Symptoms.
—The symptoms due to tumor in the bladder do not differ much from those of calculus, except that there is at first less pain. In nearly all cases there will be hemorrhage, occurring independently of exciting causes, as during sleep, not only abundant but often frequent. In the early stages pain is rarely severe. In cancer it is largely proportionate to involvement of the bladder wall and the adjacent organs, and is more common in cases of basal tumors. It is both local and referred. With a bladder filled or filling up with a tumor mass there will be reduction of capacity and frequency of urination, while in nearly all instances the essential features of cystitis are superadded. The actual evidences of tumor are its detection by the cystoscope, its discovery by vaginal or rectal palpation, or its recognition by fragments discovered in the urine.
When the cystoscope is used in these cases it usually reveals the location, size, vascularity, arrangement, and character of the tumor. Its use, however, is often difficult or impossible, because the manipulation by which the bladder is so distended as to permit its use causes hemorrhage and obscurement of the field of vision ([Figs. 657] and [658]).
With the cystoscope has been recognized also an early condition of leukoplakia, corresponding to that seen in the mouth and on the tongue, which may be regarded as a precancerous condition.
Treatment.
—The only treatment which can be made effective is complete operative removal. There is no reason why any benign tumor of the bladder should not be attacked, the most unpromising cases being those of general papillomatous involvement, where only small areas of the bladder mucosa are left uninvolved. Such a villous condition as this is serious, and may later justify an effort at extirpation of the bladder. Palliative treatment will include the arrest of hemorrhage (for which a few drops of turpentine oil are often effective), with gentle lavage of the bladder and removal of clots, securing their disintegration by injecting an emulsion of pepsin or of papain; while tenesmus, irritability, and pain are to be controlled by cannabis, suppositories, morphine, or whatever may be needed. In inoperable cases cystotomy for drainage purposes may be the final measure for relief purposes.
Radical measures include opening of the bladder, either above or below the pubis, as the cystoscope may indicate; or the former, when the cystoscope cannot be used, as it affords better means for exploration. Through this opening, which may be made larger than for mere exploratory or lithotomy purposes, and aided by artificial light (small electric lights introduced by suitable mechanism, as within a test-tube), there may be removed with scissors or curette, or even with the finger-nail, by enucleation, such growths as are met, while in nearly every instance it will be an advisable precaution to cauterize their bases with the actual cautery. Through more extensive incisions, with the patient in the Trendelenburg position and the prevesical space widely opened, the bladder mucosa may be excised, and ample drainage provided both by retention of a catheter and insertion of a siphon tube through the lower part of the opening. The suprapubic route affords better opportunities for thorough work than does the perineal, the latter being suitable only for a limited class of cases.
Fig. 658
Illumination of anterior vesical wall by Nitze’s cystoscope.