In the less severe forms of stricture only the mucous membrane and the tissues lying immediately beneath it are affected, while in the severer and later varieties the scar-like tissue forms even in the structures which form the body of the penis, or corpus spongiosum so that one can feel, by external manipulation, the hard, cord-like masses in which the urethra seems to be embedded. This condition is most common at the peno scrotal angle, just where the scrotum joins the under surface of the penis. Even a mild case of gonorrhoea may result disastrously; for the inflammatory processes very frequently last long after the attack is supposed to be over, and are followed by an extensive outgrowth of exuberant and unhealthy tissue.
Many and many a man who has had gonorrhoea and thinks himself cured will suffer from stricture when he gets older; the one precaution which it is in his power to take is, to see that he does not get a reinfection of this terrible disease. "In many cases the process remains limited for years, but even when it has thus remained dormant it may later on become active and involve more tissue. This is the underlying cause of the extensive and deeply invading strictures which are not uncommonly found in old men". Owing to the extremely slow processes which take place in stricture formation they are not common before twenty-five years of age, while the greatest number of cases occur between twenty five and forty years, and the next heaviest figures fall between forty and fifty years of age. "It is significant of the usual slowly developing character of stricture that the greatest number of patients felt the necessity of relief between the twenty fifth and fiftieth years".
Strictures vary much in the extent and depth to which they extend, and in their softness or density, their tendency, however, being to grow denser and denser, and to narrow the urinary passage more and more.
The layman very naturally might feel surprise that scar tissue should be so prone to grow and to show activity, because he notices that scars on the surface of his body remain unchanged for a lifetime. But, by way of explanation, it must be pointed out that the urethra is not only an extremely delicate tube surrounded by highly vascular tissues, but that it also must be in continual use just like the bile ducts, or even the heart; in other words the scar, being in vital tissues, itself keeps vital and takes on renewed activity with every loss of resisting power on the part of the surrounding tissues. If scar like tissue, similar to a stricture, form in the passages which convey the semen from the testicles, then it does often completely seal up these tubes and render the individual sterile, because these seminal passageways are not in any way essential to life, nor are they by any means so vascular as the urethra.
A stricture which is at first limited to one comparatively small patch of the urethra has a tendency to spread and to travel along the tissues, so that eventually there may be several different places which are the seats of the morbid process. Sometimes there is merely a narrow band or ring of stricture tissue surrounding the urethra, and sometimes the fibrous tissue extends along the tube for four or five inches; and, again, there may be stricture of the urethra in two, or three, or more places, between which there is a portion of healthy tube. Almost all strictures of long-standing duration are annular, i.e., they have grown until they completely surround the urethral canal.
The stricture tissue scar like tissue does not affect the urethra alone, but extends deeply into the substance of the penis; what we find in the urethra being only a surface indication of the deeply seated malady. These strictures present many varieties in shape and extent; sometimes they are mere thread like thickenings in the mucous membrane; sometimes there is a crescentic or valve like flap which juts out into the urethra; sometimes there is a complete diaphragm extending across the canal with an opening in the centre; and sometimes the fibrous tissue has grown to such an extent that the urine has to pass through an extremely tortuous, crooked and contracted canal.
Stricture formation may be quite rapid and develop within six months from the initial attack of gonorrhoea, but, generally speaking, the process is long drawn out.
It would be assuming a great deal on the part of any physician to promise any man who has ever had a chronic gonorrhoea, however mild, that he will never have a stricture. The patient is usually advised to present himself, perhaps not more than two or three times a year, but for many years, for observation, in order that sounds may be passed for the purpose of detecting a possible stricture in its very beginning, when the most good can be done.