PRACTICAL CONSIDERATIONS : MALE URETHRA. 1933 



When it escapes from the membranous urethra, extravasated urine is confined 

 to the region included between the layers of the triangular ligament, and only gains 

 access to the other parts after suppuration and sloughing have given it an outlet, the 

 consecutive symptoms then depending upon the portion of the aponeurotic wall which 

 first gave way. If the opening is situated behind the superior layer of the triangular 

 ligament, — i.e., in the prostatic urethra, — the urine may either follow the course of 

 the rectum, making its appearance in the anal perineum, or, as it is separated from 

 the pelvis only by the thin pelvic fascia, it may make its way through the latter near 

 the pubo-prostatic ligament, and may spread rapidly through the subperitoneal con- 

 nective tissue. 



((f) The bladder, ureteral, and kidney changes are similar to those that follow 

 obstruction from any other cause, and cystitis, sacculated bladder, ureteral dilatation, 

 and pyonephritis are not uncommonly terminal conditions in cases of stricture. 



Catheterism is one of the most important of the minor operations of surgery. 

 For its proper performance, even in the normal urethra, an acquaintance with the 

 differences in direction, mobility, dilatability, and contractility of that canal is essen- 

 tial {vide supra), as is familiarity with its relations to such structures and organs as 

 the triangular ligament, the prostate, and the rectum {q.v.). The following points 

 are worthy of mention here in their relation to the anatomy of the urethra, (a) 

 The penis is gently stretched, the dorsum facing the abdominal wall to avoid folds or 

 twists in the mobile anterior urethra, (b) In persons with protuberant bellies the 

 shaft of the catheter is at first kept parallel with the line of the groin ; if this is not 

 done, the point of the instrument may be made to catch in the upper wall, at the tri- 

 angular ligament, owing to the elevation of the handle necessitated l^y the protrusion 

 of the abdomen ; the handle should, in any event, be kept low until the tip of the 

 instrument is about to enter the membranous urethra. (<:) The penis is drawn up 

 with the left hand while the instrument is gradually pushed onward, the handle being 

 finally swept around to the median line, the shaft being kept parallel to the anterior 

 plane of the body and nearly touching the integument. The instrument is now 

 pressed downward towards the feet, while the left hand still steadies the penis and 

 makes slight upward traction. After four or five inches of the shaft have disappeared 

 within the urethra, it will be found that the downward motion of the instrument is 

 arrested, {d) The fingers of the left hand are then shifted to the perineum and used 

 as a fulcrum, while the handle is lifted from its close relation with the anterior abdomi- 

 nal wall and swept gently over in the median line, describing the arc of a circle. (.?) 

 After the shaft has reached and passed the perpendicular, the handle should be taken 

 in the left hand and the index and middle fingers of the right hand should be placed 

 one on either side of the root of the penis, making downward pressure (to straighten 

 the anterior limb of the subpubic curve, vide supra), while the left hand, depressing 

 the handle, carries the point of the instrument through the membranous and prostatic 

 urethra into the bladder. The entrance into that organ will be recognized by the free 

 motion that can be given the tip of the instrument when the handle is rotated, and by 

 the latter remaining exactly in the median line and pointing away from the pubes 

 when the hold upon it is rela.xed. 



In urethral instrumentation it should never be forgotten that the elasticity or 

 extensibility of the urethra resides for the most part in the spongy portion, as is clearly 

 demonstrated by erection, and this elasticity belongs in the greatest degree to the 

 inferior wall, which permits of easy distention or elongation, and changes its dimen- 

 sions and form with notable facility ; while the superior wall yields with much more 

 reluctance, and offers a certain resistance to all agents tending to depress or elongate 

 it. This difference increases with age, and obtains especially in senile urethroe. 



The extensibility of the inferior wall is brought into play even by a moderate 

 force, and the surgeon cannot count on its resistance. It glides before an instrument, 

 and cannot serve to guide it ; it cannot be incised with any accuracy or precision ; it 

 lacerates or ruptures when surprised by distention ; and it yields rapidly and easily 

 to mechanical pressure testing its extensibility. It should be noted, too, that this 

 elongation of the canal is chiefly at the expense of the anterior urethra. Again, the 

 spongy portion does not yield equally in all its parts, since it has been shown that of 

 the different regions the perineo-bulbar is the most distensible. The inferior wall of 



