The Bladder In The Female

In the female the vesico-uterine pouch reaches the level of the internal os and the bladder is in contact with the cervix from there down to the cervicovaginal junction or anterior fornix. From here it is in contact with the anterior vaginal wall along its upper half. The trigone extends from the middle of the anterior vaginal wall, which marks the internal orifice of the urethra, to 2 cm. ( 3/4 in.) below the cervicovaginal junction, the spot where the ureters enter the bladder walls. The absence of the prostate causes the bladder to be lower in the female and the level of the internal urethral orifice is opposite the lower border of the symphysis. It also is smaller in the female and does not show itself so readily above the symphysis on distention. Vesicovaginal fistulae frequently occur as the result of injuries during childbirth, cancerous ulceration, etc. They are located on the anterior wall of the vagina above its middle. Calculi can be extracted through an incision in the median line of the anterior vaginal wall above its middle. The commencement of the ureters can also be palpated on each side of the cervix anteriorly and impacted calculi may be removed at that point. The bladder is connected with the cervix and vagina posteriorly by comparatively loose connective tissue so that they can be readily separated by blunt dissection as far up as the internal os.

Cystoscopic Examination

The shortness and distensibility of the female urethra make the examination of the interior of the female bladder much easier than that of the male. For purposes of examination it is distended either with air or water. In order to distend it with air it is either injected directly with a rubber bulb or the patient is put in the knee-chest position, or, if on the back, the pelvis is elevated, so that the intestines gravitate toward the diaphragm. If a speculum is then introduced and the obturator withdrawn the bladder at once distends. The walls of the bladder are whitish in color with small vessels running over them. The base (trigone) of the bladder is redder than the surrounding walls. The muscular fasciculi are often seen as distinct ridges and the mucous membrane may be thrown into folds. The internal orifice of the urethra in the female is just below the lower border of the symphysis. The ureteral orifices can be seen as slightly elevated papillae 2.5 cm. or more behind the urethral orifice and 300 to its side, the trigone, when the bladder is not distended, making an equilateral triangle, with the urethra and ureteral papillae at its angles (Fig. 453).

Operations

Most of the operations on the bladder are done from above. To relieve distention tapping is done with a fine trocar or aspirating needle. It is to be inserted close to the upper margin of the symphysis and passed downward and backward. Cystotomy is performed through the median line. In making the incision three layers of fat are divided; first, the superficial fascia between the skin and muscles; second, the fatty pad between the posterior surface of the muscles and the transver-salis fascia; and third, the prevesical fat of the space of Retzius beneath the trans-versalis fascia and between the anterior wall of the bladder and the symphysis pubis. Tumors. - Growths and prostatic enlargements are often operated on supra-pubically. These are usually easily within reach of the finger. In incising the bladder the anterior vesical veins are to be avoided by keeping in the median line.

Fig. 453.   The picture on the left demonstrates a normal mucous membrane and ureteral orifice. On the right the ureteral orifice will be observed to be small, round, atrophic, and functionless. (Drawn from a case of Dr. Benj. A. Thomas* by Mr. Louis Schmidt).

Fig. 453. - The picture on the left demonstrates a normal mucous membrane and ureteral orifice. On the right the ureteral orifice will be observed to be small, round, atrophic, and functionless. (Drawn from a case of Dr. Benj. A. Thomas* by Mr. Louis Schmidt).