In this case it may be called a pelvic abscess. It may become an ischio-rectal abscess. Chronic prostatic abscess may be overlooked and unrecognized as the direct cause of many conditions: chronic urethral discharge; vesical and rectal irritation; rectal fistula; chronic inflammation of the prostatic adnexa (the ejaculatory ducts and seminal vesicles); suppurating epididymitis and orchitis; nocturnal emissions. Any abscess of the prostate may open into the rectum, bladder, urethra, perineum, or suprapubic region. Finally there is, in the case of acute abscess, the imminent danger of the general involvement of the pelvic fascia, ending in septicemia. It is manifest that a prostatic abscess is a constant menace; its evacuation must not be delayed. Sometimes the only cure is in complete removal of the gland.
Diagnosis.—There is usually a history of gonorrhea, recent or remote. Fever and a few chills; violent perineal pain, radiating to the rectum and thighs; painful and difficult urination and defecation point to probable suppuration in the prostatic region. A little later perhaps the perineum is reddened, swollen, and infiltrated. Complete the diagnosis by introducing a well-oiled finger into the rectum, which will excite much pain. On the anterior wall of the rectum will be found a large unsymmetrical swelling, more or less clearly defined, which loses itself in a doughy tumor extending toward the sides of the rectum and the anus.
There are two methods of operation: (a) the rectal route when the abscess is about to burst into the rectum; (b) the perineal route, under all other conditions. In either condition general anesthesia is indicated and its vicinity are carefully sterilized and the patient placed in the lithotomy position for the perineal incision.
Rectal route: Place the patient on the right side, flex the left thigh upon the abdomen and let the assistant hold up the left buttock. Dilate the anus and give the rectal mucosa a thorough lavage, washing with soap and water and gauze, followed by an alkaline antiseptic solution. Retract the posterior wall of the rectum with a Sims’ speculum. The anterior wall will thus be exposed to inspection, locate by touch the thinnest part of the abscess wall, for the tumor will not be so conspicuous to sight as it is to the touch.
Perineal route: An incision one inch in front of the anus, transverse, slightly curved with convexity forward (Fig. 257). This incision divides the skin and superficial fascia—edematous, it may be. Separate the edges of the wound and identify, if possible, the muscular composed of the transversus perinei, the sphincter ani and urethra, which, coming from the cardinal points, meet at the “central tendinous point of the perineum,” which is to be next incised.
Vulvar abscess: The labia majora are composed of areolar and fatty tissues, bounded on one side by skin and on the other by mucous membrane. These integuments have many sebaceous follicles and are exposed to various forms of infection and traumatism. Along these sebaceous follicles and the lymphatics, agents of suppuration may travel to reach the areolar tissues, which are so prone to yield to the attack.
Vulvo-vaginal abscess: Beneath the vaginal mucous membrane, near the junction of the lateral and posterior walls, between the lesser labium in front and the triangular ligament behind, is Bartholin’s gland. The gland is normally about the size of a small almond, and is about one or one and one-half inches from the vulvar orifice.
Pelvic abscess: Separating the pelvic peritoneum from the organs of this region are loose areolar tissues which are prone to suppurate when attacked by infective agents. Pelvic cellulitis usually begins as a lymphangitis, following the absorption of bacteria from some pelvic focus, usually the Fallopian tubes.
<Callout type="important" title="Immediate Action Required">A prostatic abscess must be evacuated immediately due to the risk of septicemia and general involvement of the pelvic fascia.</Callout>
Operation.—Cleanse the parts carefully under local or general anesthesia, incise the tumor in the direction of the long axis of the vagina from within outward (Fig. 260). Incise thoroughly, as this is the means of securing the drainage that will prevent a fistula.
Subphrenic abscess: A localized peritonitis is possible only in those localities not occupied by coils of small intestine. The region immediately below the diaphragm is of this character and it is practically shut off from the general peritoneal cavity by the transverse colon and its mesocolon.
<Callout type="risk" title="Risk of Complications">Failure to promptly address a prostatic abscess can lead to severe complications such as septicemia, recto-vaginal fistula, or chronic inflammation.</Callout>
Key Takeaways
- Prostatic abscesses require immediate surgical intervention to prevent septicemia.
- Diagnosis involves a thorough examination including rectal and perineal inspection for swelling and pain.
- Two primary methods of operation are the rectal and perineal routes, each with specific incision techniques.
Practical Tips
- Ensure proper sterilization before any surgical procedure to prevent further infection.
- Use a Sims’ speculum to retract the posterior wall of the rectum for better visualization during rectal route operations.
- Promptly address any signs of abscess formation in the prostatic region to avoid severe complications.
Warnings & Risks
- Failure to promptly evacuate an abscess can lead to septicemia and other life-threatening conditions.
- Improper surgical technique may result in injury to surrounding tissues or organs, such as the rectum or urethra.
- Inadequate drainage after surgery can cause a fistula formation.
Modern Application
While modern medical practices have advanced significantly since 1915, the principles of prompt diagnosis and surgical intervention for abscesses remain crucial. Understanding historical techniques provides valuable insights into emergency care when conventional medical facilities are unavailable.
Frequently Asked Questions
Q: What are the primary symptoms indicating a prostatic abscess?
Symptoms include violent perineal pain radiating to the rectum and thighs, painful urination and defecation, fever, chills, and a reddened, swollen, and infiltrated perineum.
Q: What are the two main surgical approaches for treating prostatic abscesses?
The two primary methods of operation are the rectal route when the abscess is about to burst into the rectum, and the perineal route under all other conditions.
Q: Why is immediate action necessary in cases of prostatic abscess?
Immediate action is required because a prostatic abscess poses an imminent danger of general involvement of the pelvic fascia, leading to septicemia and potentially fatal complications if left untreated.