Malignant disease of the bladder is almost always the warty form of cancer known as epithelioma. It springs as a sessile growth from the mucous membrane of the floor near the opening of one of the ureters, and, worrying the sensory nerves, causes irritability of the bladder and incontinence of urine. In due course septic germs reach the bladder, either from the urethra, the bowel, the kidneys or the blood-stream, and cystitis sets in. When ulceration has taken place, blood occurs in the urine, and the patient—generally beyond middle age—suffers dull or lancinating pains. Eventually the rectum may also be involved and the distress becomes extreme. The presence of the growth may be determined by sounding the bladder, by the cystoscope, and by the finger in the rectum. If the growth invades the outlet, retention of urine may occur, and the surgeon may be compelled to open the bladder from the front of the abdomen. In cases where operation is out of the question, washing the bladder with hot boracic lotion may give great relief. The treatment of cancer of the bladder by operation is, as a rule, unsatisfactory, because of the close proximity of the growth to the ureters and to the rectum. If, however, the disease were recognized early and had not invaded the neighbouring structures, and if it were upon the upper or the anterior part of the bladder, its removal might be hopefully undertaken.
Hypertrophy and Dilatation.—When there is long-continued obstruction to the flow of urine, as in stricture of the urethra, or enlargement of the prostate, the bladder-wall becomes much thickened, the muscular fibres increasing both in size and number; the condition is known as “hypertrophy.” Hypertrophy may be accompanied by dilatation of the bladder, a condition which the bladder may assume when the voiding of its contents is interfered with for a length of time.
Paralysis of the bladder is a want of contractile power in the muscular fibres of the bladder-wall. It may result from injuries whereby the spinal cord is lacerated or pressed upon, so that the micturition centre, which is situated in the lumbar region, is thrown out of working order. The result may be either retention or incontinence of urine; sometimes there is at first retention, which later is followed by incontinence. Paralysis is also met with in certain nervous diseases, as in locomotor ataxia, and in various cerebral lesions, as in apoplexy.
Atony of the bladder is a paresis or partial paralysis. It is due to a want of tone in the muscular fibres, and is frequently the result of over-distension of the bladder, such as may occur in cases of enlargement of the prostate. The patient is unable to empty the bladder, and the condition of atony gets increasingly worse.
In both paralysis and atony the indication is carefully to prevent over-distension by the urine being retained too long, and at the same time to treat by appropriate means the cause which has produced or is keeping up the condition.
Incontinence of urine may occur in the adult or in the child, but is due to widely different causes in the two cases. In the child it may be simply a bad habit, the child not having been properly trained; but more frequently there is a want of control in the micturition-centre, so that the child passes its water unwittingly, especially during the night. In adults it is not so much a condition of incontinence in the sense of water being passed against the will, but is a suggestion that the bladder is already full, the water which passes being the overflow from a too full reservoir. It is usually caused by an obstruction external to the bladder, e.g. enlarged prostate or stricture of the urethra; a calculus may produce the condition. In the child an attempt must be made to improve the tone of the micturition-centre by the use of belladonna or strychnine internally, and of a blister or faradism externally over the lumbar region, and every effort should be made to train the child to pass water at stated times and regular intervals. In the adult the cause which produces the over-distension must be removed if possible; but, as a rule, the patient has to be provided with a catheter, which he can pass before the bladder has filled to overflowing. A soft flexible catheter should be given in preference to a rigid or semi-rigid one. The best form is the red-rubber catheter, and he should be taught the need of keeping it absolutely clean. In the case of children incontinence of urine means irritability; in adults it means overflow.
The condition termed by Sir James Paget stammering micturition is analogous to speech stammering, and occurs in those who are nervous and easily put out. It would seem to be due to the sphincter of the bladder not relaxing synchronously with the contraction of the detrusor, and is sometimes caused by external irritation, such as preputial adhesions. Occasionally not a drop of urine can be passed, or a little passes and then a sudden stoppage occurs; the more the patient strains the worse he becomes, until at last there is complete retention of urine. The trouble can sometimes be cured by the removal of irritating causes, and in these cases, as well as in those in which no such cause can be discovered, care should be taken to avoid those difficulties which have given rise to the patient’s worst failures. If at any time he should fail to perform the act of micturition, he ought not to strain, but should quietly wait for a little before making any further effort. Regularity in the times of making water is also of much importance.
Retention of urine may occur in paralysis of the bladder, or in conditions where the patient is suffering from an illness which blunts the nervous sensibility, such as apoplexy, concussion of the brain, or typhoid fever. It is, however, more commonly due to obstruction anterior to the bladder, as in stricture of the urethra or enlargement of the prostate. The distended bladder can be felt as a rounded swelling above the pubes, and perhaps reaching to the level of the navel. Percussion over it gives a dull note. When the bladder is distended, it is necessary to evacuate it as soon as possible. If there is no obstruction to the flow of urine, the retention being due to atony or paralysis, a soft catheter is passed and the water drawn off. But when there is an obstruction which cannot be overcome, aspiration has to be resorted to, the needle of the aspirator being pushed through the abdominal wall into the bladder. The point of puncture in the abdominal wall is in the middle line a few inches above the symphysis pubis. The bladder may be emptied in this way very many times in the same person with only good result.
Diseases of Prostate Gland.
The prostate gland may become acutely inflamed as the result of the backward extension of gonorrhoeal inflammation of the urethra; it may also be attacked by the germs of ordinary suppuration as well as by the bacilli of tuberculosis. A sudden enlargement of a large gland lying against the outlets of the bladder and the bowel renders micturition difficult, painful or impossible, and interferes with defaecation. Pressure of the seat of the chair upon the perineum also causes distress, so the man sits sideways and on the edge of the seat. If abscess forms, it should be incised from the perineum; if allowed to run its course it may burst into the bladder, the urethra or the rectum, and set up serious complication. The treatment of prostatitis (inflammation of the prostate) consists in rest in bed, sitz-baths and fomentations. If retention of urine takes place a soft catheter must be passed. In the early stage of an acute attack a dozen leeches upon the perineum may do good. The bowels must be kept freely open, and from time to time, as the pain demands, a morphia suppository may be introduced into the bowel.
Chronic prostatitis is a legacy from a recent or long-past attack of gonorrhoea. The enlargement gives rise to a feeling of weight and fulness in the perineum, irritability of the bladder, and a gleety urethral discharge. Manual examination reveals the presence of a large, hard mass in front of the bladder, and in the mass there can often be felt softish or tender areas which seem to threaten abscess. On urine being passed into a glass, a cloudiness is seen, and material like pieces of vermicelli or broken threads may be noticed. These are the castings from the long tubular glands, and are characteristic of chronic inflammation of the prostate. The occasional passage of a large metal bougie, the use of weak lotions of nitrate of silver, the administration of quinine and iron, and the application of blisters to the perineum, may be tried as circumstances direct. The patient should lead a quiet life, free from sexual excitement. Horse-exercise, cycle-riding, rough games and alcohol should be avoided.
Enlargement of the prostate exists in a considerable proportion of men of about sixty years of age and onward. It consists of an uncontrolled growth of the normal muscular and glandular tissue of the prostate, interfering with, or absolutely stopping, the outflow of the urine. Gently pushing the bladder upwards and backwards, it increases the length of the urethra, so that in order to draw off retained urine the catheter must be longer than ordinary, but inasmuch as there is no actual narrowing of the passage it may be of full calibre. The beak should be well turned up so that it may ride in front of, and surmount, the median enlargement. Because of the thick, ring-like mass of new tissue around the outlet of the bladder, there is difficulty in micturition, and because the muscular bladder wall is now unable to contract upon all its contents a certain amount of urine is retained. As the enlarged prostate bulges up in the floor of the bladder, a pouch or hollow forms behind it, from which the muscular wall is unable to dislodge the stagnant urine. This keeps up constant irritation, and if by chance the germs of decomposition find their way thither, cystitis sets in and the patient’s condition becomes serious, not only because of the risk to which his tired and irritated kidneys are submitted, but because of the possibility of a phosphatic stone being formed in the bladder. The seriousness of enlargement of the prostate does not depend upon the size of the growth so much as upon the inability of the patient to empty his bladder completely.
The surgeon forms his estimate of the size of the prostate by rectal examination. But sometimes a patient has retention of urine from
