CHAPTER VIII THE INVESTIGATION OF THE URETHRA, BLADDER, AND (Part 1)

CHAPTER VIII THE INVESTIGATION OF THE URETHRA, BLADDER, AND URETERS Instruments used, p. 99. Anatomy, p. 100. The urethra, p. 100. The bladder, p. 101. Land- marks in the bladder, p. 102. The ureters, p. 104. The examination, p. 107. Catheterization of the bladder, p. 108. Search- ing the urethra and the bladder, p. 108. Direct endoscopy and cystoscopy with air distended urethra and bladder, p. 110. Catheterization of the ureters, p. 115. Indirect cystoscopy with water distended bladder, p. 117. Chromocystoscopy, p. 119. In this chapter we will consider only direct urethroscopy and cystoscopy by means of a simple tube (the Kelly cystoscope) and reflected light, as a means for the inspection of the urethra and bladder, for it has been found in the author's experience, to meet satisfactorily the gynecologist's requirements for diagnosis. More- over, the method is easily learned and simpler than cystoscopy with a Nitze cystoscope or instrument of that class, by which an electric lamp is introduced into the water-distended bladder. As indirect, electric cystoscopy is applicable occasionally where the air-dis- tended bladder method cannot well be used, and as many physicians prefer it as a method of diagnosis, I have added as an appendix a description of the steps of this sort of cystoscopy as I have seen it employed in competent hands. INSTRUMENTS USED Silver female catheter, long. Kelly meatus calibrator. Kelly steel urethral sounds, one set. Kelly cystoscopes, Nos. 8, 10, and 12. Kelly ureteral searcher. 99 100 THE URETHRA, BLADDER, AND URETERS Two Kelly ureteral catheters . Rubber bulb and tube for suction. Alligator bladder forceps. Uterine applicator. Sims speculum. Head mirror. To this list of instruments are added: A sterile ten-per-cent solution of cocaine hydrochlorate in water. A sterile four-per-cent solution of boric acid. Absorbent cotton. A sterile eight-ounce bottle with stopper. Two sterile two-ounce bottles with stoppers. A two-quart fountain syringe, and a Collapsible tube of lubrichondrin, or K-Y jelly. Not every woman who complains of urinary symptoms is to be subjected to a cystoscopic examination. For instance, frequency of micturition associated with early pregnancy, although not pre- cisely normal, generally represents increased congestion of the upper urethra and the neck of the bladder, due to the pregnant state, and is to be disregarded, unless the symptoms are so severe that they undermine the health by interfering with rest and sleep. Only when urinary symptoms are persistent as well as severe, are the urinary organs to be investigated. Before proceeding to the examination let us review the salient features of the anatomy of the urethra, bladder, and ureters. ANATOMY The Urethra. — The urethra is a membranous canal varying from an inch and a quarter to an inch and a half in length (3 to 3.5 centimeters) extending from the meatus urinarius to the neck of the bladder. It lies under the arch of the pubes, its lower extremity being separated from the pubic bone by about four-tenths of an inch (1 centimeter). It is parallel with the vagina and is embedded in its wall, its course being slightly curved, the concavity directed forward and upward. Its diame- ter when undilated is about a quarter of an inch (6 millimeters). ANATOMY 101 The meatus urinarius opens into the vestibule just above the open- ing of the vagina. In virgins the meatus is a vertical slit about a fifth of an inch long, formed by two little lips which close the orifice and protect it from infection. In old women these lips are lacking. The wall of the urethra consisting of three coats, muscular, erectile, and mucous, is about one- fifth of an inch thick and is dilatable to a consider- able degree, the meatus being the most resistant part. It is not safe, however, to dilate the urethra beyond twice its normal diameter, i.e., beyond half an inch (12 millimeters), because of the danger of permanent inconti- nence of urine. When the urethra is not distended the mucous coat is thrown into longitudinal folds, one of which, placed along the floor of the canal, resembles the verumontanum in the male urethra. The canal is lined with stratified epithelium, which be- comes transitional near the bladder. In the floor of the urethra are two little tubular glands, half an inch long and about a thirty- second of an inch in diameter, placed length-wise, with their ori- fices at the meatus, just within or upon the labia urethra?. These are Skene's glands. It is thought that the function of these glands is to secrete a lubricating mucus to protect the meatus from trauma during coitus. The Bladder. — The bladder, a musculo-mem- branous sac embedded in connective tissue, when quite empty and contracted is cup-shaped, and on vertical median section its cavity, with the adjacent portion of the urethra, presents a Y-shaped cleft, the stem of the Y corre- Fig. 43.— Silver Female Catheter. Fig. 44.— Kel- ly Meatus Cali- brator. 102 THE URETHRA, BLADDER, AND URETERS sponding to the urethra. When slightly distended the bladder has a rounded form and is still contained within the cavity of the pelvis ; when greatly distended it is ovoid in shape, rises into the abdominal cavity, and may reach as high as the umbilicus. Its capacity is about a pint. For purposes of description the bladder may be divided into a superior, an antero-inferior, and two lateral surfaces, also a base or fundus, and a summit or apex. The superior, or abdominal surface, is free toward the peritoneal cavity and is covered with peritoneum; the antero-inferior portion looks toward the posterior surface of the sym- physis pubis and is uncovered by peritoneum; the lateral surfaces are covered by peritoneum except in their lower portions where they come in contact with the broad ligaments; the fundus or base of the bladder is directed downward and backward and is partly covered by peritoneum and partly uncovered. It is connected with the anterior aspect of the cervix and with the an- terior wall of the vagina by areolar tissue, the union between the bladder and vagina being closer than that between the bladder and cer- vix. The upper portions of the bladder are more movable than the lower and when viewed through the cystoscope may be seen to move with respiration. The so-called neck of the bladder is the point of beginning of the urethra, but it is not a true neck, as there is no tapering part. A tonic contrac tion of the muscular fibers in the bladder wall at this point prevents the escape of urine. The bladder is composed of four coats: Fig. 46.— Kelly Evacuator. serous, muscular, submucous, and mucous. Fig. 45.— The Kelly Double- ended Urethral Dilator. Fig. 47. — Kelly Ure- teral Searcher. ANATOMY 103 The serous coat is derived from the peritoneum and is therefore partial; the muscular coat is made up of three layers of unstriped muscular fibre, two of them being longitudinal, and one, circular in direction; the submucous coat is the areolar tissue which connects the muscular with the mucous coat. The mucous coat is thin, smooth, and of a pale rose color, and is thrown into folds or rugae when the bladder is empty. There are no true glands in the mucous membrane. Landmarks in the Bladder. — When the bladder is distended with air it forms a hollow sphere. The in- ternal orifice of the urethra or neck of the bladder is a definite landmark to be recognized by the observer looking through the cystoscope as the first portion of mucous membrane which rolls into the lumen of the cystoscope as its end is withdrawn through the urethra. The ureteral orifices are two minute open- ings situated in small elevations of the mucous mem- brane of the bladder (mons ureteris), an inch apart, one on each side of the median line and each three- quarters of an inch (2 centimeters) from the internal orifice of the urethra. These three points mark out the trigone of the bladder. There is sometimes seen the interureteric liga- ment, a distinct fold elevated above the level of the surrounding mucosa connecting the ureteral orifices. The location of lesions in the bladder is described by means of these landmarks and by the natural divisions of the bladder already given. The Ureters. — The ureters are two cylindrical mem- branous tubes lying in the loose connective tissue behind the abdominal and pelvic peritoneum, about three-sixteenths of an inch (6 millimeters) in diameter and twelve inches (30 centimeters) long, extending from the pelvis of the kidneys to the bladder. The length of the ureters depends in some measure on the length of the trunk. A patient having a long trunk will have correspondingly long ureters. Different K ....v.. Fig Kell tera eter. .1 . 48.— y Ure- 1 Cath- 104 THE URETHRA, BLADDER, AND URETERS authorities give the length of the ureters all the way from ten to sixteen inches (25 to 40 centimeters). The left ureter is a little longer than the right because of the higher position of the left kidney. The ureter is funnel-shaped as it leaves the pelvis of the kidney and then the lumen has a diameter of an eighth of an inch (2 millimeters), until the ureter reaches its termination in the bladder wall, where there is a narrowing, which becomes a complete closure when the bladder is distended. This closure Fig. 49. — Kelly Cystoscope with Obturator. is effected by the oblique insertion of the ureter in the bladder wall, the mucosa and anterior portion of the bladder wall forming with the upper side of the ureter a wedge-shaped valve, the apex of the wedge being at the ureteral orifice. The ureter lies on the psoas muscle throughout its abdominal course, at the brim of the pelvis it lies on the common iliac artery. Within the pelvis it runs downward just outside the in- ternal iliac artery, and then, turning forward and crossing under the uterine artery, it passes half-way between the pelvic wall and ANATOMY 105 the cervix, at a distance of about half an inch from the latter, under the base of the broad ligament to the bladder. The ureter is com- posed of three coats, fibrous, muscular, and mu- cous. The fibrous coat is continuous with the capsule of the kidney above and- is lost in the bladder wall below; the muscular coat of the ureter proper is made up of three layers: exter- nal, internal longitudinal, and middle circular; the mucous coat is smooth and has a few longitudinal folds. It is continuous with the mucosa of the bladder below and the pelvis of the kidney above, and is composed of several layers of cells. The ureters transmit the urine from the kid- neys to the bladder intermittently by means of peristaltic waves traveling the length of the ureter. Through the cystoscope the urine may be seen to issue from the ureteral orifices in little spurts and the ureteral orifices may be seen to expand and contract, the spurts being more forcible and more frequent with greater activity of the kidneys, the normal rate being all the way from one spurt every ten seconds to a spurt every sixty seconds. Observations have been recorded which tend to prove that the movements of the orifice are less frequent when the kidney on that side is func- tionally inactive. Infection travels from the bladder up the ureter only when the valve-like arrangement at the orifice in the bladder has been destroyed, or when infective material has been introduced into the ureter, as on a ureteral catheter Or bougie. FlG# 50.-Alligato7Bladder Forceps. 106 THE URETHRA, BLADDER, AND URETERS THE EXAMINATION Suppose a woman presents herself complaining of marked pain or difficulty with urination, or she has noticed pus or blood in the urine. The examination is conducted as follows: The patient is instructed not to pass her urine, if she is able to hold it. She is placed on the table in the dorsal position (see page 33). The Fig. 51. — The Normal Bladder, Laid Open from the Front. (Kelly.) external genitals are inspected and a sharp lookout is exercised for evidences of gonorrhea, for eczematous skin lesions, or abnormali- ties of the meatus. Redness about the meatus and the orifices of the glands of Skene and Bartholin, with the possibility of expressing a drop or two of pus from the urethra by stroking its course through THE EXAMINATION 107 the wall of the vagina, makes gonorrhea most probable. Gon- orrhea being suspected, no instrument should be passed beyond the bladder neck for fear of carrying infection into that organ. Inspection shows whether the labia urethrse, which normally close the meatus in virgins, are in apposition or separated ; shows the presence of a urethral caruncle or prolapse of the mucous membrane of the urethra or a tumor in the urethra projecting through the meatus. Inspection also shows eczema of the vulva caused by the urine of diabetes mellitus. Palpation by the left forefinger in the vagina reveals thickening of the urethra and tenderness at any portion of its course, also a Fig. 52. — Urine Spurting from Ureteral Orifice, as Seen through Cystoscope. (Knorr.) suburethral abscess or tumor, and the bimanual touch reveals thickening of the bladder walls, a stone in the bladder, points of tenderness, a distended bladder, or a vesico-vaginal fistula. Per- cussion over the pubes determines an area of dullness corresponding to a distended bladder. The bimanual touch may reveal tenderness of the pelvic portion of the ureter or thickening of the ureter in this part of its course, or a stone in the ureter. To reach the upper portion of the pelvic portion of the ureter the recto-abdominal bimanual touch is best. Thin and relaxed ab- dominal walls are a necessity for success in this field of investiga- tion, although a thickened ureter may be palpated in the lowest two inches of its course by a digital vaginal examination, and, exceptionally, a thickened ureter may be seen as a ridge in the 108 THE URETHRA, BLADDER, AND URETERS vaginal mucous membrane on speculum examination of the vagina. Palpation having furnished what information it will, the next step is the passage of the silver catheter. Catheterization. — I prefer a long catheter of small caliber, because it may be used both as a searcher of the urethra and bladder as well as a catheter. The meatus, vestibule, and inner surfaces of the nymphse are sponged with three or four pledgets of cotton soaked in sterile water or weak creolin solution, each pledget being thrown away as soon as it has been used once. That is, a piece of cotton is never dipped a second time in the water. Normally the urethra, as in the case of the vagina, except just inside the external opening, is free from bacteria. Well lubricated, the sterile catheter is passed gently into the bladder, the direction of the urethra being borne in mind, at first backward parallel with the axis of the vagina until the bladder neck is reached, and then forward. Care should be taken not to touch the outer end of the catheter before the urine is collected, and the lubricating should be done directly from the collapsible tube without the intervention of the physician's fingers. The urine from the bladder is collected in the sterile eight-ounce bottle for analysis, note being made of the character of the urine as it flows from the catheter, whether clear, cloudy, or bloody. Blood at the beginning indicates that its source is the ureter or kid- ney. Also whether the last part is cloudy, showing residual pus; and the force of the stream, increased in distended bladder and in cases of pressure on the bladder by tumors or straining, decreased in atonic bladder. Suprapubic pressure may be necessary to empty such a bladder. Searching the Urethra and Bladder. — After the urine has been withdrawn the catheter is used as a searcher, the greatest gentleness being employed. The bladder walls are gone over systematically and points of tenderness noted. With a finger in the vagina and the searcher catheter in the bladder the thickness of the bladder wall at the base is estimated; a stone, foreign body, or phosphatic deposits are detected by a gritting sensation transmitted to the catheter, or, in the case of a stone, by a metallic click; sometimes a tumor is diagnosed in this way. In cases of cystitis it is not wise to sound the bladder at the same time that a cystoscopic examina- tion is to be made because the slightest trauma will cause bleeding. SEARCHING THE URETHRA AND BLADDER 109 The discharge of blood through the catheter at the end of catheter- ization is a diagnostic sign of cystitis. If there is suspicion that the bladder is contracted, its capacity may be measured by injecting with the fountain-syringe tube attached to the catheter, warm, sterile, one-per-cent boric-acid solution until the patient has a strong desire to urinate. Then disconnect the syringe tube and collect and measure the water issuing from the catheter. In cases of cystitis it is wise to irrigate the bladder with boric-acid solution before ending the examination. For this purpose the process just described is repeated several times. It is to be noted that the catheter has not been removed from the bladder since it was introduced, thus a minimum of trauma is inflicted on the urethra and vesical neck. The bladder searching being finished, the catheter is withdrawn slowly; clonic spasm of the bladder walls is noted in some cases, indicated by a drumming of the movable upper portion of the bladder on the less movable base. If the bladder is irritable or the muscular fibres hypertrophied, the catheter is seized with greater firmness at the bladder neck as it is withdrawn. When the end of the catheter reaches the urethra one notes: points of tenderness, pouches in the mucous membrane or abnormal