SYMPTOMS AND DIAGNOSIS - TUBERCULOSIS OF THE PROSTATE.
When the prostatic urethra is the seat of a tubercular deposit —with or without involvement of the bladder—the symptoms are es sentially the same as in any inflammation in this region. Pain referred to the region of the bladder, perineum, thighs, groins, ure thra, testes, and rectum may be complained of in different cases. Frequent and painful micturition, increasing in severity as the vesical neck becomes invaded, is the most uniform symptom. Some hvama turia is observed. This is not profuse as a rule, but is limited to the last few drops of urine. Sometimes, however, it is moderately free, and if the urethra is involved anterior to the triangular ligament urethrornhagia may be observed. The fusiform clot characteristic of prostatic hemorrhage is sometimes seen. Acute retention of urine may occur from the supervention of hyperaemia, simple inflammation, or the formation of a mixed abscess. The urine contains muco-pus, epithelium, thready filaments, and, if ulceration exists, particles of tuberculous tissue are sometimes observed. A chronic prostatic or recurrent discharge of a muco-purulent character is present where the prostatic urethra is involved. Bacilli may or may not be present, but are rarely to be observed unless ulceration or abscess exists. In a general way, the discharge is that of a stubborn so-called posterior urethritis—i.e., follicular prostatitis. The discharge of muco-pus is likely to be intermittent, occurring only at stool, during the coup de piston, or on digital pressure through the rectum. When the dis charge escapes spontaneously from the meatus, the anterior urethra is also involved, not necessarily in a tubercular urethritis, but in most cases being the seat of simple chronic inflammation. Sometimes a large quantity of pus suddenly appears in the urine. This is indica tive of the evacuation of the abscess per urethram.
When the tubercular deposit is at the periphery of the prostate or in the periprostatic tissue, there may be no symptoms for a long time. The patient is not likely to complain unless the bladder, urethra, or testes become involved. There may be some pain and weight in the perineum, with tenderness upon pressure, a moderate amount of rectal tenesmus and pain in defecation, but these symp toms are usually noticeable only after a sufficient amount of tubercu lar material has become deposited to produce more or less mechanical disturbance.
As will be observed, there is nothing pathognomonic in the foregoing symptomatology. The most definite symptoms are of an objective character and are to be determined by rectal exploration. The prostate is found to be the seat of an irregular nodular enlarge ment with perhaps areas of softening. A granular feel of the peri prostatic tissue has been described. The seminal vesicles are sooner or later involved as a rule and are thickened, nodular, and tender.
A definite abscess may be found. After evacuation of the tubercular abscess relative atrophy and perhaps sclerosis of the prostate are ob served. The passage of the catheter may result in the detection of the abscess cavity, usually upon the floor of the prostatic urethra.
It is obvious that it is quite easy to make diagnostic errors where there is no softening or ulceration of the prostate. The presence of bacilli in the urine or pathological discharge from the affected organ constitutes the only positive sign of tuberculosis. Since so much has been written upon tuberculosis of the genitourinary tract, many mis takes of diagnosis have been made. Among some surgeons the pres ence of more or less hardness of one or the other epididymis with a little enlargement, tenderness, and nodulation of the prostate are suffi cient to warrant a diagnosis of prostatic tuberculosis. It must be remembered, however, that simple chronic inflammation of the epi didymis may present the same signs as far as the testes are concerned. Simple adenitis—periprostatic adenitis with chronic fol licular prostatitis—may afford all of the other signs upon which the diagnosis of tubercular disease of the prostate is frequently based. In the experience of the author, it is nothing unusual to meet with such cases that have been diagnosticated as tuberculosis of the prostate. Under the ordinary measures of treatment of follicu lar prostatitis many of these cases readily yield. The inference is obvious—either many cases of tuberculosis of the prostate con stitute a mild and comparatively harmless affection, readily amenable to treatment, or else frequent mistakes in diagnosis occur.
When a sluggish, slowly developing, comparatively painless and insensitive enlargement of one or both epididymes exists with symp toms of chronic prostatic inflammation and a nodular enlargement of the prostate, as determined by rectal examination, a probable diag nosis of prostatic tuberculosis is warrantable. The detection of bacilli in the urine or discharge, or the formation of characteristic tubercular abscesses and sinuses, are necessary as a rule for a positive diagnosis. In a case presenting similar symptoms as far as the pros tate is concerned, and at the same time evidences of tuberculosis of the lungs, peritoneum, bones, or general lymphatic system, the inference regarding the prostatic disease is obvious. The heredity of the pa tient and his general condition are important factors in the diagnosis.
There is no regularity in the course of the disease. Some pa tients suffer very acutely at an early period where the urethra and bladder are involved. Others, especially when the urethra is not primarily or early invaded, tolerate the condition for a very long time. Complete arrest of the disease and a spontaneous cure may result, as is indicated in the discussion of the morbid anatomy of the disease.