1911 Encyclopædia Britannica/Bladder and Prostate Diseases
BLADDER AND PROSTATE DISEASES. The urinary bladder in man (for the anatomy see Urinary System), being the temporary reservoir of the renal secretion, and, as such, containing the urine for longer or shorter periods, is liable to various important affections. These are dealt with in the first part of this article. The diseases of the prostate are so intimately allied that they are best considered, as in the subsequent section, as part of the same subject.
Diseases of the Bladder.
Cystitis, or inflammation of the bladder, which may be acute or chronic, is due to the invasion of the mucous lining by micro-organisms, which gain access either from the urethra, the kidneys or the blood-stream. It is easy to see how Cystitis. the diplococci of gonorrhoea may infect the bladder-membrane by direct extension of the inflammation, and how the bacilli which are swarming in the neighbouring bowel may find access to the urethra or bladder when the intervening tissues have been rendered penetrable by a wound or by inflammation. Sometimes, however, especially in the female, the germs from the large intestine enter the bladder by way of the vulva and the urethra.
Any condition leading to disturbance of the function of the bladder, such as enlargement of the prostate, stricture of the urethra, stone, or injury, may cause cystitis by preparing the way for bacillary invasion. The bacilli of tuberculosis and of typhoid fever may set up cystitis by coming down into the bladder from the kidneys with the urine, or they reach it by the blood-stream, or invade it by the urethra. Another way of cystitis being set up is by the introduction of the germs of suppuration by a catheter or bougie sweeping them in from the urethra; or the instrument itself may be unsterilized and dirty and so may introduce them. It used formerly to be thought that wet or cold was enough to cause inflammation of the bladder, but the probability is that this acts only by lowering the resistance of the lining membrane of the bladder, and preparing it for the invasion of the germs which were merely waiting for an opportunity. In the same way, gout or injury may lead to the lurking bacilli being enabled to effect their attack. But in every case disease-germs are the cause of the trouble, and they may be found in the urine. The first effect of inflammation is to render the bladder irritable, so that as soon as a few drops of urine have collected, the individual has intense or uncontrollable desire to micturate. The effort may be very painful and may be accompanied by bleeding from the overloaded blood-vessels of the inflamed membrane. In addition to blood, pus is likely to be found in the urine, which by this time is alkaline and ammoniacal, and teeming with micro-organisms. As regards treatment, the patient should be at once sent to bed in a warm room, and should sit several times a day in a very hot hip-bath. When he has got back to bed, a fomentation under oil-silk, or some other waterproof material, should be placed over the lower part of the abdomen. The diet should be milk (diluted with hot or cold water), barley-water, and bread and butter; no alcoholic drink should be allowed. If the urine is acid, bicarbonate of soda may be given, or citrate of soda; if alkaline, urotropine—a derivative of formic aldehyde—may prove a useful urinary disinfectant. If the straining and distress are great, a suppository of ¼ or ½ a grain of morphia may be introduced into the rectum every two or three hours. The bowels must be kept freely open. If the urine is foul, the bladder should be frequently washed out by a soft catheter and two or three feet of india-rubber tubing with a funnel at the other end, weak and abundant hot lotions of Sanitas or Condy's fluid being used.
Chronic cystitis is the condition left when the acute symptoms have passed away, but it is liable at any moment to resume the acute condition. If the cystitis is very intractable, refusing to yield to hot irrigations, and to washings with nitrate of silver lotion, it may be advisable to open the bladder from the front, and to explore, treat, drain and rest it.
In tuberculous cystitis there is added to the symptoms the discovery of the bacilli of tuberculosis in the urine, and cystoscopic examination may reveal the presence of tubercles of the mucous membrane or even of ulceration. The patient is probably losing weight, and he may present foci of tuberculosis at the back of the testicle, the lung or kidney, or in a joint or bone, or in a lymphatic gland. Treatment is rebellious and unpromising. Washings and lotions give but temporary relief, and if the bladder is opened for rest, and for a more direct treatment, the germs of suppuration may enter, and, working in conjunction with the bacilli, may cause great havoc. Koch's tuberculin treatment should certainly be given a trial. This consists of the injection into the body of an emulsion of dead tubercle bacilli which have been sterilized by heat. As a result of this injection the blood sets to work to form an “opsonin”—a protective material which so modifies the disease-germs as to render them attractive to the white corpuscles of the patient's blood (phagocytes), which then seize upon and destroy them. Sir A. E. Wright has devised a delicate method of examination of the blood (the calculation of the opsonic index) which tells when the tuberculin injections should be resorted to and when withheld (see Blood).
Calculi and Gravel.—Uric acid is deposited from the urine either as small crystals resembling cayenne pepper, or else, in combination with soda and ammonia, as an amorphous “brick-dust” deposit, which, on cooling, leaves a red stain on Stone. the bottom of the vessel, soluble in hot water. These substances are derived from the disintegration of nitrogenized food taken in excess of demand, and from the breaking down of the human tissues. They occur therefore in fevers, in wasting diseases, and in the normal subject after excessive muscular exercises, especially if these exercises have been accompanied with so much perspiration that the excess of water from the blood has escaped by the skin rather than by the kidneys. The abundance of this deposit is in accordance with the amount of heat developed and work done in the body, and corresponds with the dust and ashes raked out of the fire-box of the locomotive after a long run. But supposing that the uric acid débris continues to be excessive, the risk of the formation of renal or vesical calculi becomes considerable, and it may be advisable to place the patient on a restricted nitrogenized diet, to induce him to drink large quantities of water, and to keep his bowels so loose with watery laxatives, such as Epsom salts or sulphate of soda, that the waste products of his body are made to escape by the bowels rather than by the kidneys. In addition to the salts just mentioned, an occasional dose of blue pill will prove helpful. A course of treatment at Contrexéville or Carlsbad may be taken with advantage.
Alkaline urine is unable to hold the phosphates of ammonia and magnesia in solution, so they are deposited in abundance either in the kidney or bladder. If the voided urine is allowed to stand in a tall glass they sink to the bottom with pus and mucus in a cloudy deposit. To remedy this condition it is necessary to treat the cystitis with which the bacterial decomposition of the urine is associated. It may be that a calculus of acid urine, such as one of uric acid or oxalate of lime, has been resting in the bladder and keeping up incessant irritation, and that the micro-organisms of decomposition or suppuration have found their way to the mucous lining of the bladder from either the bowel, the urethra or the blood-stream; undergoing cultivation there they break up the urea into carbonate of ammonia and so render the urine alkaline. This alkaline urine deposits its phosphates, which light upon the calculus and encrust it with a mortary shell, which may go on increasing in size until it may even fill the bladder. Sometimes the nucleus of a calculus is a chip of bone or a blood-clot, or some foreign substance which has been introduced into the bladder. Sooner or later the urine becomes alkaline and the calculus is encrusted with lime salts.
When urine contains a larger amount of chemical constituents than it can conveniently hold in solution, a certain quantity crystallizes out, and may be deposited in the kidney or in the bladder. If the crystals run together in the kidney the resulting concretion may either remain in that organ or may find its way into the bladder, where it may remain to form the nucleus of a larger vesical calculus, or, especially in the case of females, it may, while still small, escape from the bladder during micturition.
In children, in whom there is a rapid disintegration of nitrogenized tissues, a uric acid calculus in escaping from the bladder may block the urethra and give rise to sudden retention of urine. On introducing a metal “sound,” the surgeon may strike the stone, and if it happens to be near the bladder he may push it back and subsequently remove it by crushing. But if it has made its way some distance along the urethra, so that he can feel it from the outside, he should remove it by a clean incision.
A stone in the bladder worries the nerves of the mucous membrane, and, giving them the impression that the bladder contains much water, causes the desire and need for micturition to be constant. The irritation causes an excessive secretion of mucus, just as a piece of grit under the eyelid causes a constant running from the eye. So the urine, if allowed to stand, gives a copious deposit. During micturition the contracting bladder bruises its congested blood-vessels against the stone, so that towards the end of micturition blood appears in the urine. Lastly, cystitis occurs, and the urine contains fetid pus. A stone in the bladder gives rise to pain at the end of the penis, and it is apt suddenly to stop the flow of urine during micturition.
The association of any of these symptoms leads the surgeon to suspect the presence of a stone in the bladder, and he confirms his suspicions by introducing a slender steel rod, a “sound,” by which he strikes and feels the stone. Further confirmation may be obtained by the help of the X-rays, or, in the adult, by using a cystoscope. In a child the stone may often be felt by a finger in the rectum, the front of the bladder being pressed by a hand on the lower part of the abdomen. The cystoscope is a straight, hollow metal tube about the size of a long cedar pencil, which the surgeon introduces into the adult bladder, which has already been filled with warm boracic lotion. Down the tube run two fine wires which control a minute electric lamp at the bladder end of the instrument. At that end also is a small glass window which prevents the fluid escaping by the tube, and also a prism; at the other end of the tube is an eye-piece. By the use of this slender speculum the practised surgeon can recognize the presence of tubercle or tuberculous ulceration of the bladder, stone, or other foreign material, and innocent or malignant growths. He can also watch the urine entering the bladder by the openings of the ureters, and determine from which kidney blood or pus is coming.
The treatment of stone in the bladder is governed by various conditions. Speaking generally, the surgeon prefers to introduce a lithotrite and crush the stone into small fragments, and then to flush out the fragments by using a full-sized, hollow metal catheter and an india-rubber wash-bottle. Even in children this operation may generally be adopted with success, the stone being crushed to atoms and the fragments being washed out to the last small chip. But if the stone is a very hard one (as are some of the oxalate of lime calculi), or if it is very large, or if the bladder or the prostate gland is in a state of advanced disease, or if the urethra is not roomy enough to admit instruments of adequate calibre, the crushing operation (lithotrity) must be deemed unsuitable, and the stone must be removed by a cutting operation (lithotomy).
Lithotomy.—Cutting for stone has been long practised; but up to the beginning of the 19th century it was performed only by a few men, who, bolder than their contemporaries, had specially worked at that operation and had attained celebrity as skilful lithotomists. Patients went long distances to be operated on by them, and certain of the older surgeons, as William Cheselden, performed a large number of operations with most excellent results. The operation was by an incision from the perineum, and is ordinarily spoken of as lateral lithotomy. It was splendidly designed, and gave good results, especially in children. But it is now a thing of the past, having almost entirely given place to the high or supra-pubic operation. In the high operation the patient, being duly prepared, is placed upon his back and the bladder is washed out with hot boracic lotion, and when the lotion returns quite clean a final injection is made until the bladder is felt rising above the pubes. Then the india-rubber tube is removed from the silver catheter by which the injection has been made, and the end of the catheter is plugged by a spigot. An incision is then made in the middle line of the abdomen over the bladder region. The incision must be kept as low as possible, so that the bladder may be reached below the peritoneum, which, higher up, gives it an external, serous coat. As the bladder is approached, a good many veins are seen to be in the way, some of which have to be wounded. The bladder-wall is recognized by its coarse network of pale muscular fibres, through which, on each side of the middle line, a strong suture is passed, so that when the bladder is opened and the lotion comes rushing out, the opening which has been made into the bladder may not sink into the depths of the pelvis. A finger introduced into the bladder makes out the exact size and position of the stone, or stones, and the removal is effected by special forceps. Bleeding having ceased, the bladder-wound is partly or entirely closed by sutures and allowed to fall into the pelvis, the catheter having been removed. It is advisable to leave a drainage tube in the abdominal wound for a while, so that if urine leaks from the bladder-wound it may find a ready escape to the dressings.
Litholapaxy.—Lithotrity consists of two parts—the crushing of the stone, and the removal of the detritus. The two stages are now carried out at one “sitting,” without an interval being allowed between them, as was formerly the practice, and the term “litholapaxy” designates this method. The patient having been anaesthetized, 10 oz. of hot boracic lotion are injected, and the crushing instrument, the lithotrite, is then passed into the bladder. The lithotrite has two blades, a “male” and a “female,” the latter fenestrated, the former solid with its surface notched. When the stone is fixed between the blades the screw is used, and great pressure is applied evenly, gradually and continuously to the stone. The lithotrite is made of very tough steel, so that hard stones may be crushed without danger of the instrument breaking or bending. Care must be taken not to catch the bladder-wall with the lithotrite. This danger is avoided by raising the point of the lithotrite immediately after grasping the stone and before crushing. The stone breaks into two or more pieces, and these fragments must be crushed, one by one, until they are powdered fine enough to escape by the large evacuating catheter. If the stone be large and hard, half an hour or longer may be required to crush it sufficiently fine. When the surgeon fails to catch any more large pieces, the presumption is that the stone has been thoroughly broken up. The lithotrite is then withdrawn and the detritus is washed out by an “aspirator,” which consists of a stiff elastic ball which is connected with a trap, into which fragments of stone fall so as not to pass out on the instrument being used at later periods in the operation. A large catheter, with the eye very near the end of the short curve, is passed into the bladder; the aspirator, full of boracic lotion, is attached to the catheter, and a few ounces of the fluid are expressed from the aspirator into the bladder by squeezing the rubber ball. When the pressure is taken off the ball, it dilates and draws the fluid out of the bladder, and with it some of the detritus, which falls into the trap. This is repeated until all the fragments have been removed. After the operation the patient sometimes suffers from discomfort. His urine should be drawn off by a soft catheter at regular intervals for a few days. If the pain be severe, it can generally be relieved by fomentations. The patient must be kept in bed after the operation, and in cases where the stone has been large and the bladder irritable, the surgeon should insist on his remaining there for at least a week; in those cases which go on favourably the patients are soon able to perform their ordinary duties. Fatal terminations, however, do now and again occur from suppression of urine, the result of the old-standing kidney disease which so often complicates these cases.
To Brigade-Surgeon Lieutenant-Colonel Dennis Francis Keegan, of the Indian Medical Service, is due the fact that the operation of crushing and promptly removing all fragments of a vesical calculus is as well suited for boys as for men. In entire opposition to long-standing European prejudices, Keegan's operation is now firmly and permanently established. The old operation (Cheselden's) of cutting a stone out through the bottom of a boy's bladder is now seldom resorted to, and if a stone in a boy is found too large or too hard to lend itself to the crushing operation, it is removed by a vertical incision through the lower part of the anterior wall of the abdomen, as described above. For a successful performance of the crushing operation in a boy a small lithotrite has, of course, to be used, and it must be of the very best English make. The operation has to be done with the utmost gentleness and thoroughness, not a particle of the crushed stone being left in the bladder, since otherwise the piece left becomes the nucleus of a fresh stone and the trouble recurs.
The treatment of vesical calculi by other means than operative surgery is of little value. Attempts have been made to dissolve them by internal remedies, or by the injection of chemical agents into the bladder; but, although such methods have for a time been apparently successful, they have invariably been found worthless for removing calculi once actually formed. Nevertheless, much can be done towards preventing the formation of calculi in those who have a tendency to their formation, by attention to diet, by taking proper exercise, and by the internal administration of drugs.
Hypertrophy and Dilatation.—When there is long-continued obstruction to the flow of urine, as in stricture of the urethra, or enlargement of the prostate, the bladder-wall becomes much thickened, the muscular fibres increasing both in size and number; the condition is known as “hypertrophy.” Hypertrophy may be accompanied by dilatation of the bladder, a condition which the bladder may assume when the voiding of its contents is interfered with for a length of time.
Paralysis of the bladder is a want of contractile power in the muscular fibres of the bladder-wall. It may result from injuries whereby the spinal cord is lacerated or pressed upon, so that the micturition centre, which is situated in the lumbar region, is thrown out of working order. The result may be either retention or incontinence of urine; sometimes there is at first retention, which later is followed by incontinence. Paralysis is also met with in certain nervous diseases, as in locomotor ataxia, and in various cerebral lesions, as in apoplexy.
Atony of the bladder is a paresis or partial paralysis. It is due to a want of tone in the muscular fibres, and is frequently the result of over-distension of the bladder, such as may occur in cases of enlargement of the prostate. The patient is unable to empty the bladder, and the condition of atony gets increasingly worse.
In both paralysis and atony the indication is carefully to prevent over-distension by the urine being retained too long, and at the same time to treat by appropriate means the cause which has produced or is keeping up the condition.
Incontinence of urine may occur in the adult or in the child, but is due to widely different causes in the two cases. In the child it may be simply a bad habit, the child not having been properly trained; but more frequently there is a want of control in the micturition-centre, so that the child passes its water unwittingly, especially during the night. In adults it is not so much a condition of incontinence in the sense of water being passed against the will, but is a suggestion that the bladder is already full, the water which passes being the overflow from a too full reservoir. It is usually caused by an obstruction external to the bladder, e.g. enlarged prostate or stricture of the urethra; a calculus may produce the condition. In the child an attempt must be made to improve the tone of the micturition-centre by the use of belladonna or strychnine internally, and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pass water at stated times and regular intervals. In the adult the cause which produces the over-distension must be removed if possible; but, as a rule, the patient has to be provided with a catheter, which he can pass before the bladder has filled to overflowing. A soft flexible catheter should be given in preference to a rigid or semi-rigid one. The best form is the red-rubber catheter, and he should be taught the need of keeping it absolutely clean. In the case of children incontinence of urine means irritability; in adults it means overflow.
The condition termed by Sir James Paget stammering micturition is analogous to speech stammering, and occurs in those who are nervous and easily put out. It would seem to be due to the sphincter of the bladder not relaxing synchronously with the contraction of the detrusor, and is sometimes caused by external irritation, such as preputial adhesions. Occasionally not a drop of urine can be passed, or a little passes and then a sudden stoppage occurs; the more the patient strains the worse he becomes, until at last there is complete retention of urine. The trouble can sometimes be cured by the removal of irritating causes, and in these cases, as well as in those in which no such cause can be discovered, care should be taken to avoid those difficulties which have given rise to the patient's worst failures. If at any time he should fail to perform the act of micturition, he ought not to strain, but should quietly wait for a little before making any further effort. Regularity in the times of making water is also of much importance.Retention of urine may occur in paralysis of the bladder, or in conditions where the patient is suffering from an illness which blunts the nervous sensibility, such as apoplexy, concussion of the brain, or typhoid fever. It is, however, more commonly due to obstruction anterior to the bladder, as in stricture of the urethra or enlargement of the prostate. The distended bladder can be felt as a rounded swelling above the pubes, and perhaps reaching to the level of the navel. Percussion over it gives a dull note. When the bladder is distended, it is necessary to evacuate it as soon as possible. If there is no obstruction to the flow of urine, the retention being due to atony or paralysis, a soft catheter is passed and the water drawn off. But when there is an obstruction which cannot be overcome, aspiration has to be resorted to, the needle of the aspirator being pushed through the abdominal wall into the bladder. The point of puncture in the abdominal wall is in the middle line a few inches above the symphysis pubis. The bladder may be emptied in this way very many times in the same person with only good result.
Diseases of Prostate Gland.
The prostate gland may become acutely inflamed as the result of the backward extension of gonorrhoeal inflammation of the urethra; it may also be attacked by the germs of ordinary suppuration as well as by the bacilli of tuberculosis. A sudden enlargement of a large gland lying against the outlets of the bladder and the bowel renders micturition difficult, painful or impossible, and interferes with defaecation. Pressure of the seat of the chair upon the perineum also causes distress, so the man sits sideways and on the edge of the seat. If abscess forms, it should be incised from the perineum; if allowed to run its course it may burst into the bladder, the urethra or the rectum, and set up serious complication. The treatment of prostatitis (inflammation of the prostate) consists in rest in bed, sitz-baths and fomentations. If retention of urine takes place a soft catheter must be passed. In the early stage of an acute attack a dozen leeches upon the perineum may do good. The bowels must be kept freely open, and from time to time, as the pain demands, a morphia suppository may be introduced into the bowel.
Enlargement of the prostate exists in a considerable proportion of men of about sixty years of age and onward. It consists of an uncontrolled growth of the normal muscular and glandular tissue of the prostate, interfering with, or absolutely stopping, the outflow of the urine. Gently pushing the bladder upwards and backwards, it increases the length of the urethra, so that in order to draw off retained urine the catheter must be longer than ordinary, but inasmuch as there is no actual narrowing of the passage it may be of full calibre. The beak should be well turned up so that it may ride in front of, and surmount, the median enlargement. Because of the thick, ring-like mass of new tissue around the outlet of the bladder, there is difficulty in micturition, and because the muscular bladder wall is now unable to contract upon all its contents a certain amount of urine is retained. As the enlarged prostate bulges up in the floor of the bladder, a pouch or hollow forms behind it, from which the muscular wall is unable to dislodge the stagnant urine. This keeps up constant irritation, and if by chance the germs of decomposition find their way thither, cystitis sets in and the patient's condition becomes serious, not only because of the risk to which his tired and irritated kidneys are submitted, but because of the possibility of a phosphatic stone being formed in the bladder. The seriousness of enlargement of the prostate does not depend upon the size of the growth so much as upon the inability of the patient to empty his bladder completely.
When the surgeon has made out the existence of an enlargement of the prostate, the next thing is to find to what extent this interferes with the bladder being emptied. To do this, he asks the patient to pass as much water as he is able, and then with due precautions introduces a soft catheter and measures the amount of urine which he thus draws off—half an ounce, an ounce, two ounces, however much it may be. It is this “residual urine” which causes the annoyance and the danger of enlarged prostate, and unless arrangements can be made for its regular withdrawal serious trouble is almost certain to ensue. The passing of a large catheter may have the effect of so opening up the water-way that, at any rate for a time, the irritability of the bladder may cease, in which case the patient may be instructed in the art of passing a catheter for himself. Or the surgeon may find that in addition to the regular passing of a large catheter an occasional washing-out of the bladder with hot boracic lotion is all that is needed in the way of active treatment. At the same time, however, the patient is placed upon a plain and wholesome diet with little or no alcohol, and he is instructed to lead in every respect a regular and quiet life. To many men with enlarged prostate the passing of an instrument night and morning is no great hardship, while to others the idea of leading what is called a “catheter life” appears intolerable, or, having for a time been patiently carried out, is found not only severely trying but greatly disappointing.
In some people the very first passing of a catheter sets up a local and constitutional disturbance, the bladder being rendered irritable and intolerant, the temperature going up, and shiverings and perspirations manifesting themselves. This condition was formerly called “catheter fever,” and was looked upon as something mysterious and peculiar. It is now generally understood to be the result of septic inoculation of the interior of the bladder.Lastly, in other persons the passing of the catheter is attended with so much difficulty, distress or bleeding, that something more helpful and effectual is urgently called for.
Operative Treatment.—It has long been known that large tumours of the uterus sometimes dwindle if the ovaries are removed by operation, and Professor William White of Philadelphia thought that prostatic growths might be similarly influenced by the removal of the testicles. Beyond question considerable improvement has followed this operation in cases of enlargement of the prostate, especially where the enlargement seemed to be general, soft and vascular. A similar though perhaps a slower effect is produced when the duct of the testis, the vas deferens, is divided on each side of the body. If there is no great urgency about the case this treatment may well be tried, the bladder being all the while duly emptied by catheter and washed by irrigation. But if the case is urgent, there being difficulty or bleeding with the passing of the catheter, the bladder being excessively irritable and the urine foul, a more radical measure is needed. The best operation is that upon the lines laid down by Robert McGill, who opened the bladder through the anterior abdominal wall and removed that part of the prostate gland which was blocking the water-way. McGill's operation was improved upon by Eugene Fuller of New York, who, in 1895, published a full account of his procedure. Having opened the bladder from the front (as in supra-pubic lithotomy), he introduced his left index finger into the rectum and thrust the prostate gland towards the right index finger, which was then in the bladder. With the nail of that finger, or with the end of a pair of scissors, he made a rent in the mucous membrane of the bladder and the capsule of the gland, and then shelled out the mass of new tissue which had caused the prostatic enlargement. This operation is called “prostatectomy,” which means the removal of the prostate gland. The prostate gland, however, is not removed, but only a muscular and glandular mass (adenoma), which, growing within the prostatic capsule, encircles the urethra and squeezes the original gland tissue out of existence. Following on the lines of McGill and Fuller, P.J. Freyer has done excellent work in England towards placing this operation upon a sound basis.
Subsequently to the operation the bladder enjoys complete and needful rest, and the kidneys, which previously were in a condition of perpetual disturbance, improve in working power. The wound in the bladder and in the abdominal wall gradually closes; the function of the bladder returns, and the patient is soon able to go back to his usual occupation in greatly improved health and vigour. The operation is, necessarily, a serious one, and the age of the patient, the condition of his bladder, of his kidneys, and of his blood-vessels, require to be taken into consideration; still, the operation gives an excellent account of itself in statistics, and if a practical surgeon advises a patient to accept its risks his counsel may well be followed.
- Diseases of the Genito-urinary System, by Eugene Fuller, M.D. (London and New York, 1900).