Urethral Stricture JOHN P. BLANDY M.A., D.M., M.Ch., F.R.C.S
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Postgrad Med J: first published as 10.1136/pgmj.56.656.383 on 1 June 1980. Downloaded from Postgraduate Medical Journal (June 1980) 56, 383-418 Urethral stricture JOHN P. BLANDY M.A., D.M., M.Ch., F.R.C.S. The London and St Peter's Hospitals, The London Hospital Medical College, University of London THE earliest records of medicine are much concerned inflammation... Spasmodic stricture arises with the management of urethral strictures by means either from a contraction of the muscles sur- of catheters and sounds. In ancient India Susruta rounding the urethra, or from the urethra described the use of a reed catheter lubricated with itself... Inflammatory stricture ... is generally ghee*. In Greece, Socrates was known to joke about produced by the inflammation of gonorrhoea; the gleet of others, and poor Epicurus committed but there is another mode by which it is caused, suicide when he could no longer dilate his own and that is, the introduction of a bougie...' stricture. In Rome in the first century, Celsus (Castle, 1831). described the operation of external urethrotomy The treatment of stricture was essentially by means for a calculus impacted behind a stricture, and of intermittent urethrotomy became part of the canon of classical bouginage: copyright. medicine preserved by the Arabs only to be re- 'Bougies are made of either wax, catgut, or discovered in the Renaissance, when Ambroise silver: and they are usually numbered from 1 to Pare (1510-1590) devised an instrument for scraping 16 according to their dimension, so that the 'carnosities' from the urethra. Silver catheters surgeon may, on each occasion, know the armed with a concealed lancet were in use in 1795, size he is using, and the size last used' (Castle, and in 1817 Civiale of Paris devised a practical 1831). internal urethrotome, improved by Maisonneuve The word bougie is of some interest: Bujiyah was in 1848 to screw on to a filiform guide. Gonorrhoea the name of the Algerian town from which came http://pmj.bmj.com/ to the ancients was hardly more than a cold in an the best wax for candles, for, as Castle again writes: awkward place: Boswell makes little of his own attacks, and the gleet put a gentleman in the com- 'The wax bougie is the one in general use... pany of the great, which included Henry IV and with respect to wax bougies, before introducing Napoleon (Attwater, 1943; Lytton, 1976; N. I. them into the urethra, you should always warm Lopatkin, personal communication, 1977). them by the fire, for the purpose of rendering For many years the distinction between gonor- them soft; when, if they are introduced into rhoea and was obscured their common the urethra, and pass through the stricture, you on September 26, 2021 by guest. Protected syphilis by will ascertain the distance at which it is situated origin: from the orifice and the form and size of the 'Gonorrhoea has some relation not understood stricture will be modelled on the bougie' to syphilis: it is capable of producing inflamma- (Castle, 1831). tion of the joints and of the mucous membrane and internal structure of the eye, and is the Not all strictures would yield to the wax bougie, common cause of stricture' and indeed Castle himself preferred one made of (Mayo, 1836). silver-having first explored and obtained a cast of To the practical surgeon, there were several recog- the stricture with a warmed wax one. An instrument nizable varieties of stricture: virtually identical to the silver bougie was in regular 'There are three kinds of stricture of the urethra; use for the diagnosis of stone in the bladder-the the permanent, the spasmodic, and the inflam- silver sound clicking against the hard calculus-and matory. The permanent stricture is the result over the years in the treatment of stricture the word of a of the urethra from chronic sound became synonymous with bougie so that thickening today thay are interchangeable (Lytton, 1976; * Rendered butter used for cooking. Attwater, 1943; Loughnane, 1948). 0032-5473/80/0600-0383 $02.00 © 1980 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.56.656.383 on 1 June 1980. Downloaded from 384 John P. Blandy When modern pathology was introduced in the The fundamental difficulty was to prevent contrac- wake of the application of the microscope to human ture in the scar around the urethra, and it was from tissues surgeons began to realize that any cause of the experience of the plastic surgeon dealing with inflammation would lead to granulation tissue burns that the urologist learned that only the formation, and that this would be followed by application of skin could inhibit the contracture of scarring, which would give rise to contracture in the connective tissue. The severe aftermath of deep skin, and stricture in a hollow organ such as the burns posed an analogous problem to the plastic urethra. Unfortunately there seemed no way to surgeon: if he had the opportunity early in the hinder the process, and surgeons were obliged to course of the burn, he would remove the dead tissue, rely on regular dilatation as the standard method of apply split skin and prevent contracture. If he only management of a stricture. Indeed, even today, came in late in the course of the disease, he had to regular gentle and skilful dilatation is still the make use of Y-V and Z-plasties with which to standard against which any other method must be insert a gusset of supple and healthy skin per- measured (Blandy, 1976a). manently to enlarge the contracted scar. To do this It is small wonder that generations of surgeons in the urethra was plainly very difficult. Probably cast about for some more effective method. Of these Duplay (1886) was the first to devise such an the use of 'escharotics', i.e. caustic soda or silver operation in which at the first stage the stricture was nitrate fused to the end of a silver bougie, were in slit open and sutured to the edges of the penile or common use in the eighteenth and nineteenth scrotal skin. When it had healed and the scar was centuries, but with variable success, and with no mature, at a second stage Duplay fashioned a new great permanence (Castle, 1831). Again and again urethra from full-thickness skin. Duplay's operation surgeons devised new kinds of knife with which to was probably never very successful (Immergut, slit the stricture from within: 1967) for it was often succeeded by fistulae and 'Puncturation or division from within, I have infection. In those days without fine catgut or anti- and recommend it in biotics, and with only irritating red rubber catheters, employed successfully, in the skin could have impervious stricture situated in the first four primary healing perineal copyright. inches of the urethra-that is to say, in the part occurred only in the exceptional case. which admits of being drawn into a straight At the same period, others were experimenting line. At the common situation of stricture this with the use of large full thickness skin patches for method is and uncertain' the repair of large hernial defects, only to find that dangerous (Mayo, after a few months the skin would fold up into a 1836). pouch or tube, hairy side on the inside. This tendency Despite the newer instruments of Maisonneuve and for a tube to be formed from a buried skin strip led Otis, the position had not changed a century later: Denis Browne to devise an for (1936) operation http://pmj.bmj.com/ 'Internal urethrotomy is an operation of choice, hypospadias which was so successful that surgeons not of necessity, and by itself does not cure. came to his theatre to learn how to do it, amongst It must be followed by full sized bougies at them Johanson (1953) and Swinney (1954) who regular intervals until eventually twice a year adapted Browne's principle to the problem of the for the remainder of the patient's life' (Lough- complicated or impassable urethral stricture of the nane, 1948). adult (Fig. 1). At the first stage the narrow inflamed of the urethra was laid or cut Sometimes caused severe part open away urethrotomy haemorrhage- entirely. When it had healed, a skin strip was used on September 26, 2021 by guest. Protected an accident which led Fenwick to abandon the Otis to form a new urethra (Fig. 2). instrument at St Peter's (Attwater, 1943). Such an operation was however not without its Forcible rapid dilatation was also tried again and difficulties, for fistulae were common, and unless again-every urological department has a drawerful great care were taken with the measurement of the of rusting Kollmann's dilators, now quite out of skin strip, the new lumen was either too big, or too favour: small. Kaufman, Pearman and Goodwin (1962) 'The evolution of expanding dilators was from reported their own disillusion and their results-no those surgeons who favoured rapidity, and who fewer than 5 of their first 10 cases developing a new contended that they could quickly cure a stricture after the first stage of Johanson's operation. stricture. However, events showed that stric- In London the foremost exponent of Johanson's tures rapidly dilated were prone to recur, unless procedure was undoubtedly Turner-Warwick, whose bougies were subsequently passed at regular teaching at St Paul's Hospital, influenced his con- intervals, and if this were not done then the temporaries (including the writer) who had never ultimate condition was much worse, because of until then witnessed such a radical attempt to cure increased fibrosis' (Loughnane, 1948).