CHAPTER LXXIII TUBERCULOSIS OF THE PROSTATE AND SEMINAL VESICLES TUBERCULOSIS OF THE PROSTATE INVOLVEMENT of the prostate is exceedingly frequent in genito-urinary tuberculosis, and is undoubtedly more common as a primary infection than was formerly thought to be the case. It is difficult, however, to conceive of its primary involvement save upon an assumption of infection by way of the blood-channels. The mere fact of primary tuberculous disease in the prostate constitutes in itself no evidence upon which to construct a theory of exogenous infection. Some observers have been prone to regard the primary origin of the disease in this organ to result essentially from careless, unclean instrumentation and eroded mucous surfaces. This appears hardly tenable, first, because of the comparative infrequency of such a history in cases of primary prostatic tuberculosis, and, secondly, because of the mechanic obstacles offered to the retention and colonization of bacilli in the urethral canal, by the forceful washing of the urinary stream. After, however, an initial tuberculous infection of other portions of the genito-urinary system, the anatomic conditions are such as peculiarly to favor a secondary involvement of the prostate. Its situation at the intersection of the genital and urinary systems produces an increased exposure to secondary infection. In addition a tuberculous prostatic change having taken place, its location renders it a favorable point of departure of further tuberculous dissemination. It thus happens, irrespective of the primary focus, that this gland rarely escapes infection in case of urogenital tuberculosis. It is more or less immaterial, therefore, whether the disease is the result of an ascending infection from the epididymis, or of a descending involvement from the kidney or bladder, as it is well known that the prostate may be the receptacle of bacilli from either source. It is doubtful, however, if its secondary involvement occurs with frequency as a direct result of bladder tuberculosis. As between these two organs, it is probable that the disease extends from prostate to bladder much oftener than from bladder to prostate. The symptoms of prostatic tuberculosis may be completely overshadowed by the manifestations of vesical disease. In such an event the diagnosis is established entirely upon the results of physical examination. In other cases, in addition to the evidences of bladder irritability previously described, there may take place from the urethra a discharge of mucus or pus, in which tubercle bacilli are found. There is sometimes present an appreciable tenderness in the perineal region, with a sense of dragging weight. Physical examination through the rectum discloses the existence of prostatic enlargement and sometimes of hard, nodular masses of varying size, which often break down and form abscesses. The size of the prostate is largely a relative matter in different individuals, and the diagnosis upon examination rests chiefly upon the prseence of the small nodular lumps which are sometimes entirely unproductive of subjective symptoms. Catheterization, however, is usually attended by considerable pain. The treatment of this condition per se is largely climatic, hygienic, and symptomatic. If tuberculous disease exists in other parts of the genito-urinary system, the general principles of management are based essentially upon the indications presented by the other tuberculous processes. In other words, the treatment of the prostatic affection is often quite subordinate to that of infection in other regions. In case of primary involvement limited to the prostate the general management should conform to the hygienic and climatic considerations recommended for tuberculosis of the kidney and bladder. It has been demonstrated that change of surroundings and immediate environment may be attended with beneficial results. A prolonged sea voyage is often advocated for such invalids, provided other complications do not exist. It is doubtful if injections of iodoform in olive oil possess any decided advantage, though sometimes employed. In view of the peculiar position of the prostate and the opportunities afforded for tuberculous infection in other portions of both the genital and urinary systems, the limitations and deficiencies of surgical interference are particularly unfortunate. It has been urged that the surgery of the prostate should be delayed until the indications for active. interference are urgent in character. This presupposes not only that other measures have failed to produce satisfactory results, but also that sufficient time has elapsed for the extension of the disease to other portions of the genito-urinary tract. The propriety of excision of the prostate in case of primary tuberculous involvement prior to further bacillary dissemination is a matter for judicial surgical consideration. As there is but little technical difficulty, either to suprapubic or perineal prostatectomy, it is difficult to understand why the same rule of procedure as regards removal is not applicable to the prostate as to the kidney. It would even appear that if it is desirable to perform nephrectomy upon early cases of primary kidney tuberculosis before extension to the other kidney, bladder, and genital system, the removal of the prostate would have still wider application under similar conditions, on account of the diminished relative mortality and the lessened importance of the organ. Excision of portions of the prostate, as well as the curetment of tuberculous ulcers and sinuses, is sometimes employed. TUBERCULOSIS OF THE SEMINAL VESICLES Tuberculosis of the seminal vesicles rarely occurs save as a secondary extension of the disease from other portions of the genito-urinary tract. Instances of primary involvement, however, have been reported in connection with tuberculosis of the bladder and prostate, and sometimes of the epididymis. The symptoms are those of bladder or urethral irritability. There is usually marked excitability of the sexual organs, and not uncommonly, in later stages, impotence and sterility. Cameron and others have called attention to the clinical significance of the frequent emissions of blood-stained semen in such cases. I have occasionally observed this symptom among pulmonary invalids without detecting physical evidences of disease of the seminal vesicles. The diagnosis rests upon the detection, by rectal examination, of hard, rounded protuberances in the region of the enlarged vesicle. Tuholske suggests the possibility of confusing this condition with the shot-like masses characteristic of phleboliths. He indorses the removal of the vesicle in primary cases in accordance with Zuckerkandl's operation, which consists of a semilunar incision from the perineum with the base downward. This procedure is indorsed by many surgeons. In the event of coëxisting tuberculous involvement of the testicle and vas, necessitating their removal, as well as the seminal vesicles, a perineal incision, following the removal of the testicle and vas, may be made, through which the vesicle may be pushed from the rectum and subsequently extirpated. According to Cameron, Roux reports two such cases. Scraping or stripping of the seminal vesicle is sometimes practised, but its propriety relates almost entirely to a primary involvement. Bandet and Kendirdjy have recently reviewed 46 cases of extirpation of the seminal vesicle and vas. They regard the operation as too serious to justify its performance save in the presence of urinary fistula from tuberculosis of the vesicle, continuous enlargement of the vesicle with existence of added tubercle deposit along the vas, or rectal obstruction. CHAPTER LXXIV TUBERCULOSIS OF THE EPIDIDYMIS AND TESTES TUBERCULOUS disease of these parts originates, as a rule, in the epididymis and thence extends to the body of the testes, the vas deferens, and the seminal vesicles. The involvement of the epididymis is usually primary, though secondary infection sometimes takes place. The circulation is the almost invariable channel of infection, but it is possible that the entrance of bacilli may be permitted in rare instances through the urethra. The globus major is the part first involved in the majority of cases. Attention has been called to factors of some etiologic importance, i. e., the small size and extreme tortuosity of the arteries, and the division of the spermatic into two branches in close proximity to the epididymis. Immediate continuity of structure explains the extension of the disease from the epididymis to the testes, although a tuberculous involvement of the body of the testes rarely ensues, until tubercle deposit in the epididymis has attained extensive proportions and undergone caseation. The disease is not infrequent among young adults, and is observed more commonly between the ages of twenty and forty. It sometimes exists, however, in very early life, cases having been reported even in infancy. Several observers have recorded cases occurring under one year. The initial macroscopic pathologic change is the formation of one or more hard nodules in the globus major. These increase in size until the entire epididymis assumes the characteristics of a hard, nodular growth. The mass is irregular, knotty, and uniformly solid in the early stages. Following the period of deposit and initial hardening, a degenerative process supervenes in spots, and some of the nodules are found to have undergone caseation and softening. In such cases the skin speedily becomes adherent to the underlying tissues, and presents a peculiar glistening appearance over the site of the nodular softening. In these locations changes in color also take place. The color may be more or less purplish from the local hyperemia, or it may assume a yellowish appearance from the abscess formation superficial to the surface, with impending rupture of the skin. Perforation is followed by the discharge of a creamy, yellowish pus, which gradually changes to a thin, cheesy exudate. These tuberculous sinuses per-. sist, as a rule, indefinitely, though exhibiting at times an inclination toward spontaneous healing. Tuberculous involvement of the vas results in a thickening throughout its course, which is usually more pronounced at its extremities. Hydrocele is often present, but this varies according to the acuteness of onset, upon which depends, to a great extent, the character of the clinical symptoms. In most cases the condition is of slow, insidious development, and the discovery of the early nodular enlargement of the epididymis entirely accidental. As the tubercle deposit assumes larger dimensions, with the formation, in the epididymis, of a tumor of wooden hardness, a frequent distinguishing characteristic of the condition is noted in the absence of pain. There often are no subjective symptoms manifested aside from the sense of weight. In these chronic cases the tuberculous process is almost always unilateral, and attended by but little, if any, tendency toward the formation of hydrocele. The enlargement, however, may progress with considerable rapidity despite the absence of inflammatory manifestations. The entire organ presents the characteristics of a solid tumor, uniformly hard in consistency, and of irregular contour, the latter being due to the presence of nodular protuberances upon the surface. When caseation and softening, however, have taken place in localized areas, palpation may disclose the sharp, crater-like, overhanging edges of the suppurating nodule. Examination at this state usually reveals the presence of tuberculous infection of the vas, the cord, and the seminal vesicles. Sinus formation is also a very important characteristic of tuberculous involvement. An acute type of tuberculous disease of the epididymis is sometimes observed, which may or may not follow the history of trauma. It is easy to understand how slight injury to these parts may so lower the resistance of the tissues, as to bring into immediate activity an infection previously latent, precisely as has been described with reference to the bones and joints. Even in the absence of traumatism, however, tuberculosis of the epididymis may develop with acute symptoms and pursue a rapid course. In this event pain is pronounced and accompanied by a peculiar sickening sensation. An early formation of hydrocele is the rule in such cases, which is in decided contrast to the massive caseation exhibited in the more chronic type of the disease. When of more or less acute invasion and rapid development, the process is especially likely to extend to the opposite side. In such cases early abscess formation usually occurs. Diagnosis. An essential diagnostic consideration is the presence of tuberculous disease in other portions of the body, and especially the location of demonstrable lesions in some part of the genito-urinary system. In the absence of discoverable tuberculous change elsewhere important diagnostic data relate to the existence of a solid tumor originating in the epididymis, of peculiar hardness, irregular contour, possible localized areas of fluctuation, absence of pain, with indurated profuse nodular thickening of the vas and cord. In doubtful cases failure to respond to the specific therapeutic test is of considerable value. Gonorrheal epididymitis may usually be excluded by the history and absence of previous discharge or pain. The localized areas of caseation and softening, with tendency to sinus formation, are distinguishing features in the differentiation from sarcoma or syphilitic gumma. The latter is especially prone to appear in the testis, while tubercle deposit usually takes place in the epididymis, before the testis. In general the prognosis may be said to depend upon the health. of the individual, the degree of implication of neighboring structures, and the character of the management. Speaking broadly, the prognosis should not be considered merely with reference to the future course of the tuberculous organ, but also as regards the general welfare of the patient. Judged by this latter token the prognosis must depend almost entirely upon the nature of the surgical treatment, which of necessity is contingent upon the general health. If the prognosis is unfavorable on account of advanced and extensive pulmonary tuberculosis, the local condition assumes but little importance, and may be ignored altogether in the management of the case other than in so far as pertains to palliative non-operative measures. In such conditions the rational surgical management consists merely of incision and drainage of infected softened areas. Local cleanliness must be secured as far as possible in the hope of avoiding secondary infection. Several cases among far-advanced pulmonary invalids under my observation have displayed rather remarkable improvement in the general condition after operation. I recall one patient whose condition was regarded as extremely desperate, yet subsequent incision and drainage of both testicles established a gain of fifty pounds in weight during the course of the ensuing year. Good results are sometimes obtained by iodoform applications and injections. The employment of various injections, however, into the thickened tissues prior to the stage of softening is unworthy of commendation. Treatment. The consideration of paramount importance in tuberculosis of the epididymis and testes relates to the expediency of castration. This alone is the practical issue in patients, whose general health is not such as to suggest a fatal termination, irrespective of the local condition. It is somewhat remarkable that many writers persist in advocating extirpation of the organ only after general and non-operative measures have proved of no avail. No more culpable error can be perpetrated than to delay some form of surgical interference in young adults with unilateral infection, whose pulmonary involvement is of such a character as to suggest the probability of ultimate arrest. Physicians who endeavor to avoid the responsibilities attending early excision are committing the patient to the possibility of double infection and of extension to other portions of the genito-urinary tract. It would seem almost unnecessary to argue that a broken-down testis and epididymis can be of no possible benefit to the individual, and that the immediate removal in toto of infected tissue is indicated upon the score of the general health. It is obvious that so large a focus of tuberculous infection as a caseated testis and epididymis must constitute a distinct menace to the life of the patient. A reasonable conclusion is to the effect that there is absolutely no justification for the long-continued nursing of the affected member. Upon the other hand, its prompt extirpation in appropriate cases provides a reasonable assurance of protection to the opposite side, and to other parts of the genito-urinary system. Through the elimination of a large tuberculous focus, added opportunities are |