In addition to the more innocent and purely hypertrophic forms of prostatic enlargement, it has been recently shown, especially by Young, that the element of cancer is present in a proportion of cases hitherto quite unsuspected. It may begin as a small indurated nodule, in one or both lobes, and while developing remains confined for a relatively long period by the strong prostatic capsule. When it extends, its line of invasion is upward toward the vesicles rather than into the bladder. When the latter has become involved, if a radical operation is to be practised, extirpation must include not only the entire prostate, with its capsule, the urethra, the vesicles, but the adjacent portion of the base of the bladder. Early diagnosis in these cases is difficult, since it may occur at any age after fifty years, and, being connected with hypertrophy, produces symptoms masked by it, only the element of pain being more prominent. As the condition develops pain becomes rather disproportionate, spreads to the suprapubic region, and is intensified as the bladder fills. When pain is referred also to the rectum and lower extremities it is a suspicious symptom. The condition does not necessarily, at least at first, cause enormous enlargement. Therefore the obstructive features vary. If the portions involved can be left they will be found more dense and hard than the surrounding tissue. One peculiarity of prostatic cancer is that metastases occur more often in the bones than in the lymphatics. Consequently the pelvic nodes are not so often affected. Ulceration and intravesical tumor are rare.
Diagnosis.
—Early diagnosis is based on rapidity of growth, disproportionate pain, indurated contraction of the prostatic urethra near its apex, and absence of intravesical enlargement, as shown by the cystoscope. When there is much residual urine, without enlargement of intravesical lobes, suspicion is strengthened. If after removal of such prostate it should be shown to be more or loss dotted with “seed calculi,” as is possible, instead of with cancer, the benefit and relief to the patient would be none the less marked, while the prognosis would be all the better.
Prostatic hypertrophy leads to a collection of phenomena spoken of as prostatism. These include mechanical impediment to urination, with consequent obstruction, sometimes with complete retention, and to the consequences of the same in the direction of infection and cystitis, with added features of pain, tenesmus, and pyuria. Prostatism is a matter of gradual development. Its earliest symptoms are frequent urination with occasionally some difficulty or slowness in the act. From this as a beginning cases become gradually aggravated, until death finally ensues from retention, rupture of the bladder, pyelonephritis, or exhaustion in consequence of the pain and suffering entailed.
Prostatism may be imitated in persons whose prostates are not perceptibly enlarged, in whom the difficulty and obstruction are due to sclerosis and contracture of the vesical neck. This condition is especially common in elderly men, subjects of arterial sclerosis. This will account for instances of prostates which, on removal, are found hard and sclerosed, and yet not enlarged enough to be obstructive. If such a prostate could be divided by the cautery, benefit, even permanent relief, might ensue. Therefore, such a condition might be well attacked when diagnosticated (either by suprapubic operation or by perineal section), with the use of the Bottini galvanocaustic instrument, especially through a perineal opening.
Prostatic enlargement produces distortion of the prostatic urethra, which becomes longer, smaller, and sometimes deviated, with elevation of the level of the vesico-urethral orifice, and causes, by pressure on veins, more or less disturbance of the return circulation. Enlargement with impediment produces dilatation of the bladder, with possible involvement of the ureters or the kidneys, and thickening of the vesical walls, often with sacculation of its mucosa between its disturbed muscle fibers.
Finally come the consequences of septic infection with ammoniacal putrefaction of urine, pyuria, and perhaps pyelonephritis with uremia, which will be terminal. While the condition is generally regarded as belonging to the late years of life it may begin by natural processes at the forty-fifth year, although uncommon before the fifty-fifth.
Fig. 660
Enormous prostatic hypertrophy, necessitating suprapubic cystotomy because of impossibility of catheterization from below. (Socin and Burckhardt.)