February, 1952 69

Common Lesions of the 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. 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 , 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 . 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 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 , 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 , burning, and pain on urination, dyspareu- urgency, burning and pain on urination and often nia and occasionally . 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 . 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. The upon. If the meatus is narrow or partially stenosed, mucosa has a red, granular, irregular appearance. meatotomy should be done. Inflammation often extends from the urethra onto the trigone of the bladder, where there may be small Chronic Inflammation of the Urethra openings resembling infected, dilated ducts, small Chronic urethritis may follow gonorrheal infec- cysts filled with clear fluid, or a number of red tion, although it is less often a sequel now that there polyps with narrow stalks and long flowing fronds. is widespread use of the sulfa drugs and antibiotics Often present near the sphincter and interfering in the treatment of gonorrhea. Usually the urethra with its action are tiny inflammatory polyps. If the is tender and thickened, often with a stricture pres- inflammation in the posterior urethra has been pres- ent. The organism may be noted in material stripped ent a long time, there may be cicatricial changes February, 1952 URETHRAL LESIONS IN WOMEN 71 causing sclerosis of the bladder neck or median bar ages. It may be congenital, and often in young girls formation such as that observed in bladder neck is associated with partial stenosis of the meatus,4 obstruction in men. Patients in whom such changes which should be corrected by meatotomy. For chil- have taken place may have a dilated bladder with dren with or obstruction at the trabeculation and residual urine. In some cases the neck of the bladder, early diagnosis and proper ureters and the renal pelves may be dilated as a re- treatment is important lest irreversible changes oc- sult of back-pressure. Renal function studies and cur in the upper urinary tract. In older women the intravenous urograms to determine the status of the causes are acute or chronic infection of the urethra upper urinary tract should be made in most cases. (chiefly gonorrheal), and trauma in childbirth, in Local and constitutional therapy should be car- coitus, in rough instrumentation, or in operation. ried out. The urethra should be gradually dilated Senile strictures with induration of the entire canal by treatments at weekly intervals until a No. 28 or tend to occur in elderly women. No. 30 (French) sound will pass easily. The bladder The symptoms of stricture are variable and may should be irrigated with solutions of 1:10,000 potas- be progressive-from frequency, to terminal drib- sium permanganate or 1:10,000 silver nitrate both bling, to hesitancy and weakness of the urinary for antisepsis and to stretch the bladder, for often stream with difficulty in emptying the bladder, to the capacity has been reduced as a result of fre- complete . Often little girls with quent urination. A soothing antiseptic solution such stricture complain of great frequency during the as 5 per cent Argyrolg or 1:8,000 acriflavine then of may be introduced. If infection remains, the topical day, straining to void, of intermittency of urina- applications of 10 per cent to 20 per cent silver tion, and of . If infection occurs, as it may nitrate solution through an endoscope will prove if there is chronic stricture, the primary symptoms helpful. For destruction of inflammatory cysts and may be those of pyelonephritis, with backache, py- polyps, light fulguration of the growths and of the uria, chills and fever. Many cases of recurrent entire posterior urethra with high frequency current pyelonephritis in children and also in adults are has been found quite effective. In a few cases of due to urethral stricture. long-standing inflammation where sclerosis of the The diagnosis is made on the basis of a history of bladder neck with median bar formation has oc- difficulty in urinating and of recurrent urinary tract curred, causing less than complete emptying of the infection, and results of examination of the urethra bladder at urination, transurethral resection of the with a catheter, a sound and bougie a boule, and a obstructing tissue has been done, with good results. cystoscope. Resistance to passage of a catheter or Microscopically examined, the tissue removed in small sound will be noted and the urethra will seem such cases resembled that observed in chronic pros- to grip the instrument. The diameter of the urethra tatitis. (normally about 8 mm. in adults) can be deter- The constitutional therapy involves putting the mined with a sound or bougie a boule. In urethro- patient on a bland diet, forcing fluids, administering scopic examination, the urethral tissue will be ob- sedatives and antispasmodics such as Donnatal,® served as pale and cicatricial with loss of striae. ordering hot sitz baths, and abating any existing There may also be congestion, desquamation, ero- adjacent or distant foci of infection in the cervix, sion or superficial granulation. vagina, teeth, tonsils, gallbladder or gastrointestinal Treatment involves periodic dilatation of the tract. In a few cases in which the symptoms were urethra until the normal calibre is established, the not relieved by the measures described, proscribing use of certain foods or substances to which the patient was antibiotics for infection, hot sitz baths, and found to be sensitive, and administration of ephed- eradication of foci of infection. rine or antihistamines, was beneficial. Any concomi- Urethral Caruncle tant should be treated with Urethral caruncle, a friable, sensitive vascular the appropriate sulfa drug or antibiotic agent. tumor situated on the floor of the urethral meatus, Patients at or past the may have atro- is very common in middle-aged and elderly women. phic menopausal urethritis, characterized by thin- It is usually attached by a single base and protrudes ning and atrophy of the vaginal mucous membrane the external as a about the urethra with splotchy areas of reddening through orifice raspberry-like or petechiae extending into the vestibule. For such mass, which may be sessile but usually is freely patients the local use of estrogenic hormones6 with movable and pedunculated. It is soft and bleeds vaginal suppositories of stilbestrol, 0.1 mg. each, easily upon manipulation. The patient complains inserted nightly for three weeks, followed by a rest of pain, exaggerated by movement and urination, period of one week and then readministration if and of a blood-stained discharge. Bleeding, which is necessary, is often efficacious. Oral administration of usually spotty but may be heavy, is a prominent small doses of an estrogen is helpful in some cases. symptom. The blood is usually seen at the beginning or end of urination, or following coitus, friction Stricture of the Urethra from clothes or pads, or other trauma. Often car- Urethral stricture, which is pathologic diminu- uncles are exquisitely sensitive and cause such dis- tion of the lumen or of the distensibility of the tressing symptoms as to lead to neurasthenia, in- urethra, is a common condition in women of all somnia, loss of weight, despondency, melancholia 72 CALIFORNIA MEDICINE Vol. 76, No. 2 and other mental disturbances. On the other hand, diarrhea, and parturition must be considered. In in many cases there are no symptoms. the cases of two 9-year-old girls reported by Zeiger- While the cause of caruncles is not definitely es- man and Kimbrough,13 direct trauma-fall from tablished, various investigators have inculpated con- a bicycle and a kick in the vulva-was the precipi- gestion of the urethra, rupture of cysts of Skene's tating cause. ducts, chronic irritation of the urethral mucosa and The lesion is a red, congested mass that protrudes estrogen deficiency. Palmer, Emmett and MacDon- several centimeters from the meatus and exudes a ald,9 who studied 120 cases of urethral caruncle serosanguineous fluid. Occasionally infarction or from the histopathologic and clinical aspects, con- strangulation occurs and the mass becomes ulcer- cluded that caruncle is a partial localized prolapse ated and necrotic. Symptoms may be slight but there of the urethral mucosa, associated with chronic in- is usually frequency, pain and burning on urina- flammation. Begg1 agreed and said that the chief tion, difficulty in voiding, and bleeding, particu- cause of urethral prolapse is infection, present and larly if the mass is manipulated. past. The histological appearance of a caruncle is The method of treatment depends somewhat upon essentially that of chronically inflamed, proliferative the cause and the extent of the prolapse. If the mucosa; edema and vascular engorgement are cause is an acute inflammatory process, reduction prominent features. Caruncles are classified, accord- of the mass, the application of astringent compresses ing to the predominant histologic character, as and removal of the cause of inflammation may be granulomatous, papillomatous or angiomatous. all that is required. In some cases a catheter may be No treatment is necessary for small asymptomatic inserted and left in place until the edema subsides. caruncles. For others, the best treatment, in the In the author's experience, the most satisfactory author's opinion, is that suggested by Walther:12 treatment is to circumcise the redundant mucosa After local anesthetization or the administration of with high frequency current and fasten the cut edges Pentothal® intravenously, the urethra is stretched, to the vestibular margin of the vagina. Stellate ful- the tumor is grasped with Allis forceps or traction guration with high frequency current or slow elec- suture and pulled forward to expose the base. It is trocoagulation with a flat electrode is also consid- cut across at the base with an electric cutting loop, ered effective treatment. and the base then is thoroughly fulgurated to pre- Diverticulum of the Urethra vent recurrence. Care must be taken not to fulgu- Diverticulum8 of the urethra usually is manifest rate too much of the surrounding mucosa of the as a painful, fluctuating mass in the middle third of urethra lest stricture be caused. Topical application the urethrovaginal septum which communicates of silver nitrate solution is ineffective in the treat- with the urethral canal. It usually causes frequency ment of caruncle. of urination, and discomfort during coitus or when Many irritative urinary symptoms usually attrib- the patient is sitting or walking. At the end of urina- uted to urethral caruncle, when such a lesion is pres- tion there is often a discharge of pus or cloudy ent, are more often due to associated stricture of the urine. Formation of stones in the sac is rather com- urethra or chronic posterior urethritis. The author mon. In inspection and palpation of the ventral sur- carries out a thorough examination of the urethra in face of the urethra, a pouch can be seen and felt. all such cases in order to detect and correct patho- The contents, which can be expressed by palpation, logical changes. are often purulent. The site of the orifice into the After a caruncle is removed, the patient should be urethra can be ascertained by urethroscopic exam- examined frequently so that the urethra may be ination. For purposes of roentgenographic study, a properly dilated and recurrence of the tumor, which radiopaque material can be introduced through a is common, prevented. A microscopic study should ureteral catheter coiled in the sac. be made of all caruncles to differentiate caruncle Diverticulum of the urethra is believed to be from malignant tumors of the female urethra such caused by developmental defect, by herniation of as carcinoma and sarcoma, which are fortunately the urethral canal at a point weakened by trauma, infrequent. or by rupture into the urethral canal of a retention Prolapse of the Urethra cyst or an abscess of the urethral wall. The most effective treatment is complete surgical Prolapse of the urethral mucosa may occur in removal of the pouch with closure of the defect in infants and young girls but is most common in the urethra and urethral catheter drainage of the women past middle age. It may be partial but usu- bladder for a week or ten days. ally the entire circumference of the mucosa is in- volved. The chief predisposing cause is generally Congenital Valves considered to be a weakness of the urethral wall, Congenital valves or bands of tissue in the pos- which may be congenital, the result of trauma such terior urethra are not as common in girls as in boys as is sustained during delivery, or the result of gen- but must be considered in all cases of urinary diffi- eral weakness and debility. As precipitating causes, culty in the young, particularly when there is evi- such factors as chronic cough, straining at stool, dence of renal insufficiency. vesical tenesmus, calculi in the bladder, persistent 2901 Capitol Avenue. February,1952 URETHRAL LESIONS IN WOMEN 73

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