REVIEWING the symptoms of the disease we have to keep in mind that its progress is usually very slow. It may cover many, many years. We have to differentiate three different phases of the disease, which is nearly all cases repeat themselves with the greatest regularity: the first phase is the premonitory period, the second phase is the period characterized by retention of urine without distension of the bladder, the third and last phase is the period of the retention of urine with distension of the bladder. In each of these three phases there may be superimposed congestions or infections, resulting in altering the symptoms.
During the first period the symptoms usually are of such a slight nature, that only a few patients ask for medical advice. There is only a slightly increased desire to micturate during the day and the night; in some cases there may be a slight burning in the urethra, especially in its glans, some patients have to wait longer than before till the flow of the urine starts. That symptoms, indicating that there is an obstruction to the urinary flow, appears more prominently whenever the patients for a longer period have not passed urine. Consequently it is more troublesome early in the morning. During the day, as soon as the patients walk around, the flow of the urine is much easier. The urine itself is clear, the general feeling of the patient good, but there is diminution in the strength of the urinary flow, which, instead of being projected in the normal curve, falls directly downwards from the meatus by its own weight. When during the day the patients have been lying or for a longer period have been reading, the micturition is more difficult than during walking about. All these symptoms are aggravated by each congestion of the pelvic organs; consequently constipation, excess in eating or during or sexual excesses, especially after getting wet through, when all these patients feel worse, the desire to micturate is increased. The patient strains to propel the urine onwards but his efforts have little or no effect in strengthening the stream, on the contrary, the straining may arrest it completely. During the night the amount of urine is much greater than during the day. But there is no residual urine in the bladder. During the first phase of the disease the patient is able to empty his bladder entirely. This is an important feature in the diagnosis of the trouble.
That first period may continue for many, many years, till gradually an incomplete retention of urine becomes established and the second periods starts. The symptoms of that period are the same as the symptoms of the first phase, but they are aggravated and increased. The frequency of micturition is raised; the patients during the night must get up six to eight times to pass urine, being to do so while lying down; the pains are intensified; local congestion or even inflammation of the mucous membrane of the bladder ensures and thus induces further frequency. Periods without any pains, so frequently met with in the first phase of the disease, are getting shorter and shorter, till they finally disappear entirely. These new aggravated symptoms are due to the formation of the post-prostatic pouch spoken of above, in which gradually an increasing quantity of urine is retained after micturition. This retained urine is, as we have already seen, termed “residual” and the manner in which it causes increased frequency requires an explanation.
RETENTION OF URINE
THE bladder is a reservoir capable of containing a certain quantity of fluid, which is voluntarily discharged at convenient intervals. Let us assume, that the quantity passed during 24 hours is 50 ounces and that the capacity of the bladder is 10 ounces. It will thus be necessary to empty the bladder at least five times in the 24 hours. But if, the actual capacity remaining the same, 4 ounces of urine in the pouch, formed behind the prostate, are retained, it follows that the effective capacity is reduced to 6 ounces, so that in order to get rid of the 50 ounces, that daily flow into, it, the bladder must be discharged of these 6 ounces about eight times. Quoted from Freyer’s Lectures.
As the pouch enlarges and the bladder walls grow weaker, the quantity of urine permanently retained increases and its effective capacity diminishes, so that eventually micturition has to take place every half hour or even less. Indeed, this condition advances in the third period to such an extent that the bladder is incapable of discharging any urine whatever; and a serious symptom appears -continuous dribbling; the urine passing away by day and night as rapidly as it enters the bladder from the ureters, butt the bladder always remaining full. The urine passing in this condition is termed the “overflow” and has to be distinguished from “incontinence”, a rare occurrence in certain spinal complaints, in which the urine runs away from an empty bladder as fast as it goes in.
In this third phase of the disease there is always a remarkable distension of the bladder. The patients are not able to pass the urine voluntarily, or at best, if the bladder is over full, a few drops, but they can manages it only with the aid of the abdominal muscles. The patients kneels down, stoop low and forwards to find some position in which they are able to pass a few cubic centimeters of urine. In some cases the distension of the bladder is enormous. I remember patients, whose bladder contained more than 3 pints. In some cases there is the most astonishing fact, that the patients do not show any symptoms at all by that condition. Though the distended bladder full up nearly the whole abdominal cavity, there is no essential pain. Certainly the general condition of the patient has deteriorated, the patients are weal and emaciated, nevertheless they feel fairly well.
The progress of the disease is not always the same. It is frequently complicated by the interference of an acute and complete retention of urine. The patient having been able to pass the urine without any difficulty, all at once is unable to pass a single drop of urine, in spite of the greatest strain, in spite of using the abdominal muscles, in spite of hot baths, in spite of taking all kinds of medicines, the flow of urine is entirely stopped. The earlier such an acute retention of urine occurs, the greater the pains, since in the early phase of the disease there is no distension of the bladder, the muscles of the bladder being unable to give way to the pressure of the urine. Consequently, while the filling of the bladder by the urine coming down from the kidneys increases, the most terrible bladder-spasms arise, in a word, the most painful and most tormenting condition to which anyone may be liable. Restlessly they move about, trying to get rid of the urine. Every few minutes they move about, trying to get rid of the urine. Every few minutes they make the attempt, but everything is in vain. If there is no help and if that inflation of the bladder continues, the bladder gets violently overdistended and the most serious, often irreparable damages takes place.
Such a retention of urine is due to an engorgement of the blood vessels of the bladder and prostate. All circumstances, above mentioned, which increase the symptoms of a simple hypertrophied prostate, may induce such a complete retention. Such a retention thus occurs during the first or the second phase of the disease, but not in the third phase, because there is already a remarkable chronic retention, which has stretched the bladder-wall to a certain amount of accommodation. As a rule the disease commences with such an acute retention or at least makes it manifest. To the slight symptoms, so often existing in the first phase of the disease, the patient does no pay any attention at all until suddenly such as acute retention occurs compelling the patient to send for the doctor. As a matter of course, the disease has been established already, perhaps for many years. The fact, that such an acute retention again disappears and that the patient latter on is able to pass his urine just as before that attack, proves, that the retention is due to the congestion of bladder and prostate. But, unfortunately, we never know for certain whether or not the patient will be able to pass his urine voluntarily thereafter. Some patients, after a single acute retention, never again are able voluntarily to empty their bladder. But that is an exception. In most cases the congestion disappears and after a couple of days, or weeks or months the patients pass urine without any trouble.
But an entirely different condition arises in the cases in which gradually a chronic retention develops. Such cases are due to a permanent mechanical obstruction: either the overgrowths of the lateral lobes of the prostate have entirely compressed the urethra prostatica, or the middle lobe, spoken of above, obstructs the neck of the bladder like a valve. Such an obstruction is characterized by the fact, that the more the patient strains to overcome the obstruction, the stronger the valve-like tumour closes, making all endeavors of the patient ineffective.
The acute retentions frequently may recur. There are patients who after the slightest irregularity of living or following a slight cold get such an acute retention. In other cases such a retention recurs only after some years. Finally fortunately I have known patients, who had only a single retention and who for many years never again were taken ill.
But we are aware that an acute retention is the commencement of a chronic incomplete retention, that is to say: after the acute retention has gone and the patient is able to pass the urine voluntarily, there remains a certain amount of residual urine in the bladder.
As a matter of fact, if such acute retentions occur frequently, or if there is a chronic retention for a long time, the constitution and the whole organism will be most seriously affected. At first disorders of the digestive organs appear- always presupposed, that there is no infection of the bladder. The patents lose appetite, they do not care for meat or solid food, preferring liquid food. These disorders are the symptom of a serious blood-intoxication, a so-called urosepsis, the pressure of the residual urine on the kidneys, makes them unable to eliminate the products of metabolism from the blood.