the posterior urethra, which in this condition virtually forms a portion of the bladder, and for this reason is often called the neck of the bladder (Fig. 3). The further progress of the urine is barred by the sphincteric action of two muscles surrounding the urethra at, and immediately in front of, the apex of the prostate gland. The first is called the sphincter vesicae externus. It is a band of striated and non-striated muscular fibres, situated at the apex of the prostate. The second is called the compressor urethra'. It is a voluntary or striated muscle, and lies between the two layers of the triangular ligament, to which, and to the ischio-pubic rami on either side, it is attached. Weaving itself in various directions— above, below, and around the membranous portion of the urethra — it forms, with the adjacent circular muscle situated at the apex of the prostate, the external sphincter of the bladder. This sphincter is much more powerful than the internal sphincter, and offers a greater resistance to the passage of fluids or instruments. It is therefore the principal barrier to the passage forward of the urine from the bladder, and to the passage backward of urethral secretions or injections, and to this fact the clinical division of the urethra into an anterior and a posterior portion is due.

Fig. 3 shows the situation of these muscles and the effect on the posterior urethra of a distended bladder, the empty bladder being represented by the dotted lines.

THE ANATOMY OF THE MALE URETHRA.

Fig. 3. — Diagram Showing the Muscles of the Posterior Urethra and the Effect of a Distended Bladder on the Internal Sphincter.

The bulbous portion of the urethra is surrounded by the bulbo-cavernosus, or ejaculator urinae muscle, which plays an important role in expelling 1 the last drops of urine, and in the expulsion of the seminal fluid during ejaculation.

By contracting on the extremely vascular bulb it sends a vascular impulse forward through the lacunae of the corpus spongiosum, which, in its course, by closely approximating the urethral wall, empties its canal.

The muscular tissue of the pendulous portion is unimportant and need not concern us.

The superficial cells of the mucous membrane of the urethra are long and columnar, with the exception of a short distance (5 to 8 mm.) from the external orifice, where they are squamous, and where the subjacent membrane is beset with papillae. The epithelium rests on a basement membrane, external to which is a layer of convoluted vascular tissue which is separated from the proper substance of the spongy body by a layer of circular non-striated muscular fibres.

The urethra is beset with small racemose glands called the glands of Littre (Fig. 4). In addition to these there are numerous lacunae of considerable length (10 to 20 mm.), consisting of a reduplication or infolding of the mucous membrane, forming a deep cul-de-sac whose axis lies obliquely to the urethra, those in the anterior urethra

DISEASES OF THE UKETHRA.

opening toward the external meatus ; those in the posterior urethra, according- to Belfield, opening- toward the bladder.

On the roof of the fossa navicularis one of these lacunae attains enormous dimensions and is called the lacuna magna. Its orifice is guarded by a fold of mucous mem-

FlG. 4.— Section Through a Gland of Littre (Taylor).

brane which sometimes offers an obstruction to the passage of small urethral instruments, which may be deflected into the lacunas instead of passing along the urethra.

Opening into the floor of the bulbous portion of the urethra are the ducts, one on either side, of Cowper's glands. These two little bodies are compound racemose glands. They lie between the two layers of the trian-

THE ANATOMY OF THE MALE URETHRA. 7

gular ligament, close to the membranous urethra. Their ducts extend forward about one and a half inch, and pour a thin viscid secretion into the bulbous urethra. The urethral glands and diverticula? are important, from a pathological stand-point, owing to the fact that they are open to the invasion of the gonococci and from their location are but little amenable to local treatment. It frequently happens, therefore, that the implication of the urethral glands and lacuna? in the gonorrheal process perpetuates the disease in a chronic form, and it has often been observed that chronic lesions are most apt to be found in those portions of the urethra where the lacuna? are most numerous.

Reference has been made to the division of the urethra into an anterior and a posterior portion, the dividing point being the part grasped by the compressor urethra?. There are good anatomical, and still better clinical, reasons wlw we should adopt this division. These reasons will be brought out more fully in the body of the work, and, therefore, it will be unnecessary to enter into the subject here, further than to say that the anterior urethra comprises that portion which extends from the compressor urethra forward to the meatus, and that the posterior urethra comprises that portion which extends from the compressor urethra? backward to the bladder.

It is presumed that the reader is familiar with the anatomical divisions of the urethra into prostatic, membranous, bulbous, and pendulous portions, and therefore no description will be necessary when reference is made to these anatomical divisions.

CHAPTEE II.

ACUTE ANTERIOR URETHRITIS (GONORRHOEA).

Etiology.

The mucous membrane of the urethra is singularly well protected from atmospheric infection or climatic vicissitudes. It is not like the mucous membrane of the respiratory tract, exposed to the passage through it of air which is unstable in temperature and often laden with pathogenic micro-organisms. Nor like the alimentary tract is it exposed to mechanical or chemical irritants and the presence of decomposing material. Yet in spite of the fact that Nature has shielded it most carefully from extrinsic sources of infection, it is of all the mucous membranes the one which suffers most acutely from infectious diseases. An acute urethritis may be due to any one of a number of causes— for instance, mechanical or chemical irritation, if of sufficient intensity, will produce an acute inflammation of the urethra, the onset of which is rapid, reaching its acme in a few hours and subsiding in a few days. But this does not explain the cause of the very great majority of urethral inflammations which develop several days after sexual contact, and, for a time, increase in severity, requiring for their subsidence as many weeks as the former variety requires days, and carrying with it the property of infectiousness.

It is but natural, therefore, that this malady, which is as old as history and as prevalent as vice, should be attributed to the growth in the urethra of a micro-organism, since it required for its development a period of incubation, for its acme a definite period representing its gradual invasion of the urethra, and a stationary and declining period of nearly definite limit- It would be needless to review the claims that have been made at various times for the discovery of the micro-organism which produces gonorrhoea, each of which were in turn discarded, until, in 1879, Neisser announced the discovery of a diplococcus, called after its discoverer the gonococcus of Neisser, which he proved was the direct cause of the disease. The presence of this micro-organism has been constantly shown in the acute infectious inflammations and in all chronic inflammations of the urethra that retain infecting properties. Its presence has also been demonstrated in gonorrhoea! ophthalmia, in ophthalmia neonatorum, in the secretions of gonorrhoeal vaginitis and endometritis, also in the pelvic inflammations of the female that are of gonorrhoeal origin. It is doubtful if the gonococci will flourish in the mucous membrane of the nose or mouth, but they have been detected in the rectum in cases of gonorrhoeal proctitis and in the synovial fluid of joints affected with gonorrhoeal rheumatism. In addition to the demonstration of the gonococci in the tissues affected with gonorrhoeal inflammation, cultures of the gonococci have been made and gonorrhoea has been produced from these cultures, even when the twentieth generation has been inoculated in the urethra.

So convincing has become the cumulative evidence of the causative relationship of the gonococcus of Neisser to infectious urethritis or gonorrhoea, that the subject has passed beyond the debatable stage, and all opposition lias practically vanished before the arguments and evidence in its favor.

"While we may justly concede to the gonococcus the unenviable position of etiological factor in the production of gonorrhoea, we will commit an error if we permit it to occupy the entire domain in the production of acute urethritis, for it has been shown by a number of observers — and the number is steadily increasing — that other micro-organisms than the gonococci may produce urethral suppuration, and are not infrequently present in acute urethritis when the gonococci are absent. It has been shown also that the healthy urethra may be the habitat of pyogenic micro-organisms that remain inactive until a favorable exciting cause, that may be nonvenereal, enables them to assume an aggressive attitude toward the urethra. Figs. 5, C, 7, 8, and 9 (after Lustgarten) show the micro-organisms that may be found in the male urethra.

It will be seen, therefore, that we may recognize, according to the cause, three forms of acute urethritis.

First. Acute urethritis due to the growth of the gonococci in the urethra. This variety comprises the great majority of acute urethral inflammations and is remarkable for the highly infectious nature of the urethral discharge.

Second. Acute urethritis due to other micro-organisms than the gonococci. These cases usually pursue a milder course than the preceding variety, and the discharge is either not infectious, or if so, to a very slight extent.

Third. Acute urethritis due purely to mechanical or chemical causes. The discharge from this variety of urethritis is not infectious, unless there should be an ac-

Fig. 5.

Fig. 6.

Fig.

Fig.

Fig. 9.

Figs. 5, 6, and 7. — Micro-organisms of the Normal Urethra. Fig. 5. — a and b, Bacilli Resembling Tubercle Bacilli. Fig. 6.— Hyaline Epithelial Cell containing Streptococci. Fig. 7. — Epithelial Cell containing Pseudo-Gonococcus. Fig. 8. — Pure Culture of the latter on Agar. Fig. 9. — Gonococci from Gonorrhoea! Pus : 1-1000 diameters. (After Lustgarten. )

12 DISEASES OF THE UKETHKA.

cidental inoculation of the urethra at the same time with pyogenic micro-organisms.

It will be advisable, however, to consider these varieties

of urethritis together under the general term of acute

urethritis, special mention will only be made of each

/ variety when it is necessary to do so in order to prevent

confusion.

The gonococci have but a low vitality and are easily destroyed by extremes of temperature, they cannot be inoculated in the lower animals, and they will perish if exposed to the atmosphere for a time. The sterilization of urethral instruments, therefore, offers no great difficulty, and the conveyance of a gonorrhoea by such means is improbable, if the ordinary precautions regarding cleanliness are observed.

The microscopic examination of the urethral secretion is of great diagnostic importance, and the genitourinary surgeon should be familiar with the methods of staining

and examining the

«•:;'&$& gonococci (Figs. 9 and t/^'> / rf * * \& fouml in i 3airs > the a P-

J&ef$\^ ; £. v -'=% proximating surfaces /Wjgs.*^- - .': 3;-." ^emg flattened. They ft*3#? '^' ^' V^^ He for the most part in %*?/ * ** -^ll® the interior of the cells,

often in such numbers

Fig. 10. — Gonococci from Gonorrhoeal Pus

(American Text-book of Surgery). that the Cell is packed

full of them, but they

are also found free in the secretion, probably as a result

of their liberation by the bursting of the gonococci-laden

cells.

The method of preparing and examining the urethral secretion for gonococci is as follows (Quoted from Hyde and Montgomery's " Manual of Syphilis and Venereal Diseases," page 363) :

"In selecting gonorrliceal pus for examination it is well to avoid that found at the meatus, as this pus is more liable to contain other organisms that might render the examination complicated and confusing. It is better to obtain pus that may be scpieezed out of a deeper portion of the urethra. A small drop of this pus is thinly spread on a slide or a cover-glass, by means of a platinum wire, or by pressing the drop between two coverglasses and then slipping apart. The thin film is allowed to dry in the air, and is then fastened to the glass by slowly passing- it three times through the tip of the flame of an alcohol lamp or a Bunsen burner, the puscovered side being upward. The film is then covered with a few drops of the staining fluid, or the cover-glass is floated, film side down, on the liquid. The preparation should remain in the stain from one to five minutes, depending upon the strength of the solution, after which the surplus stain is gently washed off with a jet of cold water. The specimen can now be examined in water or glycerine, or, what is better, it can be dried carefully with soft blotting-paper and mounted in Canada balsam.

" The stain employed may be almost any of the basic aniline dyes, as methyl-blue, Victoria-blue, methyl-violet, gentian-violet, or fuchsin. These dyes may be used in aqueous solutions of varying strength, but they do not keep well, and it is best to prepare the fluid each time it is wanted. This may easily be done by keeping on hand a saturated alcoholic solution of the stain, a very small quantity of which can be added, drop by drop, to a watch-glassful of distilled water until the latter is of the required strength and color. The following is a rapid and satisfactory method : A solution of methyl-blue is prepared by dropping a saturated alcoholic solution of the stain into a watch-glassful of distilled water, or into a solution of potassium hydrate (1 to 10,000) until the liquid has a dark blue color. The cover-glass, prepared in accordance with the above directions, is floated on this liquid, pus side down, for from one to two minutes ; it is then taken out and the surplus stain is washed off. It may now be placed at once, without drying, upon a slide and examined, or it may be carefully dried and mounted on a slide with Canada balsam. In a specimen thus prepared the gonococci appear dark blue, while the cells show a very pale blue protoplasm and grayish-blue nuclei."

While no great difficulty attends the demonstration of the gonococci in acute gonorrhoea, the same cannot be said in cases of chronic gonorrhoea where the gonococci may be absent or may be confounded with other diplococci that may be present. Weichselbaum says :

"It is just as difficult to recognize gonococci in the chronic stage of the gonorrhceal inflammation as it is easy to do so in cases where the process is quite recent, as in the former the specific cocci are present in very small numbers, and may be very hard to distinguish from other cocci, perhaps occurring along with them (as, for example, in chronic gonorrhceal inflammations of the female genital tract), if they har)pen not to lie in the interior of the cells. In such cases when examining the living, artificial intensification of the process by the injection of a weak solution of corrosive sublimate may afford help, thus leading to a multiplication of the gonococci while the other bacteria are destroyed ; for the purpose of distinguishing the gonococci from other cocci, cover-glass preparations are first treated by Gram's method and afterward stained for five seconds with alkaline methyl-blue which has been diluted Avith four times the quantity of water, by which means the gonococci are stained blue, but the rest of the bacteria blackish. A still more certain method, however, in doubtful cases, is to prepare plate cultures from the secretion, using- for this purpose human serum to which an equal quantity of warm agar solution has been added in order to make it solidify."

The demonstration of the gonococci in the urethral discharge stamps it at once as both venereal and infectious, and establishes indubitably the nature of the disease. Yet the microscopical examination for gonococci as a diagnostic agent in the differential diagnosis of urethral diseases is of less importance than at first sight it may seem, and we no longer, as formerly, resort to it on all occasions. The reasons for this are the difficulties attending bacteriological examinations in general, often requiring more experience, facilities, and time than the average practitioner can furnish. To this may be added the fact that, owing to their resemblance morphologically and in their reaction to staining fluids with other diplococci found not infrequently in the urethral secretions, a positive diagnosis cannot always be made even where the utmost care is taken, and if such a diagnosis is made it is open to the unanswerable criticism that it may be inaccurate. Even Neisser admits that about five per cent, of the cases where gonococci are diagnosed as present are open to doubt and error.

The only absolute proof of the presence of gonococci is by culture and inoculation experiments, and the former is too laborious to be practicable, and the latter is obviously unjustifiable, since such inoculations must be carried on in the human urethra, as the gonococci cannot be inoculated in the mucosa of the lower animals.

Another deterrent to the range of usefulness of the microscope is the fact that it is in the cases where the demonstration of the gonococci are most important that the greatest difficulties are met with, namely, in chronic urethral discharges, where the gone-cocci may be in such few numbers that it is only after repeated examinations that they can be detected. In acute urethritis, where the gonococci are abundant and easily demonstrated, the clinical features are usually so diagnostic that he who runs may rend, and confirmatory evidence obtained by a microscopical examination will rarely be necessary.

It therefore happens that we have settled back to the comfortable position of relying chiefly on the clinical diagnosis of urethral inflammations, only bringing the microscope into requisition when the clinical diagnosis is difficult or impossible.

Acute anterior urethritis, or gonorrhoea, is derived by sexual contact with a female suffering from gonorrhoea. It is not necessary, however, for the female from whom the gonorrhoea is acquired to have the disease in an acute form, as she may still retain infecting properties when the inflammation has subsided to such a degree as to be unrecognizable by inspection. It is not even absolutely necessary that she should have the disease in any form, for well-authenticated cases are on record where two lovers have worshipped at the same shrine, the first, having a gonorrhoea, transmits the disease to the second through the medium of the mistress, the latter remaining immune.

There is often a singular tendency among the recipients of a gonorrhoea to shield the donor, and to attribute its source to less probable causes, such as a sprain, overexertion, wet feet, or alcoholic excesses, while an insinuation against the virtue of the mistress, or the possibility of her sharing her favors is indignantly repelled. On the other hand, not infrequently a married man, who is

ACUTE ANTERIOR URETHRITIS (GONORRHEA). 17

perfectly faithful to his marital vows, will present himself with all the symptoms of an acute gonorrhoea, and bluntly ask you how he came to acquire it. Iu such cases considerable tact and diplomacy may be required to prevent the incrimination of a possibly innocent woman.

A man may after sexual intercourse acquire a urethritis because he himself at some previous time had suffered from a gonorrhoea which had apparently disappeared, but in reality had lingered in some damaged patch or glandular crypt in his urethra, and only required a favorable cause, such* as sexual excess or intemperance, to briug on a renewed activity and reinfect the whole urethra. Or he may be inoculated with other pyogenic micro-organisms, such as the staphylococcus or streptococcus, which may have innocently enough found a habitat in his own urethra or in the vagina of his partner. Such occurrences are probably rare, but that they may occur is sufficient warrant for us to give the accused the benefit of the doubt, if by so doing we may possibly be shielding an innocent woman from a manifest injustice.

This disease has been innocently acquired from a soiled water-closet, or purposely by inoculation, but authenticated cases of this kind are so rare as to be deservedly ranked among the curiosities of medicine.

The exposed portion of the meatus is naturally the point of inoculation, at which point the gonococci at once begin to propagate their kind, and to invade the urethral mucosa. It is usually several days before a visible inflammatory reaction results from the invasion of the gonococci. This period is called the period of incubation.

The incubation period of a gonorrhoea is not a constant one, the variations may be dependent on the virility or quantity of the gonococci deposited on the urethra, or the more or less favorable condition of the latter to the invasion of the micro-organism.

In thirty-nine cases in which Lanz verified the diagnosis by the demonstration of the presence of gonococci the period of incubation was as follows :

Days. Cases. Days. Cases.

1 2 8 1

3 15 ' 10 1

4 4 ! 14 1

7 4 |

Taylor has recorded the incubation period in 505 cases of first infections as follows :

Days

Cases 1

Days.

Cases.

ns

9 47

R6

A gonorrhoea may therefore in exceptional cases appear as early as one day or as late as twenty days from the period of infection, but the great majority of cases have an incubation period of from three to seven days. Where the gonococci were placed in the urethra for experimental purposes, the period of incubation has been from two to three days ; but in these cases we may infer that not only a greater quantity of the micro-organisms was transferred to the urethra, but also that they were placed in more intimate contact with the urethral epithelium than occurs under ordinary circumstances.

An acute inflammation of the urethra that is due to mechanical or chemical irritation has no period of incubation, or at most a few hours after the advent of the exciting cause. Where the inflammation is due to an exacerbation of a previously latent gonorrhoea, the incubation period is usually very short, rarely over twenty -four hours. All such are, therefore, usually easily differentiated from acquired gonorrhoea, which has an incubation period of several days.

CHAPTER III.

ACUTE ANTERIOR URETHRITIS.

Symptoms and Course.

The course of a typical uncomplicated case of gonorrhoea is usually as follows : After a period of incubation varying' from three to seven daj'S, during which the gonococci have been propagating* their kind at the point of inoculation, and invading the urethra in the immediate vicinity, a visible inflammatory reaction is manifested, as a slight swelling and hyperemia of the lips of the meatus, accompanied with an itching of the parts that may be slightly painful during and immediately after urination.

The gonococci penetrate between the epithelial cells lining the urethra, passing to the deepest portion of the lacunae and glands of Littre. They may invade the submucosa, but are there found in much fewer numbers than in the mucosa, for in the former situation they have to contend with the free vascular supply of the tissues, which furnishes an army of white blood-cells, and if we accept the theory of Metsclmikoff, combats the invading micro-organisms by taking them up and carrying them to the free surface of the urethra ; hence the purulent discharge so characteristic of the disease.

The gonococci are propagated between the layers of the epithelium, and to a still greater extent on its free surface, and infect the urethra by a process of extension along the surface, and to a lesser extent by extension in •the tissues of the urethra itself. It will be seen therefore that accidental circumstances, such as injections or instrumental interference, may modify the natural course of the disease by carrying the gonococci backward and more rapidly infecting the deeper portion of the urethra.

The theory that has recently been brought forward, that infection of the entire urethra takes place almost simultaneously, through the medium of the lymphatics, seems scarcely probable, and is opposed to the clinical experience of most observers. This theory is advanced to strengthen the statement that infection of the posterior urethra is so common that it should be considered rather as a part of a typical gonorrhoea than as a complication. I cannot give support to either the theory or statement, but must hold in the light of my own clinical experience and investigation, which coincides with that of the majority of writers on the subject, that infection travels chiefly by extension along the free surface of the urethra, and that it, in uncomplicated cases, is arrested at the part grasped by the compressor urethra?, for the reason that at this point the secretions are prevented, by the tonic contraction of this muscle, from passing farther backward. When infection of the posterior urethra does take place, it may be due to the infective secretion being carried backward by the use of instruments or injections, or perhaps more often by extension of the process beyond the external sphincter by continuity of tissue. The fact that the membranous urethra is almost devoid of glands or lacunae might deter extension by the latter process.