DIAGNOSIS - ACUTE PROSTATITIS.
Although the main diagnostic points in acute prostatitis are out lined in the foregoing symptomatology, a diagnostic resume and con sideration of certain special points in the differential diagnosis would seem necessary. The patient, generally the subject of acute or chronic urethritis, complains for several days of heaviness and pain in the perineum which he is quite likely to attribute to fatigue or over-exer tion, or possibly, if he be one of the exceptionally honest patients whom we sometimes meet, to sexual stimulation or indulgence. In some cases the patient complains for several days of loss of appe tite, possibly slight chilliness and well-marked malaise. Considerable mental depression may exist for some time before definite symptoms referable to the perineum occur. Vesical and anal tenesmus with dysuria, and in the majority of cases painful and difficult defeecation, soon develop. In other instances, the first indications of impending prostatic inflammation consist in symptoms of vesical irritation. In still another class of cases, the first and most prominent symptom consists not in vesical irritability, but in urinary obstruction, which grows more and more prominent and is apt to lead to complete reten tion. It is obvious that the symptoms are governed largely by the amount of inflammation of the prostatic urethra.
In cases in which inflammation of the posterior urethra is not the point of departure, as is true in many cases of suppurative inflamma tion, there may be little or no vesi cal irritation throughout the course of the case. Digital exploration of the rectum and perineum shows perineal fulness and tenderness and a degree of bulging of the pros tate into the rectum, due to enlargement of the organ, proportionate to the severity of the inflammation and the degree to which the inter stitial and peri-prostatic tissues are involved.
Cowperitis may be mistaken for inflammation of the prostate. Palpation of the perineum, however, shows a lateral swelling and, if examined early, a distinctly circumscribed spherical tumor. The prostate on rectal examination is found to be either normal or only moderately enlarged. The urinary symptoms may be nil. The pos sibility of follicular prostatitis, without any great degree of enlarge ment of the prostate, existing as a complication of Cowperitis, or vice versa, should be taken into consideration.
Cases of acute inflammation of the prostate complicated by reten tion may require differentiation from stricture, especially that variety of the latter in which retention comes on suddenly from hyperaemia and spasm. The history of the case, digital exploration of the rec tum, and the location of the obstruction generally serve for differen tiation. It must be remembered, however, that stricture of the ure thra is quite likely to be complicated by prostatic inflammation.
Many cases of genitourinary disease of an acute character are to present features which are, to say the least, decidedly mixed. En largement of the prostate, as a cause of retention, may usually be differentiated from acute prostatitis, by the age and history of the patient and the peculiar feel imparted to the finger in digital explora tion of the The tenderness elicited by the latter method of examination may be very slight in prostatic hypertrophy. The pos sibility of acute prostatitis with suppuration or the formation of a chronic abscess as a complication of prostatic hypertrophy is to be borne in mind.
Acute cystitis may be mistaken for inflammation of the prostate. It is probable that by far the majority of cases of so-called acute gonorrhoeal cystitis are really instances of acute follicular prostatitis. The vesical lnucosa proper is rarely involved in gonorrhoeal inflam mation; indeed, it is claimed by excellent authorities that the vesical mucosa is immune to the gonococcus. Be this as it may, gonorrhoea is a mixed infection and the vesical mucosa may become infected by germs other than the gonococcus. It is not, however, particularly susceptible to simple pus infection.
abscess of the prostate is definitely formed, the diagnosis is generally easy unless the collection of pus be quite small. Espe cially is the diagnosis easy when the abscess points toward the rec tum. In many cases, however, the diagnosis is not only difficult, but the abscess is not detected until the pus has escaped by the urethra.
The author has observed a number of cases in which, although pros tatic abscess wad strongly suspected, the symptoms were of rather moderate intensity, no incision was made, and the diagnosis was only cleared up by the sudden escape of a greater or less quantity of pus from the urethra.
Zeissl calls attention to the possibility of confusion of prostatic with ischio-rectal abscess. In the latter, however, there are no es pecial symptoms referable to the bladder as a rule, and the unilat eral position of the tumor with its distinct point of departure in the ischio-rectal fossa serves to clear up the diagnosis. In some instances ischio-rectal abscess is associated with more or less reflex irritation of the vesical neck. This may prove a source of confusion. The author has observed one case in which ischio-rectal abscess occurred coincidentally with acute follicular prostatitis. The possibility of the coexistence of the two conditions is to be borne in mind. In prosta titic phlegmon, and in all forms of well-marked prostatic inflamma tion, especially where suppuration occurs, the gravity of the consti tutional symptoms and the profound nervous depression which exists are valuable points for consideration in the differential diagnosis.