THE ELIMINATION OF PAIN FROM UROLOCICAL INVESTIGATION

BY GEOFFREY PARKER, F.R.C.S., SURQEON TO OUT-PATIENTS AT TKE FRENCH HOSPITAL ; ASSISTANT SURGEOX TO THE ERITH HOSPITAL ;

LATE CLINICAL ASSISTANT TO ST. PETER’S HOSPITAL

IT may be justly claimed, I think, that few branches of surgery have made greater strides than Urology in their methods and technique in those preliminary investigations which play such an important part in all modern work.

Investigations, by means of which such terms as “ exploratory laparotomy ” and “ essential haematuria ” are rendered increasingly rare.

Interesting and important as all this is, the fact remains that not infrequently the patient of to-day, possessed, let us say, of a small calculus in the kidney or ureter, has, in the course of investigations, to pass through a much greater ordeal by cystourethroscopy, pyelography, etc., than did his grandfather sixty years ago.

The latter, it is true, might occasionally be submitted to an unneces- sary operation, but probably more usually he was relieved in one fell swoop of his stone, on the clinical diagnosis alone, albeit with an increased operative risk.

The patient, however, is concerned only with the pain he has suffered and the discomfort he is suffering before operation ; the latter varying with the gentleness and careful technique possessed by the surgeon.

Gentleness in handling patients cannot be taught, its vital importance can only be urged ; careful technique is a t the disposal of all. It is with the elimination of pain by careful technique, therefore, that I am concerned.

Local anaesthesia is no new thing. The natives of Peru in prehistoric times practised the operation of trephining for headache, using a local application of their own saliva after chewing coca leaves, having noted the numbing effect of the leaves on the tongue.

The use of cocaine for local anaesthesia in urology is more than fifty years old. Koller published a report on its use in 1884, and the following year litholapaxy was performed at St. Peter’s Hospital using 4 per cent. cocaine.

Reclus and Bransford Lewis used cocaine extensively for urological operations, the latter having a special instrument designed to deposit the cocaine tablet into the posterior urethra.

The method was neither quickly nor generally adopted ; partly on account of popular dislike for carrying out surgical procedure on the conscious patient, but mainly owing to the toxicity of cocaine and the

259

260 THE BRITISH JOURNAL OF UROLOGY

many disasters which occurred following its use on patients with impaired renal function. Further, at this time inhalation anaesthesia held the field in popularity and only comparatively recently this method has been seriously criticised authoritatively.

Chevassu, in speaking of ansesthesia in urology, condemns inhalation anaesthesia and he considers that many cases of post-operative sudden death, which are attributed to emboli, are in fact' instances of latent uremia, to which the general anaesthetic has been a contributory factor.

With the advent of novocaine and its many allied synthetic prepara- tions of low toxicity and high anaesthetic value, local, regional and spinal anaesthesia have increased in popularity and use again.

The names of these drugs are as numerous as their advocates. Diothane (McKim), neothesin (Warlther), percaine and novocaine,

to mention only a few. Probably, however, none of these drugs has as satisfactory a local anaesthetic effect as cocaine.

The addition of sodium bicarbonate to a solution of cocaine hydro- chloride in equal portions is stated by many to eliminate the toxic effects, while removing little or none of the anaesthetic value of the cocaine.

With regard to preliminary medication for urological investigation ; when the patient has been admitted to a hospital or nursing home much assistance can be gained by giving a preliminary injection of omnopon and scopolamine or the rectal administration of 3 or 4 drachms of paraldehyde, pyramidon, etc. But such methods are not suitable for the Out Patient Department or Consulting Room as they leave the patient too " doped " afterwards, and during the investigations tend to retard renal functions and vitiate the results of investigations such as the dye tests.

Ansesthesia for Urethra and Bladder Base.-Before commencing cystoscopic or other instrumentation on the male urethra, the calibre of the external urinary meatus should be noted. No amount of surface anaesthesia will remove pain produced by stretching a tight meatus, and local infiltration with 3 per cent. novocaine followed by linear division of the meatus on its ventral surface is quickly done.

For the female urethra, 5 C.C. of novocaine into the urethra and a small pledget of cotton wool soaked in the same solution and left on the meatus for a few minutes is all that is necessary in most cases.

Four per cent. novocaine without adrenaline is, I think, an excellent anaesthetic for general use. The solution should be warmed to blood temperature.

I see no advantage in the addition of adrenaline for surface anaesthesia and can imagine that it might lead to disaster if used on the hyperpietic patient, possessed of a previously traumatised or ulcerated urethra. Many of the early disasters with cocaine were probably due to some such

ELIMINATING PAIN FROM UROLOGICAL INVESTIGATION 261

factor, resulting in rapid absorption. Fillippo even condemns the use of all local anaesthetics where the bladder is acutely inflamed or ulcerated for the same reason.

A factor, which I believe to be of more importance than is generally realised, is that of time. My own practice is to fill the urethra slowly with 10 C.C. of 4 per cent. novocaine, apply a broad, flat-bladed penile clamp, and then to wait for fifteen minutes, a t the end of that time, a further 10 C.C. are introduced and instrumentation commenced.

In hospital Out Patient Departments the large number of patients to be treated, and the limited time available, admittedly raises a difficulty ; but the common practice of introducing a cystoscope or bougie immediately after introducing the local anaesthetic, should, I think, be condemned. The impinging of an instrument on an unanaesthetised stricture or unsus- pected middle lobe enlargement of the prostate causes a great deal of immediate pain and subsequent discomfort, gets the investigator no further with his work, and leaves the patient worse off than he was before.

Another practice which I believe gives rise to a certain amount of unnecessary discomfort is that of introducing a cystoscope with the sole assistance of a very small drop of a water-soluble lubricant on the beak, the rest of the instrument being dry. Paraffin is not a good lubricant for cystoscopy as it clouds the visual field, but it does not take many seconds to smear the whole length of the instrument with a water-soluble lubricant, and I am sure it eliminates some of the discomfort.

A third point, though perhaps a small one, is to make sure that the patient has not passed urine for a t least an hour before instrumentation. The cystoscope then passes gently and easily into the bladder without impinging on the trigone and bladder base. The passage of an instrument into an empty bladder, especially if carelessly done, will produce one or more hemorrhagic spots on the bladder wall, the causation of which will give rise to ingenious, though unprofitable, speculation. Finally, with regard to the position of the patient for cysto-urethroscopic investigation as distinct from operations. The supine position with the legs straight out and separated, and the pelvis slightly raised on a soft sand bag, is certainly the most comfortable. It has no real disadvantage when com- pared with the lithotomy position, and the latter, while commonly though not necessarily uncomfortable, is not pleasant, and has an adverse psychological effect on the young oE more delicate-minded.

Campbell recommends caudal anaesthesia for boys of four years and over, for ufological investigation, and reserves general anzesthesia only. " for the nervous and unruly." Using 8-10 C.C. of 2 per cent. novocaine he reports 80.7 per cent. of successes. An occasional idiosyncrasy to novocaine was observed. He humbly blames himself for 10 per cent. of

J U. T

2 62 THE BRITISH JOURNAL O F UROLOGY

his failures, but the method itself, the tender age of his patients and the lithotomy position following, should, I think, take their share.

Cystography.-For cystography sodium iodide in strengths from 10-20 per cent. are in common use. -The solution has the advantage, that diverticula lying within the outline of the bladder are demonstrated by increased density and not concealed, as they are by the. intense black shadow of lipiodol.

Sodium iodide is intensely 'irritating, particularly on an infected or ulcerated bladder. The -irritation can be completely allayed by repeated lavage after cystograms have been taken, with 2 per cent. sodium bicarbonate followed by the introduction of 200 C.C. of 311000 percaine as recommended by Frankel. The addition of a small amount of sterile liquid paraffin to this solution provides a film of lubricant over the bladder floor which seems to adhere for some days, and certainly eliminates spasm at the bladder neck.

With regard to the more remote methods of eliminating pain during investigation of the lower urinary tract, low spinal anaesthesia is probably the most popular and satisfactory for the surgeon, and certainly less of an ordeal than caudal and parasacral block for the patient. I have no personal experience of these latter methods, but after seeing them carried out, and reading of the technique they necessitate, it would appear to me that they involve as great an ordeal for the patient as the urological examination itself.

In tuberculous disease of the bladder involving the bladder base, spinal anaesthesia is certainly the quickest and most certain method for producing painless instrumentation, but it carries with it a grave and very real risk of over distension during the subsequent cystoscopy. An ulcerated bladder which for months has contracted down onto 2 02s. of urine may very easily be ruptured under a spinal anaesthetic by a disten- sion of 6ozs. A two-way continuous irrigation cystoscope is probably the safest instrument to use, distension being carried out under direct visual control.

Pyelography.-Investigation of the upper urinary tract does not involve much discomfort. The gentle passage of a paraffin-coated catheter up the wether should be painless, though some discomfort may be felt as the ureteral orifice is entered, particularly if the patient be in the lithotomy position, owing to the angulation of the catheter.

A great deal of unnecessary pain, however, frequently follows ascending pyelography . Mezo recommends the introduction of novo- caine into the renal pelvis as a preliminary to pyelography, but I feel that the method might lead to false conclusions in the subsequent inter- pretation of the results. The insensitive pelvis will give no warning of

ELIMINATING PAIN FROM UROLOGICAL INVESTIGATION 263

over distension, and apart from the associated danger, either real or imaginary, the method may convert a normal kidney into an apparent hydronephrosis. Conversely, if over distension be avoided by using a standard amount of the opaque fluid, an abnormal degree of dilatation might be missed.

My own practice is to carry out pyelography under direct visual control and to take the film the moment the typical renal pain is felt. The pelvis is then slowly emptied by suction through the ureteric catheter and 4 C.C. of 4 per cent. novocaine are introduced. The renal pain disap- pears within a few seconds, and I have not known it to return.

Chevassu has said that no method of anaesthesia can obviate gentle- ness in handling and this is or should be axiomatic in every branch of surgery.

I think that by combining this gentleness with a meticulous technique in anaesthesia, a complete urological investigation, which not infrequently is a greater ordeal to the patient than subsequent operation, may be rendered no more formidable than the simple manipulation of the procto- scope or a larynyoscopy.

References (1) M. F. CAMPBELL. “ Caudal Anaesthesia in Children.” J . Urol, 1933, XXX. (2) W. PERRY. (3) H. W. WARLTHER. J . Urol, January, 1932. (4) G. F. McKw, etc. “ Diothesene,” J . Urol., 1933, 29. (5) H. C. BUMPUS. J . Amer. Med. Aesoc., 1931, 96. (6) G. H. EWELL. J . Amer. Med. Assoc., 1931, 96 (7) EVIPAN P. COFEUNTES. Med. Ibera, 1934, 28. ( 8 ) A. FILLIPPO. “ Percaine,” Rof. Med., 1934, 1. (9) H. N. WEBBER. Med. World, 1933, 38. (10) CHEVASSU. Gazette dee ZZdp., 1933, 106. (11) R. A. HARPIN. “ Caudal Anaesthesia,” New Eng. J . Med., 1933. (12) J. M. COSTA ANN. Paul de Med. e cirug., 1933,26. (13) B. V. MEZO. “Local Anaesthesia in Pyelography,” Zeihchrijt jiir

“ Parasacral Anaesthesia,” Aus. and N.Z. J . Surg., 1932, 2.

Urologische Chirugie, August, 1930.

T 2