From a clinical standpoint, there would seem to be a broad line of distinction between the acute cases of follicular inflammation from extension of infection from the prostatic urethra and cases in which, as a result of lymphatic absorption or of infection of an abraded surface produced by traumatism, prostatic or peri-prostatic abscess occurs. On the one hand, we have a case presenting primarily all of those symptoms characteristic of irritation and inflammation of the true vesical neck, i.e., the prostatic urethra; while, on the other hand, we have a much less degree of vesical irritability with the de velopment of more or less sudden obstruction to the outflow of urine. In acute follicular inflammation retention of urine rarely results, ex cepting in cases in which there is a high degree of interstitial inflam mation. So frequent, however, is the association of retention with the occurrence of prostatic abscess that the latter is to be strongly suspected in cases of acute prostatitis in which retention of urine is a prominent factor.
In the diffuse form of the disease there is usually, as a result of extension of 'the infectious process from the prostatic urethra, a very severe degree of glandular inflammation. Associated with this is a well-pronounced involvement of the interstitial tissue. In these cases, on account of the anatomical conditions already outlined, the local pain and the constitutional symptoms are much more marked than in the acute follicular form. The diffuse form may be the re sult of lymphatic absorption, in which pain, rectal tenesmus, and urinary obstruction may develop without any preceding vesical irri tability. Abscesses may or may not occur in the diffuse variety of acute prostatitis. When they do occur they may be the result of a general infection of the organ, or an occluded duct or follicle may constitute the primary focus of infection which subsequently ruptures and infects the surrounding tissues of the prostate.
Acute suppurative prostatitis, as already outlined in the preceding classification, may occur in one of three forms : 1. Circumscribed abscess, single or multiple. These abscesses may involve any par ticular portion of the tissue of the prostate; may be of considerable size, and one or more may coalesce, forming a large abscess cavity.
2. Disseminated suppuration in - the form of miliary abscesses.
3. Abscess of the peri-prostatic tissue with or without suppuration in the prostate proper. While usually due to local sources of infec tion, any of these forms of abscess may occur as a result of general pyogenic infection, and, as shown in the table of Segond, may result from such infectious diseases as variola and mumps. Some cases of abscess are primarily due to extension of suppurative inflammation, while others are due to lymphatic absorption and infection of the tissues of the prostate. In some instances, in all probability, one or more of the numerous ducts of the prostate become occluded by the inflammatory swelling incidental to virulent inflammation, with the consequent retention of infectious pus in the form of a small abscess cavity, the walls of which are composed of the walls of the duct or the follicle involved. Such circumscribed retention ab scesses constitute foci of infection of the surrounding tissues, and when they form at the periphery of the organ they may rupture into the para-prostatic tissue with the resulting formation of an abscess in this 'situation.
Disseminated foci of suppuration in the prostate constitute the variety which is most likely to occur from constitutional infection. The rupture of a small abscess, however small, into the peri-pros tatic tissue will almost inevitably result in an abscess in this situa tion.
It is unnecessary to expatiate upon para-prostatitis, inasmuch as the most important points have already been set forth. It is sufficient to say that it most usually occurs as a secondary factor in one or the other of the foregoing forms of acute inflammation. Sup puration usually occurs, and in some cases its extent may be rather startling, the pus burrowing extensively about the rectum. Reten tion of urine is a usual concomitant of marked cases.
Prostatic Abscess.—The subject of acute prostatic abscess hardly requires consideration independently of acute prostatitis. There are several points, however, in connection with suppuration of the pros tate that merit special attention. Abscess of the prostate in the course of hypertrophy of the organ is much more frequent than is ordinarily supposed. It may occur spontaneously as a result of in
fection, although this is extremely rare. Most often it occurs as the direct result of traumatism inflicted during the treatment of the dis ease, or during the passage of the catheter for the relief of retention dependent upon it. It is the opinion of the author that in quite a proportion of cases in which a fatal result follows retention of urine from hypertrophied prostate necessitating prolonged and frequent instrumentation for its relief, the immediate cause of death is general septic or pus infection incidental to suppuration of the pros tate induced by the surgical interference. Several cases have come under the observation of the author in which the patient developed the constitutional manifestations of sepsis and finally sank into a typhoid condition and died, as a consequence of extensive prostatic and peri-prostatic abscess, which was directly traceable to bungling and injudicious attempts at catheterization. In some of these cases the resulting abscess is of a subacute or chronic character and is of prolonged duration. Rupture may finally occur into the urethra, rarely externally, in which event sudden relief of the obstructive symptoms may result. It is a noteworthy fact that some cases of prostatic abscess occurring in the course of enlarged prostate are ultimately followed by great benefit to the primary condition. The destruction of the prostatic tissue incidental to the abscess formation is followed by cicatricial contraction and a marked diminution of the mechanical obstruction incidental to the enlargement of the organ. In some instances, however, the abscess cavity not only does not be come obliterated, but remains as a suppurating pocket, opening more or less freely into the lumen of the urethra and giving rise to succes sive re-infections of the posterior urethra and bladder, or even infec tion of the anterior portion of the canal. This is true of all forms of prostatic abscess. In abscess occurring in prostatic hypertrophy it is interesting to note the marked diminution in the size of that por tion of the prostate which happens to be the seat of suppuration. In a case which the writer has recently seen an abscess in the right lobe of the prostate, in a gentleman of middle age suffering with prostatic hypertrophy, has produced so much shrinkage of the affected struc ture that it is hardly, if at all, larger than the normal, while the op posite side is still markedly hypertrophied and indurated.
The occasional occurrence of prostatic abscess in prostatiques constitutes a very practical point in the study of prostatic hyper trophy. It is by no means unusual for the first severe symptoms of prostatic obstruction in old men to occur coincidentally with the for mation of the prostatic abscess. Inasmuch as after evacuation of the abscess the symptoms practically disappear, an erroneous diag nosis is quite easily made, the case being considered as ab initio one of prostatic suppuration.
That a fatal result may follow prostatic abscess not only in old but in young subjects must be borne in mind. A case recently came un der my observation in which a young man, thirty-five years of age, was permitted to die of what was supposed to be typhoid fever, but which, as the autopsy showed, was sepsis due to a large prostatic absces. It is well in all cases of serious prostatic disease, to keep a close watch for the constitutional symptoms of suppuration. Free incision and drainage would in all probability have saved the life of the patient to whom allusion has been made. In all cases of acute prostatic inflammation it is the duty of the surgeon to be on the alert for symptoms of suppuration. Oftentimes, however, a diag nosis can only be made after the discharge of the contained pus into the urethra, bladder, or rectum.
Healing of prostatic abscess after such evacuation is often quite • prompt, but in many cases the admixture of urine with the contents of the abscess causes serious trouble by subsequent decomposition and septic absorption.
Ano-rectal fistula may result in cases in which the abscess opens or is evacuated by the knife through the rectum. Urinary fistula communicating with the rectum or with the ano-rectal fistula may also develop. Urinary fistula following evacuation of the pus through the perineum is not infrequent.