1932 HUMAN ANATOMY. 



columnar epithelium and is supported on all sides by the firm glandular structure, 

 thus offering greater resistance to and limiting the outward passage of inflammatory 

 exudate or of urine. 



The siibjective symptoms of stricture are due to the interference of the coarctation 

 with the normal passage of urine through the urethral canal and to the physical 

 changes in the urethra, and the resulting irritation and inflammation. 



The urethra behind a stricture becomes dilated and thinned, the walls atrophy, it 

 is deeply congested, the increasing pressure produces pouching or dilatation, the 

 retained urine, decomposing, sets up a superficial inflammation, the mucosa is denuded 

 of its epithelial layer, urine escapes into the spongy tissue, and abscess or serious 

 extravasation may follow. 



During this process (which may not pass through all these stages) the most 

 important symptoms having a definite anatomical basis are as follows : 



(a) Frequency of iirination : this arises first from the change in relation betw'een 

 the expulsive force required of the bladder and the accustomed demands upon it ; then 

 from extension of inflammation backward by continuity until the vesical neck is 

 involved ; often from the production of a genuine cystitis ; later from atony with 

 retention. 



iyb) Dribbling after urmation depends upon the retention behind the stricture 

 of some drops of urine, which escape by gravity after the act of micturition is com- 

 plete. It is not infrequently a very early symptom, dependent on irregular action of 

 the circular muscle-fibres of the urethra. The dribbling, which is called the ' ' incon- 

 tinence of retention," — the overflow from a distended bladder, — is a very late symp- 

 tom, following retention and usually associated with a high degree of atony. The 

 incontinence of stricture is to be diagnosticated from the incontinence of prostatic 

 hypertrophy by the fact that it is at first worse in the daytime, and only becomes 

 nocturnal later. The reverse is the case in prostatic incontinence. The mechanism 

 of incontinence of urethral origin is simple. The dilatation of the urethra behind the 

 stricture having extended to the neck of the bladder, the urinary reservoir becomes 

 in shape a funnel, the bladder representing the base, the neck situated at the point of 

 stricture. The patient being in the erect position, the weight of the column of urine 

 comes directly on the stricture, which permits it to filter through drop by drop. In 

 dorsal decubitus, on the other hand, the bladder fills up and retains its contents until 

 the changes in it and in the urethra are very far advanced. In the prostatic patient 

 it is possible that the physiological congestion of the lumbar cord produced by the 

 recumbent posture makes urination more frequent at night and during the early 

 morning hours. It lessens as the day goes on, and it is only later when the bladder 

 becomes confirmed in irritability that diurnal frequency follows. 



(^) Retention of 2irine may occur early and suddenly from an acute increase of 

 the congestion of the mucous membrane of the strictured region, or it may be a late 

 symptom and dependent on the great obstruction offered by the stricture. 



Ardor urina-, change in the character of the stream, diminution of expulsive 

 power, vesical tenesmus, and urethral discharge may occur, but are not constant, and 

 require no explanation from an anatomical stand-point. 



(yd) Extravasation of zcrine is one of the most serious of the late results of 

 stricture. The localizing symptoms — those which indicate the point at which the 

 urethra has given way — depend upon the course taken by the urine. In all that part 

 from the meatus to the scrotal curve, extravasation is accompanied by a swelling of 

 the penis, greatest in the immediate neighborhood of the point of escape. In the 

 region included between the attachment of the scrotum and the posterior part of the 

 bulb the course of extravasated urine is governed by the attachments of the deep 

 layer of the superficial fascia, or the fascia of Colles. Extravasation of urine occurring 

 through a solution of continuity in this region of the urethra will first follow the space 

 enclosed by this fascia in front and below and by the inferior layer of the triangular 

 ligament posteriorly, and as it cannot reach the ischio-rectal space on account of the 

 attachment of the fascia to the base of the ligament, and cannot reach the thighs on 

 account of the attachment of the fascia to the ischio-pubic line, it is directed into the 

 scrotal tissues, and thence up between the pubic spine and symphysis until it reaches 

 the abdomen. 



