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Prostatic Obstruction Caused by Intra-Extra Vesical Hypertrophy: Review of 500 Cases
PROSTATIC OBSTRUCTION CAUSED BY INTRA-EXTRA VESICAL HYPERTROPHY REVIEW OF 500 CASES W. R. CHYNOWETH Battle Creel" Sanitarium., Battle Creek, Michigan
One of the most important clinical conditions apt to be overlooked by the average medical practitioner is prostatic obstruction. Its great clinical importance can be readily seen when we consider the fact that from 60 to 70 per cent of men have some form of prostatic enlargement, and that approximately 50 per cent of men past the age of fifty have vesical neck obstruction to such a degree as to cause more or less urinary disturbance. Prostatic enlargements can be conveniently classified into four distinct groups: the simple congestive, the chronic infective, the hyperplastic, and the neoplastic types. The simple congestive type is found mostly in young and middle-aged men and is the result apparently of excessive venery, either cohabitation, onanism, or both. The infective type may be associated with either the congested or hyperplastic types and have a variable degree of enlargement. The chief etiological factor in this type is gonorrheal infection. According to statistics, approximately 70 per cent of men have had N eisserian infection and, in these cases, from 70 to 90 per cent had prostatic involvement. Nonspecific blenorrhea is another source of infection. Prostatic infection may also be secondary to some remote focus of infection such as teeth, tonsils, etc., as shown by Rosenow, Von Lackum and others. Morrissey (1) states that We know now that in patients who give no history of a previous urethritis, an infected prostate will show the same strain of streptococci as is found in the periapical lesions, tonsils, and sinuses. Inoculations in this group of cases have shown prostatic localization and selectivity 669
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in 70 per cent of the male rabbits injected, whereas, the control injections in female rabbits show less than 10 per cent localization in the cervix. Von Lackum (2) demonstrated the relationship of the prostatic infections and a variety of disorders such as arthritis, spondylitis, sciatica, and myalgia, also the fact that by proper treatment of the prostate these conditions tend to clear up. This can be readily understood when we consider the fact that of all toxins developing from infections of the glandular system, none are more toxic than those found in the prostate. In considering thymic conditions in prostatics Hoxie (3) says: In this connection I should like to call attention to the consistently low blood pressures accompanying this syndrome of inflamed prostate and submanubrial dullness. In apparently robust men the blood pressure will rarely exceed 100 mm. That it is not constitutional is shown by the fact that as soon as the absorption from the prostate ceases the blood pressure rises to normal levels, and the substernal dullness disappears. The hyperplastic or hypertrophied types of prostatic obstruction are commonly seen in men past forty-five or fifty. It is estimated that more than 50 per cent of men past this age have this form of prostatic enlargement, and of sufficient degree to cause urinary disturbance. Prostatic obstruction not only causes urinary disturbance, but favors diverticulosis of the bladder, infection, renal dysfunction and possible degenerative changes in the cardio-vascular system. After studying numerous records including electrocardiographs, Willis (4) found that cardio-vascular diseases were present in 42 per cent of the cases of prostatic hypertrophies. He concluded that the incidence to cardio-vascular diseases was higher in prostatic obstruction than any other disease. Bush (5) is of the opinion that the kidney dysfunction accompanying prostatic hypertrophy is due primarily to neural reflexes coming from the trigone area by way of the hypogastric afferents, then out through the eleventh and twelfth thoracic autonomics of the kidney. On the other hand Kreutzman (6) claims that
PROSTATIC OBSTRUCTION
there is a narrowing of the intramural portion of the ureters due to marked hypertrophy of the bladder wall and elevated trigone because of prostatic enlargement, which favors renal dysfunction and degeneration. Young (7) thinks this condition is due to a reflux produced by increased intravesical pressure. However, Kreutzman contends that reflux is a terminal phenomenon and not a primary condition resulting from prostatic hypertrophy. In 527 cystograms of prostatics, Bumpus (8) found reflux only in 25 cases, Graves and Davidoff (9) think that the tonic contraction of the bladder wall against a distending fluid, particularly in presence of bladder neck obstruction, is sufficient to open the ureteral orifices and favor regurgitation. Eisendrath (10) says that reflux is a comparatively rare cause of renal dysfunction, Tandler and Zuekerhankl (11) are of the opinion that in cases of prostatic hypertrophy, the vas deferens is pulled upon in such a way as to compress the ureters, thus causing upper urinary dilatation and subsequent renal dysfunction. No definite etiology of prostatic hypertrophy has been established although Beers (12) thinks that sexual activity, whether gratified or not, is the underlying cause and bases his contentions on the fact that no prostatic hypertrophy has been found eunuchs who were castrated before puberty. Of the neoplastic growths of the prostate carcinoma is most common, therefore most important for consideration. It is estimated that approximately 10 per cent of the prostates removed are found to be carcinomatous. In a report of 102 prostatectomies Troell (13) states that 12 per cent were malignant. Scholl (14) says that pathologically there are two types of prostatic malignancy with corresponding clinical pictures. The first type is of lower degree of malignancy and is made up histologically cells and glands corresponding to the normal prostatic structures. The cells are regular in size and shape and retain their identity longer. Clinically these prostates are large, nodular, hard as stone, produce marked symptoms of obstruction. The second type is made up of irregular masses of cells with no tendency to conform to the usual glandular type of prostate epithelium. The cells are loosely arranged and supported by THE JOURNAL OF UROLOGY, VOL. XXIV, NO.
6
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small amounts of connective tissue. Clinically they are small, fibrous and firmly fixed. They are more difficult to recognize, are extremely malignant and metastatize readily. The first type is usually associated with hypertrophy. The second type is rarely discovered until too far advanced for efficient treatment. In commenting on the comparative malignancy of these two types, Scholl, in his surgical review of a series of these cases, says "50 per cent of the first type were alive from one to six years after operation-90 per cent of the cases of the second type of cancer were dead, none had lived more than three years after operation, and 50 per cent had died the first year after operation." Before giving further consideration to prostatic enlargements and other forms of bladder neck obstruction, an anatomical review of the prostate may be of interest and will give an idea of certain characteristics of the gland The prostate gland is a compound tubular gland, which embryologically develops both in male and female from the Mullerian ducts, and forms a group of buds which develop into five distinct masses in the male, which correspond to the five lobes all of which fuse into one encapsulated mass about the size of a horse chestnut, weighing on an average 30 grams and pierced by the urethra and two vasa deferentia. Five-sixths of the gland consists of 3 to 50 lobules of glandular tissue containing 10 to 32 ducts which open into the colliculus seminalis. Between the glandular tissue, smooth muscles, lymphatics, blood vessels and nerves are dispersed. The innervation being a double one through the nervus erigens and nervus hypogastricus. In the female the prostate gland remains rudimentary. The prostate in man and animals remains small until puberty. In animals it undergoes definite cyclic changes closely associated with the functional activity of the testes. During the quiescent stage the prostate is composed of a few tubules lined with small flattened epithelial cells incapable of secretion. As the breeding season approaches the tubules become large and the epithelium becomes columnar in type and secretion takes place. During the rutting period the mass of tubules is many times larger than in the quiescent stage.
PROSTATIC OBSTRUCTION
673
The prostate varies in different animals as well as in different ages of the same individual. The variation of the development corresponds to the differences in the sex life. The prostate is much larger in animals highly reproductive than in animals much less so. For instance, the prostate gland in rats, guinea pigs and rabbits is proportionately larger than in cats, dogs, cattle and men. Macht (15) claims that the average weightof extirpated prostates in rats is about 200 mgm. or 1 to 500 the total weight of the animal. On the other hand in case of man the ratio is 1 to 2000. Macht concludes that "observations have led investigators to suspect that the prostatic secretion bears a direct relation to the life of the sperm." The prostatic secretion is a thin, milky, slightly alkaline fluid of characteristic odor, and contains so-called amyloid corpuscles, but no mucin. It has a direct relation to the life of spermatozoa, as has been shown by Furbringer, Steinach, Exner and Walker. It facilitates transportation of the spermatozoa through its lubricating properties, and aids in protecting them from destruction through neutralization of the acid secretions normally found in the urethra (urine) and vagina, a secretion which is detrimental to them. Besides the prostatic secretion, the prostate is supposed by some to have an internal secretion or hormone. This apparently is not definitely established, but tadpoles fed prostate experimentally developed rapidly which, as Macht says, favors the endocrine theory. However, there seems to be definite relationship between the prostate and testes. Macht and Bloom noted atrophy in the testes of prostatectomized rats. Serralach and Pares (16) claim that extirpation of the prostate in dogs causes a temporary cessation of spermatogenesis with testicular atrophy. Haberern (17), on the other hand, called attention to the fact that it was impossible to completely extirpate the prostate gland in dogs. Wheelon (18) claims that dogs are the only domestic animals which have infectious urethritis and are prone to prostatic hypertrophy; that castration has no effect on prostatic involution, whereas on all other animals castration causes atrophy of the prostate gland. The prostate normally undergoes atrophy in old age and as the
674
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glandular system degenerates it becomes a mass of fibrous tissue. Similar results are noted after complete castration, but unilateral castration has no effect on the gland. Hanes and Eccles (19) have shown that cryptorchids with functional interstitial cells show no alterations in the prostate. Hypertrophy of the prostate is seen more frequently in old men than atrophy. This is apparently an abnormal condition, due to the diminution occurring in other sex organs together with an overproduction of the testicular hormone and reduced spermatogenesis. Harrison and White (20) ' recognizing this, advocated castration as a curative measure for pro.static hypertrophy. On the contrary, Remete (21) claims that only normal prostates undergo atrophy as a result of castration; the greater the hypertrophy the less is it likely that castration will have any beneficial resuls. Prostatic infections due either primarily to venereal or other infections of the urinary tract, or secondary to some remote infection in the body, has also been considered as a definite etiological factor in persistent prostatic hypertrophy. In a series of 500 urological cases from twenty-eight to eightyfour years of age, studied by us, approximately 70 per cent had some form of prostatic involvement. Of these 60 per cent gave a definite venereal history and nearly 10 per cent had infections of the teeth or tonsils or both. Nearly 60 per cent of the prostatic smears of these had two or more pus cells to the field . Subsequent examinations of those patients showing 2 to 6 pus cells per field revealed in many cases several pus cells per field, thus warranting the diagnosis of a follicular prostatitis. The biggest percentage of those having pus in the prostatic smear gave a previous venereal history, yet nearly 10 per cent of those having pus cells present gave a negative venereal history. On the other hand, in approximately 6 per cent of those with a positive venereal history we were unable to find pus cells in tbP. prostatic smear. Simple congested prostate was diagnosed in 12 per cent of these cases. They ranged from twenty-eight to forty-five years in age.
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Fifty per cent had benign prostatic hypertrophy sufficient to cause urinary retention. In 12 per cent of these there was complete retention. Of the cases of prostatic hypertrophy 53 per cent were extravesical enlargement, palpable via rectal examination; 20 per cent were combined intra-extra vesical enlargement, determined by both cystoscopy and rectal examination; 10 per cent were of the intra.vesical type, as ascertained by cystoscopy and negative to rectal palpation. Twelve per cent were bar obstructions with or without lateral lobe involvement: Enlargements of the middle lobe are mostly adenomas; however, fibro-adenoma, fibromyoma and fibromas occasionally develop in this area. Prostatic bar enlargement is usually associated with fibrosis at the bladder neck. Five per cent of the 500 cases of this series had prostatic malignancy. In reviewing a thousand cases of benign prostatic hypertrophy Hunt claims that 85 per cent had benign obstructing prostatic lesion and the remaining cases were of the inflammatory or prostatic type. He elicited prostatic fullness by rectal digital palpation in more than 50 per cent of the men past fifty years of age. Mciver (23) reports that in 40 cases of prostatectomy 10 per cent were median bar, 20 per cent fibrosis and 70 per cent hypertrophy, All patients presenting urinary symptoms or pus cells in the urine should have a prostatic examination, especially if past forty years of age-not only examination of the gland via rectal palpation, but the possibility of retention must be ascertained. If a persistent residual of an ounce or more is present, cystoscopy is indicated to determine any possible bladder-neck obstruction. The size of the gland as determined by rectal examination is no criterion as to the degree of obstruction produced. In our series 22 per cent were neg:ative by rectal palpation whereas an additional 20 per cent had intravesical enlargement in addition to the enlargement felt in the rectal examination. Diagnosis based entirely on rectal examination may be misleading. In 2 of our cases of intravesical enlargements with negative rectal findings the residuum was 4 and 6 ounces of retention, and in the other cases the residual ranged from ½to 3 ounces.
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In the patients referred to us for urological examinations the type of urine is noted, genitalia examined, prostate examined via rectal palpation and about an ounce of 5 per cent argyrol introduced in the bladder by the Valentine method (without much pressure) or if necessary through a small rubber catheter. The patient is instructed to note the number of times he voids until the urine is free from argyrol. If it takes two or more times on repeated tests before the a:vgyrol disappears, catheterization is done to determine residual, if an ounce or more is present with repeated catheterizations, cystoscopy is indicated. In cases of hematuria cystoscopy should be resorted to as soon as can be conveniently done to ascertain the source of bleeding, keeping in mind the possibility of carcinoma. Early stages of prostatic obstruction may present only the clinical picture of frequency, with or without terminal dribbling, or there may be some hesitancy, but where the obstruction becomes a progressive one the physician must think of the possibility of infection, diverticulosis, calculi, renal insufficiency or even uremia. Thomas (24) says, "It is estimated that 50 per ce:ht of prostatics die in five years from the onset of obstruction and catheter life shortens this to two and one-half years." One of the most important questions a practitioner is called upon to decide, in respect to prostatic hypertrophy is whether surgery is indicated or not. In our experience we have found that, as a rule, in patients with a persistent residual of 2 ounces or more, the prostatic condition tends to progress, hence surgery is indicated in the majority of these cases. Where surgical treatment is indicated the mistake must not be made of waiting too long until the renal function is impaired, which may change a comparatively simple operation to a dangerous procedure. Interference with kidney function means inefficient elimination of waste products and thus favors a toxemia which affects all body tissues inducing the final stage of uremia. All operative cases should have a complete urine, blood pressure, chemical blood, including non-protein-nitrogen and blood sugar, CO2 and renal function tests. A persistently low phenol-
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sulphonephthalein output with a relatively high blood urea indicates a narrow renal reserve and only in very unusual cases can prostatectomy be done with any degree of safety where the phenolsulphonephthalein output is less than 20 per cent, or blood urea more than 50 mgm. to 100 cc. of blood. Absolutely normal values of blood urea nitrogen range from 12 to 20 mgm. per 100 cc. of blood. Safe operative percentage is 20 to 30 mgm. per 100 cc. of blood and 30 to 40 mgm. is regarded as dangerous. Thomas gives a very good blood pressure rule for prostatectomy which I have summarized as follows: High tension: (a) When (b) When Low tension. (a) When (b) When
systolic pressure is 180 or more diastolic must be under 100. diastolic pressure is 100 systolic must not be over 175. systolic pressure is 110 or less diastolic must be over 60. diastolic pressure is less than 60 systolic must be over 110.
The operation of choice is determined by the condition of the patient. According to Hunt, at the Mayo Clinic, the two-stage operation is the one most favored. This is preceded by ten days of bladder drainage with an indwelling catheter. Suprapubic drainage is done in cases of vesical calculi, diverticulosis, renal insufficiency and intolerance to a catheter, a condition found in about 6 per cent of their prostatic cases. In 1000 cases of prostatectomies done at the Mayo Clinic suprapubic drainage was done in 28.8 per cent of the cases. Hunt says the second stage should not be done less than three weeks after cystotomy. In half their cases the second stage was done in one month, 13 per cent in 100 days and 3 cases more than a year following cystotomy. His mortality rate for 1000 cases in a period of eight years was 5.4 per cent. In our cases the second stage was done on an average of ten days following cystotomy. Our longest case, excluding malignancy, was three weeks. In 90 per cent of our prostatectomies the anesthesia of choice was spinal, the advantages of which are (1) minimization of postoperative renal depression, (2) less gastro-intestinal distress, (3) less pulmonary complications. In the other 10 per cent gas anesthesia was used.
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In all our cases postoperative care was found to be as important if not more so than preoperative preparation. Physiotherapy, colon hygiene, fluids, cardiac supportive treatment and urinary antiseptics are all necessary to bring about an early and satisfactory convalescence In conclusion we cannot too strongly urge prompt and early complete urological study in all cases of urinary disturbance. Martin (25) stresses this point in his " Plea for early prostatectomies." The clinician must not be content with rectal prostatic examination, inasmuch as a big percentage of prostatic enlargement is of the intra-vesicular type or bar enlargements with little or no extra-vesicular enlargement. Some adenomas grow rapidly and produce obstruction. Some are of more gradual growth, hence rectal examination alone may not give complete information as to the real condition of the patient's prostate. If found of such nature as to warrant surgical interference this should be done as early as convenient for the best welfare of the patient, since procrastination is apt to jeopardize the patient's life by making what might have been a comparatively safe operation if done in time into a dangerous procedure. REFERENCES (1) MORRISSEY, J. H .: Surgical drainage of seminal vesicles and prostate: its indication, technique and results. Surg., Gynecol. and Obstet., March, 1928, xlvi, 541. (2) VoN LACKUM, W. H . : Clinical and experimental data on prostatic infection. Jour. Urol., September, 1927, xviii, 293. (3) Hoxrn, G. H.: Thymus in prostatitis. Barkers Endocrinology, 1922, ii, 414. (4) WrLLINS, F. A. : Heart in prostatic hypertrophy. Jour. Urol., March, 1925, xiii, 337. (5) BusH A. D. : Kidney involvement in prostatic hypertrophy. Jour. Lab. and Clin. Med., August, 1924, ix, 743. (6) KREUTZMAN, H. A. R.: Cause of renal backpressure in obstructive leisons of the urethra and bladder neck. Jour. Urol., February, 1928, xix, 199. (7) YOUNG, H . H.: Practice of Urology, i, 17. (8) BUMPUS, H . C.: Urinary reflux. Jour. Urol., October, 1924, xii, 341. (9) GRAVES, R. C. Davidoff: Studies on ureter and bladder with special reference to regurgitation of vesical contents. Jour. Urol., September, 1923, x, 185. (10) EISENDRATH, D . N . : Congenital strictures and spiral twists of the ureters. Ann. Surg., May, 1917, lxv, 552.
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(11) TANDLER AND ZucKERKANDL: Berlin Klin. Wochenshr. No. 45, 2093, 1908. (12) BEER, A.: Prostatic hypertrophy or benign enlargement of the prostate. Surg. Clin. North Amer., April, 1928, viii, 275. (13) TROELL, ABRAHAM: Prostatectomy, some remarks about indications, technique and results. Acta Chir Scandinav, July, 1927, lxii, 133. (14) SCHOLL, A. J.: Histology and mortality in tumors of the prostate, bladder and kidney. Calif. and West Med., February, 1927, xxvi, 185. (15) MACHT, D. I.: The prostate gland as an endocrin organ. Barkers Endocrinology, 1922, ii, 525. (16) SERRALACH AND PARES} Cited by Macht: The prostate gland as an endo(17) HABEREN crin organ. Barkers Endocrinology, 1922, ii, 526. (18) WHEELON, HOMER: Relation of the testes to the prostate. Barkers Endocrinology, 1922, ii, 454. (19) HANES AND EccLES Cited by Wheelon: Relation of the testes to the (20) HARRISON AND WHITE prostate. Barkers Endocrinology, 1922, ii, 455. (21) REMETE (22) HUNT, V. C.: Benign prostatic hypertrophy: Review of 1000 cases. Surg., ~~'.i,:; Gynecol. and Obstet., June, 1928, xlvi, 769. (23);:MclvER, R. B.: Prostatectomy trans-sacral and caudal anaesthesia. Series of 50 cases. Jour. Fla. Med. Assoc., June, 1926, xii, 332. (24) THOMAS, B. A.: Vital factors in management of prostatic obstruction. Ann. Surg., October, 1927, lxxxvi, 568. (25) MARTIN, W. F.: Apleaforearlyprostatectomies. Amer. Jour. Surg., June, 1928, iv, 641.
l
One of the most important clinical conditions apt to be overlooked by the average medical practitioner is prostatic obstruction. Its great clinical importance can be readily seen when we consider the fact that from 60 to 70 per cent of men have some form of prostatic enlargement, and that approximately 50 per cent of men past the age of fifty have vesical neck obstruction to such a degree as to cause more or less urinary disturbance. Prostatic enlargements can be conveniently classified into four distinct groups: the simple congestive, the chronic infective, the hyperplastic, and the neoplastic types. The simple congestive type is found mostly in young and middle-aged men and is the result apparently of excessive venery, either cohabitation, onanism, or both. The infective type may be associated with either the congested or hyperplastic types and have a variable degree of enlargement. The chief etiological factor in this type is gonorrheal infection. According to statistics, approximately 70 per cent of men have had N eisserian infection and, in these cases, from 70 to 90 per cent had prostatic involvement. Nonspecific blenorrhea is another source of infection. Prostatic infection may also be secondary to some remote focus of infection such as teeth, tonsils, etc., as shown by Rosenow, Von Lackum and others. Morrissey (1) states that We know now that in patients who give no history of a previous urethritis, an infected prostate will show the same strain of streptococci as is found in the periapical lesions, tonsils, and sinuses. Inoculations in this group of cases have shown prostatic localization and selectivity 669
670
W. R. CHYNOWETH
in 70 per cent of the male rabbits injected, whereas, the control injections in female rabbits show less than 10 per cent localization in the cervix. Von Lackum (2) demonstrated the relationship of the prostatic infections and a variety of disorders such as arthritis, spondylitis, sciatica, and myalgia, also the fact that by proper treatment of the prostate these conditions tend to clear up. This can be readily understood when we consider the fact that of all toxins developing from infections of the glandular system, none are more toxic than those found in the prostate. In considering thymic conditions in prostatics Hoxie (3) says: In this connection I should like to call attention to the consistently low blood pressures accompanying this syndrome of inflamed prostate and submanubrial dullness. In apparently robust men the blood pressure will rarely exceed 100 mm. That it is not constitutional is shown by the fact that as soon as the absorption from the prostate ceases the blood pressure rises to normal levels, and the substernal dullness disappears. The hyperplastic or hypertrophied types of prostatic obstruction are commonly seen in men past forty-five or fifty. It is estimated that more than 50 per cent of men past this age have this form of prostatic enlargement, and of sufficient degree to cause urinary disturbance. Prostatic obstruction not only causes urinary disturbance, but favors diverticulosis of the bladder, infection, renal dysfunction and possible degenerative changes in the cardio-vascular system. After studying numerous records including electrocardiographs, Willis (4) found that cardio-vascular diseases were present in 42 per cent of the cases of prostatic hypertrophies. He concluded that the incidence to cardio-vascular diseases was higher in prostatic obstruction than any other disease. Bush (5) is of the opinion that the kidney dysfunction accompanying prostatic hypertrophy is due primarily to neural reflexes coming from the trigone area by way of the hypogastric afferents, then out through the eleventh and twelfth thoracic autonomics of the kidney. On the other hand Kreutzman (6) claims that
PROSTATIC OBSTRUCTION
there is a narrowing of the intramural portion of the ureters due to marked hypertrophy of the bladder wall and elevated trigone because of prostatic enlargement, which favors renal dysfunction and degeneration. Young (7) thinks this condition is due to a reflux produced by increased intravesical pressure. However, Kreutzman contends that reflux is a terminal phenomenon and not a primary condition resulting from prostatic hypertrophy. In 527 cystograms of prostatics, Bumpus (8) found reflux only in 25 cases, Graves and Davidoff (9) think that the tonic contraction of the bladder wall against a distending fluid, particularly in presence of bladder neck obstruction, is sufficient to open the ureteral orifices and favor regurgitation. Eisendrath (10) says that reflux is a comparatively rare cause of renal dysfunction, Tandler and Zuekerhankl (11) are of the opinion that in cases of prostatic hypertrophy, the vas deferens is pulled upon in such a way as to compress the ureters, thus causing upper urinary dilatation and subsequent renal dysfunction. No definite etiology of prostatic hypertrophy has been established although Beers (12) thinks that sexual activity, whether gratified or not, is the underlying cause and bases his contentions on the fact that no prostatic hypertrophy has been found eunuchs who were castrated before puberty. Of the neoplastic growths of the prostate carcinoma is most common, therefore most important for consideration. It is estimated that approximately 10 per cent of the prostates removed are found to be carcinomatous. In a report of 102 prostatectomies Troell (13) states that 12 per cent were malignant. Scholl (14) says that pathologically there are two types of prostatic malignancy with corresponding clinical pictures. The first type is of lower degree of malignancy and is made up histologically cells and glands corresponding to the normal prostatic structures. The cells are regular in size and shape and retain their identity longer. Clinically these prostates are large, nodular, hard as stone, produce marked symptoms of obstruction. The second type is made up of irregular masses of cells with no tendency to conform to the usual glandular type of prostate epithelium. The cells are loosely arranged and supported by THE JOURNAL OF UROLOGY, VOL. XXIV, NO.
6
672
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small amounts of connective tissue. Clinically they are small, fibrous and firmly fixed. They are more difficult to recognize, are extremely malignant and metastatize readily. The first type is usually associated with hypertrophy. The second type is rarely discovered until too far advanced for efficient treatment. In commenting on the comparative malignancy of these two types, Scholl, in his surgical review of a series of these cases, says "50 per cent of the first type were alive from one to six years after operation-90 per cent of the cases of the second type of cancer were dead, none had lived more than three years after operation, and 50 per cent had died the first year after operation." Before giving further consideration to prostatic enlargements and other forms of bladder neck obstruction, an anatomical review of the prostate may be of interest and will give an idea of certain characteristics of the gland The prostate gland is a compound tubular gland, which embryologically develops both in male and female from the Mullerian ducts, and forms a group of buds which develop into five distinct masses in the male, which correspond to the five lobes all of which fuse into one encapsulated mass about the size of a horse chestnut, weighing on an average 30 grams and pierced by the urethra and two vasa deferentia. Five-sixths of the gland consists of 3 to 50 lobules of glandular tissue containing 10 to 32 ducts which open into the colliculus seminalis. Between the glandular tissue, smooth muscles, lymphatics, blood vessels and nerves are dispersed. The innervation being a double one through the nervus erigens and nervus hypogastricus. In the female the prostate gland remains rudimentary. The prostate in man and animals remains small until puberty. In animals it undergoes definite cyclic changes closely associated with the functional activity of the testes. During the quiescent stage the prostate is composed of a few tubules lined with small flattened epithelial cells incapable of secretion. As the breeding season approaches the tubules become large and the epithelium becomes columnar in type and secretion takes place. During the rutting period the mass of tubules is many times larger than in the quiescent stage.
PROSTATIC OBSTRUCTION
673
The prostate varies in different animals as well as in different ages of the same individual. The variation of the development corresponds to the differences in the sex life. The prostate is much larger in animals highly reproductive than in animals much less so. For instance, the prostate gland in rats, guinea pigs and rabbits is proportionately larger than in cats, dogs, cattle and men. Macht (15) claims that the average weightof extirpated prostates in rats is about 200 mgm. or 1 to 500 the total weight of the animal. On the other hand in case of man the ratio is 1 to 2000. Macht concludes that "observations have led investigators to suspect that the prostatic secretion bears a direct relation to the life of the sperm." The prostatic secretion is a thin, milky, slightly alkaline fluid of characteristic odor, and contains so-called amyloid corpuscles, but no mucin. It has a direct relation to the life of spermatozoa, as has been shown by Furbringer, Steinach, Exner and Walker. It facilitates transportation of the spermatozoa through its lubricating properties, and aids in protecting them from destruction through neutralization of the acid secretions normally found in the urethra (urine) and vagina, a secretion which is detrimental to them. Besides the prostatic secretion, the prostate is supposed by some to have an internal secretion or hormone. This apparently is not definitely established, but tadpoles fed prostate experimentally developed rapidly which, as Macht says, favors the endocrine theory. However, there seems to be definite relationship between the prostate and testes. Macht and Bloom noted atrophy in the testes of prostatectomized rats. Serralach and Pares (16) claim that extirpation of the prostate in dogs causes a temporary cessation of spermatogenesis with testicular atrophy. Haberern (17), on the other hand, called attention to the fact that it was impossible to completely extirpate the prostate gland in dogs. Wheelon (18) claims that dogs are the only domestic animals which have infectious urethritis and are prone to prostatic hypertrophy; that castration has no effect on prostatic involution, whereas on all other animals castration causes atrophy of the prostate gland. The prostate normally undergoes atrophy in old age and as the
674
W. R. CHYNOWETH
glandular system degenerates it becomes a mass of fibrous tissue. Similar results are noted after complete castration, but unilateral castration has no effect on the gland. Hanes and Eccles (19) have shown that cryptorchids with functional interstitial cells show no alterations in the prostate. Hypertrophy of the prostate is seen more frequently in old men than atrophy. This is apparently an abnormal condition, due to the diminution occurring in other sex organs together with an overproduction of the testicular hormone and reduced spermatogenesis. Harrison and White (20) ' recognizing this, advocated castration as a curative measure for pro.static hypertrophy. On the contrary, Remete (21) claims that only normal prostates undergo atrophy as a result of castration; the greater the hypertrophy the less is it likely that castration will have any beneficial resuls. Prostatic infections due either primarily to venereal or other infections of the urinary tract, or secondary to some remote infection in the body, has also been considered as a definite etiological factor in persistent prostatic hypertrophy. In a series of 500 urological cases from twenty-eight to eightyfour years of age, studied by us, approximately 70 per cent had some form of prostatic involvement. Of these 60 per cent gave a definite venereal history and nearly 10 per cent had infections of the teeth or tonsils or both. Nearly 60 per cent of the prostatic smears of these had two or more pus cells to the field . Subsequent examinations of those patients showing 2 to 6 pus cells per field revealed in many cases several pus cells per field, thus warranting the diagnosis of a follicular prostatitis. The biggest percentage of those having pus in the prostatic smear gave a previous venereal history, yet nearly 10 per cent of those having pus cells present gave a negative venereal history. On the other hand, in approximately 6 per cent of those with a positive venereal history we were unable to find pus cells in tbP. prostatic smear. Simple congested prostate was diagnosed in 12 per cent of these cases. They ranged from twenty-eight to forty-five years in age.
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Fifty per cent had benign prostatic hypertrophy sufficient to cause urinary retention. In 12 per cent of these there was complete retention. Of the cases of prostatic hypertrophy 53 per cent were extravesical enlargement, palpable via rectal examination; 20 per cent were combined intra-extra vesical enlargement, determined by both cystoscopy and rectal examination; 10 per cent were of the intra.vesical type, as ascertained by cystoscopy and negative to rectal palpation. Twelve per cent were bar obstructions with or without lateral lobe involvement: Enlargements of the middle lobe are mostly adenomas; however, fibro-adenoma, fibromyoma and fibromas occasionally develop in this area. Prostatic bar enlargement is usually associated with fibrosis at the bladder neck. Five per cent of the 500 cases of this series had prostatic malignancy. In reviewing a thousand cases of benign prostatic hypertrophy Hunt claims that 85 per cent had benign obstructing prostatic lesion and the remaining cases were of the inflammatory or prostatic type. He elicited prostatic fullness by rectal digital palpation in more than 50 per cent of the men past fifty years of age. Mciver (23) reports that in 40 cases of prostatectomy 10 per cent were median bar, 20 per cent fibrosis and 70 per cent hypertrophy, All patients presenting urinary symptoms or pus cells in the urine should have a prostatic examination, especially if past forty years of age-not only examination of the gland via rectal palpation, but the possibility of retention must be ascertained. If a persistent residual of an ounce or more is present, cystoscopy is indicated to determine any possible bladder-neck obstruction. The size of the gland as determined by rectal examination is no criterion as to the degree of obstruction produced. In our series 22 per cent were neg:ative by rectal palpation whereas an additional 20 per cent had intravesical enlargement in addition to the enlargement felt in the rectal examination. Diagnosis based entirely on rectal examination may be misleading. In 2 of our cases of intravesical enlargements with negative rectal findings the residuum was 4 and 6 ounces of retention, and in the other cases the residual ranged from ½to 3 ounces.
676
W. R. CHYNOWETH
In the patients referred to us for urological examinations the type of urine is noted, genitalia examined, prostate examined via rectal palpation and about an ounce of 5 per cent argyrol introduced in the bladder by the Valentine method (without much pressure) or if necessary through a small rubber catheter. The patient is instructed to note the number of times he voids until the urine is free from argyrol. If it takes two or more times on repeated tests before the a:vgyrol disappears, catheterization is done to determine residual, if an ounce or more is present with repeated catheterizations, cystoscopy is indicated. In cases of hematuria cystoscopy should be resorted to as soon as can be conveniently done to ascertain the source of bleeding, keeping in mind the possibility of carcinoma. Early stages of prostatic obstruction may present only the clinical picture of frequency, with or without terminal dribbling, or there may be some hesitancy, but where the obstruction becomes a progressive one the physician must think of the possibility of infection, diverticulosis, calculi, renal insufficiency or even uremia. Thomas (24) says, "It is estimated that 50 per ce:ht of prostatics die in five years from the onset of obstruction and catheter life shortens this to two and one-half years." One of the most important questions a practitioner is called upon to decide, in respect to prostatic hypertrophy is whether surgery is indicated or not. In our experience we have found that, as a rule, in patients with a persistent residual of 2 ounces or more, the prostatic condition tends to progress, hence surgery is indicated in the majority of these cases. Where surgical treatment is indicated the mistake must not be made of waiting too long until the renal function is impaired, which may change a comparatively simple operation to a dangerous procedure. Interference with kidney function means inefficient elimination of waste products and thus favors a toxemia which affects all body tissues inducing the final stage of uremia. All operative cases should have a complete urine, blood pressure, chemical blood, including non-protein-nitrogen and blood sugar, CO2 and renal function tests. A persistently low phenol-
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sulphonephthalein output with a relatively high blood urea indicates a narrow renal reserve and only in very unusual cases can prostatectomy be done with any degree of safety where the phenolsulphonephthalein output is less than 20 per cent, or blood urea more than 50 mgm. to 100 cc. of blood. Absolutely normal values of blood urea nitrogen range from 12 to 20 mgm. per 100 cc. of blood. Safe operative percentage is 20 to 30 mgm. per 100 cc. of blood and 30 to 40 mgm. is regarded as dangerous. Thomas gives a very good blood pressure rule for prostatectomy which I have summarized as follows: High tension: (a) When (b) When Low tension. (a) When (b) When
systolic pressure is 180 or more diastolic must be under 100. diastolic pressure is 100 systolic must not be over 175. systolic pressure is 110 or less diastolic must be over 60. diastolic pressure is less than 60 systolic must be over 110.
The operation of choice is determined by the condition of the patient. According to Hunt, at the Mayo Clinic, the two-stage operation is the one most favored. This is preceded by ten days of bladder drainage with an indwelling catheter. Suprapubic drainage is done in cases of vesical calculi, diverticulosis, renal insufficiency and intolerance to a catheter, a condition found in about 6 per cent of their prostatic cases. In 1000 cases of prostatectomies done at the Mayo Clinic suprapubic drainage was done in 28.8 per cent of the cases. Hunt says the second stage should not be done less than three weeks after cystotomy. In half their cases the second stage was done in one month, 13 per cent in 100 days and 3 cases more than a year following cystotomy. His mortality rate for 1000 cases in a period of eight years was 5.4 per cent. In our cases the second stage was done on an average of ten days following cystotomy. Our longest case, excluding malignancy, was three weeks. In 90 per cent of our prostatectomies the anesthesia of choice was spinal, the advantages of which are (1) minimization of postoperative renal depression, (2) less gastro-intestinal distress, (3) less pulmonary complications. In the other 10 per cent gas anesthesia was used.
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In all our cases postoperative care was found to be as important if not more so than preoperative preparation. Physiotherapy, colon hygiene, fluids, cardiac supportive treatment and urinary antiseptics are all necessary to bring about an early and satisfactory convalescence In conclusion we cannot too strongly urge prompt and early complete urological study in all cases of urinary disturbance. Martin (25) stresses this point in his " Plea for early prostatectomies." The clinician must not be content with rectal prostatic examination, inasmuch as a big percentage of prostatic enlargement is of the intra-vesicular type or bar enlargements with little or no extra-vesicular enlargement. Some adenomas grow rapidly and produce obstruction. Some are of more gradual growth, hence rectal examination alone may not give complete information as to the real condition of the patient's prostate. If found of such nature as to warrant surgical interference this should be done as early as convenient for the best welfare of the patient, since procrastination is apt to jeopardize the patient's life by making what might have been a comparatively safe operation if done in time into a dangerous procedure. REFERENCES (1) MORRISSEY, J. H .: Surgical drainage of seminal vesicles and prostate: its indication, technique and results. Surg., Gynecol. and Obstet., March, 1928, xlvi, 541. (2) VoN LACKUM, W. H . : Clinical and experimental data on prostatic infection. Jour. Urol., September, 1927, xviii, 293. (3) Hoxrn, G. H.: Thymus in prostatitis. Barkers Endocrinology, 1922, ii, 414. (4) WrLLINS, F. A. : Heart in prostatic hypertrophy. Jour. Urol., March, 1925, xiii, 337. (5) BusH A. D. : Kidney involvement in prostatic hypertrophy. Jour. Lab. and Clin. Med., August, 1924, ix, 743. (6) KREUTZMAN, H. A. R.: Cause of renal backpressure in obstructive leisons of the urethra and bladder neck. Jour. Urol., February, 1928, xix, 199. (7) YOUNG, H . H.: Practice of Urology, i, 17. (8) BUMPUS, H . C.: Urinary reflux. Jour. Urol., October, 1924, xii, 341. (9) GRAVES, R. C. Davidoff: Studies on ureter and bladder with special reference to regurgitation of vesical contents. Jour. Urol., September, 1923, x, 185. (10) EISENDRATH, D . N . : Congenital strictures and spiral twists of the ureters. Ann. Surg., May, 1917, lxv, 552.
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(11) TANDLER AND ZucKERKANDL: Berlin Klin. Wochenshr. No. 45, 2093, 1908. (12) BEER, A.: Prostatic hypertrophy or benign enlargement of the prostate. Surg. Clin. North Amer., April, 1928, viii, 275. (13) TROELL, ABRAHAM: Prostatectomy, some remarks about indications, technique and results. Acta Chir Scandinav, July, 1927, lxii, 133. (14) SCHOLL, A. J.: Histology and mortality in tumors of the prostate, bladder and kidney. Calif. and West Med., February, 1927, xxvi, 185. (15) MACHT, D. I.: The prostate gland as an endocrin organ. Barkers Endocrinology, 1922, ii, 525. (16) SERRALACH AND PARES} Cited by Macht: The prostate gland as an endo(17) HABEREN crin organ. Barkers Endocrinology, 1922, ii, 526. (18) WHEELON, HOMER: Relation of the testes to the prostate. Barkers Endocrinology, 1922, ii, 454. (19) HANES AND EccLES Cited by Wheelon: Relation of the testes to the (20) HARRISON AND WHITE prostate. Barkers Endocrinology, 1922, ii, 455. (21) REMETE (22) HUNT, V. C.: Benign prostatic hypertrophy: Review of 1000 cases. Surg., ~~'.i,:; Gynecol. and Obstet., June, 1928, xlvi, 769. (23);:MclvER, R. B.: Prostatectomy trans-sacral and caudal anaesthesia. Series of 50 cases. Jour. Fla. Med. Assoc., June, 1926, xii, 332. (24) THOMAS, B. A.: Vital factors in management of prostatic obstruction. Ann. Surg., October, 1927, lxxxvi, 568. (25) MARTIN, W. F.: Apleaforearlyprostatectomies. Amer. Jour. Surg., June, 1928, iv, 641.
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