366 THE ABDOMEN AND PELVIS 



Effects of Prostatic Hypertrophy. The upward growth 

 of the prostate weakens the internal sphincter of the bladder 

 so that urine enters the urethra more easily and the desire to 

 micturate is more frequent. 



A pouch gradually forms behind the collar -like elevation 

 which surrounds the internal urethral orifice, and the urine 

 which it contains can only be evacuated by straining. As the 

 tumour increases in size, the pouch becomes deeper and attempts 

 to evacuate it merely crush down the projection over the orifice 

 of the urethra. The urine in this part of the bladder cannot 

 be passed, and is termed " residual urine." The straining 

 causes hypertrophy of the muscular wall, and for a time this 

 may assist micturition. Ultimately, however, the increasing 

 amount of residual urine leads to dilatation of the bladder, 

 and urine can only be passed by the contraction of the abdominal 

 muscles. The quantity passed at one time is necessarily small, 

 so that the bladder remains constantly distended. This 

 condition may come on very gradually, and the patient, being 

 totally unaware of its nature, only complains of symptoms 

 which are referable to chronic auto-intoxication. 



Attacks of prostatic congestion are followed by complete 

 retention of urine and still further dilatation of the bladder, 

 which may never regain its muscular tone. The rapid evacuation 

 of a greatly distended and dilated bladder by the passage of a 

 catheter may be followed by severe haemorrhage, as the weakened 

 muscular wall, when relieved of its internal pressure, is unable 

 to contract, and the vessel-walls, being unsupported, give way. 



Supra-Pubic Prostatectomy. A catheter is first passed 

 into the bladder, and the viscus is then opened by the method 

 outlined on p. 359. The surgeon inserts his finger, and guided 

 to the internal urethral orifice by the instrument, he scrapes 

 through the mucous coat overlying the prostate with his finger- 

 nail. At the same time the surgeon may pass the index finger 

 of his free hand, suitably protected, into the rectum and use it 

 as a guide and support for his manipulations inside the bladder. 

 Owing to the thinning out of the muscular tissue (p. 365) the 

 tear in the mucous coat at once exposes the prostate, and 

 the surgeon thrusts his finger through into the interval between 

 the capsule and the sheath. This interval is defined by sweeping 

 the finger first round one side of the prostate and then round the 

 other. In the process the prostatic veins are torn through as 

 they pass outwards to join the pudendal plexus. The prostate 



