SYMPTOMS OF THE HYPERTROPHIED PROSTATE.
The symptoms of prostatic hypertrophy are obviously those inci dental to urinary obstruction and the various conditions secondary to, or engrafted upon it by, infection. Hypertrophy must neces sarily exist in many instances for a long time before symptoms are produced. The condition is not painful per se, and there may be no evidence of its existence until a sufficient size has been attained to produce mechanical interference with the function of urination. In quite a proportion of cases, however, more or less marked symptoms, referable to the vesical neck, exist for some years before any appre ciable degree of obstruction occurs.
As the prostate is one of the principal factors in the coup de piston, or the final spasmodic contraction of the urethral and cut-off muscles for the purpose of ejaculating the final drops of urine or semen from the urethra, one of the first symptoms of prostatic hyper trophy is difficulty in clearing the canal of fluid. Obviously, whether the prostate is an active participant in the process of closing the neck of the bladder at the termination of urination or not, it must neces sarily interfere with this process when it becomes rigid and enlarged, by resisting the pressure of the cut-off muscle. The individual soon notices a little tardiness in the commencement of the flow and a lack of force of the stream of urine. The explanation of this is very sim ple. Under normal conditions there is nothing to retard the flow of urine after the cut-off muscle has been voluntarily relaxed, the pros tate being elastic and distensible. When, however, it has become rigid and inelastic it opposes the action of the detrusor urine muscle and inhibits in a certain degree the flow of urine. This is in itself sufficient to induce sooner or later compensatory hypertrophy of the vesical walls. The stream of urine may be a trifle smaller than nor mal, but, as a rule, it is not appreciably changed, a very important point in differentiating this condition from stricture of the urethra. Pouching of the bladder at the bas ,fond occurs in many cases before appreciable symptoms are manifest, and as a consequence the bladder is never entirely empty, a few drops of urine accumulating in this situation quite early in the course of the case. If bacteria enter the bladder this residuum decomposes and produces irritation and a conse quent catarrhal condition of the vesical mucous membrane, with a resultant feeling that the bladder has not been entirely emptied. The author desires to emphasize the fact that it is not the residual urine per se that produces the irritation; it is tolerated unless infected. As the case goes on the calls to micturate become more frequent. A sense of fulness and discomfort in the perineum and rectum are ex perienced after a time, this symptom being aggravated during and after stool, particularly if the bowels be constipated. There may be so much irritation about the parts that the nerves of sexual sensi bility are affected with the production of priapism. Instances of extreme libidinousness in old men are usually associated with hyper trophy of the prostate. In other cases impotence results.
As the case progresses the cystitis becomes more marked, the bas fond increases in depth with a consequent increase in the amount of residual urine, and the obstruction at the neck of the bladder be comes so marked that the organ contains quite a quantity of urine after the patient has apparently emptied it. It is sometimes a mat
ter of surprise to the patient, especially if he consults a surgeon early in the course of the case, to find that it is possible to draw off a large quantity of urine with the catheter when he supposes that he has emptied the bladder completely.
Incontinence of urine, especially at night, is a frequent symptom. It is due to overflow of the distended bladder at a time when the tonicity of the cut-off muscle is interfered with. The normal tonicity of this complex muscle, in combination with the volitional power of the patient, is sufficient to prevent dribbling of urine (excepting after prolonged retention) in the day-time. When, however, the volition is inhibited by sleep, overflow is quite apt to occur. Another cause for apparent incontinence at night is a reflex effort on the part of the bladder to empty itself under the stimulus of inflammation about the vesical neck. A point which has hardly received sufficient atten tion is the fact that when the prostate is uniformly enlarged the neck of the bladder loses its contractility, and is rendered more patulous than usual, although it may be apparently contracted on account of the loss of elasticity. The condition is very much like that which would occur from the substitution of a small but rigid and inelastic tube for a comparatively large, elastic, and contractile one. Attacks of com plete retention eventually occur from time to time; these are usually superinduced by acute congestion of the prostate and vesical neck, incidental to excesses in eating, drinking, sexual indulgence, or to exposure to wet and cold, particularly under circumstances favoring chilling of the lower extremities. The pain and prostration due to re tention are apt to be entirely disproportionate to the amount of urine contained in the bladder; some patients will suffer severely from the retention of a comparatively small quantity of urine, while others will passively permit the bladder to become enormously distended with out sending for aid. The author recalls a case which was quite inter esting as bearing upon this point. This patient was an old gentleman of seventy-five years of age who had suffered for years from enlarge ment of the prostate with occasional attacks of retention. On this occasion, as a consequence of slight exposure, he found himself unable to pass water, the retention being associated with the most severe pain and vesical teuesmus. He was in a condition of extreme prostration as a consequence of his suffering, but stated that he had been able to pass urine four or five hours previously. The catheter showed that the bladder did not contain more than a pint and a half of urine of a comparatively healthy appearance. Cases of this kind are due to acute of the prostate and vesical neck, causing these parts to become extremely hypenesthetic. It is to be remembered in this connection that cases occasionally arise in which the bladder becomes immensely hypertrophied and contracted, so that it will contain but a few drachms of Urine. Such cases, how ever, do not present the clinical features of the case in question, in which the bladder was very tolerant of urine as long as it was evacu ated and the mucous membrane irrigated at proper intervals.