Deformities Of The Prostate Distortions And Obstructions Of The Prostatic Urethra

Sources: Surgical Anatomy

The prostate is liable to such frequent and varied deformities, the

consequence of diseased action, whilst, at the same time, its healthy

function (if it have any) in the male body is unknown, that it admits at

least of one interpretation which may, according to fact, be given of

it--namely, that of playing a principal part in effecting some of the

most distressing of "the thousand natural ills that flesh is heir to."

ut heedless of such a singular explanation of a final cause, the

practical surgeon will readily confess the fitting application of the

interpretation, such as it is, and rest contented with the proximate

facts and proofs. As physiologists, however, it behooves us to look

further into nature, and search for the ultimate fact in her prime

moving law. The prostate is peculiar to the male body, the uterus to the

female. With the exception of these two organs there is not another

which appears in the one sex but has its analogue in the opposite sex;

and thus these two organs, the prostate and the uterus, appear by

exclusion of the rest to approach the test of comparison, by which their

analogy becomes as fully manifested as that between the two quantities,

a-b, and a+b the only difference which exists depends upon the

subtraction or the addition of the quantity, b. The difference between a

prostate and a uterus is simply one of quantity, such as we see existing

between the male and the female breast. The prostate is to the uterus

absolutely what a rudimentary organ is to its fully developed analogue.

The one, as being superfluous, is in accordance with nature's law of

nihil supervacaneum nihil frutra, arrested in its development, and in

such a character appears the prostate. This body is not a gland any more

than is the uterus, but both organs being quantitatively, and hence

functionally different, I here once more venture to call down an

interpretation of the part from the unfrequented bourne of comparative

anatomy, and turning it to lend an interest to the accompanying figures

even with a surgical bearing, I remark that the prostatic or rudimentary

uterus, like a germ not wholly blighted, is prone to an occasional

sprouting or increase beyond its prescribed dimensions--a hypertrophy in

barren imitation, as it were, of gestation. [Footnote]





[Footnote: This expression of the fact to which I allude will not, I

trust, be extended beyond the limits I assign to it. Though I have every

reason to believe, that between the prostate of the male and the uterus

of the female, the same amount of analogy exists, as between a coccygeal

ossicle and the complete vertebral form elsewhere situated in the spinal

series, I am as far from regarding the two former to be in all respects

structurally or functionally alike, as I am from entertaining the like

idea in respect to the two latter. But still I maintain that between a

prostate and a uterus, as between a coccygeal bone and a vertebra, the

only difference which exists is one of quantity, and that hence arises

the functional difference. A prostate is part of a uterus, just as a

coccygeal bone is part (the centrum) of a vertebra. That this is the

absolute signification of the prostate I firmly believe, and were this

the proper place, I could prove it in detail, by the infallible rule of

analogical reasoning. John Hunter has observed that the use of the

prostate was not sufficiently known to enable us to form a judgment of

the bad consequences of its diseased state. When the part becomes

morbidly enlarged, it acts as a mechanical impediment to the passage of

urine from the bladder, but from this circumstance we cannot reasonably

infer, that while of its normal healthy proportions, its special

function is to facilitate the egress of the urine, for the female

bladder, though wholly devoid of the prostate, performs its own function

perfectly. It appears to me, therefore, that the real question should

be, not what is the use of the prostate? but has it any proper function?

If the former question puzzled even the philosophy of Hunter, it was

because the latter question must be answered in the negative. The

prostate has no function proper to itself per se. It is a thing distinct

from the urinary apparatus, and distinct likewise from the generative

organs. It may be hypertrophied or atrophied, or changed in texture, or

wholly destroyed by abscess, and yet neither of the functions of these

two systems of organs will be impaired, if the part while diseased act

not as an obstruction to them. In texture the prostate is similar to an

unimpregnated uterus. In form it is, like the uterus, symmetrical. In

position it corresponds to the uterus. The prostate has no ducts proper

to itself. Those ducts which are said to belong to it (prostatic ducts)

are merely mucous cells, similar to those in other parts of the urethral

lining membrane. The seminal ducts evidently do not belong to it. The

texture of the prostate is not such as appears in glandular bodies

generally. In short, the facts which prove what it is not, prove what it

actually is--namely, a uterus arrested in its development, and as a sign

of that all-encompassing law in nature, which science expresses by the

term "unity in variety." This interpretation of the prostate, which I

believe to be true to nature, will last perhaps till such time as the

microscopists shall discover in its "secretion" some species of

mannikins, such as may pair with those which they term spermatozoa.]



Fig. 1, Plate 61.--The prostate, a b, is here represented thinned in its

walls above and below. The lower wall is dilated into a pouch caused by

the points of misdirected instruments in catheterism having been rashly

forced against it.














Fig. 2, Plate 61.--The prostate, a b, is here seen to be somewhat more

enlarged than is natural. A tubercle, b, surmounts the lower part, c, of

the prostate, and blocks up the vesical orifice. Catheters introduced by

the urethra for retention of urine which existed in this case, have had

their points arrested at the bulb, and on being pushed forwards in this

direction, have dilated the bulb into the form of a pouch, seen at d.

The sinus of the bulb, being the lowest part of the urethral canal, is

very liable to be distorted or perforated by the points of instruments

descending upon it from above and before. [Footnote]



[Footnote: When a stricture exists immediately behind the bulb, this

circumstance will, of course, favour the occurrence of the accident.

"False passages (observes Mr. Benjamin Phillips) are less frequent here

(in the membranous part of the urethra) than in the bulbous portion of

the canal. The reason of this must be immediately evident: false

passages are ordinarily made in consequence of the difficulty

experienced in the endeavour to pass an instrument through the

strictured portion of the tube. Stricture is most frequently seated at

the point of junction between the bulbous and membranous portions of the

canal; consequently, the false passage will be usually anterior to this

latter point."--(On the Urethra, its Diseases. &c., p. 15.) ]














Fig. 3, Plate 61.--A cyst, c, is seen to grow from the left side of the

base of the prostate, a b, and to form an obstruction at the vesical

orifice.












Fig. 4, Plate 61.--A globular excrescence, a, appears blocking up the

vesical orifice, and giving to this the appearance of a crescentic slit,

corresponding to the shape of the obstructing body. The prostate, b b,

is enlarged in both its lateral lobes. A small bougie, c, is placed in

the prostatic canal and vesical opening.














Fig. 5, Plate 61.--The prostate, d, is considerably enlarged, and the

vesical orifice is girt by a prominent ring, b b, from the right border

of which the nipple-shaped body, a, projects and occupies the outlet.

Owing to the retention of urine caused by this state of the prostate,

the ureters, c c, have become very much dilated.














Fig. 6, Plate 61.--The lateral lobes of the prostate, c c, are seen

enlarged, and from the inner side and base of each, irregularly shaped

masses, a, b, d, project, and bend the prostatic urethra first to the

right side, then to the left. The part, a, resting upon the part, b,

acts like a valve against the vesical outlet, which would become closed

the tighter according to the degree of superincumbent pressure. A

flexible catheter would, in such a case as this, be more likely,

perhaps, to follow the sinuous course of the prostatic passage than a

rigid instrument of metal.












Fig. 7, Plate 61.--A globular mass, a, of large size, occupies the neck

of the bladder, and gives the vesical orifice, c, a crescentic shape,

convex towards the right side. The two lobes of the prostate, b, are

much enlarged.










Fig. 8, Plate 61.--The lateral lobes, b b, of the prostate are

irregularly enlarged, and the urinary passage is bent towards the right

side, c, from the membranous portion, which is central. Surmounting the

vesical orifice, c, is seen the tuberculated mass, a, which being

moveable, can be forced against the vesical orifice and thus produce

complete retention of urine. In this case, also, a flexible catheter

would be more suitable than a metallic one.














Fig. 9, Plate 61.--The lateral lobes, b b, of the prostate are enlarged.

The third lobe, a, projects at the neck of the bladder, distorting the

vesical outlet. A small calculus occupies the prostatic urethra, and

being closely impacted in this part of the canal, would arrest the

progress of a catheter, and probably lead to the supposition that the

instrument grated against a stone in the interior of the bladder, in

which case it would be inferred that since the urine did not flow

through the catheter no retention existed.



















Fig. 10, Plate 61.--Both lateral lobes, b c, of the prostate appear much

increased in size. A large irregular shaped mass, a, grows from the base

of the right lobe, and distorts the prostatic canal and vesical orifice.

When the lobes of the prostate increase in size in this direction, the

prostatic canal becomes much more elongated than natural, and hence the

instrument which is to be passed for relieving the existing retention of

urine should have a wide and long curve to correspond with the form of

this part of the urethra. [Footnote]



[Footnote: Both lobes of the prostate are equally liable to chronic

enlargement. Home believed the left lobe to be oftener increased in size

than the right. Wilson (on the Male Urinary and Genital Organs) mentions

several instances of the enlargement of the right lobe. No reason can be

assigned why one lobe should be more prone to hypertrophy than the

other, even supposing it to be matter of fact, which it is not. But the

observations made by Cruveilhier (Anat. Pathol.), that the lobulated

projections of the prostate always take place internally at its vesical

aspect, is as true as the manner in which he accounts for the fact is

plausible. The dense fibrous envelope of the prostate is sufficient to

repress its irregular growth externally.]








Fig. 11, Plate 61.--Both lobes of the prostate are enlarged, and from

the base of each a mass projects prominently around the vesical orifice,

a b. The prostatic urethra has been moulded to the shape of the

instrument, which was retained in it for a considerable time.












Fig. 12, Plate 61.--The prostate, c b, is enlarged and dilated, like a

sac. Across the neck, a, of the bladder the prostate projects in an

arched form, and is transfixed by the instrument, d. The prostate may

assume this appearance, as well from instruments having been forced

against it, as from an abscess cavity formed in its substance having

received, from time to time, a certain amount of the urine, and retained

this fluid under the pressure of strong efforts, made to void the

bladder while the vesical orifice was closed above.














Fig. 13, Plate 61.--The lateral lobes, d e, of the prostate are

enlarged; and, occupying the position of the third lobe, appear as three

masses, a b c, plicated upon each other, and directed towards the

vesical orifice, which they close like valves. The prostatic urethra

branches upwards into three canals, formed by the relative position of

the parts, e, c, b, a, d, at the neck of the bladder. The ureters are

dilated, in consequence of the regurgitation of the contents of the

bladder during the retention which existed ..














Fig. 1, Plate 62, exhibits the lobes of the prostate greatly increased

in size. The part, a b, girds irregularly, and obstructs the vesical

outlet, while the lateral lobes, c d, encroach upon the space of the

prostatic canal. The walls of the bladder are much thickened.














Fig. 2, Plate 62.--The three lobes, a, d, c, of the prostate are

enlarged and of equal size, moulded against each other in such a way

that the prostatic canal and vesical orifice appear as mere clefts

between them. The three lobes are encrusted on their vesical surfaces

with a thick calcareous deposit. The surface of the third lobe, a, which

has been half denuded of the calcareous crust, b, in order to show its

real character, appeared at first to be a stone impacted in the neck of

the bladder, and of such a nature it certainly would seem to the touch,

on striking it with the point of a sound or other instrument.












Fig. 3, Plate 62, represents the prostate with its three lobes enlarged,

and the prostatic canal and vesical orifice narrowed. The walls of the

bladder are thickened, fasciculated, and sacculated; the two former

appearances being caused by a hypertrophy of the vesical fibres, while

the latter is in general owing to a protrusion of the mucous membrane

between the fasciculi.



Fig. 4, Plate 62.--The prostate presents four lobes, a, b, c, d, each

being of large size, and projecting far into the interior of the

bladder, from around the vesical orifice which they obstruct. The

bladder is thickened, and the prostatic canal is elongated. The urethra

and the lobes of the prostate have been perforated by instruments,

passed for the retention of urine which existed. A stricturing band, e,

is seen to cross the membranous part of the canal.



















Fig. 5, Plate 62.--The prostate, a a, is greatly enlarged, and projects

high in the bladder, the walls of the latter, b b, being very much

thickened. The ureters, c, are dilated, and perforations made by

instruments are seen in the prostate. The prostatic canal being directed

almost vertically, and the neck of the bladder being raised nearly as

high as the upper border of the pubic symphysis, it must appear that if

a stone rest in the bas fond of the bladder, a sound or staff cannot

reach the stone, unless by perforating the prostate; and if, while the

staff occupies this position, lithotomy be performed, the incisions will

not be required to be made of a greater depth than if the prostate were

of its ordinary proportions. On the contrary, if the staff happen to

have surmounted the prostate, the incision, in order to divide the whole

vertical thickness of this body, will require to be made very deeply

from the perinaeal surface, and this circumstance occasions what is

termed a "deep perinaeum."












Fig. 6, Plate 62.--The lower half, c, b, f, of the prostate, having

become the seat of abscess, appears hollowed out in the form of a sac.

This sac is separated from the bladder by a horizontal septum, e e, the

proper base of the bladder, g g. The prostatic urethra, between a e, has

become vertical in respect to the membranous part of the canal, in

consequence of the upward pressure of the abscess. The sac opens into

the urethra, near the apex of the prostate, at the point c; and a

catheter passed along the urethra has entered the orifice of the sac,

the interior of which the instrument traverses, and the posterior wall

of which it perforates. The bladder contains a large calculus, i. The

bladder and sac do not communicate, but the urethra is a canal common to

both. In a case of this sort it becomes evident that, although symptoms

may strongly indicate either a retention of urine, or the presence of a

stone in the bladder, any instrument taking the position and direction

of d d, cannot relieve the one or detect the other; and such is the

direction in which the instrument must of necessity pass, while the sac

presents its orifice more in a line with the membranous part of the

urethra than the neck of the bladder is. The sac will intervene between

the rectum and the bladder; and on examination of the parts through the

bowel, an instrument in the sac will readily be mistaken for being in

the bladder, while neither a calculus in the bladder, nor this organ in

a state of even extreme distention, can be detected by the touch any

more than by the sound or catheter. If, while performing lithotomy in

such a state of the parts, the staff occupy the situation of d d d, then

the knife, following the staff, will open, not the bladder which

contains the stone, but the sac, which, moreover, if it happen to be

filled with urine regurgigated from the urethra, will render the

deception more complete.














Fig. 7, Plate 62.--The walls, a a, of the bladder, appear greatly

thickened, and the ureters, b, dilated. The sides, c c c, of the

prostate are thinned; and in the prostatic canal are two calculi, d d,

closely impacted. In such a state of the parts it would be impossible to

pass a catheter into the bladder for the relief of a retention of urine,

or to introduce a staff as a guide to the knife in lithotomy. If,

however, the staff can be passed as far as the situation of the stone,

the parts may be held with a sufficient degree of steadiness to enable

the operator to incise the prostate upon the stone.