Discussion on lower urinary obstruction.

My contribution to this discussion is concerned with obstructions in the anterior urethra: they are not very common, but because we are so often concerned with congenital obstructions of the posterior urethra and of the bladder neck there is a tendency to overlook anything between the external meatus and the external sphincter. I shall not comment on meatal stenosis which is well known to us all, save to remark that a useless meatotomy had been performed on several ofmy cases where the obstruction was actually placed much further back, and it is clear that meatal stenosis is sometimes diagnosed without justification and without adequate investigation. The first group of anterior obstructions to be considered are the 'obliterations' in which the whole urethra is atretic and without lumen over a considerable length. Two cases of absent abdominal muscles in my series had complete obliteration of the urethra, and of course a severe upper tract dilatation leading to death in the neonatal period: these very serious cases are in much the same situation as the posterior urethral valve cases discussed by Rickham. Of more immediate surgical interest are the partial obliterations of which the following case is an example. A boy of 10 months had never thrived and had suffered recurrent pyrexia with urinary infection. An intermittent very fine jet of urine had been seen to emerge from a tiny sinus in the perineum. The bladder was distended and an intravenous pyelogram showed advanced upper tract dilatation. On attempted instrumentation and later exploration, it was found that almost the whole of the urethra in front of the bulb was atretic with a minute lumen lost altogether at times, while the sinus in the perineum led to the dilated posterior urethra. A skin tunnel was brought up to the dilated segment; bladder emptying is now satisfactory, but the ultimate prognosis cannot be good. Perhaps the most interesting group of anterior urethral obstructions comprises the congenital