BLADDER AND PROSTATE DISEASES.
Cystitis, or inflammation of the bladder, which may be acute or chronic, is due to the invasion of the mucous lining by micro organisms, which gain access either from the urethra, the kidneys or the blood-stream.
Any condition leading to disturbance of the function of the bladder, such as enlargement of the prostate, stricture of the urethra, stone, or injury, may cause cystitis by preparing the way for bacillary invasion. The bacilli of tuberculosis and of typhoid fever may cause it by passing into the bladder from the kidneys with the urine, or invade it by the urethra. Frequently bacteria are introduced by way of catheterization. The first effect of inflammation is to render the bladder irritable, 'so that as soon as a few drops of urine have collected, the individual has intense or uncontrollable desire to micturate. The effort may be very painful and may be accompanied by bleeding from the overloaded blood-vessels of the inflamed membrane. In addition to blood, pus is likely to be found in the urine, which by this time is alkaline and ammoniacal, and teeming with micro organisms. As regards treatment, bed, hot baths, milk diet and abstinence from alcohol are indicated, while frequent washing out of the bladder with weak antiseptics is necessary if the urine is foul.
Chronic cystitis is the condition left when the acute symptoms have passed away, but it is liable at any moment to resume the acute condition. If the cystitis is very intractable, refusing to yield to hot irrigations, and to washings with nitrate of silver lotion, it may be advisable to open the bladder from the front, and to explore, treat, drain and rest it.
Tuberculous cystitis is a late manifestation of tuberculosis in kidney, prostate or epididymis and is very intractable.
Calculi and Gravel.—Uric acid is deposited from the urine either as small crystals resembling cayenne pepper or, in combina tion with soda and ammonia, as an amorphous "brickdust" deposit, which, on cooling, leaves a red stain on the bottom of the vessel, soluble in hot water. These substances are derived from the disintegration of nitrogenized food taken in excess of demand, and from the breaking down of the human tissues. They occur therefore in fevers, in wasting diseases, and in the normal subject after excessive muscular exercises, especially if accompanied with much perspiration. If the uric acid debris continue to be ex cessive, renal or vesical calculi may be formed. In an alkaline urine, e.g., where a stone has led to cystitis, phosphates of am monia and magnesium are deposited.
A stone in the bladder causes a constant desire and need for micturition and the urine contains mucus and blood. Lastly, cystitis occurs, and the urine contains foetid pus. A stone in the bladder gives rise to pain at the end of the penis, and it is apt suddenly to stop the flow of urine during micturition.
Treatment.—Usually the stone is crushed within the bladder by a lithotrite and the fragments flushed out through a hollow metal catheter. But if the stone is very hard or large or other conditions contraindicate, lithotrity must be replaced by a cutting operation (lithotomy).
The treatment of vesical calculi by other means than operative surgery is of little value. Attempts to dissolve them by internal remedies, or by the injection of chemical agents into the bladder have invariably been found worthless for removing calculi once actually formed.
Rupture of the bladder may be caused by a kick or blow over the upper part of the abdomen, or by a wheel passing over it; or it may be a complication of fracture of the pelvis. The great danger is supervention of septic cellulitis, but if thorough drain age and asepsis be carried out and the rent be sewn up recovery is not impossible.
Malignant disease of the bladder is almost always the warty form of cancer known as epithelioma. It springs as a sessile growth from the mucous membrane of the floor near the opening of one of the ureters, and is one of the severest forms of cancer owing to the local changes it produces and its tendency to cause a fistulous opening between bladder and rectum in the male or vagina in the female. Though it may be primary, cancer of the bladder is usually due to extension of growth from the uterus or rectum.
Paralysis of the bladder may result from injuries whereby the spinal cord is lacerated or pressed upon. The result may be either retention or incontinence of urine; sometimes there is at first retention, which later is followed by incontinence. Paralysis is also met with in certain nervous diseases, as in locomotor ataxia, and in various cerebral lesions, as in apoplexy.
Atony of the bladder is a partial paralysis. It is due to a want of tone in the muscular fibres, and is frequently the result of over-distension, such as may occur in cases of enlargement of the prostate. The patient is unable to empty the bladder, and the condition of atony gets increasingly worse.
Incontinence of urine may occur in the adult or in the child, but is due to widely different causes in the two cases. In the child it may be simply a bad habit, but more frequently there is a want of control in the micturition-centre, so that the child passes its water unwittingly, especially during the night. In adults the water which passes is the overflow from a too full reservoir.
It is usually caused by an obstruction external to the bladder, e.g., enlarged prostate, calculus, or stricture of the urethra. In the child an attempt must be made to improve the tone of the micturition-centre by the use of belladonna or strychnine in ternally, and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pass water at stated times and regular intervals. In the adult the cause which produces the over-distension must be removed if possible; but, as a rule, the patient has to be provided with a catheter, which he can pass before the bladder has filled to overflowing.
Retention of urine may occur in paralysis of the bladder, or in conditions where the patient is suffering from an illness which blunts the nervous sensibility, such as apoplexy, concussion of the brain, or typhoid fever. It is, however, more commonly due to obstruction anterior to the bladder, as in stricture of the urethra or enlargement of the prostate.
BIBLIOGRAPHY.—G. J. Thomas, "Diverticula of the Urinary Bibliography.—G. J. Thomas, "Diverticula of the Urinary Bladder," Tr. Am. Urol. Ass., x., p. (1916) ; A. Adler, Mitt. a.d. Grenzgeb. d. Med. u. Chir, p. 487 (1918) H. A. Kelly and C. F. Burnam, Dis. of the Kidneys, Ureters and Bladder (1922); H. Cabot, Modern Urology (1924); H. W. B. Cairus, "Observations on the Etiology and Treatment of Cystitis," Brit. J. Surg., p. 78 (1925-26) ; H. H. Young and D. M. Davis, Practice of Urology (1926).