If the urine becomes infected, the symptoms become very marked. The frequency of urination may be every two hours, every hour, or even three or four times within an hour. There may or may not be hypogastric pain, depending upon the degree of cystitis present. and the act of urination is apt to be attended with vesical tenesmus. In rare cases in which there is moderate enlargement of the prostate, but in which the symptoms may have been so mild as to escape ob servation. after the patient has gone an unusually long time without passing water, he may find himself unable to do so, and resort to the catheter will be necessary. This retention may be the first evidence which the patient has had that the prostate is affected.
The amount of pain varies in different cases. In the milder forms of the affec tion it is usually entirely absent. In more pronounced types of the disease the patient will complain of indefinite pains in the hypogastrium, the groins, or small of the back, and a sense of fullness in the perineum or rectum. In the later stages more or less severe pain will be present either as a result of a distended bladder or of cystitis. There may be a soreness or smarting of the urethra and shooting pains in the glans, similar to those felt in cases of stone in the bladder. In the cases accompanied with severe cystitis in which there are frequent and violent efforts made to pass water the tenesmus which is present may result in the production of hemorrhoids or of pro lapsus ani. In the later stages of the affection the urine is very apt to contain blood, sometimes in microscopical quan tity only, while in other cases the amount of bleeding is very great. As long as the bladder remains uninfected there are no characteristic changes in the condi tion of the urine. In the presence of infection the usual evidences of cystitis will be observed. The enlarged pros tate sometimes causes a marked erethism or even priapism. The presence of re sidual urine and the ammoniacal decom position which is apt to result predis pose to the formation of phosphatic cal culi, and it is a matter of common ex perience that patients suffering from enlargement of the prostate frequently have a stone in the bladder.
Diagnosis.—The diagnosis of enlarge ment of the prostate is, as a rule, at tended with little or no difficulty.
Among the conditions which may give rise to symptoms more or less similar are stricture of the urethra, prostatitis, cys titis, vesical calculus, and the various tumors which are met with in the blad der. Stricture of the urethra will be
eliminated if a full-sized urethral instru ment can be passed without meeting an obstruction. Prostatitis, if acute, would be most apt to follow urethritis. and would be accompanied by fever and much more marked local tenderness than will be observed in the case of senile hypertrophy. The chronic form usually occurs in earlier life, and is accompanied by the characteristic symptoms given under the discussion of chronic prosta titis. Vesical calculi, if present, would be detected by the use of a vesical sound. •\esical tumors are rare; they would be suspected after excluding stone and en larged prostate. The eystoscope may as sist in arriving at a positive conclusion. The final test for enlargement of the prostate is digital examination, through the rectum, by which means we are able to detect the presence or absence of any increase in size. The patient should also be examined invariably for residual urine, by passing a catheter immediately after he has emptied his bladder as com pletely as possible. The length of the _urethra is increased in hypertrophy of the prostate in some cases to the extent of one and one-half to two inches, which fact should be borne in mind in passing the catheter. In some cases the use of the cystoscope may be of material assist ance in reaching a diagnosis.
In examining patients for enlargement of the prostate it is essential to keep to a routine position, such as bending over a chair with the body at right angles to the legs, because the form, position, and consistency of the gland alters greatly with the position of the patient. In tu berculosis deposits should be detected in the testicle, epididymis, prostate, or blad der, in about SO per cent. of the cases. These tuberculous deposits are noted in three clinical conditions: In young males who notice a lump in one epididymis or the other, in young males who complain of symptoms of vesical stone, or in adults who complain of symptoms of vesical stone.
It is possible for prostatic deposits to become absorbed, but this absorbing often changes materially the size and shape of the organ. When the deposits do become absorbed in one part, almost always there is invasion of another por tion, possibly beyond the reach of the ex amining finger. E. Hurry Fenwick (Brit. Med. Jour., Feb. IS, '99).