The infectious products of inflammation of the bladder may at any time, whether under the exciting influence of traumatism or through the medium of a secondary infection of the prostate and prostatic urethra, produce acute prostatitis.
Rectal and anal disease exert so profound an influence over the vascular and nervous supply of the prostate that their importance as etiological factors predisposing to acute inflammation of the organ is by no means surprising. Physical exertion, particularly that in volved in walking, running, lifting, bicycling, and other forms of athletic exercises, in which more or less strain is brought to bear upon the perineum, tends to produce an irritable and hyperemic condition of the prostate, in the presence of which any source of in fection is apt to manifest itself in the form of acute inflammation of the organ. In by far the majority of cases of acute prostatitis there exists some urethral source of infection, either patent or obscure, as a direct exciting cause of the acute inflammation. True suppurative inflammation of the urethra is not, however, absolutely necessary in order that infection by germs or germ products may occur. Thus the infection may consist of the products of decomposing urine, or the secretions of urethral or prostatic catarrh, confined behind some obstruction of the urethra, such as is afforded by prostatic hyper trophy or stricture of the canal. The cause is likely to be a recent gonorrhoea of an acute virulent type, but the infective inflammation may be subacute or chronic. Simple urethritis, acute or chronic, presents a secretion teeming with germs and their products, which may at any time produce acute inflammation of the prostate. It must be remembered in this connection that it is probably the mixed character of the infection which is in all cases responsible for the cases in which suppuration of the prostate or peri-prostatic tissues occurs.
Laying aside the cases of acute follicular prostatitis—i.e., poste rior urethritis occurring in the course of acute or chronic gonorrhoea, the pus microbe and its products are responsible for prostatic com plications. It is safe to assert that in most of the cases of acute prostatitis, an area of suppuration or bacterial infection exists in the deep urethra. The cause may consist of a suppurative or chronic infective inflammation of the bulbous or bulbo-membranous region. These conditions existing, the slightest traumatism or the occurrence of active hypermnia may at any time produce an acute and violent inflammation of the prostate. One of the most frequent causes is the mechanical disturbance of the prostate incidental to sexual inter course. During the occurrence of the venereal orgasm the muscular tissues of the perineum, and incidentally of the prostate, act very much upon the principle of the bulb of the ordinary Davidson syringe. The spasmodic contraction incidental to the orgasm alternates with relaxation, during which the deep perineal muscles and the prostate probably exert what may be termed an aspirating effect upon the urethra. The superfluous semen is drawn back into the deep urethra preparatory to the occurrence of the spasmodic muscular contraction by means of which the last few drops of semen are to be expelled into the urethra and thence into the vagina. During the aspiration of the semen into the deep urethra, any infectious materials which may exist in the anterior portion of the canal are forcibly drawn into the deeper parts, where they produce acute infection. This, while pri
marily an acute follicular prostatitis, may be followed at any time, and perhaps within a very short period, by acute diffuse inflamma tion and possibly abscess of the prostate. It is a matter of common observation that patients presenting themselves with acute prostatitis in the course of gonorrhoea, confess to sexual indulgence or the occur rence of a nocturnal emission as the immediate exciting cause. In the opinion of the author, the foregoing constitutes a logical explana tion of its occurrence.
In quite a proportion of cases, infection of the prostate in the course of gonorrhoea or urethritis is a result of deep injections or the passage of instruments. While it is true that in some instances the exciting cause would seem to be a high degree of chemical irritation produced by the injection, it is probable that in by far the larger proportion of instances in which the prostatitis can fairly be attrib uted to the use of injections, the fluid so used is only indirectly responsible for the occurrence of the prostatitis, inasmuch as it serves merely as a carrier of germ infection. It is probable that the in jection of pure water would be equally, if not more, effective in this respect. It has been the experience of the author that the frequency of prostatic complications is directly proportionate to the vigor with which the treatment of acute gonorrhoea is pursued. Some of the worst cases coining under observation are due to the passage of in struments for the relief of retention, or for the treatment of the urethritis. Soluble bougies and deep urethral irrigation, used during the acute stages of urethral inflammation, have been responsible for a large number of cases. The soluble bougie or the tube used in deep irrigation acts as the carrier of germ infection which the in jected solution is too weak to destroy. Then, too, we have the abrad ing effect of the instrument or soluble bougie upon already degener ated and readily removable epithelium. This opens up avenues of infection which otherwise might possibly never occur.
The excessive use of terebinthinate and balsamic preparations has been said to cause prostatitis. It is possible that in very large toxic doses these drugs, in combination with an already existing infection of the deep urethra, may be operative in producing acute inflamma tion, but under no other circumstances. Cantharides in poisonous doses produces inflammation of the prostate in common with all the other structures composing the genito-urinary tract.
In concluding the subject of the etiology of acute prostatitis, the author desires to emphasize the paramount importance of infection as a factor in the etiology of the disease, and to insist on the sub ordinate character of by far the larger proportion of the causes enu merated not only in the table of Segond, but in the much simpler etiological classification already suggested. A further practical point of great importance is the clinical fact that, given an acute or chronic source of infection, and especially the former very slight interference with the urethra and bladder may serve to precipitate an acute in flammation and perhaps abscess of the prostate.