The section of the urethra and bladder is made from the former into the latter ; in the male the corpora cavernosa should be separated through the septum. The incision into the bladder must terminate in that already made. <Callout type="important" title="Important">Always ensure the incision aligns properly to avoid complications.</Callout> 1. The Bladder. (a.) General Morbid Conditions. The distention of the bladder naturally depends upon its contents ; still there are cases where it is rather owing to some mechanical obstruction, outside the bladder, to the discharge of urine, or to muscular paralysis of the bladder itself. In the former case the walls are thickened also, to be diag- nosticated from the appearance of the inner surface, as the bundles of unstriped muscular fibre are thickened and become very prominent, trabecular hypertrophy., while between them very deep pockets are often situated (diverticula). Thickening of the vesical mucous membrane alone is pro- duced by oedematous swelling, which may result from many kinds of inflammation of the bladder itself, or in its imme- diate vicinity. The shape of the bladder is frequently altered when the place where the urachus formerly opened is made prominent as a small conical projection. This represents the lowest degree of the more marked deformity, where the urachus remains open to a greater or less extent. Another variation in shape is produced by small pocket-like projections of the walls, diverticula, which are usually situated on the posterior wall and are partly congenital, and partly acquired in the manner already described. In most cases the color of the mucous membrane is pale gray, though injected veins are often prominent in the trigonum, and near the origin of the urethra, especially in old females. In recent inflammation the color becomes red, when very severe a dark red, but it is seldom uniform over the whole surface, being often confined to the projecting muscular bundles, and always more marked here than in the surrounding portions. A slaty color indicates chronic inflam- mation, and is distributed in like manner. The consistency of the vesical walls increases with the thickness. The mucous membrane if oedematous is often soft and gelatinous. (b.) Special Morbid Conditions. Hsemorrhages are the first affections to be mentioned, and may be the accompaniments of inflammatory processes, or may result from a general hasmorrhagic diathesis (phosphorus poisoning, etc., endocarditis ulcerosa). Inflammation of the bladder is either simply catarrhal^ when the mucous membrane is swollen and more or less red- dened, or it is purulent with intense reddening, swelling, and a purulent secretion ; it may also he fibrinous (more rarely), with the formation of a false membrane easily removed, or diphtheritic and necrotic, which produces different appear- ances, according to the extent and degree. In recent cases gray deposits are occasionally seen tightly adherent to the red- dened and hsemorrhagic mucous membrane of the trigonum, and to that covering the muscular bundles of the fundus. In more advanced cases these are increased both in area and in depth, and on section a gray infiltration within the mucous membrane may be seen. In the most severe and certainly in the rarest cases, the whole mucous membrane may become necrotic, and separate as a complete cast from the muscular tissue. In such cases it is usually studded with concretions and consequently has a sandy feel. Tuberculous affections of the cystic mucous membrane possess great interest and have a characteristic appearance. The two forms which have often been mentioned occur here also, the disseminated, acute miliary tuberculosis rarely, but the localized form leading to the formation of ulcers is met with more frequently. In relation to the first, it is to be remembered that lymphoid follicles exceptionally occur, which may be easily mistaken for tubercles. They may be distin- guished from tubercles by their size, frequent regular dis- tribution, and the absence of any trace of cheesy degeneration in their centre ; their appearance without other tuberculous affections is also of importance, and the presence of vessels within them is easily recognized by the microscope. The second form is especially interesting, as the tubercles in the bladder tend to form in a typical manner the char- acteristic so-called lenticular ulcers. These are the ulcers which have been already described as occurring in the bronchi, being characterized by a flat cheesy base and a sharp jagged border, within which intact nodules are situated. The mucous membrane around them is often reddened, and they frequently coalesce, forming larger ulcers which have a scalloped outline. The favorite seat of these ulcers is also the trigonum and fundus. They occur only in extensive tuberculous affections of the urinary and sexual apparatus, especially of the male. Tumors of the bladder are relatively rare, especially the primary form. Secondary carcinoma of the posterior wall in cases of carcinoma uteri, is the most frequent. In the begin- ning, merely rounded projections of the mucous membrane are to be seen ; later, however, small nodular tumors appear upon the surface and may finally attain a considerable size, and also break down by the extension of the ulcerative pro- cess from the Vagina, thus producing a vesico-vaginal fistula. Sometimes the secondary nodules are situated around the opening of one of the ureters, so that hydronephrosis results ; still obstruction of the ureter by tumors is more frequent when they are situated behind or near the bladder. Among the primary tumors, besides the soft cancers which appear in the form of large nodules, there are the so-called villous cancers (carcinoma papillosum). These send projec- tions into the bladder in the form of papillee, which are often arborescent, and contain cylindrical cancer cells and numer- ous vessels, so that vesical haemorrhage often results Their favorite seat is on the trigonum Lieutaudii. The ends of the 230 DIAGNOSIS IN PATHOLOGICAL ANATOMY. papillae often become enlarged by incrustations of uric acid salts, when they become of a light yellow color, and float very freely when water is poured upon them. They must not be confounded with condylomata, which also possess villi. The means of distinguishing them were mentioned in treating of cancer of the skin. Rupture of the bladder, besides resulting from tubercu- lous and carcinomatous ulceration, may also be produced by direct mechanical injury, especially during child-birth and in the operations attending it. It usually follows partial ne- crosis of the posterior or often of the anterior wall only, where it presses against the symphysis. Such an injury and con- sequent necrosis is followed by a violent gangrenous inflam- mation of the connective tissue about the bladder (^pericystitis gangrcenosa). 2. The Urethra. Many affections of the urethra are similar to those of the bladder, and not unfrequently diseases in the latter extend into it, especially into the posterior portion of the male urethra. Only those alterations therefore which are peculiar to this tract will now be considered. An affection of the blood-vessels, which appears more particularly in females, has been incidentally mentioned in considering the bladder ; it consists in a dilatation and injection of the veins at the neck of the bladder, and of those of the urethra, the so-called vesical varix. Simple thrombosis (even phlebolites) and the inflammatory form (thrombophlebitis) may occur, followed by embolism of the lungs. In geneial, the more complex male urethra is much more subject to disease than that of the female. One of the most important is narrowing, stricture of the urethra. It may occur in all degrees, from the very slightest contraction to an almost complete closure, through which it is next to im- possible to pass the smallest probe. The stricture is usually situated within the membranous portion, and a fibrous thick- ening (from chronic inflammation) or cicatrices (from ulcers of the mucous membrane) may be observed, both at the place where the stricture is situated and in its immediate vicinity. Lacerations are often present in cases of stricture, false pas- sages being made by improper catheterization. Some of these may be recent, while others are of long standing and already partially healed. The same thing happens when the canal is narrowed by enlargement of the prostate, and one then sees, especially in the prostatic portion, long canals which run outside the urethra and into the prostate. Such a laceration may cause suppuration about the urethra within the gland (peri-urethritis), and when the abscess (peri- urethral) discharges into the urinary tract, an extensive gan- grenous inflammation of the cellular tissue may result, owing to the effect of the urine upon the tissues. Such an effect may also be brought about by anything which causes per- foration of the urethra. Of the remaining affections tuberculosis may be borne in mind. This occurs onl}^ in the male, and has the same ap- pearance as in the bladder, but more frequently causes exten- sive destruction of the walls, especially in the pars prostat- ica. The wider female urethra is more frequently the seat of tumors, of which the condylomata are most frequently found. {d.') THE PROSTATE. The prostate is to be examined by dividing it transversely in front of the colliculus seminalis ; variations in its size are very common, as it is frequently enlarged, especially in old men. The enlargement may involve both lateral lobes, and is then of comparatively little importance, or it may affect the so-called middle lobe, which, as is well known, first ap- pears in consequence of its enlargement. It then projects more or less into the neck of the bladder, and may be the cause of hypertrophy and catarrh of the bladder, and of lacerations of the urethra from catheterization (false pas- sages). Atrophy may be the result of chronic inflammatory proc- esses, and also occurs in old subjects. In such cases the sec- tion is very frequently found to be covered with black or 232 DIAGNOSIS IN PATHOLOGICAL ANATOMY. brown pigment, as though sprinkled over with snuff. These little brown concretions, the so-called prostatic calculi, may, under certain conditions, attain a very considerable size, and in part show the amyloid reaction. Purulent inflammation (prostatitis apostematosa) affects sometimes only one lobe, and again, the whole organ ; all degrees may be found between abscesses the size of a pea and suppuration involving the whole gland. In the latter case, the discharge may take place on either side, especially on the posterior. When tuberculosis exists in the urinary organs, the pros- tate, as a rule, is also affected. In recent cases, only small, cheesy nodules are seen, and fresh, gray tubercles are sit- uated in their neighborhood. Later the cheesy masses in- crease in size, soften in the centre, and large cavities filled with soft, cheesy material, are then seen ; they are sur- rounded by a firm, dry, yellow mass, around which an in- distinct tubercular eruption is frequently met with. Hypertrophy may be due to either an increase (hyper- plasia) of the glandular portion or of the interstitial tissue. The former is soft, grayish-yellow, and a fluid rich in cells may be pressed (adenoma) from the section ; when the cut surface is examined the ducts of the gland are seen provided with conical projections. No fluid can be pressed from the latter form, and upon section, only the fibro-muscular inter- stitial tissue is seen to be increased (^fihromyomd). The two forms may occur combined. Tumors of a carcinomatous or sarcomatous nature also are met with, though but seldom. (e.) THE VESICUL^ SEMINALES AND THE VASA DEFE- RENTIA. In order to examine the vesiculce seminales, the floor of the fossa between the rectum and bladder is to be turned upwards, so that the prostate may lie upon the left index finger, the posterior wall of the bladder is then to be strongly drawn away with the thumb from the anterior wall of the TESTIS, EPIDIDYMIS, AND SPERMATIC CORD. 233 rectum, which is held by the middle finger. The two sacs will then be seen as two long projections behind the neck of the bladder. They are then opened for examination by making a longitudinal incision through them. The ends of the vasa deferentia may be easily seen at the same time, and may be slit open with a pair of small scissors. The contents of the vesiculas seminales are subject to many variations, both in respect to quantity and composition. It is not always possible to find spermatozoa, even when the contents of the vesicles are present in large quantities ; in their stead are round cells, which contain, especially in old subjects, and cachectic individuals, abundant bro^wn pigment- granules. These may give to the whole fluid a brown color, apparent to the naked eye. The consistency of this fluid is frequently thick and gelatinous, in which case round or cylin- drical colloid masses, often containing empty spaces, are found with the microscope. Inflammation is rare, but chron- ic, fibrous, and purulent forms occur. The changes most frequently found both in the vesiculge seminales and their excretory ducts, are those produced by tuberculosis, which presents the same characters here as in the ureters, and is associated with general genito-urinary tuberculosis. In an early stage the innermost layer of the mucous membrane is of a yellow color, and covered with a thin layer of cheesy material. Later, the canal becomes filled with this mass, and the yellow color (cheesy degeneration) of the wall extends further in. At the same time a chronic inflammation is set up at the periphery, giving to the connective tissue a fibrous character. (/.) THE TESTIS, EPIDIDYMIS, AND SPERMATIC COED. In examining the testes their 'position is first to be noted. As is well known, it not unfrequently happens that either one or both do not lie in the scrotum but in the abdominal cavity, or somewhere within the spermatic canal (pnonorchis^ cryptorehis'). In the latter case it is often possible to deter- mine their position by feeling upon the outside. In such 234 DIAGNOSIS IN PATHOLOGICAL ANAT03IY. instances their size is almost always abnormal, being usually small, and the tissue atrophied; sometimes, however, they are enlarged. Such retained testes are liable to be the seat of various kinds of tumors. 1. The Spermatic Cord and Tunica Vaginalis Propria. The spermatic cord demands attention, before the testis, occupying its normal position within the scrotum, is reached. Various affections may be found bearing the generic name of cele. First varicocele, a thickening of the whole sper- matic cord, caused by a varicose dilatation and coiling of the veins of the plexus pampiniformis (most frequent on the left side). Then comes hydrocele with its various sub- divisions. Congenital hydrocele is that variet}'' in which the pocket of peritoneum (processus vaginalis peritonei), pro- duced by the descent of the testis, remains open ; the testis lies as a prominent body at the bottom of and within the pouch. Another form is hydrocele of the cord, in which the walls of the peritoneal pocket are united above the testis, and at the origin, while the portion between these two points is converted into a cystic enlargement, varying in size and position. If there are several cystic dilatations pres- ent, the term cystic hydrocele of the cord is used. This may be easily mistaken for a hydrocele herniosa, which is pro- duced by a collection of fluid within a hernial pouch the ori- fice of which is obliterated. As a rule this sac lies near the peritoneum, and is often surrounded by a thick, fatty capsule. Hydrocele tunicce vaginalis propprice testis leads us directly to the testis, it being an affection characterized by a collection of fluid between the parietal layer of the pouch and the testis. The fluid is sometimes clear, watery (with fibrinogenous substance), at others purulent, and very fre- quently bloody, especially in large hydroceles. The blood has often undergone changes, and the contents of the sac then have a chocolate color and a pulp-like consistency (Ä00- matocele~). Sometimes the watery fluid is cloudy, like milk, due to the presence of cells containing fat granules, granular THE TESTIS AND EPIDIDYMIS, 235 corpuscles, or to fat drops. At the upper extremity of the testis, cysts, which may attain the size of a walnut, project into the sac and are connected with the spermatic canals, and consequently contain spermatozoa (spermatocele) . Cysts may also arise from what is known as the hydatids of Mor- gagni. The walls of a true hydrocele of long standing show many changes of an inflammatory nature^ so that there is no sharp line of demarcation between the two. The changes consist principally in a sclerotic thickening (periorchitis fibrosa)^ which is often partial and may become cartilaginous or calcified. At other times, growths resembling warts, pa- pill«, etc. (periorchitis prolifera'), make their appearance ; these also consist of a dense fibrous tissue, and may become detached (free bodies), often being calcified in their centre. Finally other cases may present an adhesion between the tunica
Key Takeaways
- The bladder and urethra can show various signs of inflammation, obstruction, or tumors.
- Tuberculous affections are a significant concern for the urinary tract, especially in males.
- Strictures and varicoceles are common issues that need careful examination.
Practical Tips
- Always ensure proper alignment when making incisions to avoid complications during bladder and urethra examinations.
- Be cautious of signs of tuberculosis, as it can lead to extensive damage if left untreated.
- Regularly check for varicoceles in males, especially those with a history of testicular issues.
Warnings & Risks
- Incorrect incisions or improper handling of the prostate can lead to severe infections and complications.
- Tumors in the bladder or urethra may not always be visible, so thorough examination is crucial.
- Hydroceles can mimic other conditions, so it's important to differentiate them accurately.
Modern Application
While this chapter provides valuable insights into diagnosing urinary tract issues, modern medical practices have significantly improved diagnostic tools and treatments. However, understanding the signs of inflammation, obstruction, or tumors remains critical for initial assessments in remote or resource-limited settings.
Frequently Asked Questions
Q: What are some common signs of bladder distention mentioned in this chapter?
Bladder distention can be naturally caused by its contents but may also result from mechanical obstruction, the discharge of urine, or muscular paralysis. The walls of the bladder become thickened when there is a mechanical obstruction, and the mucous membrane may show signs of oedematous swelling due to inflammation.
Q: How can one differentiate between a hydrocele and a hernia?
A hydrocele involves a collection of fluid within a peritoneal sac, often near the peritoneum with a fatty capsule. A hernia, on the other hand, is caused by a protrusion of abdominal contents through a weak spot in the abdominal wall, typically with an obliterated orifice.
Q: What are the signs of tuberculosis affecting the bladder and urethra?
Tuberculosis can cause extensive destruction of the bladder walls, especially in males. It presents as cheesy nodules and gray infiltrations within the mucous membrane. Chronic inflammation is also a common sign.