Cases of neuralgia of the prostate following operations upon that organ, or operations upon the bladder involving it, are occasionally met with. The author has at the present time under observation a case in which he operated through the perineum for the purpose of draining the bladder in a case of obstinate cystitis in a young adult. The result was perfect as far as the cystitis is concerned, but the pa tient has been tormented ever since the operation by ano-perineal pain and crural and testicular•euralgia. There is no condition of the prostate, bladder, or rectum which will serve to explain the difficulty. Another case is that of a man operated upon for large-calibred stricture of the penile urethra, in whom there have existed for some years a persistent, deep-seated, intermittent perineal pain, frequent urination, and marked hypermsthesia of the prostatic urethra. Careful exploration failed to detect any morbid condition which would serve to explain the trouble. The operation of urethrotomy, while perfectly effective as far as the stricture was concerned, com pletely failed to relieve the prostatic neuralgia.
Acute or chronic hypermmia of the prostate is responsible for some cases of hypermsthesia and neuralgia of this organ, and in such cases the perturbation of the blood supply is really the essential con dition. Unfortunately, however, the pain is not only the most prominent feature in such cases in the mind of the patient, but it often persists in spite of all measures tending to correct the circula tory disturbance. That a strong psychic element enters into these cases, as indeed it does in the majority of cases of genitourinary disease, is admitted. Psychical disturbance, as indicated in the etio logical table already given, may be the starting-point not only of vas cular disturbance attended with neuralgia and hypersthesia, but may produce neurotic disturbance independently of disturbances of the circulation. Prolonged and unnecessary treatment of the pros tatic urethra is not only likely to produce a hypermsthetic condition of this part, but also persistent and obstinate psychical disturbance, perhaps amounting to hypochondriasis or even melancholia, with or without painful sensations, real or imaginary—in this region. Hysteria in the male from this cause is by no means as infrequent as is ordinarily supposed.
Psychoses from prostatic irritation are very frequent, but care must be taken to carefully discriminate between those cases which are psychical ab initio and those in which the psychical element is simply an ingraft upon the symptoms produced by organic disturbance. Acute or chronic inflammation of infectious origin is of course the most frequent condition, but many cases occur in which, after the in flammation has disappeared, neuralgic pain referable to the neck of the bladder and radiating into the perineum, testes, thighs, and rectum, persists in spite of all treatment, often perhaps because of it. Re flex irritation produced either from the vesical or urethral side of the prostate is quite often seen. Urethral and perineal pain, associated
with stricture and stone in the bladder, are familiar examples. Stric ture of the urethra occasionally produces neuralgia referable not only to the prostate, but apparently involving the entire bladder. A case at present under treatment demonstrates this clinical fact to excellent advantage. A gentleman, thirty years of age, suffered from pain in the region of the bladder associated with frequency of micturition, for six or seven years. He had been operated upon for stricture some time prior to the beginning of his neuralgic pain, and he was inclined to attribute the disturbance to the urethrotomy. Examination revealed several strictured bands of large calibre which had evidently escaped the original operation. A second urethrotomy was advised and per formed with perfect. relief of the patient's symptoms. A peculiar feature in this case was severe hypogastric pain whenever the urine was held for several hours. This has completely disappeared since the operation.
The term hypermsthesia of the prostate should comprehend those cases of so-called vesical irritability which have been described by some authors as neuralgia of the vesical neck. The more important and highly sensitive parts involved in the sexual and urinary func tions are integral parts of the prostate. The prostatic urethra de rives most of its importance (save that incidental to its function as an outlet from the bladder) from certain anatomical and physiological peculiarities of the prostate proper. The elaborate and highly sensi tive nervous supply of the prostate is the seat of urinary desire. The nervous supply of the prostate is also responsible by virtue of spe cial nervous filaments—supplied chiefly to the caput gallinaginis—for the voluptuous sensations incidental to the performance of the sexual function. Hypermsthesia of the prostate manifests itself in two ways. First, by heightened sensibility of the prostatic urethra to the pressure of urine with resultant frequent micturition. This is associated perhaps with an inhibition of the function of the false vesical sphincter, as a consequence of which the urine enters the highly sensitive prostatic urethra at more frequent intervals. The capacity of the bladder itself is in all probability diminished by reflex irritation of the nervous supply to the vesical muscle. A careful con sideration of the physiology of micturition readily explains the so called vesical irritability resulting from prostatic hyperwsthesia. The sexual function of the prostate is likely to be profoundly dis turbed by hypermstbesia of the organ, particularly if the region of the caput gallinaginis be involved. Nocturnal pollutions, imperfect erection, and premature orgasm, or perhaps complete impotentia coeundi may result, these conditions being by no means readily amen able to treatment.