Health and Prostate

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

Diseases of the Prostate Gland

Prostatitis

2. Chronic Prostatitis

Chemotherapy has given a new hope in the treatment of chronic prostatitis, with the introduction of the sulf onamides and mandelic acid. Other useful drugs are salol and methenamine used with acid sodium phosphate. When prostatic pain is very severe, sedatives are often necessary. The barbiturates usually suffice, but occasionally it is necessary to give codeine, pantopon, or morphine. When there is pain in the region of the prostate, or during micturition, the patient should be given a soothing prescription, such as Kirwin’s mixture:

Spices and alcohol should be eliminated from the diet and constipation avoided. When there is marked vesical irritation, a restricted diet should be used, which limits meat, tea and coffee, and eliminates certain foods which are irritating to the bladder, such as asparagus, carrots, tomatoes, berries.

The application of heat to the inflamed prostate has definite therapeutic value. Relief may often be obtained by hot sitz baths, hot rectal irrigations, diathermy, or radiothermy. The Elliott treatment regulator, introduced through the rectum, is an effective method of applying dry heat directly to the prostate and adjacent structures.

Occasionally a prostate becomes so infected that no amount of treatment by these methods will effect a cure. Total prostatectomy is then indicated.

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

Diseases of the Prostate Gland

Prostatitis

2. Chronic Prostatitis

To secure uncontaminated prostatic secretion the patient is first asked to void his urine; the penis and meatus are cleansed with green soap and water; and the anterior urethra irrigated with rivanol dextrose, acriflavine, or other antiseptic solution. The patient kneels on the table and a small endoscopic tube is inserted to a point beyond the external sphincter into the prostatic urethra. He then bends over and rests on his hands or elbows. The prostate is massaged firmly but gently and finally the prostatic urethra emptied by vigorous strokes down the middle depression of the prostate. The uncontaminated prostatic fluid is received in a sterile test-tube which the assistant holds at the end of the endoscope.

Normal prostatic fluid is opalescent and viscid, and microscopically is seen to consist of corpora amylacea, lecithin globules, columnar epithelia, and occasional hyaline globules. In chronic prostatitis, the prostatic secretion is less opalescent than the normal fluid, and the normal elements are replaced by pus cells and degenerated epithelial cells. The degree of infection is measured by the amount of pus in relation to the lecithin. In well-developed chronic prostatitis much of the lecithin content will be replaced by pus cells, often in clumps. As the condition improves, the pus cells diminish and the normal elements reappear. Bacteria may be present in great numbers.

Urethroscopic examination of the posterior urethra is advisable in cases where palpation of the prostate and vesicles, analysis of the voided urine, and microscopic examination of the secretions have proved inconclusive. The marked chronic inflammatory changes that may be revealed by such examination not infrequently are the only clue to a low-grade prostatitis and vesiculitis.

Prognosis. The patient suffering from long-standing prostatitis is not easily cured and it is advisable so to inform him at the outset of treatment. Relief of symptoms by some form of therapy, especially urethral dilatation, massage, rectal heat, and chemotherapy, is possible in most cases; but reversion to a normal prostatic fluid is more difficult to obtain and requires complete removal of infectious foci and restitution of prostatic drainage.

Treatment. In general, treatment consists of dilatation of the prostatic urethra, prostatic massage, urethrovesical irrigations and instillations, heat applied in the form of hot rectal irrigations, hot sitz baths, or diathermy, chemotherapy, and hyperpyrexia and vaccine therapy in selected cases.

The elimination of distant foci of infection, in the tonsils, teeth, sinuses, or colon, is of the greatest importance. In these cases, local measures are useful in relieving the symptoms, but are of little value in cure of the prostatitis, which is dependent upon removal of the primary focus.

The main problem in the treatment of chronic prostatitis is the restitution of free drainage, since retention favors infection. The most effective method of restoring the potency of prostatic and ejaculatory ducts is by a gradual, gentle, but thorough dilatation of the prostatic urethra to its maximal capacity. Urethral dilatation should precede massage of the partially or totally retentive gland since massage is beneficial only when drainage can take place through patent ducts. Active instrumentation is permissible in most cases at the time of the first consultation, the only clinical requirement being a clear first glass of urine. Dilatation is best carried out by means of sounds (passed upon a bladder partly filled with a mild antiseptic solution). Dilatation is carried on two or three times a week until the largest possible sound has been passed on at least three occasions and has remained tight, indicating that the maximal capacity of the urethra has been reached. The voided urine should be examined before each instrumentation, and treatment discontinued whenever the urine becomes cloudy. A mild urethritis may develop when the occluded ducts resume drainage and empty their infectious contents into the urethra. It may then be necessary to employ urinary antiseptics: sulfanilamide, mandelic acid, salol, or methenamine with acid sodium phosphate — their selection depending upon the nature of the infecting organism. Clinical proof of improved drainage can be obtained by a comparison of the amount and composition of the secretion before and after dilatation.

When satisfactory drainage of the diseased prostate has been restored, digital massage may be given once or twice a week upon a bladder partly filled with antiseptic solution. The aims of prostatic massage are: (1) the gentle expression of the accumulated secretion, (2) a stimulation of the contraction of smooth muscle fibers, and (3) the stretching and final removal of marginal adhesions. The technique, as well as the results obtained, vary widely with different operators. The patient may stand with the body bent forward, as over the back of a chair, or be placed in the Sims’ position, or he may rest upon his knees and elbows. The operator, with his gloved index finger in the rectum, exerts gentle pressure upon the lobes palpable from that position, using a downward stroking motion with the force directed toward the urethra, the object being to empty the prostatic acini of their purulent contents and to break up adhesions about the gland. Secretions later may be expressed from the ejaculatory ducts and the sinus pocularis by bringing the firmly pressing finger downward along the posterior urethra. Most patients with chronic prostatitis are benefited by intelligent application of prostatic massage; but too early, too vigorous, too frequent, or unduly prolonged massage may cause acute epididymitis or other unfavorable reactions. The degree of pressure is a matter of experience and is governed largely by the degree of inflammation present. As a rule, massage is carried out twice a week at first — the treatments tapering off, as the condition improves, until the patient is receiving massage once a week, then every ten days, semi-monthly, and finally once a month.

Hyperpyrexia and vaccines, serums, and injections of foreign proteins have a limited usefulness. Hyperpyrexia has been found highly beneficial in certain severe cases of gonorrhea and in the treatment of most gonococcal complications, but it is expensive, very uncomfortable, and attended with considerable risk. We have found vaccines very helpful in certain cases of arthritis where the infective focus was in the prostate, but in other cases their use has resulted in no appreciable benefit. Intraprostatic injections of antiseptic solutions have been recommended for recalcitrant pyogenic prostatitis; our experience has been that the benefits are not sufficient to offset the hazards of this method.

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

Diseases of the Prostate Gland

Prostatitis

2. Chronic Prostatitis

Symptoms. The signs and symptoms of chronic prostatitis vary greatly. The most frequent complaints are of pain, a urethral discharge, which may be profuse or merely the so-called “morning drop,” and some disturbance of sexual function, always accompanied by neurasthenia. The pain may be local or referred. Ordinarily, it is located in the perineum, and may be described by the patient simply as a “heaviness” in the rectum. With this type there is generally a history of the passage of prostatic fluid on defecation. The pain may be referred down the back or inner sides of the legs, or into the groins, penis, or sacrum; or it may simulate that produced by renal or ureteral stone. Frequent and painful urination, urgency, and difficulty are all common complaints, and result largely from involvement of the posterior urethra and bladder neck. If abscess occurs in the course of a chronic prostatitis, which is not uncommon with pyogenic infections, there is increased leukocytosis and pain, chills, and a rise in temperature.

Frequently the predominant symptoms are metastatic, with absence of local symptoms, so that the prostate is not suspected.

Diagnosis. The diagnosis of chronic prostatitis should be based on (1) rectal palpation, (2) repeated analyses of the voided urine, (3) microscopic examination of the prostatic secretion and ejaculate, and (4) urethroscopic examination of the posterior urethra and vesical neck. It is often wise to delay this last procedure until the most distressing symptoms have been allayed by treatment.

Rectal palpation, though of the greatest importance, is not of itself sufficient to establish the diagnosis of chronic prostatitis since, not infrequently, palpation of the chronically inflamed gland may reveal no gross changes, yet pus cells will be found in the prostatic strippings. Many a prostate that feels normal functions poorly and contains large amounts of pus and debris, and many microorganisms.

Often, however, careful rectal palpation will reveal changes in and about the gland. It will be hard and nodulated, and usually adhesions can be felt extending from its lateral borders to the seminal vesicles and adjacent pelvic tissues. Such a prostate is ordinarily, but not always, enlarged, and sometimes there are boggy spots between the areas of induration. Areas of normal gland are usually present.

Microscopic examination of the prostatic fluid, expressed by massage, is the only reliable method of demonstrating the presence of infection in the gland. Often the diagnosis must rest solely on microscopic evidence of pus in the expressed secretions. In treating a case of chronic prostatitis, frequent microscopic examinations of the unstained prostatic fluid should be made, as the conditions present in the gland can be ascertained in this way much more accurately than by palpation. Negative findings on one examination of prostatic secretion are, however, insufficient proof of the absence of prostatitis, since pus in some instances does not make its appearance until after the prostate has been massaged from two to five times. The secretion expressed from the first massage may be from normal portions of the gland, and two or more manipulations may be necessary to open a pathway into the urethra from a closed-off focus of infection. Massage for diagnostic purposes must, of course, be carried out firmly enough to express the secretions, but very gently and cautiously; otherwise, epididymitis may result. The prostatic fluid should be stained at least once to ascertain the presence or absence of bacteria, and their type. Bacteria are more readily identified on smear than in culture, but many of the more chronic cases fail to show bacteria either on smear or in culture.

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

Diseases of the Prostate Gland

Prostatitis

2. Chronic Prostatitis

Chronic inflammation of the prostate gland is a very common condition in adult males. In our series of 350 postmortem studies, a large number of the specimens showed evidence of inflammation of the prostate.

The chronically infected prostate is a common focus of infection, and urologists have repeatedly emphasized the importance of examining the gland and its secretion when searching for the source of obscure infectious conditions. We regard the prostate as second only to infected tonsils as a cause of arthritis. It may also be responsible for endocarditis, neuritis, iritis, and myositis.

Etiology and Bacteriology. Chronic prostatitis may result from any cause which congests the gland, such as long-standing infection, sexual abuse, or instrumental or other trauma. Other possible etiological factors are prostatic calculosis, stricture of the urethra, and certain vitamin deficiencies and endocrine dyscrasias.

Chronic prostatitis is most frequently the sequel to an acute infection, which may be caused by either the gonococcus or other organisms. The incidence of acute prostatitis as a complication of gonorrheal urethritis has been variously estimated at from 50 to 90 per cent; and untreated acute gonorrheal prostatitis, or incompletely treated posterior urethritis, is undoubtedly the most important factor in the production of chronic prostatitis. Only immediately after the acute inflammation has subsided is the gonococcus to be found in the prostatic strippings.

Chronic inflammations are by no means always due to the gonococcus, however. Non-specific infection is common, and may be a direct extension from the urethra; or blood-borne from a focus in the tonsils, teeth, or sinuses; or the aftermath of an acute systemic infection. The most common organisms demonstrated are the colon bacillus and the staphylococcus, streptococcus and their subforms.

Pathology. Microscopically, there are usually to be observed regions of inflammatory reaction in and about the acini, characterized by an increase of the polymorphonuclear cells, lymphocytes, and plasma cells, with marked proliferation of connective tissue. In other cases, the micro-pathological changes consist in circumscribed areas of round cell or polymorphonuclear cell infiltration. Minute abscesses are sometimes observed.

In a large percentage of cases, cystoscopic examination will show pathological changes in the region of the bladder neck, trigone, or posterior urethra. There is usually more or less involvement of the seminal vesicles, which may be soft and atrophic, or enlarged and indurated.