Polyps of the Male Urethra. BY HERMAN GOLDENBERG, M.D., Physician to the Mount Sinai Dispensary; Assistant Physician for Skin and Venereal Diseases to the Out-Patient Department of the New York Hospital. REPRINTED FROM ®|je Neto ¥orfc JHe&ical Souvnal for May 9, 1891. Reprinted from the New York Medical Journal for May 9, 1891, POLYPS OF THE MALE URETHRA. By HERMAN GOLDENBERG, M. D., PHYSICIAN TO THE MOUNT SINAI DISPENSARY ; ASSISTANT PHYSICIAN FOR SKIN AND VENEREAL DISEASES TO THE OUT-PATIENT DEPARTMENT OF THE NEW YORK HOSPITAL. Polyps of the male urethra are so rarely diagnosticated during life that it is worth while reporting the following- cases, which may be found, for various reasons, interesting and instructive: Case I-J. L., fifty-nine years old, had never had gonor- rhoea or other venereal disease. He enjoyed perfect health up to the beginning of June, 1890, when he was suddenly, without apparent cause, unable to pass his urine. Notwithstanding the strongest efforts, not one drop could be voided, while up to that date the stream had been normal and the micturition Lad not been accompanied by pain. Internal medication, Sitz-baths, and rest were inefficacious. It therefore was necessary to catheterize the patient. This was done without trouble. As he was not able to pass his urine for the following two days, he was sent by his physician to a hospital. There urethrotomy, in- ternal and external, was at once performed. The patient made a norma) recovery and was discharged at the end of six weeks. He then came to the writer for the passage of sounds. He complained of difficult and frequent micturition, the stream when it came being unsatisfactory. There was also a rather profuse purulent discharge consisting of epithelium and Copyright, 1891, by D. Appleton and Company. 2 POLYPS OF THE MALE URETHRA. pus cells. Microscopical examination did not, however, reveal any gonococci. The urethra was very tender, especially near the bulb and in its posterior part. A sound No. 14 English passed with some difficulty, always causing a haemorrhage from the urethra lasting for one to two days. As these symptoms were without apparent adequate cause, I subjected the patient to an endoscopical examination in the presence of two colleagues. One of them expressed rather pessimistic views as to the value of this method for diagnosis. It strangely enough happened that I remarked that if in one thousand examinations one polyp should be discovered, the labor would be well repaid. On withdrawing the endoscope, near the bulb, a prominent body like a growth was visible, nearly tilling the entire field of vision. The bright-red color of this tumor contrasted with the paler hue of the surrounding mucous membrane, to the upper and left wall of which the tumor was attached by a broad pedi- cle. The growth was of the size and shape of a split bean, the free convex surface moist and shining. The foregoing charac- teristics led me to make the diagnosis of a mucous polyp. Various instruments for the removal of these tumors of the urethra have been recommended. The removal in the present instance was as follows: Having brought the growth promi- nently in view, the endoscope was closely pressed against that side of the urethra from which the polyp sprang. The penis was then well stretched, and by a sharp pushing movement the tumor was easily and cleanly sliced from its base. The removal was complete and painless, the bleeding minimal, and the wound smooth and clean-cut. This case is of special interest because the patient had submitted to radical operations with only partial ameliora- tion of his symptoms. Without the endoscope he might have remained a sufferer for a long time, or perhaps even been given up as having incurable gleet. The tumor, hardened in alcohol, imbedded in celloidin, and stained with haematoxylin, was found to consist of a base- ment substance of clear transparent tissue, in spots slightly POLYPS OF THE MALE URETHRA. 3 granular; in other places, fibrillary tissue-transformation of fibrillary into mucous tissue. In this mass were numer- ous round cells and many small blood-vessels imbedded, the whole being surrounded by a capsule composed of flat- tened epithelium. a d 6 6- a e I i a, intercellular tissue ; b, cells (spindle-shaped, round, and mucous) ; c, blood- vessels ; d, capsule. Iii addition to the foregoing case, I wish to relate another instance of urethral growths of a different nature. Case II.-A. K., twenty-four years old, consulted me for a urethral discharge which seemed to be of a gonorrhoic nature. I must state that neither microscopical nor endoscopic examina- tions were made, but simply that an injection was prescribed which did not relieve the symptoms. Then my attention was drawn to a few small venereal warts on the prepuce, and a still smaller one on the meatus. Thus being made suspicious that similar appearances might be inside the urethra, I examined the patient endoscopically and found in the neighborhood of the fossa navicularis three warty growths each of about the size of a pea. They were of a dark-red color, bleeding upon the slight- est touch with the probe, and were exceedingly tender. They 4 POLYPS OF THE MALE URETHRA. resembled so much the external vegetations that there could be no doubt as to their identity. They were easily removed by a small, sharp spoon, and, on account of their bleeding, touched with a 20 per cent, nitrate- of-silver solution. Microscopically, they were found to consist of extensively hypertrophied and hyperplastic epithelium, into which the at- tenuated and hypertrophied papillae were drawn-the usual picture presented by papillomata. It is indeed remarkable that so little has been written about the so-called polyps of the male urethra. Tn text-books on general or genito-urinary surgery their occurrence is either entirely ignored or only cursorily men- tioned. There are only three cases on record in American literature of the last five years, viz.: Harte, R. II., A Contribution to the Tumors of the Ure- thra, with a Report of Two Cases.* Eversole, A Case of Vegetation in the Urethra removed by Aid of Endoscope, f Neither of these authors gives a description of the his- tology of the specimens. Briggs, A Case of Papillomatous Urethritis. J Grunfeld is the one to whom we owe most of our knowl- edge about urethral polyps. He had observed eighteen cases in the male urethra up to 1881. Since then there have been only about eight cases reported by German authors which, where a microscopical examination had been made, were found to be papillomata, with the exception of one case reported by Neuberger,* which corresponded histologically with my first case. * Univers. Med. Mag., Philadelphia, 1888- 89. f St. Louis Polyclinic, 1889. t Boston Med. and Surg. Jour., 1889. * Wiener med. Presse, 1889, No. 23. POLYPS OF THE MALE URETHRA. 5 Lately, Oberlander has published a very elaborate article on Urethritis Papillomatosa,* in which he maintains that polyps of the male urethra are not of rare occurrence, with- out giving the number of cases which he has observed. According to him, all such urethral growths are papil- lomatous, not fibromatous, and in consequence he wants to substitute the name "papillomata" for "polyps." Von Antal has the opposite views, believing the ma- jority of urethral polyps to be fibromatous. Neither one has given a histological description of these growths. In regard to the indefinite terra "polyps" I would say that it is derived from the Greek (TrokimovQ, many-footed), and it is not founded upon a histological basis. The name is simply used to designate a benign, more or less movable, outgrowth from the surface of a mucous membrane and not extending into the deeper tissues. The term is therefore a general term, and includes papillomata, fibromata, etc. Histologically, we find the polyps of the urethra, like those of other mucous membranes, composed of various tissues, and then they are called mucous, fibrous, angeiomatous, adenomatous, or any combination of these. Commonly they are found to be fibrous, and are either papillary (not papil- lomatous), developing from the papillae of the mucous mem- brane, or submucous, growing from the submucous tissue. Both consist of a stroma of fibrillary tissue in which con- nective-tissue cells and blood vessels are imbedded. The whole is usually covered by a more or less thick lax er of flattened or cylindrical epithelium, which, however, is not necessarily present. If the desquamation of the epithe- lium, for sime reason or another, took place during the formation of the polyp, the latter may be connected with the adjacent part of the urethra by a capsule of connective tissue. * Monatshefte fur prakt. Dermatologie, 1889, Band x. 6 POLYPS OF THE MALE URETHRA. Papillomata of the urethra do not differ histologically in any way from those on the skin, or the so-called con- dylomata acuminata. Therefore they do not require any further description. After a careful perusal of the scant literature on this subject, I conclude that papillomata are much oftener seen than the submucous fibromata. In fact, the case reported by Neuberger and my first case are the only fibromata of the urethra on record. The papillomata are more vascular than the fibro- mata, and therefore bleed more easily, and, as they probably contain the nerve terminations, they are more tender. As to the aetiology of the polyps, formerly the opinion was prevalent that all these tumors of the urethra were caused by a gonorrhoic infection. This is extremely natu- ral when we consider that gonorrhoea is so widespread that it is extremely rare to find a patient suffering from urethral disturbances who has not at some time or other had gonor- rhoea. We are only too prone to argue, "post hoc, ergo propter hoc." Gonorrhoea is without doubt one of the prin- cipal setiological factors, but by no means the only one. There are cases on record, and my first case is one of them, where urethral growths developed without a preceding gon- orrhoea. Why may a polyp not develop independently of an infection as well in the urethra as in the nose or larynx? Furthermore, urethral polyps are much more common in the female urethra, where gonorrhoea is not so frequently found as in the male. The symptoms of urethral poljps are identical with those of gleet and stricture and depend for the most part upon the location and size of the neoplasm. A polyp in the posterior urethra may give rise to the same subjective symptoms as urethro-cystitis-viz., frequent and painful POLYPS OF THE MALE URETHRA. 7 micturition and pollutions. Oberlander professes to have restored the potentia coeundi, which had been lost for sev- eral years, by the removal of posterior urethral polyps. The subjective symptoms are usually not so pronounced when we find the trouble situated in the anterior part of the urethra. But I can easily understand that a poljp located in the bulb of the urethra, as in my first case, might produce the same symptoms as a severe stricture. The polyp acts as a foreign body on the mucous membrane, and may cause such a reflex contraction of the musculus com- pressor partis membranaceai ("cut-off muscle") that the efforts of the patient to void his urine are absolutely fruit- less. We then have the same picture as in a so-called spas- modic stricture. There seems to be a difference in the symptomatology of fibromatous and papillomatous polyps, inasmuch as the latter are more painful and bleed easier, for anatomical reasons already mentioned. Harte expressed a view, which I can confirm from my own cases and some others on record, that fibrous polyps occur in later life and are single, not specially sensitive, and show little tendency to bleed, whereas papillomata are more frequently found in early periods of life, are multiple, tender to the touch, and prone to haemorrhage. A diveisity of opinion exists, as I stated before, about the frequency of these urethral tumors. They are surely not so rare as most authors are inclined to think, and will be found oftener the more frequently the en- doscopic method is used. I can not share the view expressed by Oberlander that it is absolutely necessary to use an electro-endoscope for the diagnosis of polyps. Ocular examination c»f the urethra, in order to become as popular as it deserves, must be simple and quick, espe- cially in dispensary practice. We must use a method which does not require an expensive and complicated appa- POLYPS OF THE MALE URETHRA. 8 ratus with its attending difficulties. All we need is a tube, a reflector, and good light. Thus the examination does not take longer than a thorough testing of the urine for albumin and sugar, and does not require more time or skill than the examination of the larynx. It is to be hoped that the time is not far off when the endoscope will be considered as ne- cessary an instrument in the diagnosis of urethral diseases as the laryngoscope is in the diagnosis of those of the larynx. 107 East Fifty-ninth Street. Jg a REASONS WHY Physicians Should Subscribe The New York Medical Journal, Edited by FRANK P. FOSTER, M. D.,' Published by D. APPLETON & CO., 1, 3, & 5 Bond St X. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE: It is the exponent of the most advanced scientific medical thought. 3. BECAUSE: Its contributors are among the most learned medical men of this country. 4. BECAUSE : Its "Original Articles" are the results of scientific observation and research, and are of infinite practical value to the general practitioner-. 5. BECAUSE : The "Reports on the Progress of Medicine," which are published from time to time, contain the most recent discov- eries in the various departments of medicine, and are written by practitioners especially qualified for the purpose. 6. BECAUSE : The column devoted in each number to "Therapeu- tical Notes " contains a resume of the practical application of the most recent therapeutic novelties. 7. BECAUSE : The Society Proceedings, of which each number con- tains one or more, are reports of the practical experience of prominent physicians who thus give to the profession the result* of certain modes of treatment in given cases. 8. BECAUSE : The Editorial Columns are controlled only by the desire to promote the welfare, honor, and advancement of the sci- ence of medicine, as viewed from a standpoint looking to the best interests of the profession. 9. BECAUSE : Nothing is admitted to its columns that has not son* bearing on medicine, or is not possessed of some practical value xo. BECAUSE: It is published solely in the interests of medicine, and for the upholding of the elevated position occupied by the profession of America. Subscription Price, 86.00 per Annum. Volumes begin in January and July.