Prostatitis

PROSTATITIS (prostatitis), inflammation of the prostate gland; occurs as a result of penetration of microorganisms into it, most often the gonococcus. Sometimes there is a mixed infection (staphylococci, streptococci, B. coli, etc.). According to statistics by Socin and Burckhardt, 90% of all cases are of gonorrheal origin, but secondary flora quickly joins the gonococci and displaces them. The penetration of infection into the prostate gland can occur by various routes. Most often, gonococcal infection from the posterior urethra passes directly through the excretory ducts into the prostate gland. The lymphogenous route may occur when infection passes from the anterior urethra into the prostate gland. The appearance of prostatitis without involvement of the posterior urethra in the first days of acute anterior urethritis, as well as pathological-anatomical studies, confirm the possibility of such a transition. Sometimes the hematogenous route occurs. Thus, cases of prostatitis after abscess of the tonsils by Frisch, after panaritium have been reported; other authors observed prostatitis in angina, pyemia, furunculosis, typhoid fever, influenza, etc. Predisposing factors for the development of prostatitis are causes of both general and local nature. A sedentary lifestyle leads to stagnation in the pelvic organs. Constant sexual excitations, abnormal sexual intercourse (coitus interruptus) contribute to prolonged hyperemia of the sex glands and incomplete outflow of secretions, which facilitates the introduction and fixation of infection in the prostate.

364.-Clinically, prostatitis is divided into acute and chronic forms. From a pathoanatomical point of view, acute prostatitis is divided into 4 forms: catarrhal, follicular, parenchymatous, and phlegmonous. It is not always clinically possible to clearly delineate these forms, as transitional stages and combinations of different forms are commonly encountered. Quite often, these forms develop sequentially from one another, i.e., they represent different stages of development of the same acute inflammatory process. Pathoanatomical studies by Rost showed that inflammation quite quickly spreads to the interstitial tissue. Zaiglaev, based on his pathoanatomical research, believes that the inflammatory process is most sharply expressed around the lymphatic vessels and spaces. In some places, localization of the process can be seen exclusively in the interstitial tissue without damage to the gland lumens.-Catarrhal prostatitis (prostatitis catarrhalis), or in Goldberg's terminology, endoglandular, represents the primary stage of developing inflammation. The epithelium of the prostate excretory ducts is penetrated by leukocytes and begins to desquamate, filling the lumens of the excretory ducts. Inflammation in this form of prostatitis proceeds sluggishly, changes in the shape and size of the prostate gland are barely noticeable, and only a slight edema of the parenchyma can sometimes be noted, indicating a violation of blood and lymph circulation in the organ.-Follicular prostatitis (prostatitis follicularis) is a further stage of development of the inflammatory process: proliferation of the epithelium is sharply expressed, the epithelium of the follicles is penetrated by leukocytes, the mucous membrane of the excretory ducts is swollen and in places obstructs the lumen, which leads to retention of purulent exudate in the follicle and the formation of an abscess within it. The lesion spreads to the interstitial tissue, where a small-cell infiltration and quite sharply expressed edema are visible. The size of the follicle increases, it protrudes above the level of the gland, and can be palpated as a grain, a pea, and is painful on pressure.-In the parenchymatous form (prostatitis parenchimatosa), the gland is enlarged in size, of firm consistency. On pressure, seropurulent, bloody exudate is secreted. Subsequently, the inflammatory infiltrates resolve, and either complete recovery with the formation of connective tissue elements occurs, or the existing infiltrates and small abscesses progress, and, merging with each other, destroy the tissue of the prostate. These abscesses may be located in various lobes of the gland or, merging with each other, form one abscess located inside the capsule of the gland (phlegmonous prostatitis). In individual cases, inflammation spreads to the tissue surrounding the prostate and forms phlegmonous periprostatitis, and the inflammation can spread along the areolar tissue, along the veins, and through the lymphatic pathways. Even more rarely, periprostatic phlebitis (phlebitis periprostatica) is observed, characterized by the presence of dense inflammatory strands. This form particularly easily leads to pyemic processes. Symptoms and course of acute prostatitis are diverse, depending on the nature of the pathoanatomical process. In the catarrhal form, the process can proceed almost without any subjective phenomena or be limited to a slight increase in the urge to urinate. Among the objective symptoms, some swelling, puffiness of the prostate gland, and the presence of threads in the second portion of urine can be noted. In the secretions of the prostate, leukocytes can be found in greater or lesser quantities. With further development of the process and its transition to the follicular form, urination becomes more frequent, accompanied by tenesmus; painful sensations in the perineum and during defecation appear. On palpation, tenderness on pressure, enlargement of the gland can be determined, and in individual areas, follicles distended with pus protruding above the surface of the gland can be palpated. When pressure is applied to them, they disappear due to the emptying of the secretions into the urethra. The urine becomes cloudy in the second portion, with an admixture of comma-shaped threads. In the secretions, there is a significant number of leukocytes, located in clusters. Inflammation at this stage can end in complete recovery. Products of inflammation are absorbed, the gland returns to a normal state, or the inflammatory process can take a sluggish chronic course. In other cases, the follicles merge, and the follicular form passes into the parenchymatous. This form of inflammation can involve either the entire organ (prostatitis parenchimatosa) or only part of it (prostatitis parenchimatosa partialis). The extent of the process is manifested by an increase in the volume of the prostate gland. Patients complain of dull pain in the anus, increasing during defecation, and of pain in the perineum. Urination with localization of the process in the peripheral (lateral) parts of the prostate is slightly more frequent, but somewhat difficult and slightly painful at the end of the act. When the inflammatory focus is located directly near the posterior urethra, the urge to urinate becomes more frequent, pain appears at the end of the act, the urine stream becomes intermittent, and sometimes complete retention of urine is observed. The general condition of patients may not be disturbed, and feverish phenomena are usually absent. The urine is cloudy in both portions. In other cases, the process progresses, involving not only the interstitial tissue but also the surrounding areolar tissue (paraprostatitis). Then the general condition of patients is disturbed, and the temperature (t°) often rises (to 39°). Urination occurs slowly and with pain, the urge to urinate becomes very frequent, especially at night, although the amount of urine excreted is insignificant. The pains take on a drilling and tearing character, are localized in the area of the rectum, spreading toward the sacrum, the thighs, and the glans penis. Any pressure on the perineum is painful. All these phenomena usually last 5-6 days, after which the intensity of the process begins to subside, subjective sensations pass, and the disease takes a chronic course. If, however, the inflammation progresses, then on palpation, in cases where the abscess is located in the lateral lobes of the prostate gland near the wall of the rectum, fluctuation is determined. If the abscess is located deep, closer to the urethra or in the accessory lobe of the prostate, only an enlarged, firm, hot to the touch prostate gland is palpated. In the further course, the process may undergo reverse development and end in clinical recovery, or the abscess may rupture into neighboring tissues and organs. According to Segon's statistics, the most common outcome of the purulent process is the rupture of pus into surrounding organs and tissues. Out of 102 cases, rupture into the urethra was observed 35 times, into the rectum-18, simultaneously into the urethra and rectum-21, into other places-28 times. Out of 40 cases of acute purulent prostatitis, Belostotsky observed rupture of pus into the urethra 20 times, into the rectum-10 times, into the areolar tissue of the perineal part or into fossa ischio-rectalis-9 times, and into the urinary bladder-1. After rupture into the urethra, rectum, or urinary bladder, all subjective disturbances disappear. In cases where the abscess ruptures into the urinary tract, the urine becomes cloudy and contains a large amount of pus. In cases where the outflow of pus is difficult due to a narrow exit opening, periodic retention of pus outflow can be observed, accompanied by an increase in t° and other clinical phenomena. Upon opening the abscess, in most cases the wound heals with a scar, and in very rare cases, urinary extravasations with all their serious consequences may occur. Atypical course of the inflammatory process, with its spread to surrounding tissues, with the occurrence of phlegmonous periprostatitis, clinical phenomena intensify: chills appear, and t° is usually not below 40-41°. On palpation of the gland, its borders are indistinct, the contours are smoothed, the inflammatory infiltration involves the surrounding tissues and spreads in all directions. The process may undergo reverse development, which is rare, or an abscess forms, and then fluctuation can often be felt at the site of the prostate. An even more severe course is rarely encountered 'phlebitis of the periprostatic venous plexuses.' In these cases, all symptoms of a general, septic condition are present. Locally, on palpation of the area of the prostate gland, a firm and unevenly bumpy tumor can sometimes be determined, producing the impression of a bundle of thick cords. Diagnosis of acute and subacute prostatitis does not present particular difficulties. One should make it a rule to examine the prostate gland when the two-glass urine test is cloudy.-The prognosis for catarrhal and follicular acute prostatitis, both as to life (quoad vitam) and as to complete recovery (quoad valetudinem completam), is favorable, although they sometimes recur and take a chronic course. Parenchymatous forms usually also end in resolution, more rarely they pass to suppuration, which can involve the surrounding areolar tissue. In these forms, the prognosis is already serious for life, especially in the elderly, as the possibility of a fatal outcome cannot be excluded.--As for the therapy of prostatitis, bed rest, a light diet, and daily bowel movements are necessary conditions for successful treatment.

Sitting warm baths at 37-43° are recommended twice a day for 15 minutes, or hot small enemas with a capacity of up to ³/₁ glass at 50-52° three to four times a day. If 10 minutes after the introduction of the enema there is still a desire to defecate, the water should be released, but if there is no desire, the enema can be left. Instead of enemas, some authors use the Arzberger apparatus (see Arzberger's apparatus). For severe pain and frequent urges, it is necessary to resort to narcotics in suppositories ( pantopon, morphine, belladonna, etc.) or to add opium to the small enema. In case of urine retention, urine should be drained with a Nelaton catheter or a Mercier elastic catheter. After catheterization, the bladder should be washed with a solution of argentic nitrate or mercuric cyanide in a dilution of 1:4,000. Local treatment of the urethra with large irrigations should not be interrupted. Of the general immunotherapy measures, the best results are obtained from intramuscular injections of milk, starting with 3.0-5.0 (see Proteinotherapy). If the case has progressed to suppuration, general symptoms have developed, or the abscess has ruptured into the surrounding cellular tissue, it is necessary to resort to surgical intervention - opening of the abscess with subsequent drainage of the cavity (prostatotomy).

Chronic prostatitis (prostatitis chronica) is an extremely frequent disease. According to Voskresensky, chronic P. is observed in the first months after acute gonorrheal infection in more than 70% of cases. Approximately the same figures are given by Kasper, Buschke-Langer and others. It is undeniable, however, that the frequency of occurrence of chronic P. is connected with the method of treating urethritis. Rosenfeld, who treated 1,462 cases of acute gonorrhea with large irrigations according to Janet, obtained complications of chronic P. in only 14%. Holtzov believes that almost all posterior urethrites are complicated by P. According to Zaigraev, superficial forms of posterior urethritis may not cause chronic P., but deep lesions as a rule are complicated by inflammation of the gland. The most frequent etiological factor in chronic P. is gonorrheal infection, but the finding of gonococci in the prostate secretion is quite rare, and it should be considered that inflammation of the prostate during gonorrhea, caused by the gonococcus, is often maintained by a mixed flora. Pathological-anatomical changes in the prostate in chronic forms of inflammation are extremely diverse both in localization and extent and in the histological picture. At the same time, a desquamative catarrh of the excretory ducts, small-cell infiltration of the walls, and the development of connective tissue elements can be present. Along with this, the formation of cavities of various sizes filled with mucopurulent content, and strands of a scarred character, piercing the gland in different directions, can be observed, and in places normal prostate tissue can be seen. Depending on the predominance of one or another picture, chronic P. can be divided into catarrhal, follicular, abscessing or cavernous forms, and interstitial. Symptoms. Subjective complaints in chronic P. sometimes are completely absent, and only some adhesion of the urethral lips and a small amount of threads in urine cause the patient to consult a physician. In other cases, patients complain of itching in the urethra, anus, perineum, dull pain in the sacrum, lower back, in the region of the kidneys, testicles, thighs, along the course of the sciatic nerve, etc. These sensations are usually not constant. Often they are intensified after sexual intercourse, more rarely with abstinence. Some patients complain of disorders of sexual functions in the form of increased erections, pollutions, absence of sexual desire; later, weakening of erections, premature ejaculation occurs. In a long process that has caused a weakening of the tone of the smooth muscle of the excretory ducts of the prostate gland, phenomena of prostatorrhea (see) are observed. Spermatorrhea is less frequently encountered, as a result of weakening of the tone of the sphincters of the spermatic ducts and the ejaculatory ducts (ductus ejaculatorius), passing through the prostate gland. From the urinary sphere, an increase in the urge to urinate, especially at night, can be observed, and often their imperativeness can be noted. At the end of the act of urination, unpleasant sensations remain, as if of mild tenesmus, and the last portions of urine flow slowly, drop by drop, which is explained by the weakening of the musculature of the posterior urethra. The urine is macroscopically transparent, with an admixture of threads of a mucopurulent nature. Characteristic of prostatitis are comma-shaped threads in the second portion of urine, coming from the excretory ducts of the prostate. In the absence of an inflammatory process in the urethra, the urine can be completely transparent, without threads. On the contrary, in a sharply expressed and prolonged process in the gland with weakening of the tone of the smooth musculature in the prostate and posterior urethra, the urine can be turbid in both portions. Quite often the turbidity of urine in P. is due to phosphaturia, the appearance of which (Voskresensky) coincides with a worsening of the process in the prostate gland. According to Oppenheim, here we are dealing with the influence on the urine of the alkaline pathological secretion of the prostate, causing the precipitation of phosphates. The diagnosis of chronic P. is based on the palpation of the prostate gland through the rectum and microscopic examination of the secretion obtained by massage. During palpation, attention should be paid to the size, shape, surface, consistency and sensitivity of the prostate. Since all these data are relative and can vary within wide limits, it is necessary to decide the question by comparing the right and left lobes of the gland. Sometimes instead of an increase, a decrease or depression of one of the lobes can be established, which is usually observed as a result of the destruction of part of the parenchyma of the gland by a purulent process. The consistency of the gland is also subject to fluctuations in the normal state from soft-elastic to dense. It is dense when it contains a large amount of connective tissue elements, of soft consistency when there is a significant development of muscle fibers. In pathological processes, hardening of the gland is observed as a result of a sharply expressed proliferation of connective tissue or as a result of a solid inflammatory infiltrate that has not yet undergone reverse development. A uniformly soft, flabby consistency is usually observed in persons leading an abnormal sexual life (coitus interruptus, masturbation, etc.). For chronic P., unevenness of consistency is characteristic. The presence of softer areas among a dense gland or, conversely, hardened areas among the general elastic mass indicates the presence of inflammatory changes in the corresponding areas of the parenchyma. In the first case, it is a matter of the presence of an infiltrative process or foci of melted tissue; in the second case, there are changes of a scarred nature, as a result of previous inflammation. The sensitivity of the gland varies individually. A distinction should be made between sensations of an irradiating nature (to the glans penis), which are physiological, and painful sensations experienced at the place of pressure with the finger and indicating a pathological process occurring here. The results of the analysis of the gland secretion are of decisive importance for the diagnosis of chronic P. In microscopic examination, practically the presence or absence of lipid grains freely suspended in the liquid part of the juice should be taken into account, which are a product of the functional activity of the prostate gland and belong to the group of phosphatides. Lipids included in the protoplasm and nucleus of leukocytes (the phagocaryotic group) are of no importance for judging the state of the prostate gland. In the secretion of the prostate gland during its inflammation, in addition to elements of normal secretion, a greater or lesser amount of leukocytes is contained. In order to be sure that the pus cells come from the prostate gland, the urethra, both anterior and posterior, should be cleansed beforehand by washing of pathological products that may be present there. A sign that the examined secretion comes from the prostate gland is the presence of fatty-degenerated cells in the purulent accumulations (Porudominsky-Feigin). The amount of lipid grains is usually in inverse proportion to the number of leukocytes in the prostate secretion. The deeper and more extensive the process, the less lipids and the more leukocytes. With improving process as the number of leukocytes decreases, we have an increase in the amount of freely located lipid grains. In those cases (Fronstein) where leukocytosis decreases but there is no increase in lipids, the possibility of the presence of an encapsulated purulent focus in the prostate tissue should be taken into account. During urethroscopy, hyperemia in the prostatic part of the urethra and swelling of the seminal colliculus can be established, and often even phenomena of bullous edema. The transitional fold of the bladder during cystoscopy appears hyperemic, uneven, in places tongue-like protruding into the lumen of the internal opening of the urethra. The prognosis in chronic P. should always be made with caution. Restoration of the anatomical structure of the gland is usually not observed; as for the freeing of the prostate gland from infection and inflammatory foci and bringing it closer to normal function, this can be achieved with correct, sometimes prolonged treatment. The diagnosis of clinical cure should be made on the basis of combined examination by palpation and repeated microscopic examination of the secretion. The absence or presence of single leukocytes in the prostate juice with a large amount of lipid grains is a symptom of clinical cure. Chronic P. can cause impassability for spermatozoa of the ejaculatory ducts as a result of the development of scars around them and thus cause the phenomenon of azoospermia. Loss of elasticity and violation of the integrity of the smooth musculature as a result of chronic inflammation can be the cause of prostatorrhea and spermatorrhea. Therapy. Catarrhal forms require only local treatment, and 3-5 massage sessions, conducted every other day, usually arrest the process. In deeper forms of P., treatment must be carried out for a long time and persistently. First of all, one should be concerned about strengthening the body: physical exercise without sharp movements of the lower extremities, a corresponding diet, regular daily emptying of the bowels, complete sexual abstinence, protection from sexual excitations.

Patients with pronounced nervous disorders should be prescribed hydrotherapy. Symptomatically, to reduce subjective sensations, suppositories or microclysters with narcotics (morphine, opium) are used. Local treatment mainly consists in the application of massage and diathermy. Attempts to treat chronic P. without the use of massage ended in failure. Pechersky and Rabinovich, in 116 cases of chronic P. treated only with protein therapy and microclysters, could note recovery in only 7, but with the use of massage they confirmed 56% cure within 5 months: with combined treatment with diathermy, Kabachnik and Timofeyev could confirm cure in 81% of cases within 2 months. Massage should be started after the acute inflammatory phenomena have subsided, first in the form of light stroking; after 2-3 weeks, when the acute phenomena in the gland have passed, vigorous finger massage can be begun. The massage is performed with the index finger inserted into the rectum with the patient lying on his right side. Special devices proposed for massage, as well as vibrational massage produced by a special device, do not achieve their purpose. The movement of the massaging finger should be directed along the course of the excretory ducts of the prostate gland, which open into the prostatic groove on both sides of the seminal tubercle. Consequently, the movement of the massaging finger when massaging the upper third of each lobe should be from top, outside downward and inward; when massaging the middle third—from outside inward; and in the lower third—from outside, bottom upward and inward, and the massage should be performed as much as possible only on the pathologically altered area of the prostate gland. The massage should be painless and is usually repeated every other day. After the massage, the patient should urinate, either with urine that was left in the bladder before the massage, or with fluid previously introduced into the bladder (potassium permanganate, lunar caustic, oxy-cyanate). The duration of a massage session varies; one should massage for as long as necessary to reduce the volume of the gland, which is felt by the massager. Usually this period ranges from 1 to 2 minutes. The course of massages, the number of which varies depending on the severity of the case (but not less than 10-12 sessions), should be ended gradually, for which the massage is first performed every 3 days, then every 5-7 days. The prostate secretion should periodically be subjected to microscopic examination; the establishment of a constant leukocytosis with a significant amount of lipids indicates the absence of infection in the prostate. The use of diathermy should be combined with prostate massage. In diathermy, one special electrode is inserted into the rectum, the other is placed on the perineum. A diathermy session lasts 15-20 minutes, during which the patient should feel pleasant warmth. The use of exogenous heat, in the form of microclysters, Arzberger's apparatus or Frank's apparatus, is a good adjunct in the treatment of chronic P. The use of this type of heat is especially indicated when the process is localized in the peripheral parts of the prostate. Good results were observed by some authors from the use of mud therapy. In P. with the presence of atony of the smooth musculature, it is advisable to use, in addition to massage, faradization of the prostate gland or d'Arsonval currents. The treatment of chronic P. should be accompanied by treatment of the posterior urethra in the form of washing it according to Jane, instillations, lubrications through an endoscope with a 5-10% solution of lunar caustic, galvanocauterization. A good adjunct to the local treatment of chronic P. is immunotherapy in the form of milk or vaccine.