urological conditions in relation to venereal disease* · urological conditions take in the...

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UROLOGICAL CONDITIONS IN RELATIONTO VENEREAL DISEASE*

By J. SWIFT JOLY, F.R.C.S.

MADAM PRESIDENT, LADIES AND GENTLEMEN,-Thereis no doubt it is for the benefit of the patient that there arespecialists, and it is for the benefit of the profession atlarge that there should be specialists; but I sometimeswonder whether it is good for the specialist himself-whether he does not become narrow and have his viewsrestricted to one small portion of the subject of generalmedicine. I sometimes also wonder whether he does nottend to work in a water-tight compartment, and more orless ignore those who are working in neighbouring fields.

It was with very great pleasure I accepted your kindinvitation to me to come here, because it gives me theopportunity of saying something about the border-linebetween venereal disease and urology, and I expect Ishall learn as much from the ensuing discussion as youwill from my address.The first point I want to make concerns diagnosis.

We all make mistakes, some of them excusable, some not.The urologist may ignore or pass over a chronic prostatitisand be very much surprised if the patient developsgonorrhoeal urethritis three days after the examination.A venereal disease specialist may consider that thechronic pyuria from which the patient is suffering, is dueto the urethral focus, and not to some disease in theupper urinary tract. A few years ago I operated on ayoung man for stone in the bladder. He had a calculusthe size of a walnut, and had been treated for chronicgonorrhoea for a period of three and a half years. Afterremoval of the stone the pus cleared from the urine, andthere was no sign of urethral infection. Another patienthad a chronic pyuria with staphylococcus albus. He hadbeen under treatment for a considerable time at one ofthe large clinics, and had been admitted into hospital to

* An Address delivered before the Medical Society for the Study of VenerealDiseases, January 25th, 1935.

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UROLOGICAL CONDITIONS

hasten his cure. After remaining as an in-patient for amonth he was discharged to have a rest from all treat-ment. The day after he got home he passed no urine.He was brought into an L.C.C. hospital, and I saw himthirty-six hours after the commencement of anuria. Icut down on the right side and found a stone in the upperend of the right ureter, which I removed. On X-rayexamination another stone was found in a correspondingposition on the other side; that also I removed. I kepthim under observation for a long time, because I wasanxious to find out whether he had two totally differentconditions, or whether the pyuria was due to the calculi.But repeated examinations failed to reveal any sign ofurethritis.

It should be possible to avoid such mistakes, and itgenerally is possible if the last half-ounce of urine in thepatient's bladder is examined separately from theremainder of the specimen. If that last half-ounce is freefrom pus, the source of the pyuria must be below thebladder. If there is pus in that specimen, the source ofthe trouble is in the bladder itself, or in the kidney.That addition to the ordinary test is a very useful oneit has saved me from error on several occasions.

Talking of tests, there is a point I have often wonderedabout: I can never make out why the two-glass test hassuch a tremendous vogue. It seems to me to be uselessin the way it is generally employed at present. It wasintroduced by Sir Henry Thompson fifty years ago withthe idea of distinguishing between the pyuria arisingfrom the bladder, and that in the kidneys. The patientwas asked to pass urine into two glasses. The first ofthem was discarded. Any pus in that was assumed to bea contamination from the urethra, and examination forhis urinary condition was made from the second glass.As a test in gonorrhoea that test does not seem to me tobe at all satisfactory. The test I employ is one I foundwas habitually used at St. Peter's Hospital when I wentthere as house surgeon in I907. It is performed asfollows. The anterior urethra is washed out with a clearsolution, and any threads, flakes, or pus in it are judgedto come from this portion of the canal. The patient isthen asked to pass a sample of urine, but not to emptyhis bladder completely. This carries away the pus orddbris from the posterior urethra. The prostate and/or

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BRITISH JOURNAL OF VENEREAL DISEASES

the seminal vesicles are then massaged, and their contentsexpressed into the urethra. The patient then passesanother sample of urine which contains the secretion ofthese glands. Finally the last half-ounce or so of urinein his bladder is passed into another glass, and it showsthe state of the upper urinary tract. This test is accurateenough for all practical purposes, and does not take longto carry out. I only mention it as the two-glass test isstill often recommended, especially in foreign text-books.By means of this test it is easy to watch the onset of

posterior urethritis in cases of acute gonorrhoea. Longbefore the patient has any symptoms of infection in theposterior urethra, pus and debris can be collected fromthis part of the canal, and one can watch the gradualincrease in these inflammatory products. It is alsointeresting to note the proportion of cases in which aposterior urethritis develops. On looking over my oldcase sheets, I found that it developed in all the caseswhich were first seen two or more days after the appear-ance of the discharge, in 75 per cent. of cases seen duringthe second day, and in a little less than 50 per cent. ofcases seen during the first day. This is additional evidence,if additional evidence is really needed, of the importanceof early treatment in acute gonorrhoea.

In the treatment of gonorrhoea the surgeon has twoaims. The first is to destroy the gonococci as quickly aspossible, and the second is to prevent the invasion ofsecondary organisms. A man with living gonococci inhis urethra is a menace to society, but it is not alwaysrecognised that one with a secondary infection may be amenace to himself. It is largely in connection with thesesecondary organisms that I wish to speak to-night.

Looking over my old notes, I noticed that the invasionof secondary organisms was practically absent in caseswhere I carried out all the treatment myself, but itbecame a serious factor when the treatment was eitherentirely neglected, or carried out by the patient. Everyurologist knows that infection always follows self-catheterisation, and in many instances proves fatal; butone may be inclined to overlook the fact that the patientwho injects or irrigates his urethra is exceedingly liable toinfect the canal. The average patient will listen atten-tively while the methods of self-irrigation or self-injectionare explained, but very few of them will at the same time

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take in the principles of asepsis. If the necessity ofcleanliness has been impressed on him, he soon becomescareless, and as his first lapse is rarely followed by direresults, he continues in his careless habits. I feel certainthat in clinics where the treatment of acute gonorrhoea iscarried out entirely by the surgeon or by a well-trainedorderly, the percentage of secondary infections will bemuch smaller than in those where the treatment iscarried out by the patient himself.There are various types of secondary infections. In

some cases a great number of organisms are to be seen onthe film together with a comparatively small number ofpus cells. This type is, in my opinion, comparativelyharmless, and clears up rapidly under suitable treatment.In other cases there is a chronic pyuria with only a smallnumber of organisms visible in a stained film. In thesecases it is often necessary to cultivate the organism inorder to identify it. This type is, I believe, far moredangerous, and is much more prone to give rise to long-continued urinary sepsis. In such cases the pyogeniccocci are usually the infecting organisms. The staphylo-coccus albus is the most common, but all forms ofstaphylococci may be found. Streptococci are seldompresent alone, but a mixed infection of " streps " and"staphs" is extremely resistant to treatment.A chronic coccal infection of this type is often dis-

missed as being harmless and of no consequence eitherto the patient or to those with whom he may haveconnection. This is a mistaken view. The infection maypersist for years. It tends to spread widely in the urinarytract, and is often the origin of calculous disease orpyonephrosis occurring in later life, and lastly there is anincreasing amount of evidence that it may be spreadthrough the sexual act. This last point deserves moreattention than it has hitherto received. The followingcase may serve as an example. Some years ago I wasconsulted by a man who had been married six weekspreviously, and whose wife had developed salpingitis.He stated that eight years before he developed gonorrhoea,for which he was treated for two years. He was thenpronounced cured, but he had a residual infection due tothe staphylococcus albus ever since. Before his marriagehe had consulted several urologists in America andFrance, all of whom said that the infection was non-

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specific and harmless. On the strength of this he married.His wife was under the care of a gynaecologist who failedto find any evidence of a gonococcal infection, and whoasked me to see the husband in order to ascertain if thehusband could still be infectious. I found a very chronicprostatitis, and was always able to cultivate the staphylo-coccus albus from the expressed secretion. There was noevidence of a gonococcal infection. This case is sugges-tive, but it is not conclusive. It shows, however, thatthere is a risk in allowing a man with a chronic non-specificurethritis to marry, and that the surgeon should beexceedingly cautious in giving his consent. On the otherhand, there are cases where marriage appears to beharmless for the female and beneficial for the male.

There is another reason why I lay so much stress onthis type of chronic non-specific infection. I believe itto be the origin of most of the unfortunate sequelke ofgonorrhcea. The gonococcus does not, in my opinion,tend to persist indefinitely in the urethra. Cabotannounced the comforting doctrine that it usually diedout in about two years. I cannot agree with this state-ment, but I have only twice seen it persist for more thanseven years. An organism which tends to become extinctin a comparatively short time cannot be held responsiblefor a stricture developing ten, fifteen, or even twentyyears after an attack of gonorrhoea. Again, in cases ofchronic stricture one very rarely finds the gonococcus,except when there is a history of recent re-infection.I, therefore, believe that in most cases, a chronic strictureis not the result of a pure gonococcal infection, but of anon-specific urethritis following gonorrhoea. The follow-ing case is, however, a direct contradiction of thisstatement. About three years ago a young man, abouttwenty-five, consulted me for stricture. He said that hehad been infected when a baby by a Chinese nurse, andhad never had connection in his life. The first part ofthe story was afterwards confirmed by his father. Duringthe previous year symptoms of obstruction occurred, and astricture was diagnosed by his local doctor. I found a verytight stricture at the level of the suspensory ligament, forwhich he has been continuously under treatment. Whenhe first consulted me a mixture of gonococci, " staphs, "and " streps " were found in his urine. After about ayear the gonococcus disappeared, but the pyogenic cocci

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are still present. This patient had no treatment duringthe interval of about twenty-two years that elapsedbetween subsidence of his original infection, and theonset of obstructive symptoms, yet the gonococcus musthave persisted in his urethra for all those years. Inaddition it was present in sufficient numbers to be readilyrecognisable in every smear that was taken. The otherorganisms were only identified by culture.

I think that one is justified in describing two types ofurethral stricture. The first occurs early, usually within ayear of the gonorrhceal infection. The stricture is usuallylinear, and only involves a very short portion of theurethra. The calibre is as a rule fairly large, so that thereare no obstructive symptoms, and as there may be littleor no difficulty in passing a sound, they can only be*diagnosed by means of the urethroscope. In fact theyare usually found on a routine examination. Lastly, themucous membrane is healthy down to the face of thestricture. If the infection has died out, or been cured,they do not tend to contract. I have urethroscopedmany of these patients at regular intervals for periodsup to ten years from the time of the original gonorrhoea,without finding any tendency for the stricture to contract,provided the urine remained sterile. As a rule, however,I took the precaution to dilate the urethra fully beforedischarging the patient. In all the cases of this typeI have seen, the secondary infection was absent orinsignificant.The second type comprises the chronic stricture cases

which crowd out all urological out-patient departments.The patient usually presents himself because he hasdifficulty in micturition, and this does not occur tillseveral years after his attack of gonorrhoea. On urethro-scopy there is usually a stenosis at the level of thesuspensory ligament, which is narrow enough to holdup an ordinary urethroscope tube. The whole of theperineal urethra is more or less strictured, and under airdistension, ring after ring of contraction, each narrowerthan that in front of it, can be seen extending down to atight stricture in the bulb. In addition, the mucousmembrane of the whole urethra is profoundly altered.The blood-vessels, usually so apparent in the normal-urethra, are quite invisible. The light yellow colour of-the normal urethral mucosa is changed to a dirty grey

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tint, and there is evidence of long-continued infection inall the follicles of Morgagni. In these cases it is rare tofind the gonococcus, but there always is a severe non-specific infection, and all sorts of organisms can beobtained from the urine or from a smear. In addition.there is a large amount of pus in the urine. In thesecases the stricture always tends to recontract, and thepatient requires life-long treatment.

I have described these two conditions as differenttypes of stricture. It would be more correct to designatethem as different degrees. Every bad stricture mustpass at some time through a stage where the stenosisresembled that described as the first type. The soledifference between the two is that in the second typethe infection persisted, while in the first it cleared up.The infection is always non-specific. This brings us backto my original thesis, that every care should be taken toprevent a secondary infection by means of careful treat-ment in the initial stages of an acute gonorrhcea. It maynot be possible to stamp out the disease, but if treatmentcan be devised by which the onset of a secondary infectioncan be absolutely prevented, then gonorrhoea will beshorn of its devastating sequeke. The whole future ofa gonorrhoea patient often depends on the treatment hereceives during the first two or three weeks of his illness,and to my mind the great advantage of the new VenerealClinics is that the patients receive careful treatmentduring this period.Turning once more to the question of stricture, we have

in the past been inclined to lay too much stress on themechanical obstruction, and too little on the infection.The latter gradually spreads until the whole of theurinary tract becomes involved. A man develops astricture, the infection spreads to the periurethral tissuesand gives rise to perineal abscesses and urinary fistuke.It also spreads upwards involving the prostate and/orthe seminal vesicles, the bladder, and finally reaches thekidneys. When both kidneys are infected, the patientbecomes a chronic invalid, and his life is materiallyshortened.The following is the history of one of these cases. The

patient is now aged thirty-five. He contracted gonorrhoeawhen he was twenty. His treatment was intermittentand incomplete, and he left the clinic before he was

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discharged as cured. About five years later he beganto have difficulty in micturition, and two or three yearsafter this he developed an abscess in his perineum, whichwas allowed to burst of itself. This was followed by asecond abscess, and later by a third, and so on. I firstsaw him about five years ago, that is, about ten yearsafter his original gonorrhoea. He had a very densestricture, and a great mass of inflammatory fibroustissue in his perineum, which was riddled with sinusesdischarging pus and urine. I dissected out this mass,and did an internal urethrotomy. He did very well for atime, and then disappeared. He returned recently with avery foul cystitis, and severe pain in the right loin. Theurethra took a No. I2 English fairly easily, and a radio-gram showed a large stone in the pelvis of the rightkidney, which was functionless. As the urine from theleft kidney was sterile, I removed the right. It was apyonephrosis without any excretory value. During hisconvalescence he developed a left-sided pyelitis, with atemperature rising up to I05. This was relieved bytying in a catheter. This patient is still a young man,his only kidney is now infected, and the remainder of hisurinary tract is also involved. I do not think that he canlive for more than a few years. This is the final resultof a single attack of gonorrhoea. Fortunately these casesare rare when compared with the enormous number ofacute gonorrhceas seen every year.Even if the infection spreads no higher than the

prostate it can still be a serious menace. A chronicprostatitis is frequently followed by an overgrowth offibrous tissue in the gland. This in turn involves theinternal sphincter, and transforms it into a rigid inelasticring. Patients with this condition develop serious obstruc-tion, with all its harmful effects on the kidneys. Thisform of prostatic obstruction-the obstruction due to the" small, fibrous prostate '-is usually the direct resultof a post-gonorrhceal non-specific infection, with or with-out true stricture formation. If untreated, it is just asfatal as the obstruction caused by the enlarged adenoma-tous gland. It usually occurs in patients about fifty,that is, distinctly below the " prostatic age." Up to thepresent, treatment has been difficult, as one has toremove not only a small, fibrous, adherent gland, but theneck of the bladder as well. Recently good results have

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been obtained by per-urethral resection, but in manycases an open operation is to be preferred.About two years ago, one of these patients was

admitted under me into St. Peter's Hospital. He hadmarked obstruction from a small fibrous gland, in which aradiogram showed a few small calculi. His blood ureawas then well above the 200 mg. per I00 c.c. A supra-pubic cystotomy was performed, and the patient wasdischarged with a permanent drainage apparatus. Hereturned a couple of weeks ago, and after two yearsYdrainage the blood urea was still io8. As his generalcondition was good I decided to operate, and removedthe prostate together with the internal sphincter. He ismaking satisfactory progress, but is still in hospital.True prostatic calculi are so often associated with

stricture and chronic prostatitis that I think most cases ofthis condition must be considered to be sequels ofgonorrhcea. If the calculi do not give rise to symptomsI do not advise any treatment. If there is residualurine, I usually treat the stricture first. If the patient isstill unable to empty his bladder completely, I removethe gland. This relieves the obstruction, but, of course,the patient must keep his stricture well dilated.There is another question I wish to raise. It is the

relationship between true urinary calculi and gonorrhoea.At St. Peter's Hospital about 43 per cent. of all renalcalculi are infected at the time of the operation. Itis not possible to say if the infection is primary, or ifthe stones formed in sterile urine, which afterwardsbecame infected. Grossmann, from von Lichtenberg'sclinic, found that 42 per cent. were infected at the timeof operation. He definitely states that the source ofinfection was gonorrhoeal, and that there was a residualinfection of the internal genital organs from which thekidneys became contaminated. The commonest organismhe found was the staphylococcus albus, and he also foundsimilar cocci in material expressed from the prostate andseminal vesicles. Hellstr6m has shown that in some casesof this type the infection is primary. This he demon-strated by dissolving the calcareous portion of the stone,and then cutting sections of the remaining colloid frame-work. He found clumps of organisms in the centre ofthe stone, which probably formed the nucleus of thecalculous formation. In a few instances he was able to

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cultivate the organisms, and usually proved them to bethe staphylococcus albus, in other cases he was unable togo further than to say that they were Gram-positivecocci. He concludes that the staphylococcus albus is aspecific stone-former, and that it precipitates the limesalts and has the power of building them into concretions.At St. Peter's Hospital we also find the staphylococcusalbus is very frequently associated with stone formation,but I do not think there is sufficient evidence to say thatit has any specific action. It tends to render the urinealkaline. This alone is sufficient to cause a precipitationof calcium phosphate, which is the principal constituentof these stones. The crystals become deposited on thesurface of the organisms in accordance with the generalprinciple of adsorption. On this theory, the rdle of thecocci is secondary, and they only create conditionsfavourable for stone formation. Still the fact remains,that if there was no infection the stones would probablynot form. There is also some evidence that the infectionoriginated as a post-gonorrhceal urethritis.The last point I wish to mention is the question of

sterility after gonorrhoea. It is well known that sterilityfrequently follows double epididymitis, owing to blockageof the vas. Much can be done by anastomosing the vasto the upper pole of the epididymis, and good resultsfollowing this operation have been reported from America.I have also had a few successful cases. The questionnaturally arises, can this sterility be prevented by moresuitable treatment of acute epididymitis. There is oftena considerable amount of inflammation round the tubulesof the epididymis, and I feel that if the exudate wasdrained away, there would be less tendency for the lumenof the vas to be permanently obliterated.

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