Part 47

Retention of urine is caused by paralysis of the bladder, from over-distention, from injury or disease of the spinal chord, from pressure on the spinal chord or nerves. In such cases the bladder often attains a very large size. At first the accumulation produces all the uneasy symptoms formerly mentioned, but after some time these subside, and the urine drains away according as it is secreted, without, however, the original accumulation and tumour being diminished. This state of the urinary system is very common in old people, who neglect natural calls to empty the viscus during the night, or while sitting socially after dinner. The uneasiness gradually goes off, and when they at length think of making water, none can be got to flow. Sometimes they remain in this state—the bladder full, and becoming more and more distended—for days, drinking gin and water, juniper tea, or other popular remedies. Incontinence then takes place, and the dribbling of the urine affords considerable relief; this state of matters is often allowed to continue for weeks. Thus the power of expulsion may be lost for ever, though sometimes it is regained even under very unfavourable circumstances. I recollect attending a man upwards of eighty, labouring under retention of urine with incontinence, and whose bladder required relief by the catheter for ten or twelve days; at the end of that period the bladder regained its expulsive power and retained it; and cases are on record in which the power of expulsion has returned after the lapse of several months. Retention thus induced is often complicated with disease of the prostate gland or of the urethra. The patient, perhaps, has been for a long time incapable of emptying his bladder completely; a portion of the urine always remains in the most dependent part of the viscus, and the quantity retained becomes greater and greater, until from some slight cause the power of expulsion is lost entirely. In these cases the bladder, though much increased in capacity, is also much thickened.

Retention from inflamed urethra, attended with swelling and spasm about the neck of the bladder, is preceded by hardness and tenderness in the course of the urethra, and a smarting felt when a drop of urine passes along. Retention not unfrequently takes place during gonorrhœa, from the dread which the patient has of making water; and from the swelling of the lining membrane.

Retention from abscess in the perineum was formerly noticed.

Retention from injuries in the perineum. The urethra is either severely bruised, perhaps lacerated, or torn completely across; and if the patient attempts to make water before proper means are adopted, blood and urine are extravasated into the cellular tissue exterior to the canal. In cases of slighter injury, retention may occur on account of the inflammatory swelling of the parts supervening secondarily.

Retention from stricture of the urethra is of very frequent occurrence, and most difficult to manage. The state of the urethra and bladder in this disease has been already adverted to, but it is necessary to bear in mind the thickening of the latter, and the dilatation which uniformly takes place behind the stricture. All the urgent symptoms of retention may, in this case, arise from the accumulation of but a few ounces of urine. The bladder contracts frequently and very forcibly, causing great suffering. Temporary relief is experienced when the urethra gives way by ulceration, and the urine becomes extravasated into the cellular texture; the patient gets up, and, if in the dark, thinks that the stricture has yielded, and that he is passing urine naturally. But soon he feels a glowing heat in the perineum; the parts swell and become livid; violent constitutional symptoms come on, the discoloration advances, the integuments slough, ill formed matter is discharged, and disorganised cellular tissue mixed with putrid sanies is exposed. The parts exhale a urinous odour, which, when once smelt by the practitioner, can never afterwards be mistaken. Occasionally œdematous swelling of the penis takes place, particularly of the prepuce, when it has been pulled at and bruised during the patient’s efforts to make water, and this must not be confounded with infiltration of urine; I have seen it occur some time after the bladder had been relieved by the catheter. Infiltration of putrid serosity into the cellular tissue of the prepuce, the subcutaneous tissues of the penis, scrotum, and lower part of the abdomen, occasionally also takes place to a great extent, after the bladder has been relieved by the catheter, the coverings are destroyed, and the patient may, even despite of active treatment, perish in consequence. In such cases, a small quantity of urine may possibly have escaped into the cellular tissue before the bladder has been relieved, so as to commence the mischief.

Retention from the lodgement of calculi. Temporary obstruction to the flow of urine is sometimes experienced from calculus in the bladder. Complete and fatal retention has arisen from calculi having become impacted in the urethra, and been allowed to remain there, blocking up the passage entirely.

Retention from affections of the prostate gland and neck of the bladder, inflammatory or indolent. In acute inflammation of the prostate gland and cervix vesicæ, the other parts around swell, the mucous membrane becomes turgid, and the mucous secretion is increased. Suppuration may take place, and an abscess, chronic or acute, form in the substance of the gland, or in the cellular tissue exterior; the parietes of the abscess may give way, and the matter discharged into the bladder, into the rectum, or into the cellular tissue of the perineum. Bloody and mucous discharge from the urethra, frequent desire to make water, sudden stoppage of the urine whilst making water, pain in the glans penis, and other symptoms of stone in the bladder, followed a fall on the back. Afterwards, a tumour pointed into the rectum, and was opened; purulent matter was profusely discharged, and afterwards urine escaped through the aperture. The patient died in three weeks, from irritative fever, with gastro-enteritic symptoms. Along with thickening of the bladder, and disease of its mucous coat, there was found a large abscess of the cellular tissue, communicating with an abscess in the third lobe of the prostate gland, and that with the cavity of the bladder.

When the affection is less acute, the prostate slowly enlarges, from opening out of its texture, and deposition of new matter in the interstices, it becomes hypertrophied. The whole gland may enlarge uniformly, but generally one part protrudes more than the others. When the third lobe enlarges, it necessarily projects into the bladder, or into the prostatic portion of the urethra, and there, acting like a valve, causes much more formidable obstruction to the flow of urine than does enlargement of the lateral lobes; the obstruction is the more complete the greater the distention of the bladder. At first, this lobe is but slightly prominent, and of a conical form; but as it enlarges, its regularity of shape disappears, the tumour is nodulated, and in general somewhat pyriform. It occasionally projects to one side of the passage. The affection is seldom met with, unless in old people.

In consequence of prostatic enlargement, pain is felt in the perineum, with occasional throbbing, and a sense of weight; there is frequent desire to make water, the bladder is irritable, and discharges ropy mucus. There is more or less irritation of the lower bowels; there is an almost constant desire to empty the rectum, from a feeling of fulness there, and pain, often severe, is felt on going to stool; when the enlargement is great, the bowel is considerably compressed, and the feces, when solid, are passed flattened like portions of tape. Frequently there is thin mucous discharge from the urethra. In making water, the urine, as it were, hesitates, and after a while passes away, at first in drops, and afterwards in a scanty and irregular stream; pain is felt at the point of the penis, in the loins and hips, and often in the inside of one or both thighs. On attempting to pass the catheter, its extremity is obstructed in the prostatic region, and the swelling can be felt by the finger introduced into the anus. Examination of the tumour, per anum, is very often a painful proceeding; it is best accomplished after a catheter or sound has been introduced. The disease is often coexistent with calculus in the bladder. The tumour is very seldom malignant, but proves both troublesome and dangerous from its size. The bladder may become distended in consequence, though retaining the power of partially relieving itself; or the urine may come away involuntarily after some time; or retention may be complete, and, if not relieved, the bladder may slough.

It is to be recollected, that in retention of urine, from whatever cause, and particularly in that arising from prostatic enlargement, the urethra is elongated, and the bladder rises into the abdomen like the gravid uterus. The reason of such change of relative situation is sufficiently obvious, being chiefly mechanical.

Fungous, or other tumours, furnishing blood or vitiated puriform matter, now and then grow from the internal surface of the bladder, unconnected with the prostate gland. Worms, too, occasionally lodge in the bladder. Either of these circumstances may induce retention of urine. Another cause of obstruction is hernia of the bladder.

There is no disease in which the patient is more liable to be ‘bungled out of his life,’ than in retention of urine. Great credit is to be gained by judicious and skilful management of the various stages, and by expert use of the catheter in difficult cases, when other practitioners, perhaps, after being foiled, have proposed operations alarming to the patient, and, in themselves, dangerous. In no disease are patients more grateful for relief, for in this the agony is often unbearable. Immediate abatement of all painful symptoms follows skilful and prompt measures; and the superior science of one man over others is made apparent to the most ignorant observer. In over-distended bladder from paralysis, the catheter can in general be passed without difficulty. It should be of a large size, and its introduction should be repeated as often as nature calls for relief, perhaps three or four times during the twenty-four hours, until the viscus regains its tone; and this, unless irrecoverably lost, will generally be restored in a few weeks at most. Repeated introduction of the instrument is here preferable to the retaining of it; the latter measure should always be avoided, unless absolutely indispensable, for a foreign body lodging in the urethra and neck of the bladder must always be a source of more or less irritation; and experience shows that the bladder sooner recovers its tone when the instrument is introduced only to draw off the urine, when the uncomfortable feelings of distention come on, than when it is constantly retained. The patient soon learns to pass the instrument himself, and thereby saves the surgeon from frequent attendance, whilst, at the same time, the bladder is opportunely relieved. Stimulants, as the tinctura lyttæ, given internally, with external friction, blistering, and the application of strychnine to the raw surface, may contribute towards restoration of the muscular power of the organ. Injections into the bladder have been recommended, but are both hurtful and inefficient. Enemata, containing turpentine, or other stimulating fluids, are of service.

In retention from inflamed urethra, the catheter should, if possible, be dispensed with. The introduction of it is excruciatingly painful, and will certainly aggravate the original affection. Blood should be abstracted both from the system and from the perineum; fomentations, with the warm bath or the hip bath, are afterwards to be employed. The retention is usually induced by hard exercise, or intemperance in living; these of course must be abandoned, and their opposites enjoined. Camphor alone, or combined with opium or hyoscyamus, is to be given internally in large doses. Opium may also be useful, administered in the form of an enema or suppository. If relief is not soon afforded by such soothing measures, the bladder must be relieved by the catheter; and if the surgeon be foiled in the introduction of this, as he ought not to be, the only resource is to puncture the bladder from the rectum—a harsh measure, to be sure, and one not indicative of surgical talent, but still preferable, in the eyes of both patient and practitioner, to death.

In retention from abscess in perineo, a little delay is allowable under the employment of palliatives, when the affection is acute. The abscess must be freely opened as soon as its seat is discovered; and until the evacuation of the matter, the use of the catheter should be deferred if possible. In cases of chronic abscess, the catheter must be used, and does no harm.

In retention from injury of the perineum, the catheter should be passed before the patient attempts to make water, and the instrument must be retained; thus extravasation of urine in addition to the blood into the cellular tissue will be avoided. If extravasation has occurred, the perineum, scrotum, or other parts, must be freely incised wherever the urine has been effused, in order to prevent the direful effects of lodgement of that fluid; and then the catheter should be passed and retained as in the former instance. If the surgeon be foiled in introducing an instrument, as he may be, and if the prostate be sound, the bladder must be relieved by puncture from the rectum.

Retention from stricture is, as already observed, the most difficult to manage. No time can be put off in bleeding or warm bathing, in giving internal remedies, or exhibiting enemata. The viscus is making violent exertions to relieve itself, and if these are left unassisted, or not rendered unnecessary, they may prove the patient’s destruction. The system may be drained of blood, and the body parboiled, without the patient being relieved. The case requires immediate and decided practice; for whilst the surgeon is consulting about what is to be done, the urethra may give way, and the patient be lost. The discharge of a small quantity of urine may follow the introduction of small flexible bougies, up to the contracted point, but the bladder is not relieved. The throwing of cold water on the thighs may, in slight cases, induce such contraction of the expelling muscles as may overcome the resistance in the urethra, and this method has been had recourse to after failure with the catheter; but he must be a very poor surgeon indeed who is foiled, when such practice afterwards proves successful.

Immediate recourse must be had to the firm silver catheter, proportioned in size to the tightness of the stricture, and the difficulties afforded to its introduction must be overcome by skill and perseverance; it is no easy matter to pass the instrument in many cases, and particularly when ineffectual attempts have been made previously. By gentle insinuation, and perseverance in moderate pressure, properly directed, the obstacle can always be overcome,—and that without the infliction of any injury to the parts. I may here observe, that I have never yet been foiled in passing the catheter, though very many severe and difficult cases have fallen to my lot; in other words, I have never been obliged to abandon my attempts to obtain an exit for the urine by its natural passage, and, as a last resource, to mutilate and endanger a patient by making an unnatural aperture in his bladder. Yet circumstances may soon occur to me in which the introduction of an instrument along the urethra shall be impossible; no man, it has been said, can be always wise or always fortunate; and he who pretends to invariable success must be either a knave or a fool.

Should the surgeon fail in passing the catheter, the bladder must be relieved at all hazards; and if the prostate be sound puncture by the rectum may be performed. This is neither a difficult nor a dangerous operation, else it would not be so often resorted to; it does not require so much skill and management as does the passing of a catheter. Neither is it painful to the patient; the parts to be perforated are thin, there is scarcely any effusion of blood, and all is done in the dark. But it is an operation which should never be thought of, unless as a last and desperate remedy; it is one in which I have had no personal experience, though when a student of surgery I have seen it done a few times. The procedure gives temporary relief, but then the urethra still remains to be put into a proper condition; a man cannot always void his urine and excrement through one common cloaca. If the urethra be cleared, the recto-vesical aperture may soon close. After the bladder is relieved, the urethra may become quieter, and admit of an instrument being more easily passed; but it is of very great consequence to effect the introduction of a catheter at the first.

Rather than puncture the bladder, the stricture should be cut down upon, and an opening made into the dilated part of the urethra behind the obstruction. A firm silver catheter is passed down to the stricture, and retained there by an assistant; an incision in the line of the central raphe—supposing the constricted part to be in the perineal region—is made over the extremity of the instrument, the contracted part of the urethra is divided, and the catheter passed on into the bladder. Thus, even in the worst cases, the natural canal is at once established. In every instance of difficulty and complication, the catheter, however passed, should be retained for two or more days. The above is the only admissible mode of puncturing by the perineum. It has been proposed to reach the bladder from the perineum either by extensive incisions or by the random thrust of a long trocar; the latter mode is unscientific, the former is unnecessarily painful, serious, and difficult; both are dangerous, and to be avoided.

The symptoms of extravasation of urine have been already detailed. The practice must be bold, and adopted without hesitation or delay. No bulging or fluctuation in the perineum is to be waited for. It is to be kept in view, that the escape of urine into the open cellular tissue may occur in a case of bad stricture, from rapid ulceration or sloughing, without any of the dilated portion of the canal behind, induration or abscess having preceded it; in the greater number of cases the infiltration arises from the giving way of the parietes of a cavity comunicating with the canal. Urinary infiltration thus supervenes upon urinous abscess. Extravasation can never be mistaken or overlooked by a man of any experience, and who is endowed with common observation. The effect and extent of the perineal fascia must be borne in mind; it diminishes or precludes—when the point at which the urethra has given way is interior to it—external appearance of the mischief, and by confining the deleterious fluid increases the infiltration internally. A free and deep incision holds out the only chance of relief; punctures or trifling scratches are worse than useless; neither is there any need of passing bougies or catheters, or of puncturing the bladder.

The following instructive case may be briefly detailed. A man applied at a public hospital for relief, with a large swelling in the hypogastrium, occasioned by extensive infiltration of urine into the cellular tissue of the abdominal parietes. The tumour was mistaken for distention of the bladder, and a long trocar was plunged in above the pubes without a drop of urine escaping. The patient died during the night. The bladder was found contracted, and the external cellular tissue of the abdomen full of urine, from the giving way of the urethra.

When judicious and energetic practice is adopted without delay, patients often make wonderful recoveries. The following may serve as an example:—An elderly man laboured under retention, and his bladder became distended to a very great degree; attempts had been made to relieve him, but proved unsuccessful. A catheter was passed, and retained for three days. During my absence in the country retention again occurred, followed by extravasation. On my return I found him insensible, but immediately turned him round in bed, and opened the perineum freely, giving vent to fetid urine, sloughs, and matter. Next day he was delirious, and knew no one; he hiccoughed, and had cold extremities; “he fumbled with the sheets,” and “his nose was as sharp as a pen.” A physician in attendance, well acquainted with disease, declared that he could not live six hours. But the urine had a free exit, the hiccough ceased on the exhibition of spiritus ammoniæ aromaticus, and wine and brandy were poured into him liberally, the only favourable symptom being, that he still retained the power of swallowing—when that is lost, all is generally lost. He took soup along with the stimulants readily and greedily, and, to the astonishment of every one, recovered rapidly; afterwards the stricture was got rid of, and restoration to perfect health completed. Many cases of similar import might be related, all showing the great danger of extravasation of urine, and the advantage of early and decided treatment. I once also witnessed, in the Royal Infirmary, an unexpected recovery from extravasation into the corpus spongiosum urethræ. This occurrence is always attended with most imminent risk; and is generally the result of retention from stricture. The urine escapes into the bulb, or anterior to it. Alarming constitutional symptoms quickly supervene; rapid sinking is threatened. The whole penis, scrotum, and perineum are swollen, but the swelling is hard, and most marked in the glans and along the course of the urethra. The glans blackens, unhealthy abscesses form in the spongy body, and before these give way, or at least before the sloughs begin to separate, the patient usually perishes. The man to whom I allude, however, recovered, retaining a part of the penis, as well as a considerable portion of its integuments; the rest sloughed and were discharged.

In regard to retention from swelling at the neck of the bladder, it may be observed, that spasm of that part of the viscus has been, by some, considered as a cause of the affection; it is not easy to explain or understand how this should occur, and such an idea is a bad one for him to entertain who enters on the treatment of the disease. The capacity of the bladder varies much in cases of enlarged prostate; in general the organ bears a good deal of distention, and the urgent symptoms do not appear rapidly. Nevertheless, it is the duty of the surgeon, immediately on being called, to relieve the bladder. When the prostate is very large, and retention has continued long, it is impossible to reach the cavity by a common catheter. Those who employ this instrument in such cases are often much puzzled; they continue long in their fruitless endeavours, and, from rashness, generally produce a discharge of much blood, but no urine; they then become alarmed on finding the instrument always filled with coagulum, and suppose that blood has been effused into the bladder, and that the symptoms of retention have been thus introduced. A catheter is to be used, which is two or three inches longer than the common one, possessing a larger curve, of such a size as to admit of being passed easily, and not so small as to render it liable to interruption from entanglement in the lacunæ of the urethra. The posterior part of the urethra is elongated to no slight extent by the enlargement of the prostate, and, besides, the whole canal is stretched by the distended bladder rising high in the abdomen. In short, the bladder is farther away from the surgeon than it is in other cases of retention, and he requires an instrument proportionally long in order to reach it. No time is to be put off. A cautious and persevering endeavour must be made to bring away the urine by the natural passage. Force is prejudicial and unnecessary. It is true that the projecting third lobe of the prostate has not unfrequently been perforated by the catheter, and no unpleasant consequences have resulted, the urine continuing to flow, perhaps freely, through the artificial opening there; but still it is always an injury, often an unnecessary injury, and as such to be avoided. The catheter is to be passed steadily on till it approaches the prostatic region; it is then to be guided by the forefinger of the left hand introduced into the rectum, and when the point is lost in passing through the gland, the instrument is carefully carried forward by depressing the handle, and, if long enough, it will infallibly reach the urine and relieve the bladder. It must, indeed, be a very extraordinary case in which the bladder cannot be reached with the catheter.

When enlargement of the prostate, whether of the whole gland or principally of the third lobe, presents an insuperable obstacle to the passage of the catheter, and when the surgeon has taken care to assure himself that such is the case, I conceive that he ought to perforate the gland in the direction of the natural course of the urethra, not with the catheter, but with an instrument better adapted for the purpose—a long canula, or catheter with open end, very slightly curved towards the extremity, provided with two wires, one blunt and bulbous at the extremity, the other pointed as a trocar, both made so as to project a short way beyond the end of the canula. The canula is passed on to the resisting body, its orifice occupied by the bulbous wire, which is then withdrawn, and its place supplied by the trocar, the instrument being held steadily in the proper direction. The trocar, or stilet, is pushed forwards along with the canula; the former is then withdrawn, and the latter retained. This proceeding I consider quite safe in the hands of an experienced surgeon, one well acquainted with the urinary passages—but not otherwise. It is in every way preferable to puncture of the bladder above the pubes, to puncture behind the prostate, or to puncture of the prostate along with wound of the rectum.

As before noticed, I never have had occasion to puncture the bladder but once—and that was above the pubes, and for an unusual affection of the bladder, the particulars of which have been already detailed. The result of the experience of several eminent surgeons, both in this country and abroad, is similar.

Elastic gum catheters have been recommended in this affection, and it is said that after the instrument has been passed to the prostatic region, its entrance into the bladder is facilitated by gently withdrawing the stilet, the point of the catheter being thereby curved upwards, and, as it were, lifted over any central projection of the prostate that may impede its straightforward introduction. But according to my experience, this instrument is far inferior to the firm and long silver catheter.

In all cases of retention when the urine cannot be brought away per vias naturales, and when no farther assistance or advice can be procured immediately, the surgeon should puncture the bladder rather than leave the patient to his fate; and the operation should be performed early. He must not temporise till all chance of recovery has gone by. By not operating till late, in this or any other disease, when by the delay no reasonable chance of saving the patient remains, our department of the profession is brought into discredit and contempt. Delay is more dangerous than even the worst mode of making an opening into the bladder; and while life exists, the patient should have his chance. Some defer extreme measures from day to day, either from hesitation or from a false hope that matters may ultimately change for the better, but the delay of one hour is in many cases most hazardous. In retention from disease of the prostate extravasation of urine is more dangerous—more certainly fatal—than in other circumstances. Here a part of the vesical parietes gives way by sloughing, and the fluid is effused within the ilio-vesical fascia; in other cases the extravasation is usually beyond that fascia, and beneath the fascia of the perineum.

Puncture by the Rectum is, in cases of enlarged prostate, inadmissible and highly dangerous; the operator must either perforate the gland, or enter the cavity of the abdomen. Even in the healthy state of parts, there is very little space between the posterior part of the prostate and the reflection of the peritoneum. The operator having ascertained that the prostate is sound, and the rectum empty, introduces the fore and middle fingers of the left hand into the bowel, and along these passes a trocar and canula from four to five inches in length, of moderate calibre, and of a curve rather greater than that of the sacrum. He places the point of this instrument on the part to be perforated, and fixes it there, the point of the trocar being hitherto withdrawn within the canula; the stilet is then protruded, and both carried onwards into the bladder. The part to be perforated is immediately behind the prostate and in the mesial line. Puncture above the Pubes is easily enough performed when the bladder is capacious, but it is at best a dangerous operation. The wound is made through loose cellular tissue; urinary extravasation into that tissue is apt to occur, and often proves fatal. If the bowels are inflamed, or evince a tendency towards inflammatory action, the danger is increased, for a formidable wound is made in the immediate vicinity of the bowels. The operation has been resorted to when the catheter might have been passed without much difficulty; this statement may appear harsh, but it is too true, and can be borne out by indisputable facts. It is brought forward more as a caution to the young than as a reflection on the senior members of the profession. Some patients have recovered from the operation, and lived in misery for months and years, passing their urine through a canula retained in the wound. An incision is made above the symphysis pubis, in the mesial line, dividing the integuments and cellular tissue, to the extent of from one to two inches; on thus exposing the coats of the bladder, a flat trocar with a canula is pushed into the cavity of the viscus, at the lower part of the wound; the trocar is withdrawn, and the urine evacuated.