PRACTICAL CONSIDERATIONS : MALE PERINEUM. 1915 



The same symptoms frequent micturition, referred pains, tenesmus are caused 

 by a vesical calculus and have the same anatomical basis. They are most marked 

 if the stone is small, rough, and movable, so that in the erect position it falls upon 

 the trigonal surface. Such a stone may roll or be forced by the stream of urine 

 into the vesical outlet and produce sudden interruption of micturition. This 

 symptom is seen most often in young male children, in whom the relatively vertical 

 position of the bladder, the marked tenesmus caused by the presence of the stone, 

 and the small size of the vesical orifice favor its production. The tenesmus in 

 children is often so excessive as to result in prolapse of the rectum, which is affected 

 by and participates in the straining expulsive efforts. 



In a sacculated bladder a very large stone may lie in a pouch with but little of 

 its surface presenting towards the bladder-cavity (encysted stone) and give rise to 

 almost no subjective symptoms. 



Perineal lithotomy is much less frequently done than formerly, on account of the 

 application of Bigelow's operation of litholapaxy to the great majority of calculi, and 

 of the revival of suprapubic lithotomy and its use in a considerable proportion of the 

 remainder. A description of the parts involved in this operation serves, however, 

 as Treves has said, to give a proper conception of their important anatomical re- 

 lationships. 



The Male Perineum. This region a fissure when the thighs are approxi- 

 mated becomes an ample lozenge-shaped space when the legs and thighs are flexed 



FIG. 1625. 





-Tuber ischii 



\^-^ 



Tuber ischii . 



,:', -v -- \ 



Anus 



Subcutaneous 

 fibres of sphinc- 

 ter ani externus 



-Tip of coccyx 



Dissection of perineum; skin has been removed, leaving superficial fascia undisturbed. 

 Sound has been passed through urethra into bladder and scrotum drawn forward. 



and the latter are strongly abducted, the lithotomy position. It corresponds to 

 the outlet of the pelvis. On the surface it is bounded roughly by the scrotum 

 anteriorly, the buttocks posteriorly, and the upper limits of the inner aspects of the 

 thighs laterally. More deeply the boundaries are the symphysis pubis and subpubic 

 ligament anteriorly, the coccyx posteriorly, and the greater sacro-sciatic ligaments, the 



