Urethral Pathology in Girls
Supervisor: Prof. Dr. N.J. Bakker
Faculty: University of Rotterdam, 12-Jan-1972
The cause of chronic urinary infections and of micturition difficulties in girls is often a disorder of the urethra. The aim of this thesis, which involves the study of 182 girls suffering from urethral pathology, is to come to a better understanding of these disorders. The diagnosis, the therapy and the results of treatment are examined to see whether there is reason to reconsider the diagnostic criteria currently used.
In Chapter I the various forms of urethral pathology in girls are briefly discussed. These concern mainly three kinds of disturbance: bladder-neck obstruction, distal urethral stenosis and meatal stenosis. Chronic urethritis can also occur. Rare disturbances such as the formation of valves in the female urethra, hypospadia, etc. are not discussed. As to bladder-neck obstruction there is no general agreement. Mostly it is thought to be a congenital disorder with histologic changes in the region of the bladder-neck and the proximal part of the urethra.
Some authors distinguish between a primary and secondary form of bladder-neck obstruction. Histological examination has never been carried out post-mortally in girls in whom bladder-neck obstruction had been diagnosed. It is assumed that changes in the fibres of the muscles and connective tissue in the wall of the bladder-neck and of the urethra must be the cause. However, there is no certainty about this.
Because of the divergence of the diagnostic criteria there are conflicting views about the frequency of occurrence of bladder-neck obstruction. In recent years this diagnosis has been made comparatively less frequently. In this dissertation bladder-neck obstruction is discussed as a functional disorder.
Distal urethral stenosis is a relatively circular stricture, which is located close behind the external urinary meatus. The diagnosis is made by calibration of the urethra using the bougie á boule. This disorder is more commonly found than bladder-neck obstruction. Some authors, however, are in doubt about the existence of this disorder.
Meatal stenosis is a stricture at the external urinary meatus. This disorder, which occurs not infrequently, is also traced by means of calibration of the urethra.
Chronic urethritis is a persistently occurring inflammation of the urethra and the vesical trigone. In most cases this inflammation is combined with the other forms of urethral disorders, mentioned before. Chronic urethritis only very rarely occurs as a separate disorder.
Chapter II is concerned with the symptomatology and the methods of examination in urethral pathology. The symptoms can be classified mainly into three groups : 1. Symptoms arising from alterations of the lower urinary tract. There mostly dominate the picture and consist principally of micturition complaints. Sometimes abdominal pain or haematuria may be the overt symptoms. 2. Symptoms arising from alterations of the upper urinary tract. These are most often caused by chronic pyelonephritis and vary according to age. Under the age of two years gastrointestinal disorders are to the fore, from two to five years fever is often the dominating symptom, whereas above this age the patient often complains, apart from a disturbed micturition and fever, of lumbar pain together with more general disorders. 3. Symptoms arising from disturbance of kidney-function. These occur only very infrequently and change with age.
Physical examination rarely discloses any disorder. Urethral pathology is generally allied to an infection of the urinary tract. The most probable pathogenesis is an ascending infection coming from the perineum and vulve.
With the X-ray examination routine measurement includes a cystogram and a micturition-urethogram plus an intraveneus urogram. In 30-50% of the patients with urethral pathology a vesico-ureteric reflux is found. The micturition-urethrogram is considered of little importance in dia-gnosis. In most patients the 'peg-top' urethra indicates the existence of a urethral disorder. This can be localized both proximally and distally. No pictures of the urethra exist which can be considered as being characteristic of any form of urethral pathology in girls.
The intraveneus urogram demonstraties, in the majority of patients, no aberration. The great importance of this examination lies in detecting the possibility of pyelonephritis existing. Not much value is attached at the present time to pressure and flow measurements.
The diagnostics of bladder-neck obstruction are chiefly based on four methods of examination. These are cystoscopy, calibration of the urethra, investigation for the existence of a bladder-residue and the micturition-urethrogram. The most important criterion is the presence of trabeculation of the bladder wall. If on calibration, no peripheral obstruction is found, a clear trabeculation, in the absence of a neurologic disorder, is indicative of the existence of bladderneek obstruction. The diagnosis is, therefore, made by means of exclusion. The finding of a residue together with certain X-ray-pictures of the urethra add up to the diagnosis.
A distal urethral stenosis is established by calibration of the urethra. lt can occur in combination with a meatal stenosis. There is, as yet, no agreement as to which criteria should be borne in mind when calibrating with the bougie á boule. Also the value of finding a distal urethral stenosis is still open to question.
Together which the calibration the presence of trabeculation is the most important criterion for the diagnosis. A spasm of the striated muscul-ature around the urethra must be given consideration in differential diagnosis.
As to meatal stenosis the same diagnostic criteria apply as for distal urethral stenosis. The only difference is the localization of the disturbance.
Chronic trigono-urethritis is diagnosed by means of cystoscopy by giving an excessively strong vascular injection into the trigone.
In Chapter III a discussion is given about the methods of treatment and their results in urethral pathology. Some authors advise that the treatment of bladder-neck obstruction should be started with conservative measures. Transurethral resection of the bladder-neck is employed very rarely and nowadays generally abandoned. Since 1958 Y-V-plasty of the bladder-neck for the treatment of bladder-neck obstruction is frequently applied. The results obtained with this method are not in every case favourable. Recently this operation has been used with increasing reserve. Similar favorable, possibly even better, results have been obtained with internal urethrotomy. In view of the simplicity of this intervention the choice of the treatment of bladder-neck obstruction has, in recent years, tended towards this kind of treatment.
Dilatation of the urethra yields good results in cases of distal urethral stenosis. The same applies to the treatment of this disorder by means of internal urethrotomy.
A meatal stenosis should be treated by means of meatotomy. The results obtained with this treatment are satisfactory.
Since vesico-ureteric rellux may disappear by treating the urethral disturbance, it is generally recommended first to await the outcome of the treatment of the basic disorder.
In Chapter IV the author's findings on the examination of 182 girls suffering from urethral pathology are discussed. Complaints of enuresis were strongly dominating. The great majority of the patients had had recurrent infections of the urinary tract, mostly due to E. Coli. In 76% of them no changes were found on intraveneus urography. Twenty-five girls (14%) showed, on X-ray examination, symptoms of pyelone-phritis. In total a vesico-ureteric reflux was found in eighty girls (44%), in most cases of grade I. In almost all the uretero-renal systems with a pyelonephritis a reflux was also demonstrated. A normal I.V.U. by no means excludes the existence of reflux. On the micturion-urethrogram very divergent pictures of the urethra were to be seen. No correlation was found between the degree of trabeculation of the wall of the bladder and the occurrence of pyelonephritis. A 'peg-top'-configuration of the urethra was, in 22 out of the 23 patients, accompanied by a trabeculation. Only 24 of the 125 uretero-renal systems with a reflux showed on cystoscopy a deviated orifice of the ureter. In cases of orifices with a gaping aspect or a lateralization, a reflux was almost always found. In the case of 25 girls the diagnosis of bladder-neck obstruction was given. The most important diagnostic criterion amounted to the presence of trabeculation of the wall of the bladder in the absence of a distally localized obstruction.
A distal urethral stenosis was found in 130 cases; in 50 of them this was accompanied by a meatal stenosis. In all these cases the bougie á boule halted distally in the urethra on calibration. A comparison of the results of calibration with an analogical series of patients from the literature proved not to be possible.
In 26 patients a meatal stenosis alone was found. In the majority of them this diagnosis was made using calibration. In one girl a meatal stenosis together with a bladder-neck obstruction was diagnosed.
A chronic trigono-urethritis existed in 23 patients, in all of them accompanied by another kind of urethral pathology.
In Chapter V the methods of treatment and the subsequent results of 182 girls suffering from urethral pathology are reviewed. The result with respect to the infection, the symptoms of enuresis and the reflux were respectively used as graduated scales.
The milder forms of bladder-neck obstruction were primarily treated by dilatation of the urethra. The more severe forms were treated with Y-V-plasty of the bladder-neck or with internal urethrotomy. These methods of treatment all had a favourable influence on the infection and the enuresis symptoms. Y-V-plasty and internal urethrotomy, moreover, had a favourable effect with regard to the reflux. After the treatments, a decrease in the appearance of the trabeculation was ascertained. The results of antireflux operations, performed in 5 patients, were good.
Dilatation constituted the routine-treatment for patients suffering from a distal stenosis of the urethra. In some cases internal urethrotomy was carried out. The effect of this treatment on the infection is good and is satisfactory for the complaints of enuresis. In most of the patients the reflux also disappeared as a consequence of the urethral treatment. In a not insignificant number of the patients a secondary treatment was necessary and in most of these cases the diagnosis was altered.
The patients suffering from a distal stenosis of the urethra together with a meatal stenosis were treated by meatotomy, mostly in combination with dilatation. In some of them the meatotomy was combined with internal urethrotomy. The effect of this treatment on the infection and the reflux was good, and on the enuresis satisfactory. The recovery of the reflux and of the symptoms of enuresis runs, for the greater part, parallel with the disappearance of the infection.
All girls with a meatal stenosis were treated with meatotomy,usually in combination with dilatation of the urethra. The effect of this on infection, enuresis and reflux were satisfactory.
In Chapter VI a brief discussion is given. The accent of this lies on a review about the distal urethral stenosis. It is an established fact that great doubts still exist about the understanding of bladder-neck obstruction and distal urethral stenosis. On account of the data from the literature and of the author's findings from 182 girls with urethral pathology no cause has been found to bring about a modification in the criteria for the diagnosis.]