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A Case of Urinary Obstruction due to Enlargement of the Anterior Prostatic Lobe
A CASE OF URINARY OBSTRUCTION DUE TO ENLARGEMENT OF THE 4"NTERIOR PROSTATIC LOBE IRVING SIMONS ·Nashville, Tennessee
The occurrence of tumor formations of either fibrous or adenomatous nature, which involve the anterior prostatic lobe to the exclusio:µ of the rest of the prostate must be exceedingly rare. A survey of the literature fails to reveal any reported cases of this condition which had been diagnosed clinically and removed. Wade (1) reported a case of solid tumor of the anterior lobe but his material was obtained at autopsy, the case having died without operation. H. Thompson (2) reviewing 125 cases of prostatic hypertrophy reports 3 cases in which there was an isolated hypertrophy of .the anterior commissure. A cyst of the anterior prostatic commissure was reported by Abbe (3). It is of interest in this connection to review in brief the embryology of this region. Lowsley (4) in his comprehensive studies on the embryology of the prostate describes five groups of tubules growing out from the posterior urethra at about the 12th week of intrauterine life. They spring from the urethral floor beneath the ejaculatory ducts and the bladder, from the prostatic furrows, from the floor of the urethra beyond the ejaculatory ducts and from the anterior urethral wall forming respectively the median, lateral, posterior and anterior prostatic lobes. The anterior lobe tubules are relatively few in number and in the thirteen weeks fetus average about 12, 8 being paired while 4 spring directly from the mid line. These tubules however fail to keep pace with the development of the other prostatic lobes and at the twenty-second week they show definite signs of atrophy. At the thirtieth week these anterior tubules have shrunk still further in size and their number has beendiminished by one-half. Thus 43
44
IRVING SIMONS
in the specimen studied there were but 8 small branching tubules communica ting with the anterior urethral wall. This degenerative process continues until birth, at which time the anterior lobe consists of but 2 small branching tubules which open upon the ventral wall of the prostatic urethra at its mid portion. Among 93 specimens of prostates studied by Lowsley· (4) 2 were found having hypertroph ied anterior lobes. Legueu (5) reporting 500 cases found only 3 instances of anterior lobe hypertrophy and Alexander Randall in a personal communication states that he has yet to find such a case in his extensive autopsy studies of contracture of the vesical neck. The following case of anterior lobe enlargemen t causing urinary obstruction is believed to be of sufficient interest to. warrant its report in detail. · This patient, aged twenty-seven, was seen in May, 1917. He gave a history of gonorrhea contracted nine years )Jefore and a year later suffered from marked urinary frequency which lasted for four or five weeks, then clearing up spontaneously. About a year later he had another attack of vesical irritability and was treated by urethral dilatations for a supposed stricture of the urethra. This instrument ation was followed by complete urinary retention. He was catheterize d for a week at the end of which time an external urethrotom y was performed and urinary drainage through a perinea! tube continued for several weeks. This was followed by no symptomat ic improvement. Cystoscopy July 1, 1917, showed 100 cc. of very purulent residual urine. Study of the prostatic orifice revealed a tumor mass springing anteriorly and occupying about one-fourth of its circumference. It was smooth, rounded and was apparently of the size of the distal phalanx of the little finger. It was apparently sessile and the mucous membrane covering it was smooth and only slightly inflamed. The bladder wall showed changes typical of long standing obstruction . There was marked hypertroph y of the interuretera l bar and bas fond formation. Ureteral catheterization revealed a double pyelitis, both urines containing pus and staphylococcus albus. This promptly cleared up with lavage with 1 per cent silver nitrate.
URINARY OBSTRUCTION
45
At operation on December 10, 1917, the bladder was opened suprapubically . Springing from the anterior aspect of the prostatic orifice and extending for some distance into the urethra was a mass measuring 1.5 by 1 by 1 cm. The normal looking mucosa which covered it was incised transversely and the mass removed. A catheter was introduced per urethram and the bladder closed. On examination three months later there was no residual urine. On section the specimen removed is composed largely of fibrous tissue and smooth muscle. There are several gland elements which resemble normal prostatic tissue and the larger ducts are quite dilated. At no point however is the picture even suggestive of adenoma. REFERENCES (1) WADE: Prostatism. Ann. Surg., March, 1914, !ix, 3, p. 321. (2) THOMPSON, H.: Disease of the Prostate. 6th edition. London, 1886. (3) ABBE: Cyst of the prostate producing urinary obstruction. Ann. Surg., xxx, p. 762. (4) LowsLEY, C. S.: The development of the human postate gland with reference to the development of other structures at the neck of the urinary bladder. Amer. Jour. Anat., 1912, xiii, p. 290. (5) LEGUEU: Traite d'Urologie. Paris, 1910.
The occurrence of tumor formations of either fibrous or adenomatous nature, which involve the anterior prostatic lobe to the exclusio:µ of the rest of the prostate must be exceedingly rare. A survey of the literature fails to reveal any reported cases of this condition which had been diagnosed clinically and removed. Wade (1) reported a case of solid tumor of the anterior lobe but his material was obtained at autopsy, the case having died without operation. H. Thompson (2) reviewing 125 cases of prostatic hypertrophy reports 3 cases in which there was an isolated hypertrophy of .the anterior commissure. A cyst of the anterior prostatic commissure was reported by Abbe (3). It is of interest in this connection to review in brief the embryology of this region. Lowsley (4) in his comprehensive studies on the embryology of the prostate describes five groups of tubules growing out from the posterior urethra at about the 12th week of intrauterine life. They spring from the urethral floor beneath the ejaculatory ducts and the bladder, from the prostatic furrows, from the floor of the urethra beyond the ejaculatory ducts and from the anterior urethral wall forming respectively the median, lateral, posterior and anterior prostatic lobes. The anterior lobe tubules are relatively few in number and in the thirteen weeks fetus average about 12, 8 being paired while 4 spring directly from the mid line. These tubules however fail to keep pace with the development of the other prostatic lobes and at the twenty-second week they show definite signs of atrophy. At the thirtieth week these anterior tubules have shrunk still further in size and their number has beendiminished by one-half. Thus 43
44
IRVING SIMONS
in the specimen studied there were but 8 small branching tubules communica ting with the anterior urethral wall. This degenerative process continues until birth, at which time the anterior lobe consists of but 2 small branching tubules which open upon the ventral wall of the prostatic urethra at its mid portion. Among 93 specimens of prostates studied by Lowsley· (4) 2 were found having hypertroph ied anterior lobes. Legueu (5) reporting 500 cases found only 3 instances of anterior lobe hypertrophy and Alexander Randall in a personal communication states that he has yet to find such a case in his extensive autopsy studies of contracture of the vesical neck. The following case of anterior lobe enlargemen t causing urinary obstruction is believed to be of sufficient interest to. warrant its report in detail. · This patient, aged twenty-seven, was seen in May, 1917. He gave a history of gonorrhea contracted nine years )Jefore and a year later suffered from marked urinary frequency which lasted for four or five weeks, then clearing up spontaneously. About a year later he had another attack of vesical irritability and was treated by urethral dilatations for a supposed stricture of the urethra. This instrument ation was followed by complete urinary retention. He was catheterize d for a week at the end of which time an external urethrotom y was performed and urinary drainage through a perinea! tube continued for several weeks. This was followed by no symptomat ic improvement. Cystoscopy July 1, 1917, showed 100 cc. of very purulent residual urine. Study of the prostatic orifice revealed a tumor mass springing anteriorly and occupying about one-fourth of its circumference. It was smooth, rounded and was apparently of the size of the distal phalanx of the little finger. It was apparently sessile and the mucous membrane covering it was smooth and only slightly inflamed. The bladder wall showed changes typical of long standing obstruction . There was marked hypertroph y of the interuretera l bar and bas fond formation. Ureteral catheterization revealed a double pyelitis, both urines containing pus and staphylococcus albus. This promptly cleared up with lavage with 1 per cent silver nitrate.
URINARY OBSTRUCTION
45
At operation on December 10, 1917, the bladder was opened suprapubically . Springing from the anterior aspect of the prostatic orifice and extending for some distance into the urethra was a mass measuring 1.5 by 1 by 1 cm. The normal looking mucosa which covered it was incised transversely and the mass removed. A catheter was introduced per urethram and the bladder closed. On examination three months later there was no residual urine. On section the specimen removed is composed largely of fibrous tissue and smooth muscle. There are several gland elements which resemble normal prostatic tissue and the larger ducts are quite dilated. At no point however is the picture even suggestive of adenoma. REFERENCES (1) WADE: Prostatism. Ann. Surg., March, 1914, !ix, 3, p. 321. (2) THOMPSON, H.: Disease of the Prostate. 6th edition. London, 1886. (3) ABBE: Cyst of the prostate producing urinary obstruction. Ann. Surg., xxx, p. 762. (4) LowsLEY, C. S.: The development of the human postate gland with reference to the development of other structures at the neck of the urinary bladder. Amer. Jour. Anat., 1912, xiii, p. 290. (5) LEGUEU: Traite d'Urologie. Paris, 1910.