Health and Prostate

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Carcinoma of the Prostate Gland

Carcinoma of the prostate, because of its frequency and its essentially fatal nature, presents the urologist with his most baffling problem. Young’s statistics (1935) reveal that a fifth of the male patients who seek relief of obstruction of the vesical neck have carcinoma of the prostate.

Pathology. A striking morphologic peculiarity of carcinoma of the prostate gland, that has been emphasized by most authors, is the diversity of its forms. In the same case, in different portions, the carcino-matous proliferation may be found at one time as an adenocarcinoma and again as a scirrhous, a medullary, or a squamous-cell carcinoma.

A large percentage of prostatic carcinomas are associated with benign hypertrophy. In only 10 (13 per cent) of the 72 cases studied by Wilson and McGrath was there no evidence of associated hypertrophy.

Chart I

Incidence, By Age-Groups, of Carcinoma in Relation to Benign Enlargement in 280 Cases

In his very complete study of 280 prostates from men between the ages of 31 and 90 years, Robert A. Moore found the occurrence of carcinoma and benign enlargement to be as shown in Chart I. It is evident, therefore, that the possibility of carcinoma must be kept in mind in every case of prostatic hypertrophy.

Numerous careful studies show that in over 75 per cent of cases the carcinoma starts in the posterior lobe (the portion of the gland which does not participate in benign adenomatous hypertrophy).

Prostatic carcinoma is, as a rule, insidious and slow-growing, though highly malignant, and may remain confined to the prostate and periprostatic region for long periods. Only 10 to 20 per cent, according to Barringer, are radiosensitive.

In many cases, by the time the growth has become sufficiently advanced to be clinically diagnosed, it has extended beyond the posterior lobe into the lateral and median lobes and upward to the base of the prostate. There it may penetrate the capsule and involve the seminal vesicles. Through the prostate’s rich supply of lymphatics, the carcinoma may extend to the pelvic nodes, or, by the perirectal plexus, to the abdominal nodes. Dissemination through the blood stream may occur early, and distant metastases, particularly in the bones, are often detected before the occurrence of local symptoms. The small prostatic tumor often disseminates widely. The high frequency of skeletal metastases, and the predilection for the pelvis and lumbar vertebrae, have been noted by practically all observers.

Symptoms. The symptoms are not characteristic. Disturbances of urination are usually the first symptoms, but advanced carcinoma may be present without urinary symptoms. Pain — referred to the sacroiliac region, rectum, perineum, or suprapubic area — is often an early symptom, and may be due to metastases to the bones. Terminal hematuria, retention, loss of weight and strength, and constipation are significant, but late, symptoms.

Diagnosis. Carcinoma of the prostate has, unfortunately, usually existed for a long period by the time it is recognized. The diagnosis is based upon the findings of rectal palpation and microscopic examination of a biopsy specimen removed by means of an instrument, such as the Lowsley biopsy instrument. In well-advanced cases recognition is usually not difficult; but in early cases, in the soft (medullary) type of carcinoma, and in carcinoma superimposed upon a benign hypertrophy, diagnosis may be difficult. A single, small nodule may easily escape notice, especially when masked by edematous prostatic tissue or in the absence of symptoms. The entire gland may be irregularly enlarged, of a board-like hardness, and fixed; but usually the growth is in the form of a nodule or hardened area in the posterior lobe, where it is readily palpable by rectum. Evidence of the fixed gland may be seen on cystourethroscopic examination.

Prognosis and Treatment. The prognosis in the past has been cheerless in the extreme. Over 95 per cent of the cases are beyond cure when first seen. The high early incidence of pelvic lymphadenopathy, capsular infiltration and invasion of the contiguous structures, and skeletal metastases precludes the successful surgical treatment of the disease in most cases.

In cases in which the carcinoma is confined to the prostate and periprostatic region, total or subtotal perineal prostatectomy yields a fair percentage of cures estimated upon a 3 to 5 years’ basis, and prolongations of life for considerably longer periods are not uncommon. If seen too late for hope of radical removal, partial perineal prostatectomy, or transurethral resection of the obstruction, with implantation of radon seeds, is the method of choice.

Improvement in prognosis is dependent on an increase in the number of early diagnoses, with radical removal.

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Sarcoma of the Prostate

Sarcoma of the prostate is relatively rare, and may occur at any age. A review of the literature by Lowsley and Kimball, in 1934, disclosed only 132 reported cases, 35 of which occurred in patients under 22 years of age. These tumors usually grow rapidly and attain large size, early infiltrating the bladder, seminal vesicles, and rectum. Growth of the tumor backward beneath the base of the bladder pushes the latter upward and forward, causing obstruction of the ureteral orifices, urethral orifice, and urethra, with resultant partial or complete retention. Growth of the tumor toward the perineum causes prolapse of the rectum, with obstruction to defecation and urination.

Diagnosis. Early diagnosis is essential. In early cases rectal examination may be negative, but usually reveals a palpable nodule. Occasionally the growth may be indurated and nodular, but usually it is of uniform consistency and has an elastic “balloon-like” feel; hence the condition may be erroneously diagnosed as abscess. The diagnosis can positively be made by needle biopsy.

Prognosis and Treatment. The prognosis is poor. The most favorable results have been achieved through the use of radium and Roentgen rays. In early cases, the skilled use of these agents may prove curative, and in late cases they may give relief and prolong life. Operative intervention should be limited to the relief of obstruction and the treatment of complications.

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Prostatic Calculus

Incidence and Etiology. Prostatic calculi are relatively common. In an autopsical study of 250 prostates from subjects of all ages, I found one or more stones in approximately one-fifth of the glands.

Prostatic calculosis may occur at any period of life, but is rare before the age of 30 years. Of the twenty-three patients reported on by Lowsley and Hawes, only one was under 40 years of age.

Distinction must be made between (1) endogenous, or true prostatic calculi, namely, concretions formed within the prostatic substance, and (2) exogenous, or false calculi, which are urinary stones that have lodged in the prostatic urethra or have formed primarily from urinary sediments in a communicating pouch. The nucleus of a true prostatic stone is composed of organic material of an albuminoid nature: corpora amylacea, a blood clot, epithelial detritus, a clump of bacteria, or necrotic tissue from an abscess. The inorganic element forming the laminated layers about the nucleus is composed of inorganic salts.

The exact etiology of true prostatic stones is unknown. The most commonly held theory is that first advanced by Thompson in 1868, namely, that they have their origin in corpora amylacea, which, under certain conditions, act as foreign bodies and set up an inflammatory reaction in the mucous membrane of the acini enclosing them, as a result of which calcium phosphates and carbonates are cast off; these impregnate the corpora amylacea and convert them into calculi.

Pathology. True prostatic calculi are usually multiple, small, rounded (without facets), and scattered indiscriminately throughout the parenchyma. Occasionally a cluster of stones will be found in one lobe while the remaining lobes are free of calculi. Sometimes there will be a single large stone, or one large stone in association with numerous smaller ones.

Microscopically, the portion of the gland containing the calculi shows distended acini, the mucosal linings of which are infiltrated by lymphocytes or by polymorphonuclear leukocytes.

Benign adenomatous hypertrophy and prostatic calculosis not infrequently occur together (18 of 23 cases, Lowsley and Hawes). The calculi are seldom, if ever, located within the adenoma, but are found between it and the capsule, embedded in the remnants of the true prostate. Frequently, however, calculi-containing prostates show no sign of hypertrophy. They may be senile and fibrotic, with atrophy of the parenchyma and evidence of inflammation.

Symptoms and Diagnosis. The most important symptoms are disturbances of urination, the actual passage of calculi either spontaneously or following massage, and localized or referred pain — in the perineum, suprapubic region, rectum, or down the penile shaft. In many cases the symptoms are overshadowed by those of an associated hypertrophy or prostatitis. In others, no symptoms are present, and the stones are discovered accidentally.

It .is frequently possible to make a presumptive diagnosis of prostatic calculi by the rectal palpation of a hard, circumscribed area suggestive of stone or a nodule, or by the eliciting of crepitation. Urethroscopic examination may reveal the presence of stones in the prostatic ducts. Positive diagnosis is made by roentgenography. Cysto-urethrograms are of value not only in revealing the calculi, but in determining the type and degree of obstruction to urination, and associated pathology, if present.

Treatment. Small calculi, that are discovered accidentally and give no subjective symptoms, are best left alone. In older men, who have neared the end of sexual life, we prefer to treat prostatic calculosis by total prostatectomy, both when there is associated adenomatous hypertrophy and when there is no hypertrophy but infection and fibrosis are present. Prostatotomy, transurethral resection, and even the usual conservative perineal or suprapubic prostatectomy often leave enough calculi or infected prostate to cause persistence or recurrence of symptoms, as has been repeatedly demonstrated by postoperative roentgenograms. Younger men with numerous stones in their prostates should be treated by prostatectomy as a rule. Transurethral resection is also frequently employed, but has the disadvantage that stones are often left behind in the prostate.

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Tuberculosis of the Prostate Gland

Etiology and Incidence. Tuberculosis of the prostate is a disease of the young adult and, as a rule, is observed in those in the third and fourth decades of life. It is almost always a secondary involvement in a progressive tuberculosis which is extending throughout the urogenital system. In most instances it is probably an extension from the seminal vesicles. Between 50 and 70 per cent of all cases of tuberculosis of the male genital tract show involvement of the prostate.

Pathology. At first the prostatic lesion may be confined to the region about the ejaculatory duct on the side corresponding to the infected vesicle, whence it spreads, by way of the acini or the lymphatics, to other parts of the gland. In the rare cases in which the prostate is infected by tubercle bacilli conveyed in the urine, the initial lesion is periurethral.

The first pathological change is the formation of tubercles. The tubercle bacilli are apparently first deposited in the walls of the small capillaries. Other tubercles develop from these original foci and extend in the usual manner. Later stages are fibrosis, caseation, and suppuration. Suppuration may result in rupture of an abscess through the prostatic capsule, with the formation of an intractable perineal fistula; or there may be rupture into the urethra. Spontaneous healing is rare. Small caseous areas may become encapsulated and latent, or they may undergo calcification and encapsulation.

Symptoms and Diagnosis. With well-walled-off tubercles, there may be no untoward symptoms whatsoever. If the tubercles have coalesced and finally ruptured into the urethra, there will be frequency, dysuria, hematuria, and pyuria.

Rectal examination reveals a nodular, elastic gland, usually affected on one side only, and differing from a carcinomatous condition in that it lacks the board-like consistency usually associated with the latter. The secretion may show tubercle bacilli. Differential diagnosis is based chiefly on microscopic study of a specimen of diseased tissue.

Treatment. The hygienic, dietary, and therapeutic measures advocated for postoperative and inoperable tuberculosis of the urogenital tract are usually prescribed, and good results have been obtained by us therefrom in some cases. When calcium deposits are present, total prostatectomy is indicated. On the other hand, in acute and subacute tuberculosis of the prostate, operation is distinctly contraindicated. Even in the presence of abscess, it is preferable to allow it to absorb or rupture into the urethra rather than to evacuate it through the perineum, as this is likely to result in a persistent fistula. Radical removal of the genital tract is inadvisable in patients with extensive involvement of the prostate gland.

Cysts of the Prostate Gland

Cysts of the prostate gland are decidedly rare. They may be either congenital or acquired. The most common is the simple retention cyst, which may arise in any portion of the gland and is merely a normal acinus the duct of which has become occluded, causing expansion of the acinus.

Treatment. Smaller retention cysts, producing no symptoms, are best left alone. When treatment is necessary, destruction of the cyst by fulguration, or removal by prostatic resection instruments, is the treatment of choice.

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Syphilis of the Prostate Gland

Syphilis of the prostate appears to be exceedingly rare. We have personally never encountered a case, and very few have been reported in the literature.

Symptoms and Diagnosis. There is nothing pathognomonic either in the symptoms or the rectal findings. The chief symptom is perineal pain, usually aggravated by urination. Less common are hematuria, pain on defecation or coitus, urinary disturbances, and retention. Prostatic massage usually produces a more or less characteristic discharge. On rectal palpation the prostate will be found markedly irregular, enlarged, and sometimes nodular. The Wassermann test is usually positive.

Prostatic syphilis is a late manifestation of lues, and occurs, usually, between the ages of 40 and 65 years, when it may be very difficult to differentiate it from hypertrophy of the prostate and carcinoma.

Prognosis and Treatment. If diagnosed early, the disease responds readily to antiluetic treatment; if unrecognized, the prostate may be destroyed by gummas.

Treatment consists of the usual antiluetic measures, reinforced by surgical drainage of necrotic gummas.

The Department of Urology of the New York Hospital
(Given January 31, 1941)

Diseases of the Prostate Gland

Prostatic Abscess

Etiology. Abscess of the prostate gland may follow failure of an acute diffuse parenchymatous prostatitis to subside or to become chronic. Multiple small abscesses in the stroma coalesce to form one large abscess. A frequent cause is the gonococcus, but our own studies have shown that many other organisms may be present in abscess cavities in the prostate. Prostatic abscess may result from improper instrumentation; or occur as a complication of systemic infection; or be secondary to superficial pyogenic infections, such as carbuncles, boils, and felons. In the last event, the causative organism is the Staphylococcus aureus.

Symptoms and Diagnosis. The symptoms are pain in the perineum, chills, fever, and frequent and painful urination which may progress to complete retention. Leukocytosis is present. Chronic abscess may persist for weeks without producing local symptoms. There are occasional cases of huge prostatic abscesses in which the only symptom is difficulty of urination; this is due to the type and lack of toxicity of the infecting organism.

The diagnosis usually is not difficult. By rectum, the prostate is felt to be enlarged, hot, tender, and often asymmetrical. The presence of fluctuation is conclusive. If no fluctuation is detected, a needle may be inserted into the suspected area and pus withdrawn, if present. If neither fluctuation nor pus is noted, a cystourethrogram may be helpful.

Prognosis and Treatment. An untreated prostatic abscess may rupture into the urethra or rectum, or burrow into the perineum, bladder, or even the peritoneum, with dire results. Abscesses which empty their entire contents into the urethra are likely to be of the follicular type, or at least not deeply seated in the parenchyma. Spontaneous evacuation through the rectal wall is a surgical calamity.

If proper drainage is instituted, convalescence is usually satisfactory, although every case must be followed by a period of observation and treatment to insure a normal gland.

Evacuation of a prostatic abscess through the posterior urethra is the method of choice. A perineal section is done, the finger introduced into the prostatic urethra, and the honey-combed interior cleaned out so that no pockets remain. A tube is then introduced into the bladder, diverting the urine and conducting the pus out through the perineal wound.

Evacuation may also be accomplished from outside the urethra. The posterior surface of the prostate is exposed as in a Young perineal prostatectomy, the abscess incised, and a tube inserted into it and fixed in position. The transvesical route is occasionally employed, but our own experience with it has not been encouraging.