ETIOLOGY - ACUTE PROSTATITIS.
The causes of acute prostatitis, as outlined by some authors, con stitute a rather complex subject, presenting many elements of im practicality and sources of confusion. Practical clinical experience shows that while many predisposing elements necessarily enter into consideration, acute prostatitis is precipitated in the majority of instances by causes of rather a common character. This nearly all cases are found to be due to direct extension of acute inflammation of the urethra, usually of gonorrheal origin. Other factors are to be taken into consideration, it is true, in those cases in which suppura tion results, because of the clinical fact that in by far the larger proportion of cases of acute prostatitis suppuration does not follow. The author bases this broad assertion upon the view that in the larger proportion of cases of acute inflammation of the prostate the process is limited to the glandular structures of the organ, and par takes of the same characters as the original gonorrhoeal infection with certain modifications due to anatomical and physiological peculiarities of the affected part. Mechanical interference with the prostate, in cidental to the treatment of acute or chronic bladder difficulties or for the purpose of exploration, is responsible for most of the remain ing cases. Even here we have gonorrhoeal or other infection of the urethra as the principal etiological factor, the instrument used acting merely as a carrier of infection, or establishing a locus minoris resis tentice by injuring the prostatic urethra. The experience of every practical surgeon has shown that in every case of urethral disease, acute or chronic, more particularly in the acute forms of inflamma tion, the patient is constantly liable to the development of an acute inflammation of the prostate.
In view of the careless, routine, and often over-vigorous treat ment of gonorrhoea, to say nothing of the vicious self-imposed hy gienic conditions of the patient, it is a matter of surprise that prostatic complications do not occur in every case of gonorrhoeal in fection. That patients with virulent urethritis of specific origin should escape prostatic complications, is to the mind of the author somewhat remarkable, when we consider the high degree of infec tiousness of the various microbial organisms and their products char acteristic of that typically mixed infection known as gonorrhcea. Acute prostatitis may be developed by very trifling causes during the course of a gonorrhcea. These causes may consist in ill-advised attempts to cure the disease, or in misconduct on the part of the patient.
The disease is especially liable to follow indiscretions or excite ment of a sexual character. Alcoholic and dietetic excesses and over-exertion play a most important role in developing this complica tion in the course of a gonorrhcea.
As a preliminary to the discussion of the etiology of acute pros tatitis in detail, a presentation of the various etiological factors as accepted by various authorities may be serviceable. The etiological table of Segond is one of the most elaborate schematic outlines of etiological possibilities that have thus far been presented in connection with acute prostatitis. In considering this table, the practitioner should understand that it will prove of little value unless the various causes outlined therein be assigned their true importance as etiologi cal factors. This being understood, the table itself will enable us to reduce the etiology of acute prostatitis to a comparatively simple basis.
As a broad proposition, it is safe to assert that by far the ma jority of cases of acute prostatitis are due to infection in some form. This being accepted, it is obvious that many of. the causes outlined in Segond's table are factors secondary and subordinate to infection. If we add to the cases produced by infection the relatively much smaller number of cases produced by mechanical and chemical vio lence, we have practically included all the causes of acute prostatitis. It is to be understood also that in many instances chemical and trau matic injuries of the prostate induce acute prostatitis solely by carry ing infection or by opening up avenues for the absorption of infective material. It is of course a difficult matter to separate these cases from those in which the inflammation is immediately due to trau matic or chemical causes. Generally speaking, however, it is safe to assume that in the cases in which suppuration occurs, chemical or traumatic injury to the prostate, if it exists at all, acts as a factor subordinate to infection: The following rather simple classification may give a somewhat clearer insight into the etiology of acute prostatitis than either the elaborate etiological table or the general remarks thus far presented: Exposure to cold unassociated with a gouty or rheumatic diathe sis is not, in the opinion of the author, a very efficient cause of acute prostatitis, unless some source of infection be present. That pro
found disturbance of the circulation of the prostate may result from chilling of the surface of the body, particularly when the lower ex tremities are exposed to cold and wet, is admitted. That this will result in acute prostatitis in cases in which some source of infection is not already present, cannot, however, be accepted in the light of our present knowledge of the germ origin of disease. Given, how ever, the existence of infection of the urethra, prostate, or bladder, the disturbance of the circulation incidental to exposure may develop a lessened degree of resistance to germ infection on the part of the prostate which may result in acute prostatitis with or without the occurrence of abscess. Cases are frequently met with in which pa tients presumably have had no infectious disease of the genitouri nary tract, but in whom a certain degree of irritation of the neck of the bladder results from exposure to cold. It will be found, how ever, that in such cases there usually exists a more or less marked tendency to rheumatism or gout. Many of the cases of so-called prostatitis consist merely in an irritation of the mucous membrane of the prostatic urethra, clue to the development of an excess of uric acid crystals in the urine incidental to chilling of the surface of the body. That such cases are frequently diagnosed as acute prostatitis, the author is fully aware. In the majority of such cases, however, not only is there an entire absence of true inflammation of the pros tate, but there is no inflammation of the prostatic urethra itself, the condition being merely one of local irritation of a highly sensitive nervous structure resulting from the presence in the urine of irritating crystals of uric acid and possibly of oxalate of lime. The prolonged contact of the perineum with a cold and damp surface is said to be an efficient cause of acute prostatitis. While this may be a cause of sec ondary importance, in all probability it is not capable of inducing acute inflammation of the organ in question unless some source of infection exists. The gouty and rheumatic diatheses, either alone or associated with exposure to cold and wet, may develop prostatic irri tation and possibly precipitate true acute prostatitis in cases in which infection already exists. The influence of gout and rheumatism is exerted not only in the direction of aberration of the quality and quan tity of urinary solids and an alteration of urinary reaction, but also in the production of an intrinsic irritability of nervous and vascular structures, by virtue of which they react more promptly and markedly to sources of irritation. It is obvious that an individual who is ex posed to psychical or physical causes of sexual excitement is espe cially predisposed to the development of acute prostatic inflammation in the presence of infectious genito-urinary disease. It is certain that if this particular predisposing cause could be entirely eliminated in the majority of cases of acute or chronic genito-urinary disease, the proportion of cases in which prostatitis develops as a complication would be very materially reduced. Acute or chronic disease of the urethra constitutes a constant menace to the prostate. Stricture of the urethra, which seems to have been entirely overlooked by Segond, is worthy of consideration in this regard. These conditions of acute or chronic inflammation may produce acute prostatitis from compara tively trifling exciting causes. It is obvious that chronic prostatic disease, especially those forms in which a focus of infection exists in the prostatic urethra or bladder, are likely to be complicated by acute prostatitis. Especially is this true if traumatic interference, in the form of violent or often-repeated catheterization, be added as an ex citing cause. Acute prostatitis or para-prostatitis is a rather fre quent complication of prostatic hypertrophy. What has been said of acute and chronic disease of the prostate applies equally to cystitis.