The principles and practice of modern surgery

by Roswell Park

Symptoms.

—The cardinal symptoms of cystitis are three in number, i. e., pain, frequency of micturition, and pyuria, the latter being the consequence of changes in the urine, as well as in the bladder wall, while the pain and the thamuria are expressions of irritation, especially of the base of the bladder and the posterior urethra. In fact, all the more violent expressions of cystitis are found at the lower part of the bladder rather than in its upper portion. Obviously, then, irritation of adjoining organs is more easily accounted for, e. g., of the urethra, the seminal vesicles, the prostate, and the lower ends of the ureters.

The pain may be severe, and is especially complained of with each act of urination. It is referred not only to the region of the bladder proper, but along the urethra to the end of the penis in the male, and down the thighs in both sexes. With frequency of urination there is also distressing urgency, so that once the necessity be felt nothing can restrain the promptness of the act. In fact so powerful is the expulsive tendency that the tenesmus affects not only the bladder but often the rectum, while the feeling or desire to urinate continues after the bladder has been emptied of its last drop, even for several minutes, and may cause the patient to sit in agony for some time. The distress produced in acute cases of cystitis is excessive, and sedatives and anodynes constitute no small part of the treatment.

The amount of pus contained in the urine will vary with the degree of acuteness and the stage of the disease. At first it is but slight, but rapidly increases, until the urine may contain thick mucus and pus up to one-third or more of its volume. Finally blood may appear, by whose appearance a serious degree of inflammation is betokened.

Later, at a variable date, the putrefactive element is introduced; and when the urine begins to smell of ammonia—i. e., when ammoniacal decomposition has once begun—the bladder is thereby the more irritated and the case made still worse.

No vesical mucosa left suffering from such acute inflammation will remain unaffected in its tissue elements, but will rapidly become more or less thickened. In fact the entire bladder wall undergoes a process of thickening, from hypertrophy of its inner and its muscular or middle coats, the latter due to extra activity in consequence of the constant tenesmus. There results in time a marked eccentric hypertrophy, whose result is really a contraction of the bladder cavity and a distortion of its lining. Under these circumstances, also, the mucosa becomes sacculated, and numerous little pockets, which may contain decomposing urine, serve to complicate the situation; while, finally, more or less incrustation or calculous degeneration and implantation modify the character of the mucous coat. For all these changes to occur requires time, but their combined effect is such thickening and contraction of the bladder as to permanently alter it and lead to a final concentric hypertrophy.

Tuberculous Cystitis.

—The picture presented by tuberculous disease of the vesical mucosa is, in the beginning, one of miliary or disseminated involvement; but later, when ulcerative changes have taken place, the end results are scarcely different from those rehearsed above, save that the ulcerative element is more predominant, and there is great probability of involvement of the ureters or of any of the adjoining organs. As conditions do not essentially vary, neither do symptoms, and a diagnosis of tuberculous cystitis often must, in the early stages, be reached by a process of exclusion, corroborated perhaps by the cystoscope.

Postoperative Cystitis.

—A different clinical type of irritation, or mildly infective cystitis, is known to be a sequel of certain operations, not alone those upon the pelvis. In the majority of cases it occurs when catheterization has been required, the first event being urinary retention, by which the bladder mucosa must be more or less disturbed. It may be perhaps accounted for by the fact that the urethra is practically never free from germs, which, in that canal, seem to be innocent, but which, carried upward into an irritated bladder may excite serious inflammation. These cases are perhaps more frequent after pelvic operations for cancer. There seems, however, no doubt but that repeated catheterization for several days lowers bladder resistance.