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THE MANAGEMENT OF ENLARGED PROSTATE
Lecture delivered at the Royal College of Surgeons of England
on
8th April 1954
by
E. W. Riches, M.C., M.S., F.R.C.S.
Surgeon and Urologist, The Middlesex Hospital.
The word "management" implies the conduct of the case; it has
also a dictionary definition of trickery or deceitful contrivance, but most
of the tricks are only the application of the results of experience, and each
surgeon will have well-tried methods of his own which he finds effective.
In the present connection it will be used to indicate the manner of treating
the patient and it will be taken to include the preliminary assessment,
the decision whether or not to operate, the method of treatment, including
some operative details, the after treatment, and the complications.
Patients with enlargement of the prostate may present in a number of
ways, and from the clinical aspect they fall into four groups:
1. Those with urinary symptoms.
2. Those in whom prostatic enlargement is found on routine examination but whose main complaint is not urinary.
3. Patients with acute retention of urine.
4. Patients with chronic retention of urine.
Many men now seek advice at an earlier stage than formerly, and
some expect operation too soon, but there are'still those who come too
late when serious renal damage has already occurred.
Group 1.-Patients with Urinary Symptoms
The patient who comes with urinary complaints presents the least
difficulty. His age is generally more than 60, and although men in the
early fifties occasionally require surgical treatment they are often better
treated expectantly as long as they can be seen regularly. The prophylactic removal of a normal prostate by any route is not to be recommended
and may be followed by an increase of symptoms and a high incidence of
complications. The need for operation depends on a combination of
symptoms and signs rather than on any one single factor such as the
amount of residual urine, or the number of times micturition occurs in
the night. The symptoms and signs must therefore be considered.
Obstructive symptoms are the surest indication for operation and are
due to changes in the bladder neck and the prostatic urethra caused by
the enlarged gland. Alterations in the act of micturition such as difficulty
or delay in starting, especially when the bladder is overfull, a poor
vertical intermittent stream with a terminal dribble, the need to sit down
to micturate and to open the bowels at the same time are all characteristic.
An intelligent patient learns to avoid over-distension. To estimate the
force of his stream it is better to watch him pass urine if he can do it in
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THE MANAGEMENT OF ENLARGED PROSTATE
company; a stream of good projectile power is usually an indication
that prostatectomy is not yet needed.
Increasedfrequency of micturition is more noticeable by night than by
day. The bladder loses its capacity for adaptation to its content; some
urine enters the posterior urethra and starts the reflex desire to void so
that there is urgency as well as frequency. Increased frequency alone is
not one of the best indications for operation and as Ogier Ward (1953)
has pointed out, it is by no means always relieved by prostatectomyon the contrary it is sometimes made decidedly worse. A man may
wake for other reasons, such as having cold feet, and may get into the
habit of emptying his bladder on waking; wearing bed-socks will
sometimes reduce nocturnal frequency.
Pain is absent unless there is cystitis or prostatitis; even a bladder
stone does not always cause pain as it is cushioned by the residual urine.
The presence of a stone when the prostate is enlarged is, however, a definite
indication for prostatectomy and the stone is removed at the same time.
Haematuria occurs in about 11 per cent. of benign cases; the bleeding
is initial, painless and bright red in colour. It is an indication for further
investigation and possibly for operation.
Signs. The main objective sign is the palpation of an enlarged
prostate on rectal examination. The best position both for patient and
examiner is with the man lying on his back with the knees and hips
flexed. The gland can be felt with the sensitive pulp of the right index
finger and the left hand can be used to press down above the symphysis
and make the examination bimanual if the bladder is not too full. The
size, consistency, mobility and tenderness of the prostate must be estimated,
and the presence of firm nodules or of infiltration assessed. The distinction
between benign enlargement and early malignancy is often very difficult,
but at a later stage the malignant prostate feels hard and fixed and
extensions of growth can be felt at its upper lateral angles.
Examination of the cardio-vascular system, the central nervous system,
the abdomen, the external genitalia, and the urine must not be omitted.
The differential diagnosis lies between prostatic obstruction, urinary
infection, urethral stricture and the neurogenic bladder of tabes. It is
not wise to pass a catheter solely to estimate the amount of residual
urine; a knowledge of the exact amount is of little practical value and
catheterisation opens the risk of introducing infection. The presence of
urinary infection can generally be detected by inspecting and smelling
the urine; its nature and the sensitivity of the infecting organism can be
found by the bacteriological examination of a mid-stream specimen and
medical treatment may then show that prostatectomy is unnecessary.
If the symptoms are present but the prostate is not enlarged it may be
necessary to pass a bougie in order to exclude or diagnose a stricture,
and if there has been haematuria other causes of bleeding must be
excluded by cystoscopy, but if the prostate is enlarged this is always done
in the theatre immediately before operation. Cystoscopy when the
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E. W. RICHES
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THE MANAGEMENT OF ENLARGED PROSTATE
prostate is much enlarged is apt to cause fresh bleeding or to precipitate
acute retention, and is not advisable for out-patients. This investigation
should not be long delayed as 10 per cent. of patients with benign enlargement of the prostate and haematuria were found to have carcinoma of
the bladder as well (Riches, 1954).
Treatment
If both symptoms and signs are present in sufficient degree, operation
will be advised, and obstructive symptoms carry more weight than the
others. A frequency of twice nightly alone is not sufficient justification
for operation, but if the frequency is enough to disturb sleep or to regulate
social or business activities operation is indicated.
Fig. 2. Oval filling defect in the bladder caused by enlarged lateral lobes with
no middle lobe. The left ureter is hooked.
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E. W. RICHES
Some patients can continue under expectant treatment. They must
empty the bladder regularly, avoid all excesses and sudden changes of
temperature, and particularly they must obey the call to micturate when
it comes and avoid enforced retention. If expectant treatment is to be
used the patient must be seen regularly; an intravenous pyelogram at
the outset will give a good idea of the state of the bladder and kidneys
and the quantity of residual urine (Fig. 1).
Hormones have been used in treatment but with little success. Testosterone has a tonic effect on the bladder but none on the size of the prostate.
Stilboestrol, so effective in malignant disease, has no effect on benign
enlargement. Its use may disguise a carcinoma and frustrate early
diagnosis. If carcinoma is suspected the serum acid phosphatase should
be estimated before it is given.
Group 2.-Casual Finding
When prostatic enlargement is discovered as a casual finding in the
course of a general examination for some other condition it does not
necessarily mean that the prostate should be removed. If the main
complaint is not urinary operation is probably unnecessary, but if there is
a history of a recent hernia or piles associated with straining it is probably
wise to operate. Leading questions about urinary symptoms are valid if
signs are present, and an intravenous pyelogram may show confirmatory
evidence of prostatic obstruction in the shape of hooking of the lower
ends of the ureters or a filling defect in the bladder base. The alteration
in the angle of entry of the ureters into the bladder is valuable as an early
sign of upper tract obstruction. An oval filling defect in the bladder
base is, however, more often caused by enlarged lateral lobes, which
can be felt per rectum, than by a middle lobe projection which cannot
(Fig. 2). In the latter case the filling defect is more localised, and a
flattened bladder base may be produced by subtrigonal enlargement
(Fig. 3).
Group 3. Acute Retention
Occasionally acute retention is the first symptom of prostatic
obstruction, but more often there are some preceding symptoms although
the patient does not mention them. The most frequent exciting cause of
acute retention is enforced holding of urine when the bladder should be
emptied. A long train journey without access to a lavatory acts in this
way, and a long car drive in the winter in the company of ladies should
be avoided by a modest man. The detrusor muscle becomes overstretched
and cannot overcome what may normally be a minor degree of obstruction.
During the war we saw many cases of " shelter retention." A sudden
move from a hot room into the cold night air, especially after a good
dinner may also precipitate retention when the prostate is already
enlarged; alcohol in excess may promote a rapid diuresis and cause the
patient to forget to empty his bladder. Campbell Begg (1954) has recently
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THE MANAGEMENT OF LNLARGED PROSTATE
Fig.
3.
Filling
defect produced by middle and lateral lobe enlargement with
subtrigonal hypertrophy. The ureters are hooked.
drawn attention to the frequency of acute prostatitis as a cause of acute
retention and to the dangers of immediate prostatectomy for this condition.
Prostatic retention must be diagnosed from stricture or an impacted
calculus in the urethra. This may involve the passage of a urethral bougie
or catheter.
Acute retention is a painful condition and the first desire and duty of
-the doctor is to relieve the pain. This can best be done by removing the
'cause, that is, by emptying the bladder, and the rational way to do it is
by passing a catheter. The patient's agreement to go into hospital should
first be obtained. One attack of retention is the precursor of others and
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E. W. RICHES
is an indication for operation. Occasionally one catheterisation will
restore micturition, but more often the retention recurs and repeated
catheterisation becomes necessary, and the more often it is repeated the
more certain becomes the introduction of infection with all its sequelae.
In acute retention there is no need for slow decompression of the bladder.
There is always need, however, for skill and gentleness in passing the
catheter; trauma to the urethra is more serious than infection and
must be avoided at all costs. The best catheter to use is a small stiff
rubber Tiemann's which can be boiled or a gum-elastic bicoude which
can be kept sterile in formalin vapour and rinsed before use. The newer
plastic catheters of similar shape have much to recommend them; they
can be boiled and they retain their smooth surface longer than a gum
elastic. Never use a rough catheter or use a catheter roughly.
If the doctor is not skilled in catheterisation it is better to empty the
bladder by the more tedious method of suprapubic aspiration with a
lumbar puncture or serum needle. It should be inserted well above the
pubes and passed in a downward and backward direction.
In some clinics the use of the catheter is forbidden and cases of acute
retention are treated by immediate prostatectomy, the pain of retention
being relieved by morphia until operation can be arranged. This method
permits of only the minimum pre-operative investigation and treatment,
but is a useful one under suitable conditions. It entails " a full time
urological service backed by radiological and pathological facilities
throughout the 24 hours" (Fergusson, 1952). It is the practice in my
clinics for the pain of acute prostatic retention to be relieved by suprapubic aspiration or a single catheterisation; the patient's general condition
is assessed, his blood urea estimated, and an emergency intravenous
pyelogram done. Prostatectomy is then carried out before the bladder
has had time to fill again unless some contra-indication is found. In this
way " midnight operations " are usually avoided. In most instances one
finds that the patient has already been catheterised before his admission,
but a one-stage prostatectomy under antibiotic and chemotherapeutic
cover is still safe.
The sharp differences of opinion in the use of the catheter amongst
urological surgeons throughout the country were shown by the correspondence in the British Medical Journal starting on December 6th, 1952,
and continuing until March 7th, 1953. All the writers, however, were
agreed on the fundamental need of avoiding infection.
Group 4.-Chronic Retention.
The term " Chronic" implies that the retention has been present for
a long time and in this condition there is little or no pain; the patient
may be quite unaware of his grossly distended decompensated bladder
(Fig. 4). The condition, however, is more serious than acute retention;
long continued back pressure will damage the kidneys, and renal tissue
whichislostcan neverbe replaced. Symptoms of uraemia may mimic those
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THE MANAGEMENT OF ENLARGED PROSTATE
of gastro-intestinal disease; loss of appetite, dryness in the mouth, loss-of
the sense of taste, loss of weight, constipation, nausea and vomiting are
amongst the common complaints. Drowsiness by day, sleeplessness by
night and mental changes are the precursors of uraemia, and if the urine
Fig. 4. Chronic retention with overflow. There is enormous distension of the
bladder, hydronephrosis on the right side and no excretion on the left. The
patient had been catheterised before admission and the urine was infected. Good
recovery after two-stage prostatectomy although the bladder remained atonic
for some weeks.
is also infected the outlook is most serious. The bladder is full and there
may be overflow incontinence. The finding of albumen in a clear urine
is an indication of renal damage.
In chronic retention do not pass a catheter; there is no pain to relieve
and the sudden emptying of a bladder distended for a long time may
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E. W. RICHES
produce such changes of pressure in the kidneys as to give rise to their
flooding with arterial blood and blockage of the tubules. Haematuria
is followed by gradual anuria and death in uraemic coma. The damaged
kidneys are more susceptible to infection and acute pyelonephritis may
supervene on catheterisation and cause death; it is difficult to see how it
can cause the rapid onset of the renal bleeding which sometimes occurs
and this must be a decompression phenomenon. It is remarkable how
well such patients may get along until someone interferes with them. The
worst treatment of all is to empty the bladder by catheter and allow it
to fill again; any drainage established must be maintained until
prostatectomy.
The patient should be sent into hospital where full blood chemistry
estimations are made. His treatment there will vary with the views of the
surgeon. If the blood urea is less than about 100 mg. per 100 ml. and the
intravenous pyelogram shows some excretion, and the urine is not infected
and the general and cardio-vascular conditions are satisfactory it is our
practice to do a one-stage prostatectomy. If any one of these conditions
is not fulfilled, we prefer to drain the bladder first, but a poor general
condition is a more potent reason for drainage than a poor renal function.
When the patient is first seen it is impossible to forecast how long
drainage will be required; prolonged drainage by urethral catheter
inevitably leads to infection in a closed bladder, and when drainage is
needed we therefore prefer to insert a small (16F) suprapubic catheter.
It is put in obliquely from a point well above the pubes and gives a
watertight fit (Riches, 1943). The bladder is decompressed over a Kidd's
U-tube for 12 hours and then allowed to drain freely into a bottle
containing formalin (4 ozs. of 10 per cent. solution). The air inlet to the
bottle is protected by a filter containing formalin tablets (Fig. 5).
When the general condition has improved and the blood urea is stabilised, even if it is still above the accepted normal, prostatectomy is
performed. The high insertion of the catheter leaves a virgin field through
which the operation can be done with adequate exposure.
Associated Medical Conditions affecting Treatment
Acute retention may supervene on a mild degree of chronic retention
in patients who are confined to bed for some other illness such as cardiac
failure or pneumonia. The use of a mercurial diuretic in such a case is
often the precipitating cause of retention. These patients are unfit for
immediate prostatectomy and must have a period of drainage during
which their medical treatment is continued. For them the small suprapubic catheter is life-saving; it can be inserted under a local anaesthetic.
Apart from those in whom the urinary symptoms become acute many
of these patients have more or less serious medical conditions which require
investigation and treatment. Allanby (1952) investigated a series of my
prostatic cases and recorded the results in more than 100. He pointed out
the benefits accruing from delaying operation until the men could be
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THE MANAGEMENT OF ENLARGED PROSTATE
properly investigated, given breathing exercises and made as fit as possible.
The absolute contra-indications for prostatectomy from the cardiovascular aspect are cardiac failure until compensated, cardiac ischaemia
due to coronary artery disease, very recent coronary thrombosis (within
six weeks) or recent symptoms of cerebral arterio-sclerosis, and syphilitic
aortitis with incompetence. Many of these patients can be made fit for
prostatectomy by medical treatment during a period of suprapubic
drainage. Hypertension, valvular disease without incompetence, and
arrhythmias are not considered contra-indications, and operation has
not been forbidden on account of respiratory disease alone. There may
be seasonal reasons for deferring operation in a patient with bronchitis or
r OARMALIN. TABLETS
whAPPED IN GAuIfE.
4- 40
IoPOdLI
Fig. 5. Antiseptic drainage bottle for indwelling catheter, whether suprapubic or
urethral.
emphysema, and one would not operate in cases of active pulmonary
tuberculosis, carcinoma of the bronchus or pulmonary failure. A diabetic
should be stabilised before prostatectomy.
Scorer (1953) treated 150 patients with retention by suprapubic
catheterisation and stressed the value of the method in the older men
desperately ill in a medical ward.
There is rarely need for a formal suprapubic cystostomy but if it is
done let the catheter enter well above the pubes and run obliquely down
to the bladder with a watertight junction. The low suprapubic tube
entering just above the symphysis and passing straight into the bladder
from the lower end of a long vertical incision should never be seen,
although it often is. It leaks and smells and leaves a scarred field for the
second stage of the operation.
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E. W. RICHES
The Surgical Treatment
To return to the one-stage operation which is used in the majority of
cases there are some important points which are applicable whether the
retropubic operation of Millin (1945) or the Harris operation (1934) or
Wilson Hey's method (1945) is used. I prefer the retropubic route
because it gives the best exposure of the prostatic cavity. The same care
is needed before transurethral resection.
Pre-operative Tests
The preliminary tests of renal function done in every case are the
blood urea, and an intravenous pyelogram, unless the blood urea is more
than 100 mg./100 ml. when there will probably be no visible excretion.
A urine concentration and dilution test is also performed in doubtful
cases.
A general examination is made by a physician; this includes an
electrocardiograph in most cases.
Operation
A transverse skin incision gives adequate exposure and heals more
kindly than a vertical.
The most important part of the operation is the removal of the prostate;
it should not be hurried but should be done gently and with care to
preserve the mucous membrane from the verumontanum downwards
(see Figs. 2 and 3).
The main arterial vessels entering at the postero-lateral angles should
be secured or sealed by diathermy before they are divided, and bleeding
should be controllable without the use of any form of pack.
The trigone, which forms a shelf between the bladder and the prostatic
cavity, should be widely resected, and the raw area remaining closed
by sutures of fine plain catgut. This will expedite the complete re-epithelialisation of the cavity (Fig. 6).
Any urethral catheter used for drainage should be anchored by a sling
stitch passed through the abdominal wall rather than by stitches to the
penis. A plastic catheter seems less liable to produce a urethral stricture
than does a red rubber one; it should rarely exceed size 20 (F). The
catheter should drain to a formalin bottle (Fig. 5) and should be removed
as early as possible; 48 hours is generally enough.
Any true diverticulum present should be excised at the same operation
(Fig. 7). Bilateral vasotomy should be performed.
Post-operative Care
Cover against infection is given by penicillin, 300,000 units twice daily,
and sulphadiazine, 0 5 g. four times daily, for five days unless there is
some specific infection present which is sensitive to other substances.
A fliud intake of five pints a day is aimed at. Liquid paraffin is given
from the second day, with an added aperient such as cascara on the
second evening.
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THE MANAGEMENT OF ENLARGED PROSTATE
-4
Fig. 6. Autopsy specimen from a patient who died from pulmonary embolism
16 days after retropubic prostatectomy The bladder neck has healed.
The patient is allowed up after 48 hours; he uses a commode rather
than a bedpan.
During the first 12 hours gentle irrigation of the catheter by a modified
Canny Ryall syringe using sodium citrate (3-8 per cent.) may be necessary
to keep the catheter clear of clots Routine irrigation of the bladder is
not practised.
Complications
Most patients
now leave hospital about two weeks after operation, but
it takes up to two months for the prostatic cavity to heal. In consequence
there may still be some frequency or other evidence of urinary infection
at this stage. As a course of sulphonamide and penicillin and -possibly
other antibiotics has already been given it is better to use a milder urinary
antiseptic if further treatment is considered necessary. An acid urine
is better than an alkaline and hexamine is more useful than potassium
citrate.
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10-2
E. W. RICHES
Epididymitis is generally prevented by ligature of the vas, but still
occurs in a few cases. It takes a less severe course than when the vas has
not been tied, and it is treated by rest and support; its occurrence may
be an indication for further chemotherapy.
Osteitis pubis, an infective complication, is fortunately rare; it
produces prolonged disability but some cases are said to have been
relieved quickly by cortisone.
If the bladder has been over-distended for many weeks before operation
it may remain atonic; in such a case daily catheterisation may be
necessary, combined with Carbachol (oral) 1 tab. b.d. and testosterone
linguets, 10 mg. daily.
Fig. 7. Chronic retention with a diverticulum of the bladder and reflux up the
left ureter. The diverticulum was excised at the time of prostatectomy.
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THE MANAGEMENT OF ENLARGED PROSTATE
Fig. 8. Atonic bladder persisting for two years after prostatectomy in a case of
long-standing chronic retention.
A few of these cases are improved by an extensive partial cystectomy.
Fig. 8 shows the bladder nearly two years after prostatectomy; it
held a gallon before operation and despite preliminary drainage
has never recovered its tone. Chronic retention with overflow had
been present for a long time and this man is going to have a partial
cystectomy.
Post-prostatectomy obstruction at the bladder neck is less common
with the modern practice of trigonectomy; it is treated by endoscopic
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E. W. RICHES
resection. A meatal stricture sometimes occurs. If there is a diminution
in the stream it is wise to pass a metal bougie.
Incontinence is rare and usually transient after open operation for benign
enlargement.
Conclusions
Without attempting to assess the relative merits of transurethral and
open operations one can say with certainty that the results of prostatectomy have improved greatly during the past ten years. The ability to
close the bladder rather than leave in a large drainage tube has shortened
convalescence and made it less uncomfortable. Good results, however,
depend on the absence of infection and gross renal damage. The mortality
is about 4 per cent. and is mainly due to medical conditions. The
mortality is doubled in cases of retention; catheterisation in these cases
introduces the risk of infection and should be avoided or limited to one
act. An indwelling urethral catheter is almost always followed by
infection and although prostatectomy may still be safely accomplished, the
incidence of post-operative complications is increased. Where drainage
for more than two days is likely to be needed the small high suprapubic
catheter has many advantages over the urethral catheter. There is still a
place for the two-stage operation; the indications for it are medical
conditions, gross renal damage and serious urinary infection.
REFERENCES
ALLANBY, K. D. (1952) Arch. Middx Hosp. 2, 162.
BEGG, R. CAMPBELL (1954) Lancet 1, 340.
FERGUSSON, J. D. (1952) Postgrad. med. J. 28, 35.
HARRIS, S. H. (1934) Brit. J. Surg. 21, 434.
HEY, W. H. (1945) Brit. J. Surg. 33, 41.
MILLIN, T. (1945) Lancet 2, 693.
OGIER WARD, R. (1953) Modern Trends in Urology (Edit. Riches) p. 248, London,
Butterworth.
RICHES, E. W. (1943) Lancet 2, 128.
(1954) Trans Med. Soc. Lond. (In the press).
SCORER, C. G. (1953) Lancet 2, 1222.
DIARY FOR AUGUST
There will be no lectures at the College during August.
DIARY FOR SEPTEMBER
Wed.
Thurs.
Wed.
Wed.
Mon.
Tues.
8
9
15
22
27
28
Second L.D.S. Examination begins.
College closed for Staff Outing.
Pre-Medical Examination begins.
First Membership Examination and D.C.H. Examination begin.
D.Orth. Examination begins.
Surgical Lectures and Clinical Conferences begin.
Final Membership Examination begins.
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