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Common Lesions of the Urethra in Women CARL E

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Common Lesions of the Urethra in Women CARL E February, 1952 69 Common Lesions of the Urethra in Women CARL E. BURKLAND, M.D., Sacramento Lesions of the urethra should always be consid- SUMMARY ered a possible source of abdominal discomfort in Urethral disease in women and women. Recognition of them is important not only girls often because of the distress they cause in themselves and is overlooked. As the urine may seem to be the erroneous normal as determined by repeated urinalysis, diagnoses and needless procedures the symptoms-urinary frequency and burn- that may result if they are overlooked, but also be- ing-may be attributed entirely to other pel- cause of the back-pressure effects upon the upper vic disease or to functional disorder. Since urinary tract. Urethritis in young girls'0 particu- erroneous diagnosis may lead to unnecessary larly has never been given the emphasis merited by procedures or to neglect of treatment with the incidence and importance of the disease. Too consequent development of severe disease in often in girls pyelitis is erroneously diagnosed and the kidneys or ureters, it is important to con- chronic urethritis overlooked or improperly evalu- sider urethral lesions as a possible cause in ated until more serious disease results from it. any case of abdominal discomfort in women. The most common urethral diseases in women are The most common lesions of the urethra in acute and chronic urethritis, stricture, caruncle, in- women are urethritis, stricture, caruncle, in- flammatory polyps and cysts in the posterior urethra flammatory polyps and cysts, prolapse of the and in the neck of the bladder, prolapse of the urethra, and diverticulum. In some cases urethra, and diverticulum. can on diagnosis be made simply the basis ANATOMIC AND ETIOLOGIC FACTORS of inspection and palpation. In others more extensive diagnostic procedures must be car- As the urethra in females is close to the organs ried out in order that treatment may be de- of the generative tract, it is susceptible to trauma finitive. at childbirth and to inflammation from being con- The methods of treatment, varying with tinually bathed in secretions arising from the vagina the nature of the lesion, are outlined herein. and cervix which contain a variety of pathogenic organisms. It is also exposed to contamination from the rectum. Hence the abatement of chronic endo- cervicitislor vaginitis and proper rectal and vaginal AN often overlooked cause of urinary frequency hygiene are important in the elimination of urethral and urgency in women, with burning and pain inflammation. Opening on the floor of the urethra when urine is discharged, is urethral disease of one just within the meatus are para-urethral or Skene's kind or another. glands (tubulo-alveolar glands) which play an im- In a study of 1,000 women with frequency of uri- portant part in persistent infection, chiefly gonor- nation, Bugbee2 noted that lesions of the urethra rheal, in the urethra. A few observers5 have noted were partially or wholly responsible in 690 instances. that in some women there are glands in the posterior Stevens,"1 in a report on 650 consecutive cases of urethra closely resembling the prostate. Hypertrophy urinary disturbances in women, said that in 123 of these glands or infection in them may lead to cases the symptoms were caused entirely by disease urinary obstruction. of the urethra, and in 501 cases partly by lesions there. DIAGNOSIS AND TREATMENT The In some cases of urethral disease there is referral diagnostic procedures-not all of them nec- of pain to the groin, to the lower essary in all cases, of course-consist of ordinary abdomen, to the inspection and palpation of the urethra, lumbar or sacral regions, to the rectum, or to the determina- thighs. Misinterpretation of pelvic myalgia in such tion of the diameter of the lumen (normally about 8 mm. in women), analysis and culture of urine re- circumstances may lead to unnecessary operations moved or to diagnosis of psychoneurosis and to neglect of by catheter, endoscopic and cystoscopic in- a distressing and potentially dangerous disease. It spection, measurement of residual urine, histologic is particularly noteworthy that diagnostic attention study of sections of removed tissue, and roentgeno- may be misdirected because in urethral graphic delineation of the urethral channel. In ad- disease dition in a there may be no abnormality in the urine as deter- many cases complete urologic examina- mined by simple urinalysis. tion, including studies of renal function, ureteral catheterization, and x-ray visualization of the upper Presented before the Joint Meeting of the Sections on urinary tract, should be carried out in order to make General Practice and Urology at the 80th Annual Session sure that the disease is confined to of the California Medical Association, Los Angeles, May 13 the urethra. The to 16, 1951. more extensive examination is particularly impor- 70 CALIFORNIA MEDICINE Vol. 76, No. 2 tant if there is blood or pus in the urine. It should from the Skene's glands. The symptoms are urinary be borne in mind that lesions elsewhere in the uri- frequency and urgency and constant dull pain which nary tract as well as diseases of the generative or- is often referred to the suprapubic region, to the gans often coexist with urethral disease. They may vagina or to points higher in the abdomen. The cause symptoms similar to those of disease of the treatment is to force fluids, administer penicillin or urethra, which is one reason for confusion and over- one of the newer antibiotics and order hot sitz baths. sight in diagnosis. Persistent foci of infection in the cervix, in Skene's glands or in Bartholin's glands Acute of the Urethra should be cleared up. Inflammation Chronic nonspecific or nongonorrheal urethritis, Acute urethritis in women is due in most in- a very common disease in women, occurs most often stances to gonorrheal infection, but nonspecific in- in patients in middle life and in married women. fection of the urethra is commoner in females In many cases the cause is obscure but it is usually than in males. It may be caused by trauma in diffi- the aftermath of acute inflammation of the urethra. cult labor, masturbation or coitus, by prolonged, Neglect of vulvar hygiene, trauma of childbirth, too vigorous or too frequent instrumentation, by irritation from sexual intercourse or masturbation, the instillation of strong chemical solutions, by the cervicitis, vaginitis, and infection at more remote use of improperly sterilized catheters or instruments, points (teeth, sinuses, tonsils) are considered as or by the presence of other foreign bodies, such as etiological factors. Stricture of the meatus is a pre- calculi. Patients frequently note the onset of dys- disposing factor. Hunner7 put great emphasis on uria soon after catheterization following delivery or focal infection elsewhere as a factor in nonspecific major operation, particularly operation on the pel- urethritis in women: "One learns by experience to vic organs. Interstitial urethritis may result from suspect a distant focal infection as the etiological infection focused elsewhere in the body (tonsils, factor in any urinary tract lesion, whose symptoms sinuses, teeth, cervix). Dietary errors, highly acid appear only periodically, the intervals being marked urine, and alcoholic excesses may cause much irri- by freedom from symptoms." The author agrees tation in the urethra. The urethral changes may be with this opinion and believes that with the use of secondary to cystitis or pyelonephritis. A constricted the sulfa drugs and antibiotics there is a tendency urinary meatus, interfering as it does with free to omit looking for foci of infection elsewhere, par- drainage, predisposes to infection. In some cases ticularly in the bowel and the generative organs. the origin of the urethritis is indeterminate. The usual symptoms of chronic urethritis in wo- The symptoms are diurnal frequency, urgency, men are diurnal and nocturnal frequency, severe nocturia, burning, and pain on urination, dyspareu- urgency, burning and pain on urination and often nia and occasionally hematuria. The diagnosis is suprapubic and lumbosacral discomfort. Pronounced made on the basis of the history, physical examina- nervousness is often present. Less common are se- tion, urinalysis, smears or culture of the urethral vere tenesmus, a sensation of incomplete emptying secretions, and at times examination of the urethra of the bladder, and stress incontinence. While hema- with a cystourethroscope. turia occurs occasionally, by and large the results Digital examination should be done by placing of urinalysis are normal. Upon inspection and ex- the index finger in the vagina and palpating the amination with the finger in the vagina, the urethra ventral surface of the structure. The urethra should may be noted to be slightly thickened or indurated, then be gently stripped, particularly in the region reddened, and tender. Passage of a catheter or of the Skene's glands. By this means, tenderness, sound may be difficult because of sensitivity or stric- thickening or induration of the urethra, suppura- ture. A pelvic examination, including speculum ex- tion or the presence of a diverticulum may be noted. amination of the cervix, should be carried out. A patient with acute inflammation of the urethra There may be contraction and sclerosis of the uri- must force fluids, eat a bland diet, abstain particu- nary meatus and inflammation of the Skene's ducts. larly from alcohol, tea and coffee, and take hot sitz The inflammatory changes, however, usually are baths daily. The urine should be alkalinized, and if limited to the deeper portions of the urethra3 and causative organisms such as gonococci, colon bacilli the bladder neck. When cystocopic examination is or staphylococci are found, the appropriate sulfona- carried out, inflammation of the entire urethra may mide or antibiotic should be given. In some cases be noted, but it is more pronounced in the posterior rest in bed or rest off the feet should be insisted porti'on where the blood vessels are prominent.
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