PRACTICAL CONSIDERATIONS:' MALE URETHRA. 1931 



A rare complication ( Cowperitis) may result from infection of the bulbo- 

 urethral glands through their ducts which empty into the bulbous urethra. The 

 first symptom usually developed is pain in the perineum, much increased by press- 

 ure, and rendering sitting or walking markedly painful. The inflammatory swell- 

 ing of the glands is resisted by the two layers of the triangular ligament between 

 which they are situated and by the deep perineal fascia, and this resistance, associ- 

 ated with the determination of blood to the part by gravitation, imparts, as in other 

 inflammations where the same conditions exist, a throbbing element to the pain 

 which renders it peculiarly distressing. 



Posterior Urethritis. Although it is true that the compressor urethrse muscle 

 constitutes a sphincter which, by its tonic contraction, keeps the membranous part 

 of the canal constantly closed against injections forced through the meatus, the 

 gonococcus, as it passes backward in the deeper layers of the epithelium, is not 

 arrested by this muscle, but with few exceptions invades the posterior urethra, from 

 which region it can readily extend to the prostatic ducts, the seminal vesicles, the 

 vas and epididymis, and, much more exceptionally, to Cowper's glands and to the 

 bladder. 



To some or all of the above symptoms may then be added : (a) frequent and 

 urgent urination, as the normal slight desire to urinate, felt when the bladder is 

 moderately distended, the internal vesical sphincter dilates, and the urine comes in 

 contact with the prostatic urethra, is transformed into an uncontrollable desire when 

 the prostatic mucosa is inflamed and hypersensitive ; (^) tenesmus from spasm of 

 the internal sphincter transmitted to the detrusors and due to the same excitation 

 in the neighborhood of the vesical neck ; (V) cystitis (page 1914) may follow direct 

 extension of the infection by way of the mucosa ; (d~) prostatitis (page 1980) from 

 its spread along the prostatic ducts or into the prostatic follicles ; (^) epididymitis 

 (page 1952); or (/") vesiculitis (page 1960), from its following the vas deferens or 

 the seminal ducts. 



Chronic urethritis is apt to follow an acute attack because : (#) the canal affords 

 periodical passage to a secretion, the urine, which is liable, by reason of changes in 

 its constitution, to become an actual irritant; ($) it is exposed, at times of erection, 

 to intense congestion of all its vessels, and the converse is also true, a congested or 

 irritated spot along the urethra predisposing to erection ; (^) gravitation, the propor- 

 tionately excessive supply of blood to the region, and the absence of extravascular 

 resistance due to the loose character of the spongy tissue, all favor the persistence 

 of any congestion left after a first attack of urethritis ; (d) the condition of approxi- 

 mation of mucous surfaces, as of the urethral walls during the intervals of micturition, 

 is here, as elsewhere, unfavorable to the disappearance of granular or injected areas 

 or other traces of inflammation. The tendency of the gonococcus to establish itself 

 in the deeper layers of the mucous lining, and to multiply there where it is compara- 

 tively inaccessible, is another cause of the frequent occurrence of the chronic forms 

 of urethral inflammation. 



Stricture of the urethra is an important and frequent sequel of urethritis. It 

 consists essentially in a contracting peri- urethral deposit of fibrous tissue due to the 

 organization of the exudate deposited in the submucosa during the existence of a 

 urethritis. The situation of stricture varies, but there can be no doubt that the great 

 majority are to be found in the bulbo-membranous region, which includes a space 

 from about one inch in front of the anterior layer of the triangular ligament to the 

 prostato-membranous junction. The next most frequent seat is in the first two inches 

 of the urethra. The frequency of strictures in these regions is due to the fact that 

 they are exceptionally vascular and that chronic urethritis is especially apt to become 

 localized at those points. The especial abundance of follicles in the bulbous urethra 

 favors urine leakage and submucous exudate there. Gravitation in both regions 

 favors chronic congestion and may possibly of itself explain the clinical facts as to 

 frequency. The smallest number are found in. the middle of the spongy urethra. 

 These remarks apply to the form of stricture produced by urethritis. Traumatic 

 stricture usually affects the membranous urethra. Stricture of the prostatic urethra 

 is practically unknown, probably because in that region the submucous connective 

 tissue is relatively scanty, the urethra is lined with vesical or transitional instead of 



