The Treatment of Stricture of 
the Urethra. 
by 
FRANK H. WHITTEMORE, M. D., 
NEW HAVEN,’ CONN. 
REPRINTED FROM 
2TI)c Neto York jfttetrical .journal 
for June 27, 1885. Reprinted from the New York Medical Journal 
for June 27. 1885. 
THE TREATMENT OF STRICTURE OF THE 
URETHRA* 
By FRANK H. WHITTEMORE, M. D., 
NEW HAVEN, CONN. 
So much has been said and written in recent years in 
regard to the treatment of stricture of the urethra, that one 
who has not had an opportunity to make a special study of 
the subject must often be embarrassed in selecting a plan 
of treatment adapted to any particular case. And yet 
nearly every general practitioner has several of these cases 
come to him each year for treatment. Their frequent ap- 
pearance in my own consulting-room has compelled me to 
devote considerable time to the study of the subject. It is 
my purpose in this paper to present some observations, 
from the standpoint of the practical surgeon, upon those 
methods of treatment which have proved of most value in 
my own practice, and which seem to me likely to give the 
best results in the hands of the general practitioner. 
On account of their comparative rarity, and in order to 
avoid extending the length of the paper unreasonably, all 
consideration of traumatic strictures will be omitted, and the 
discussion will be limited to those gradually forming stric- 
tures which are the result of a chronic inflammation of the 
urethral mucous membrane. 
The most constant symptom of stricture is gleet. Con- 
* Read before the Connecticut Medical Society, May 28, 1885. 2 
THE TREATMENT OF 
versely, gleet ordinarily depends upon stricture, and usually 
stricture of large caliber. A man can not have a urethral 
discharge lasting over six weeks without damaging his 
urethra. After a gonorrhoea has lasted six weeks the in- 
flammatory process is becoming localized, and a thickening 
of the peri-urethral tissue is almost inevitable. At the same 
time I do not consider that every man who presents himself 
for treatment with chronic urethritis and a moderate coarc- 
tation of the urethra has an organic stricture. Tt may be 
merely a thickening which, if allowed to go on, will develop 
into an organic stricture. 
Another very constant symptom of stricture, and one 
which is generally present in the forming stage, is the drib- 
bling of urine after the act of micturition is apparently 
completed. This is due to a loss of the normal elasticity of 
the urethra at the point where the deposition of plastic ma- 
terial is taking place, and the inability of the compressor 
urethrae muscle to overcome the abnormal resistance. A 
portion of the urine is consequently retained behind the 
coarctation, and subsequently escapes drop by drop. 
Only old strictures, as a rule, cause symptoms in the 
absence of a gleety discharge. Such strictures may cause a 
variety of symptoms. Frequent micturition, if present dur- 
ing the day, should lead the surgeon to suspect stricture. 
He should also inquire if the stream is small, forked or 
twisted, if the urine falls drop by drop, if there has been 
retention, and finally if the patient has bad gonorrhoea. 
These cases are generally strictures of small caliber, which 
may easily be detected. 
I have known an old tight stricture, of ten or fifteen 
years’ duration, to have been treated, as chronic inflam- 
mation of the bladder, with buchu, alkalies, and supposi- 
tories, by a physician of the highest reputation. When a 
patient has chronic cystitis, it is always well to consider STRICTURE OF THE URETHRA. 
3 
what causes it. Inquire in regard to urinary symptoms, 
and examine with a suitable instrument. It may be arrested 
in the deep urethra. Such cases are not uncommon. 
In strictures of large caliber it is a nice point to tell 
where coarctation is taking place. It is impossible to do 
this with a steel sound, as most men try to do. This is 
why so many men fail to tind a stricture; why, conse- 
quently, so many strictures go untreated; and why, further- 
more, it is so common for a man who presents himself for 
treatment with a gleet to exclaim, after a stricture is de- 
tected, “ Why, Dr. So-and-so told me a couple of weeks ago 
that 1 had no stricture.” 
In order to detect a stricture of large caliber, it is neces- 
sary to use either a urethrometer or a set of metallic or 
flexible bulbous bougies. I prefer the bougies. My own 
experience, moreover, has been that a moderate degree of 
coarctation is more readily detected by the flexible instru- 
ments than by the olive-headed bougies of Otis. Of course 
it is not difficult to detect a stricture of small caliber with 
any instrument. It is, however, difficult for a man who has 
not used both to realize what a difference it makes whether 
one uses a steel sound or a bulbous bougie for the detection 
of a stricture of large caliber. Repeatedly men have come 
to me with chronic gonorrhoea or gleet, and have told me 
that they had been examined by a surgeon, and assured 
that they had no stricture. I have then tried a flexible bulb- 
ous bougie, and seen it arrested in less than two inches 
from the meatus. Then I have tried a solid blunt steel in- 
strument, and passed it right through the stricture without 
the least resistance. But it is these very strictures of large 
caliber which it is important to detect and cure before they 
become organized. 
When a patient comes to you in whose urethra you sus- 
pect the existence of a stricture, you first measure the cir- 4 
THE TREATMENT OF 
cumference of the penis; then, bearing in mind the ratio 
which this bears to the caliber of the normal urethra, you 
select a bougie of such a size as the measurement shows 
that the meatus ought to admit. Having well oiled the in- 
strument, putting the penis gently on the stretch, you care- 
fully pass the bougie along the urethra. If it enters the 
bladder without encountering any resistance, there is no 
stricture. If a stricture exists, the bougie will be arrested. 
Then take a smaller instrument and repeat the manoeuvre 
and so continue until you find one which will pass the point 
of obstruction. This shows the caliber of the stricture. 
Then, recognizing the well-known fact that where there are 
several strictures the nearer the meatus the larger the caliber 
of the stricture, the examination is continued in the search 
for other strictures, a smaller and smaller instrument being 
used in order to detect narrowings nearer and nearer the 
bladder. 
Having determined the existence and location of one 
or more strictures, do no more at this sitting. Warn the 
patient that the next act of micturition will probably be 
attended with some pain. Then, having given him such 
directions in regard to his hygiene and having prescribed 
such constitutional treatment as his individual case requires, 
direct him to return in three or four days for further treat- 
ment. 
Every case of stricture should be treated as a whole. 
The physical condition of the patient should be studied. 
Most of these patients are run down and in an anaemic con- 
dition, due partly to the local irritation and suppuration, 
and partly to mental worry. Such patients need iron and 
general tonics. 
Like every other inflamed organ, the urethra which is 
the seat of stricture should be placed at rest as far as pos- 
sible ; all sources of irritation should be removed. The STRICTURE OF THE URETHRA. 
5 
urine should be rendered as unirritating hs possible. All 
articles of food which have a tendency to cause crystals 
of uric acid to be present in the urine should be avoided. 
The diet should, therefore, be mild and unstimulating, and 
the amount of nitrogenous food ingested should, as a rule, 
be limited. The use of all kinds of alcoholic stimulants, 
including beer and ale, should generally be stopped. Coffee 
also should be omitted. Smoking, in my experience, has 
proved as injurious in some cases as alcohol, and should be 
forbidden. 
In strictures of large caliber, with gleet, it is necessary 
to neutralize the urine with alkalies. The fluid extract of 
kava-kava I have used a great deal of late, and in cases 
attended with a gleety discharge it has proved beneficial. 
There is a great difference in urethrae, some being very irri- 
table. Bromide of potassium will do a great deal for these 
cases. Given in full doses for a few days, it blunts the sen- 
sibility of the urethra. A combination of bicarbonate of 
potassium, kava-kava, and hyoscyamus is often very effective 
by rendering the urine alkaline, by lessening urethral irri- 
tability, and by diminishing the gleety discharge. 
Finally, the patient should be warned to be as pure in 
word, thought, and action as possible. If a single man, he 
should abstain absolutely from sexual intercourse. The so- 
ciety of lewd women and lascivious thoughts and conversa- 
tion should always be avoided. In this way nervous and 
vascular activity about the genital organs may be great!v 
diminished. 
When the patient returns, if his meatus is not up to the 
required standard, it must be enlarged. It should be a 
golden rule in surgery that all strictures of the meatus must 
be cut, for you can not stretch them. This may be done in 
several ways, some men preferring a bistoury, some scissors, 
and others a urethrotome constructed especially for the 6 
TIIE TREATMENT OF 
purpose, the best one, perhaps, being that of Civiale. My 
own practice is to use the latter. The incision should always 
be made downward in the floor of the urethra. In perform- 
ing this operation great care should he used to make the 
opening sufficiently large to admit a bulbous bougie of a 
size a little larger than that which our measurement of the 
penis has shown that the urethra should admit, in order to 
make allowance for the contraction which takes place in 
healing; but the operator should also be cautious not to 
make the incision unnecessarily large, lest he create an arti- 
ficial hypospadias. If too large an opening is made, it 
subjects the patient to the exceeding inconvenience of not 
being able to pass his water in a compact stream. In some 
instances, where a perhaps too enthusiastic follower of the 
teachings of Dr. Otis has, in the excess of his zeal, carried 
the incision beyond the bounds of nature and of reason, the 
sufferer has been obliged to sit down upon a vessel or a 
water-closet to urinate. In one or two cases which have 
come to my knowledge such patients have applied to the 
surgeon with a view of having a plastic operation undertaken 
for the relief of the deformity resulting from this barbarous 
mutilation. 
The haemorrhage following this operation is sometimes 
quite abundant, but ordinarily stops spontaneously in a few 
minutes. If, however, it does not do so, it can generally be 
arrested by wrapping a little cotton around a probe and ap- 
plying some tincture of iodine to the cut surfaces. The 
haemorrhage having ceased, a piece of lint should be in- 
serted within the meatus and allowed to remain until carried 
away by the stream of urine. This serves the double pur- 
pose of preventing union of the cut surfaces, and also tends 
to prevent recurrence of the ha;morrhage. 
There are several ways in which the patulous condition 
of the meatus may be maintained. You may pass in every STRICTURE OF THE URETHRA. 
7 
<lay a full-sized bulbous bougie, or a conical steel sound, or 
a so-called fossal sound, made especially for this purpose. 
I am in the habit of employing the latter. Experience has 
shown me that, if an instrument is not passed in every day, 
granulations grow so rapidly in this situation that in two 
days it will be impossible to pass it without subjecting the 
patient to a great deal of pain—much more than where it 
is passed every day. It is not generally necessary to con- 
fine the patient to the bed or to the house after this opera- 
tion. He should bathe the parts twice a day in hot water, 
and should not walk much for a day or two. In this way 
it is possible to obviate a tendency to inflammation at the 
site of the operation, and also in the adjacent parts, as the 
lymphatic glands. Should the wound in healing show a 
disposition to become a little sloughy, it is well to dust over 
the surface a little iodoform or bismuth. 
When the wound of the meatus has healed, which 
usually occurs in about two weeks, the gleety discharge, for 
which the patient sought treatment, very often has stopped. 
If it has not, we again explore the deeper portion of the 
urethra, using as before the flexible bulbous bougies. 
Many strictures are reflex in character, and entirely dis- 
appear when the meatus has been enlarged. The necessity 
of relieving a contracted meatus before attending to a stric- 
ture of small caliber in the deep urethra is illustrated by the 
following case: 
The patient had gleet, and, five inches from the meatus, 
a so-called impassable stricture, through which a filiform 
bougie could not be passed. He had also a stricture of large 
caliber in the pendulous urethra, and a small meatus. He 
could only pass a little water, drop by drop, and I feared 
retention. I at first attempted to pass a filiform instrument 
through the stricture, but failed, although a No. 14 Ameri- 
can could be easily passed down to it. Each time I saw 8 
THE TREATMENT OF 
him 1 persisted in the attempt as long as I dared, fearing 
lest inflammatory swelling in the urethra should be excited. 
In the mean while he was kept in bed and received appropri- 
ate constitutional treatment. Having made a thorough trial 
of this plan of treatment, and being unable to reach the 
bladder, 1 threw aside the filiform instruments, ignored for 
the time being the deep stricture, and gave him a meatus 
which would admit a No. 21 sound. When the meatus had 
healed, a full-sized conical steel sound was passed down to 
the face of the stricture, and gentle and continuous press- 
ure was made. This was repeated once in four days. At 
the third trial the instrument passed immediately into the 
bladder. 
After the meatus has been sufficiently enlarged, should 
other strictures exist, the question of treatment at once in- 
volves a determination of the comparative merits of gradual 
dilatation and internal urethrotomy. My own preference is 
for gradual dilatation, which I carry out in the following 
way: Having determined the caliber of the stricture, a 
sound, of such a size as the bulbous bougie has shown that 
it will admit, is introduced. If this passes easily, the next 
size larger may, if possible, be gently passed through the 
stricture. Inasmuch as strictures are rarely encountered be- 
yond the triangular ligament, it is not necessary to pass a 
sound beyond this point. By avoiding this we not only do 
away with the most distressing part of sounding, but also 
lessen in no small degree the danger of exciting epididy- 
mitis, prostatitis, and cystitis. Some surgeons advise that 
the instrument should be left in the urethra for five minutes 
or even longer. My own conviction is that when the in- 
strument has passed the strictured point it has accomplished 
all that it can do. I consequently withdraw it at once, be- 
lieving, as I do, that any instrument in the urethra produces 
irritation, and that, the longer it is allowed to remain there, STRICTURE OF THE URETHRA. 
9 
the greater is the irritation produced. By the simple press- 
ure in passing an instrument through the stricture all the 
good possible from this plan of treatment is effected. The 
way in which the use of a sound benefits a stricture depend- 
ent upon the organization of plastic material is in no way- 
analogous—as many seem to suppose that it is—to the ac- 
tion of over-distension in relaxing muscular spasm. In view 
of both of these considerations, straight steel sounds are 
both useful and convenient. In treating strictures of the 
urethra it is a good rule never to employ a steel instrument 
of smaller size than a No. 9 American, on account of the 
great danger of making a false passage. Furthermore, 
whenever, in introducing instruments into the urethra, blood 
is drawn, it is time to stop. 
In regard to the frequency with which sounds should 
be introduced into the urethra for the cure of stricture 
there is a considerable diversity of practice among surgeons. 
The older the stricture, the more firmly organized has be- 
come the plastic material, and, in consequence, it requires 
less frequent introduction of instruments. These cases of 
stricture, which we will designate as strictures of small 
caliber—using that term to designate strictures which 
will not admit a No. 9 bougie—will improve faster by 
not introducing an instrument more often than once in six, 
seven, or even eight days. The exact interval appropriate 
for each individual case can only be learned by observing 
the effect upon that case of introductions at different inter- 
vals. As a rule, it is poor surgery to introduce an instru- 
ment into an old, firmly organized stricture more frequently 
than has been indicated. If a sound is introduced every 
day or two, it causes inflammation or swelling, and you can 
not tell how the dilatation is progressing. In treating 
strictures of large caliber, which, as a rule, are not so firmly 
•organized, and in which, as a consequence, there is not so 10 
THK TREATMENT OF 
much vascular reaction, the introduction may be repeated 
once in four days. Practitioners do not, it seems to me, 
appreciate the value of gradual dilatation because they do 
not observe carefully enough the effect of a single intro- 
duction of a sound. 
At the next visit of the patient, the largest instrument 
which passed through the stricture easily is again passed. 
Then the next size larger is tried. If this is grasped, or 
tightly held on withdrawal, no more is to be done at this 
time. Should it pass easily, we again try a still larger one. 
Usually it will not be possible to use an instrument more 
than one size larger than that previously used. At each 
succeeding visit the same plan is followed of first intro- 
ducing that instrument which was introduced last at the 
previous visit. The size of the instrument is thus gradually 
increased until the full caliber of the urethra has been 
reached. When this has been attained it is necessary to 
continue to pass the full-sized instrument at such gradually 
increasing intervals as experience shows are not so long as 
to permit so much contraction, at the point where the stric- 
ture existed, as to render the introduction of the instrument 
nt all difficult. 
The plan of treatment thus outlined has, in my experi- 
ence, proved uniformly successful. In none of the cases 
which have fallen under my observation have I had occasion 
to have recourse to internal urethrotomy, perineal section, 
or electrolysis. Divulsion I have used only in some half- 
dozen cases of traumatic stricture, the consideration of 
which has been purposely excluded from the discussion. I 
will now state briefly why I do not use one of the other 
methods rather than gradual dilatation. 
Perineal section is undoubtedly indicated in some cases 
of impassable stricture, particularly when complicated by 
sinuses. But I have been so fortunate, up to the present STRICTURE OF THE URETHRA. 
11 
time, as not to meet with any case in which I have not 
been able, by the exercise often of considerable patience, to 
finally pass the stricture, and eventually to remove the 
obstruction and see the sinuses close up. 
Electrolysis requires for its performance a variety of 
expensive apparatus which easily gets out of order, and is 
hardly practicable except in the hands of an expert in elec- 
trical treatment. In the short time since its introduction 
to the attention of the profession it has not been sufficiently 
simplified to be available for the general practitioner. Any 
cases, therefore, in which it may seem to be indicated 
should, for the present, be sent to the electrologist. 
In regard to internal urethrotomy, which has a few 
earnest advocates, 1 have but little to say. In operations 
upon the urethra, the best results, as regards freedom from 
disagreeable and even dangerous complications, will be ob- 
tained by him who uses the minimum of violence. Fur- 
thermore, it is a rule of practice with me, in the treatment 
of any surgical lesion, to always select a method of treat- 
ment which, while its final result is satisfactory, is at the 
same time absolutely free from danger, in preference to 
one which is unquestionably attended by no inconsiderable 
risk. Gradual dilatation, in almost every case, gives favor- 
able results, and may be carried on with perfect safety and 
without interfering with the ordinary business of the pa- 
tient. Internal urethrotomy, on the contrary, always neces- 
sitates the confinement of the patient to his bed for several 
days. It is not infrequently followed by haemorrhage, sup- 
pression of urine, septicaemia, extravasation of urine, and 
perineal abscess. Nor can the fact be overlooked that in- 
stances of death following the operation are occasionally 
reported, and, considering the tendency among medical 
men to report favorable cases and to say nothing of un- 
favorable ones, it is but fair to presume that the actual 12 
THE TREATMENT OF STRICTURE OF THE URETHRA. 
mortality is much greater than is generally supposed. 
Moreover, the operation does not effect a complete cure, 
but the passage of a sound at regular intervals is just as 
necessary as after treatment by gradual dilatation. Now 
and then an old, very resilient stricture is met with which 
is made worse by attempts at dilatation, or one in which 
bladder symptoms are so urgent, in consequence of long- 
continued obstruction, that prompt relief is necessary. Ure- 
thral fever sometimes follows attempts at gradual dilatation 
in cases of this kind, which, however, are more apt to be 
seen in metropolitan hospitals and dispensaries than in pri- 
vate practice. Internal urethrotomy should, therefore, be 
reserved as a last resort for cases in which other, less dan- 
gerous, methods of treatment, after repeated trials, have 
failed, or in which immediate relief is imperatively de- 
manded. I am thoroughly convinced that such cases are 
exceedingly rare. 
Finally, I wish to emphasize a few points which I con- 
sider of especial importance: 
First. Constitutional treatment should be employed in 
every case. 
Second. If the meatus is small, enlarge it. 
Third. Do not use the sound too frequently. 
Fourth. Do not keep it in the urethra too long. 
Fifth. Do not introduce it too far. 
Sixth. Internal urethrotomy is occasionally, though 
rarely, necessary. The lew York Medical Journal, 
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