Don’t Ask

More than most citizens, a doctor needs to ask probing questions. I did. Usually.

The portion of external human anatomy on which we sit, that located between tailbone behind and pubic bone in front, between ischial tuberosities from side to side, is known broadly (no pun intended) as the perineum. The mores of society dictate that the area rarely becomes sunburned.

Injuries to the perineum and those organs lurking beneath it are varied: Falling astraddle the frame of a bicycle or a fence; a quarter-of-an-inch wide, seven inch-long sliver of wood, picked up from sliding along a splintery bleacher seat; a severed urethra when a logger lost his footing and landed on the stump of the tree he had just cut down. I once had a patient who was a bronco-buster. Daily pounding had produced in him the worst prostate infection I have ever seen.

Then there was... let’s call him Josh.

During all my years of teaching interview techniques to medical students, the mantra I adopted was, “If the doctor asks enough open-ended questions, the patient’s answers will guide him toward the diagnosis.” I found this axiom to be true with comforting regularity. Having elevated it to the status of dogma, I am reminded of one time when my sole question was my standard opening line, “What brings you here tonight?” (Yes, an after-hours call.)

Josh was a man in his thirties. I knew, in that way such information oozes about a small town, that he was a bachelor, something of a loner, that he lived out near the end of the Hardscrabble Road, and that he was nominally a farmer. In Northpine, in 1955, that translated as “hillbilly poor.” He habitually bore a vaguely scruffy look, haystack hair, beard always a week or so past encounter with a razor, clothing even further past a date with a washtub. I had not previously seen him as a patient.

After I asked that opening question, he stood without a word, somewhat gingerly, I noted, and loosened his belt. I began the mental process known as Reaching a Diagnosis. He opened his trousers and slid them down. Aha. Hernia? Inflammation of the urethra? A lad with a touch of clap is often taciturn about his circumstances. He exposed normal and unremarkable genitalia. I pulled on rubber gloves, squatted before him, and cocked an eyebrow up at him. Without a word, he pointed at a spot on the very bottom of his anatomy. I palpated.

There was a small, hard bump lying just beneath perineal skin overlying his urethra. More than a bump, I found. It extended as a rod-like structure in the general direction of his bladder. There was no external penetrating wound in the skin. Now, this is a fairly inaccessible part of masculine anatomy. My eyebrows cocked over-time. Josh studied the far wall.

I escorted the man into our x-ray room and snapped a picture. Nestled within his urethra, extending toward the prostate and bladder, was a dense shadow on the film of a type produced by metal. I muttered, “It resembles... but how would... ”

Josh scanned the ceiling.

I said, “If I didn’t know better, I’d swear that looks like the, uh... ”

He glanced over his shoulder at the wall opposite.

“It really must come out of there,” I said. “I can send you to Duluth to a urologist.”

He shook his head, side to side.

“Or, I can make a little incision and, uh, remove it.”

His head bobbed once.

So.

After injecting a dollop of lidocaine anesthetic and making a miniscule incision, I retrieved a Bic pen replacement part. Reconstruction: the filler had, uh, found its way blunt-end-first into the urethra, had disappeared entirely upstream of the opening meatus. Then, the relatively sharper writing end had pierced the fragile urethral wall and hung it up, preventing any return trip.

I inserted an indwelling Foley rubber catheter, on the premise that while it healed the urethra needed a guide as to where it should open and where it should not. I prescribed an antibiotic to discourage infection. Josh dutifully returned after a few days to have the catheter removed.

As he prepared to leave that last time, I remembered my dictum about the importance of a thorough medical history, but somehow... I just couldn’t. He departed without my asking that all-illuminating question.

I have wondered, though.