4. DIAGNOSIS, TECHNIQUE OF PHYSICAL EXAMINATIONS


A though guide for the diagnosis of enlargement of prostate….


WHEN the symptoms characterized in detail above are present, the diagnosis of the disease is easy; it only has to be completed by the physical examination of the patient.

TECHNIQUE. The patient is first directed to pass all the urine he can and we note the strength and general character of the stream. After doing this-He is then placed on his back on a couch; the glans penis and foreskin are thoroughly washed with an antiseptic and a soft (rubber) catheter is slowly and carefully introduced. Our choice of catheters will lie between a Nelaton (rubber) or, Thieman vulcanized or a French coude. This latter is, as a rule, the most easily introduced. In nearly all cases I usually anaesthetize the urethra by injecting a few c.cm. (3) of Novocain; by thus diminishing the congestion of the urethra, we facilitate the catheterism considerably. The quantity of urine drawn off, if any,. indicates the amount of “residual” urine. This will vary from a few drachms to three or four pints, according to the phase the disease has reached when the patient first comes for examination. If the quantity be considerable, the patient may be surprised because he had just passed his urine and was of the opinion that he had emptied his bladder. If the bladder is very much distended and the quantity of residual urine be very large, we have to be very careful. Some idea of the amount of the residual urine can be obtained by percussion of the area above the pubes. Dullness on percussion especially in thin subjects, is a valuable guide. As above mentioned, if the whole of a large amount of residual urine should be drawn off too quickly the patient may faint due to the haemorrhage from the blood vessels of the bladder giving way through loss of the habitual support. If the quantity of residual urine be moderate, a second or third subsequent and similar examination should be made to avoid error as to the real quantity of “residual” urine. By introducing the catheter we pay attention to the length of the urethra. If there is considerable lengthening the diagnosis of an enlarged prostate is certain. The passing of a rubber sterilized catheter for the purpose of diagnosis should not set up any trouble whatever.

The next step of the examination is the rectal palpation of the prostate. The patient should be placed on his knees on the couch, with his head bent forward and downward. The buttocks are rendered prominent by the thighs being flexed on the legs. The forefinger, covered with an indiarubber finger-stall is lubricated and introduced slowly and gently up the rectum to avoid giving pain, and a careful survey of the prostate is made. The extent of the enlargement, if any, should be noted, whether it is general, or confined to one lobe or side more than to the other, whether the contour of the gland is smooth or nodulated. What is the consistency, whether soft, indicating adenomatous enlargement, or hard from inflammatory fibroid tumour; also whether pressure on the prostate is painful and, if so, to what degree. Severe pain with fluctuation will suggest the probability of an abscess, particularly, if the patient has had fever recently. Intense hardness with nodulation would suggest malignant tumour (cancer or sarcoma of the prostate); and a very hard nodule in the substance of the gland, accompanied by tenderness on pressure, the presence of a stone in the prostate. The finger should pass beyond the gland, if possible, and sweep the base of the bladder, to ascertain whether it is normally soft or hardened from malignant infiltration. Possibly a stone may be felt in the post-prostatic pouch. The examination will be facilitated by making counter pressure on the abdomen above the pubes with the other hand. We can obtain no information at all by rectal palpation regarding the condition of the amount of outgrowths in the bladder. In fact, there may be a great outgrowth of the prostate into the cavity of the bladder, when no enlargement of the gland is disclosed by rectal palpation. Only cystoscopy can reveal this condition. The cystoscopy gives us a clear and instructive picture of the enlarged prostate. We see the outgrowth of the gland into the bladder, forming a narrow pass for the urethra, we find the so-called third lobe, referred to previously, and we overlook the whole condition of the bladder. Noticing the trabecula and diverticula (ridges, furrows, pockets, etc.), and any inflammation of the mucous membrane. We can discover stones in the bladder, especially in the diverticula, etc. I have to underline, the cystoscopy is indispensable for an exact diagnosis. If performed carefully by an expert, it is neither very painful nor dangerous. During my own practice of about 47 years I have performed many, many thousands of cystoscopies without any serious accident. Certainly, there are cases of prostatic hypertrophy, in which owing to the obstruction of the urethra cystoscopy cannot be performed. The question, whether or not in a given case cystoscopy ought to be resorted to, has to be decided by the expert. If cystoscopy should not be advisable, we have to resort to the X-ray examination of the bladder.

On the whole the diagnosis of enlargement of the prostate is easy, although the same symptoms may be due to various causes- tumours of the bladder, cancer or sarcoma of the prostate, etc. Finally there are cases of retention of urine without enlargement of the prostate.

The following two cases of Dr. Stutzin may illustrate this tent.

Case 1.-F.L., 41 years of age, suffering for the last 30 hours from a complete retention of urine, the bladder overdistended reaches the umbilicus. The patient was extremely excited. While trying to introduce the catheter into the urethra I had most strongly to restrain and argue with the patient; when touching the glans penis with the catheter the patient cried aloud, striking out with hands and feet. Only after getting tired, and after having convinced himself that he had sufficiently resisted, a thick catheter was introduced without any difficulty. Such attacks were repeated at short intervals. There was no mechanical obstruction to the flow of the urine at all, the prostate being rather infantile. Through examining the patient’s history thoroughly it was disclosed, that before such an attack occurred, there was always something of a disappointment; either a conjugal conflict, or a disappointing contemplated law suit, etc. There was quite clearly an escape into the disease and the unconscious intention that by such an annoying retention of urine he would be able to withdraw from difficult situations. For a long time the sexual power of the patient had been greatly diminished.

Case 2.-S.K., 66 years of age, has been castrated 20 years ago in consequence of a tubercular infection of both testicles and a few years became entirely impotent. At the same time very peculiar retentions of urine appeared. The patient always predicts such a retention, he gets evidently more and more excited, till at last the retention occurs. While under clinical treatment everything took place very sensationally. All the other patients had to participate in the affair. The patient, if there is no retention, being able to empty his bladder entirely, at each such retention asks to have the catheter given to him. As soon as he touches the glans with the catheter the urine flow starts voluntarily at once. There is no structure of the urethra, nor is there an enlarged prostate. The patient physically and mentally has the characteristic eunuchoid feature.

Wilhelm Karo
Wilhelm Karo MD, homeopath circa mid-20th century, author of the following books - Homeopathy in Women's Diseases; Diseases of the Male Genital Organs; Urinary and prostatic troubles - enlargement of the prostate; Rheumatism; Selected Help in Diseases of the Respiratory System, Chest, etc; Selected Help in Children's Diseases; Diseases of the skin.