Rectal lymphogranuloma venereum in Jamaica

Lymphogranuloma venereum is a major public health problem in Jamaica. With improvement in the standard of living, better housing, better general education, a healthier sex education, and a more active programme of venereal disease control, the incidence of rectal lymphogranuloma should diminish. The early diagnosis and treatment of the proctocolitis by drugs is effective and should reduce the incidence of stricture. Major operations should be reserved for cases in which the more conservative methods of treatment are unlikely to succeed or have failed. At present, in Jamaica, operation necessitating a permanent colostomy should be considered more carefully than in this country. Unfortunately our attempts to eradicate the disease by operation and leave the patient with a functioning anus have been attended with only very limited success. Some of the failures may be attributed to insufficent experience with these operations, but involvement of the sphincter in the dense fibrotic process is probably responsible for the majority. In these fibrotic sphincters functional control is impossible. In a small number of cases intra-sphincter proctectomy in one stage by the method described by Dimitrui and Gregoresco (1933) has given promising results where the sphincter is free. The disease appears to be self-limiting. There has been no evidence of reactivation after removal of the affected gut even though this is rarely a complete en bloc excision or indeed even after colostomy only. Our follow up has been short. I have deliberately avoided the term "cure" because rarely has the compliment fixation reaction been reversed to negative. The significance of a persistently positive serological reaction in the absence of clinical evidence of disease is yet to be assessed. We have come a long way since John Hunter described the bubo 175 years ago and Frei placed the study of the disease on a firm aetiological basis 140 years later. In the past 35 years our knowledge of the lympho-granuloma venereum virus has increased, but the problem of treatment of rectal stricture, the most disabling complication of the disease, awaits solution. Morte (1933) stated: "The study of the stricture of the rectum is as fascinating as the treatment is discouraging. " In 1960 we can say: "Treatment of rectal stricture is often disappointing, but the results are encouraging" (Summary)

Pathology and treatment of urethral structure and its complications in Jamaica

The pathology and treatment of 66 severe or complicated strictures of the urethra are reviewed. There is little evidence from this series that lymphogranuloma venereum is an important cause of urethral stricture and its complications. The importance of avoiding the formation of false passages with bougies is emphasized. Fistulous tracks fall into definite patterns. A study of these in association with the urethrograms will allow pre-operative assessment of the extent of the lesions, and therefore of the extent of resection likely to be required. The suggestion is made that when unilateral hydronephrosis is present, obstruction at the lower end of the affected ureter is sometimes the result of infection which spread from the prostate gland or which was initiated by the passage of a bougie outside the urethra posterior to the base of the bladder. Patients with long-standing cystitis in association with stricture of the urethra may develop a carcinoma which is usually squamous celled and situated away from the base of the bladder. Impassable strictures and those complicated by fistula and abscess formation are best treated by excision and anastomosis in one stage when short and situated in the bulbo-membranous urethra, and by two-stage excision and reconstruction when long, multiple or in the penile urethra. (Summary)

Complications of urethral stricture

Sixty-six patients with urethral stricture treated by excisional surgery have been described. Complications involving the urethra and peri-urethral tissues, the renal tract proximal to the stricture, and the rest of the body have been studied. The operative methods employed have been briefly described. The indications for excisional surgery have been discussed, and may be summarised as follows: (1) No fistulae present - (a) Strictures found to be impassable after two separate and gentle attempts at bouginage under anaesthesia. (b) Strictures for which dilatations at frequent intervals are necessary, and which are accompanied by persistenta urethral discharge or perineal induration and tenderness. (2) Fistulae present - (a) Penile strictures should be excised and the urethra reconstructed in two stages. (b) Bulbous or membranous strictures with fistulae arising at or below the level of the membranous urethra may be treated by one stage excision and anastomosis, with temporary diversion of the urine. (c) Strictures in bulbous or membranous urethra with fistulae arising from above the perineal membrane, must be treated by extensive resection of diseased tissue with reconstruction of the urethra in two stages. (d) Single fistula, urethral diverticulum, or fistulae without associated stricture formation, may be treated by excision of diseased tissue and external urethrostomy. (e) The very severe lesions and those patients whose age, kidney function or state of nutrition precludes major surgery should be treated by some form of permanent diversion of the urine (AU)