Chronic inflammatory vesical neck obstructions

CHRONIC INFLAMMATORY VESICAL NECK OBSTRUCTIONS A CLINICAL AND ANATOMICAL STUDY* JOSEPH A. HYAMS, M.D., F.A.c.s., AND SAMUEL E. KRAMER, M.D. NEW YORK

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neck and sphincter, urethra1 changes as we11 as those taking pIace in the prostate and semina1 vesicIes, has not been cIearIy correIated. If an infection be superimposed upon one or more of these uncorreIated structures, we may IogicaIIy assume that other structures in reIation to those infected wiI1 Iikewise become invoIved. Variation in anatomica structure has a direct inffuence on the pathogenesis. These are important points to bear in mind, not onIy on the diagnosis and treatment, but on the morbidity of this condition. Because of the correIation of objective instrumenta and operative observations with microscopic studies of the excised surgica1 specimens and routine necropsy specimens, our understanding of the gross and microscopic pictures is cIear and definite. However, the probIem of pathogenesis and etioIogy is stiI1 a moot question. The pathogenesis of a condition such as contracture must be obscure as Iong as the different stages in the production of termina1 pathoIogy cannot be demonstrated. The initia1 Iesion cannot be known and appreciated without a definite conception of the pathogenesis and therefore the etioIogy is diffrcuIt to deduce. In an effort to arrive at a better understanding of the underIying morbid processes of this condition, we have carried on, for the past year, a study of its pathogenesis and etioIogy. In this work, microscopic studies were made of IO surgica1 punch specimens removed from cIinicaIIy and cystoscopicahy proven cases of median bar or vesica1 neck contractures, with the McCarthy visuaIized punch. ParaIIeI with this, gross and microscopic observations were made of the bladder, vesica1 neck and posterior urethra, and adnexa of 50 fresh cadavers seIected from severa hundred necropsies, whiIe at the same time

of the Iiterature wiII PERUSAL show that there is considerabIe confusion in our conception of median bar, due not onIy to the fact that the term median bar incIudes obstructive eIevations of fibrous and gIanduIar types, which of themseIves are separate entities, but aIso due to visuaIization ‘of pathology through the use of different types of diagnostic cystoscopic instruments. Diverse types of pathoIogy are stiI1 grouped under the origina descriptive term suggested by C. J. Guthrie in his Iecture on median bar, deIivered before the RoyaI CoIIege of Surgeons in London, in 1830, nearIy one hundred years ago. In 1850, Mercier, in his report, described the same condition aIthough his name has often been erroneousIy associated with the eIevated interureteric ridge. From this date to the beginning of the present cenadvances can tury, no reaIIy important be said to have been made in the cIinica1 or pathoIogica1 conception of this subject. Since then, the work of ZuckerkandI, AIberran, Chetwood and others, foIIowed by LowsIey’s carefu1 embryoIogica1 and anatomica studies of the prostate and its contiguous structures, the thorough work of RandaII on the prostate, subcervica1 gIands and bIadder neck, and the anatomicaI studies of the interna sphincter and vesica1 neck by Young and his associates, have aided materiaIIy in cIarifying our understanding of the fibrotic bar and scIerotic vesicaI neck obstruction. The fibrous median bar is best described as a cicatricia1 obstruction caused by fibrotic eIevation of the posterior vesica1 Iip with or without coarctation and constriction of the entire circumference of the vesico-urethral orifice. The reIation of fibrous median bar formation to deep seated cicatricia1 changes in the vesical * Read before the Section of Genito-Urinary

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18, 1929.

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cystoscopic observations were made of cIinica1 patients presenting earIy and Iate symptoms and physica signs of vesica1 neck obstruction. On fresh necropsy materia1, visua1 and paIpatory evidence of elevations, noduIes, and contractures of the vesica1 neck was cIass&ed according to RandalI’s types of contracture or fibrous bar. From specimens showing this type of deformity transverse and sagitta1 seria1 sections were made of the posterior urethra, vesica1 neck and trigone, including the contiguous prostate and seminal vesicIes. This enabIed us to perceive the underIying pathoIogy in the posterior urethra, prostate and seminal vesicIes in necropsy material which was compared with the microscopic picture of surgica1 specimens removed by means of the punch in proven cIinica1 cases. Where cases of acute, subacute and chronic infection of upper and Iower urinary tracts were encountered, simiIar seria1 sections of the posterior urethra, vesicaI neck and trigone were made. By noting the changes in the vesica1 neck structures in a11 stages of inflammation of the posterior urethra, prostate and semina1 vesicles, accurate deduction couId be made of the underIying etioIogy and pathogenesis of bIadder neck fibrosis. In addition to the we11 deveIoped prostatic glands, which empty on the floor of the posterior urethra, a homoIogous group of superficia1 gIands exist in the posterior urethra, vesica1 neck, and trigone (Fig. I). In many cases, they are rudimentary or absent. In other instances, they extend for varying distances into the mucosa and submucosa, and occasionaIIy the muscularis. In the posterior urethra these gIands predominate on the sides and roof. On the vesica1 neck and trigone, they are aImost aIways Iimited to the centraI portion of the posterior vesica1 Iip. AIthough they are given a variety of names, we shaI1 caI1 them submucosa1 gIands of the posterior urethra, vesica1 neck and trigone. We shaI1 Iater demonstrate the importance of these structures in the deveIopment of submucosa1 fibrosis.

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Pseudo-adenomatous hypertrophy of the submucosal gIands of the vesica1 neck or of the gIands of the posterior prostatic

FIG. I. Schematic representation of glandular structures of posterior urethra, vesica1 neck and trigone. (From Jacoby.) I, Short mucosal glands of posterior urethra and vesical neck. 2 and 3, SubmucosaI gIands of posterior urethra, vesica1 neck and trigone, reaching superficial layer of muscuIaris. 5, Prostatic glands arising in the premontane and postmontane urethra. 8, Ejaculatory duct. g, MuscIe of posterior urethra, vtlsical neck and trigone. IO, Urethral lumen.

commissure, may cause eIevation of the posterior Iip of the vesica1 neck. However, they are usuaIIy excIuded when fibrosis of the vesica1 neck is considered, except in those rare instances where a combination of both factors exists. In the accepted conception of the pathoIogy of vesica1 neck cicatrizations, inff ammation is beIieved to account for a11 those cases cIassified as acquired. Fibrosis of the retrogressive type associated with senie1 changes and arterioscIerosis, is not considered as important. Primary congenita1 muscIe hypertrophy of the sphincter with secondary fibrosis due to congestion and infection accounts for some of the cases reported. The excised surgica1 specimens in our series on the basis of the history, clinica and microscopic findings, conformed with the accepted views. One specimen, cIinicaIIy and microscopicaIIy, suggested congenita1 hypertrophy of the sphincter with superimposed superficia1, submucosa1, active, chronic inff ammation (Fig. 2). AI1 the specimens showed microscopic other changes evidentIy due to acquired inffammatory causes, and cIinicaIIy consisted of (I) cases of typica findings of contracture or bar; (2) cases of atonic bIadder without a neurogenous cause; (3) one case of atonic

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bladder in which a destructive spondyIitis, aroused suspicion of a neurogenous eIement. The microscopic picture of this

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urethra1 inffammation, as we11 as typica vesica1 neck contractures and bars, it was possibIe to find changes in the superficia1

FIG. 2. Low-power photomicrograph of punch specimen cIassified as congenital hypertrophy of sphincter with active chronic inflammation in submucosa. Large vessek in submucosa indicate Iong-standing congestion.

group of cases Ieft no doubt as to the inflammatory factor (Fig. 3). In addition to fibrosis in the submucosa and disorganization of the muscuIaris by scar tissue, accumuIation of round ceIIs was found in the submucosa and muscularis, frequentIy perivascular and periacinar. GIands se’emed to pIay an important r8Ie in the inflammatory process in some cases, because of the depth of their penetration into the muscuIaris and their evident cystic diIatation and intra-acinar and periacinar ceIIuIar exudation. AI1 stages of inffammation were noted, from an active and recent process, to a quiescent stage of scar in which gIanduIar eIements and muscIe tissue were simiIarIy embarrassed by the fibrous overgrowth. Based upon cIinica1 and operative studies of cases of median bar and scIerosis of the vesica1 neck, and very infrequent and inadequate post-mortem examinations, the associated pathoIogy in the contiguous centripeta1 structures must be a matter of conjecture. In the course of routine microscopic seria1 studies of the vesica1 neck and.contiguous structures in necropsy specimens showing a11 stages of posterior

structures which corresponded to the microsopic findings in the excised surgica1 specimens. Where this occurred, the contiguous structures of the posterior urethra, prostate and semina1 vesicIes were subjected to carefu1 study. By noting the effect of acute and subacute inflammation of the posterior urethra and adnexa upon the vesica1 neck, the preceding stages in the deveIopment of contracture of the vesica1 neck couId be folIowed. In addition, the deep seated changes in the prostate and semina1 vesicIes couId be studied in those necropsy specimens which were manifestIy the Iast stages of fibrosis. By a study of our materia1 a definite conception of the pathogenesis was formed. Acute inflammation, caused by infection or mechanica irritation, resuIts in vesica1 neck changes which may be regarded as an acute inflammatory bar, because of the edematous appearance of the vesica1 neck and eIevation of the Aoor. This is found associated with acute posterior urethritis, prostatitis, semina1 vesicuIitis, and Iess frequentIy with descending urinary infection. The submucosa of the posterior urethra is infiItrated with acute inflamma-

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tory exudate which is aIso seen in the fibrol nuscuIar stroma of the prostate. The prostatic : gIands show hyperpIasia

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tures of the vesicaI neck and trigone showed hyperpIasia, cystic diIatation, periacinar and intra-acinar exudation with

FIG. 3. Low-powel . photomicrograph

of punch specimen, typica of acquired inflammatory type. Marked fibrosis of submucosa. MuscuIaris shows marked perifascicular and intrafascicular fibrous and round ceII infiltration and round ceI1 i nvasion especially of superficial Iayers; chronically inflamed, cystic glands seen extending rather deepIy into muscularis.

with marked intra-acinar and periacinar exudation. The mucosa1 and submucosa1 gIands of the posterior urethra, vesica1 neck and trigone are swollen, hyperpIastic and fiIIed with acute inffammatory ceIIuIar exudate, with corresponding acute exudation and infiItration in the superficia1 supporting tissues (Fig. 4). Due to continued infection, congestion or irritation of these structures, a stage of subacute or active chronic inflammation ensues. In this cIass of specimens, changes were noted which corresponded to some of the excised surgica1 tissues. In addition to typica chronic prostatitis and semina1 vesiculitis, the superficia1 gIanduIar struc-

round and pIasma ceIIs. FrequentIy a rather thick Iayer of granuIation tissue in different stages of organization was noted in the submucosa, and in the vesica1 neck and trigona1 regions the superficia1 muscIe Iayers showed simiIar changes. This highIy vascuIar fibrous reaction is unquestionabIy the stage preceding that of actua1 cicatrization of the submucosa and muscuIaris of the sphincter and trigone (Fig. 5). In the final stage, corresponding to that of the excised surgica1 specimens, a gradua1 transition is seen from active chronic inflammation of the superficia1 gIands and their supporting tissues, to the picture of fibrosis with definite evidence of chronic

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inff ammation which has become quiescent. In many cases, a moderate number of cystic or hyperpIastic submucosa1 gIands

FIG. 4. Transverse section of low magnification through entire prostate and vesical neck of case of prostatic abscess. Higher magnification reveaIed concomitant acute inffammatory exudation in and around superficial submucosal gIands.

may be found in the fibrous tissue repIacing the sphincter muscIe. In some cases, compressed gIands were noted, and in others no gIands were seen. In none of the cases were evidences of inflammation absent, and from the studies of the preceding stages, it can be said that the superficia1 gIand structures of the vesica1 neck pIay an important rbIe in determining the degree and depth of the inffammatory reaction in the submucosa and muscularis, even though this may not be evident in the Iate stages. In some of these specimens of frank vesicaI fibrosis the prostate showed a corresponding advanced scIerosis with increase in the interacinar fibrous tissue and compression of the gIanduIar eIements. In others, onIy miId quiescent chronic inffammation was noted in the prostate and semina1 vesicIes (Fig. 6). In most of the specimens iIIustrating the fina stage of scIerosis, there was a

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definite IocaIization of the fibrosis to the region of the posterior vesica1 Iip. In others, the process aIso invoIved the sides and roof, but rareIy to the extent that was noted on the posterior vesica1 Iip. From our studies, it wouId appear that the cause for this IocaIization is definiteIy due to the submucosa1 anatomica structure, gIands of the vesica1 neck and trigone predominating on the posterior aspect of the vesico-urethra1 orifice. Productive changes in the stroma of chronicaIIy inffamed submucosa1 gIands and subsequent cicatrization expIains the fibrotic transverse eIevation of the ffoor of the sphincter which causes obstruction (Fig. 7). The conception of this entity as a stricture of the vesica1 neck due to a deep seated scIerosis of the surrounding prostate is not satisfactory, since it cannot expIain the transverse fibrotic eIevation Iimited to the floor of the neck, and aIso faiIs to account for the spIendid resuIts which foIIow the remova of a reIativeIy smaI1 piece of superficia1 tissue from the posterior vesica1 Iip. When the coarctation is due to a smaI1 scIerotic prostate, minor surgica1 procedures are of no avai1. The diagnosis of vesica1 neck obstruction in the surgical cases was based on bimanua1 recta1 paIpation of the prostate and examination with the cysto-urethroscope, its forward vision giving an undistorted view of the posterior urethra, sphincter and bIadder, and permitting an accurate estimation of the reIative amount of eIevation of bar formation and sphincteric change. In many instances it was suppIemented by the use of the McCarthy panendoscope, not only to obtain the forward and IateraI view, but as an added means of gauging the eIasticity of the sides and roof of the interna sphincter. In every case, a compIete uroIogica1 examination was made which incIuded detaiIed history, physical examination, and such roentgen and Iaboratory diagnostic measures as were necessary for a compIete diagnosis. WhiIe not aIways present in each of the foregoing cases, the presence of the obstruc-

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tion at the floor of the vesica1 neck was often suspected when introducing the instrument, when it was found necessary

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to the verumontanum to a more rounded crest. Shortening of the retromontane urethra with an appearance of excavation

FIG. 5. Low-power microscopic section through chronicalIy inflamed and cystic submucosa1 gIand of vesical neck region. Active chronic inflammation aIso seen in supporting stroma. This pathoIogica1 picture represents intermediate stage of chronic inflammation preceding that of acquired inffammatory vesica1 neck fibrosis.

to eIevate the tip at the internal sphincter. Cystoscopicahy there was diIatation of the bIadder in one instance, marked trabecuIation in aI1, with saccuIations and diverticuIa in many. The presence of bas fond was constant, as we11as depression or eievation of the trigone. EIevation of the sphincter Aoor varied from a thin to a dense transverse foId, sufficient to obscure the interureteric ridge when viewed from the urethra1 aspect of the bar. The postmontanaI portion of the posterior urethra was seen arising aImost verticaIIy to the uppermost portion of the bar, whiIe in some instances, it made a vertica1 ascent from a depression immediateIy posterior

on the urethra1 aspect of the sphincter was observed in severa cases. The appearance of the mucosa, prostatic ducts and verumontanum showed no acute or subacute inffammatory change, but evident termina1 fibrosis. ResiduaI urine ranged in amounts from 4 to 44 oz. Repeated cystourethroscopic examinations have impressed us with the fact that the vesica1 neck changes as seen through the cystourethroscope in these patients with fibrotic bar and scIerotic vesica1 neck might be considered as termina1 pictures of many of the cases which are so frequentIy observed in practice, and who are being treated for chronic

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posterior urethritis with associated chronic prostatitis, vesiculitis, and descending infections of the urinary tract. AI1 types are

neck changes present diffIcuIties in diagnosis which demand the utmost judgment and care in differentiation on the part

FIG. 6. Longitudinal section of floor of posterior urethra and vesica1 neck extending from verumontanum to interureteric Iigament. Prostate shows marked increase in interacinar fibrous tissue with compression of glanduIar elements. Seminal vesicles show advanced scIerosis. A we11 defined group of submucosa1 glands seen extending into floor of sphincter which aIso shows marked fibrous invasion.

FIG. 7. Transverse section through vesicaI neck and adjoining prostate. Sphincter muscle shows extensive fibrosis with few compressed submucosa1 glands. Prostate shows definite but quiescent chronic inflammatory changes.

seen cystocopicaIIy in these prefibrotic and tissue changes : the acute, subacute earIy chronic stages. The sphincter floor does not show a dense transverse eIevation of the posterior vesica1 Iip but a ridge of distinctly inff ammatory or hyperpIastic tissue. Its surface is engorged and often surmounted by edema of a cystic type or a more diffuse cobbIe-stone appearance, whiIe often Iarge flattened or peduncuIated poIyps are observed. The postmontane area is engorged and is vertical, or its rounded surface buIges toward the objective Iense of the instrument; diIated prostatic ducts are often seen; the verumontanum is enlarged, shows surface edema, with ejacuIatory duct openings evident at times. The findings indicating urinary obstruction, nameIy bas fond, trabecuIation and hypertrophy of the trigone, are Iess in this prefibrotic stage, and residua1 urine is smaI1 in amount or absent. A moderate degree of intraurethra1 encroachment of one or both Iateral prostatic Iobes is not infrequentIy seen in these earIy types of cases; the encroachment is not marked and is seen to reduce and increase by turning the irrigating fluid on and off. These inflammatory types of vesica1

of the urologist. One can easiIy become a median bar enthusiast. The patient is often uncomfortabIe and frequentIy demands reIief. The premature use of the punch or cutting current, in most instances, wiI1 not onIy be unsatisfactory, but resuIts in a distinct increase in disturbance rather than an ameIioration of symptoms. We beIieve the use of the punch shouId be reserved for those cases of quiescent fibrosis in which there is definite subjective and objective evidence of obstruction. Has the frequency of occurrence of median bar been overestimated? We beIieve that whiIe one frequentIy sees eIevations of the posterior Iip at the mortuary tabIe and in routine cystoscopic examinations, they shouId not be confused with reIativeIy infrequent, true fibrotic changes of the posterior Iip for which the best treatment is remova by visuaIized punch or destruction by the cutting current, wherein the inflammatory process at the bIadder neck, prostate and semina1 vesicIes has become quiescent. We wish to express our appreciation to Dr. CharIes Norris, Chief MedicaI Examiner of New York City, who permitted the use of necropsy materia1, without which this presentation wouId not have

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been possibIe, and to Dr. Joseph McCarthy for the use of microscopic sections ofsome of his specimens removed by him with his visuahzed punch from median bars and aIso to Miss AIice E. SIavkin, technician, through whose untiring efforts and skiI1, thousands of exceIIent sections were obtained for this study. Our pathoIogica1 work has been constantIy supervised by Dr. NichoIas AIter and Dr. Lawrence Sophian, PathoIogists at the New York Post-Graduate Hospital REFERENCES GUTHRIE, G. J. On the Anatomy

and Diseases of the Neck of the Bladder and of the Urethra. Lond., Burgess, 1834. On the chronic thickening of the neck of the bladder. Lond., Med. CYSurg. J., 4: 459, 715, 1824. Anatomy and Diseases of the Neck of the BIadder. Lond., 1832. MERCIER, L. A. Lettre a mes confr&es, en res onse B une Iettre du Dr. J. Leroy, soi-distant d’ f. troIIes, sur les maIadies de Ia prostate et du co1 de la vessie. Paris, 1854. Recherches anatomiques, pathoIogiques et therapeutiques sur Ies vaIvuIes du co1 de la vessie, cause frequent et peu connue de retention d’urine, et sur Ieurs rapports, avec Ies inflammations et Ies &rCcissements d’urethre. Ed. 2, Paris, 1856. Recherches sur le traitement des maIadies genitourinaires. Paris, 1856. TANDLER and ZUCKERKANDL.Studien zur anatomie und KIinic der prostatahypertrophy. Berlin, x922. JACOBY. Zr. f. urol. Cbir., 14: 6-37, 1923. ALBARRAN and MOTZ. Ann. d mal. d org. gtnito-urin., 20: 769-817,

1920.

CHETWOOD, C. H. Contracture of the neck of the bladder. Med. Rec...__ so: 767-76. _ 1001. Also J. A. _ M. A., 60: 257-59, 1913. Discussion 26567. Different types of fibrous obstruction of the bladder outlet and their treatment. Surg. Gynec. Obst., 21: 202-5, 1915. Practice of UroIogy. Ed. 3. N. Y., Wood, 1921. Stenosis of the bIadder outlet. AM. J. SURG., 39: 96104, 1925. A review of the subject of stenosis of the neck of the bIadder embracing the titIes of contracture, sclerosis, and bars. Tr. Am. Ass. Genito-&in. Surg., 18: 83-103, 1925. LOWSLEY, 0. S. The embryoIogy of the prostate and its relation to the surgery of obstructive conditions. AM. J. SURG., Nov. 1912. The development of the human prostate gIand with reference to the deveIopment of other structures at the back of the human bIadder. Am. J. Anat., 13: 299-346, rgr2. RANDALL, A. Median bars as found at autopsy. J. Ural., I, 383-403, 1917. Varying types of prostatic obstruction. J. Ural., 5: 287-308, 192 I. YOUNG, H. H., and WESSON,M. B. The anatomy and surgery of the trigon. Arch. Surg., 3: I-37, 1921.

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YOUNG, H. H. Practice of UroIogy. Phil., Saunders, 1926. V. r, PP. 142, 145, 154; v. 2, pp. 481, 499. STEPITA, C. T. The McCarthy visualized punch. AM. J. SURG., 3: 153, 1927.

DISCUSSION DR. NICHOLAS M. ALTER: The pathoIogist is often confronted with great difficuIties when trying to reconstruct the various stages of the pathoIogica1 process, The findings in the autopsy room and in the operating room often show terminal or advanced stages of pathoIogica1 Iesions. This applies particularly we11 to the obstructive lesions of the vesica1 neck where probabIy the earliest stages of the process cause great functional disturbance without essentiaIIy interfering with the vitaIity of the patient. Specimens removed at various stages of a pathoIogica1 process Iead to considerabIe confusion in the Iiterature in regard to classification. Drs. Hyams and Kramer have undertaken an important and diffrcuIt task, trying to cIear this confusion. In the various types of obstructions they see various stages of the same process. Drs. Hyams and Kramer were reIativeIy conservative and modest in their cbncIusions considering the vast amount of work and materia1. I had opportunity to watch this work in my department. Drs. Kramer and Hyams have been studying about 2000 slides for a period of a year. DR. LAWRENCE SOPHIAN: I have had the pIeasure of going over the materia1 that Dr. Hyams and Dr. Kramer selected. The two phases of the work which especiaIIy deserve to be brought up are: first, the soundness of applying genera1 pathoIogica1 concepts to specia1 regions, such as the posterior urethra; the processes can be traced through acute, subacute, and chronic stages in the vesical neck. Second, the presence in that particurar Iocation of the smaI1 submucosa1 glands, which are not we11 understood, makes a probIem in that the condition is IikeIy to persist because such gIands enabIe the bacteria to persist and reach a state of symbiosis. These gIands are reIated embryoIogicaIIy to the prostate itself and have the same embryoIogica1 derivation. They do not reach further than the superficia1 Iayers, but in some sections they couId be traced further in; in others, they represented smaI1 pits. We hope that by having a Iarger amount of materia1 the r&e which the superficia1 gIands pIay can be worked out better at some future time.