RESULTS OF LACERATION OF THE PERINEUM.
[Illustration: FIG. 56.--Rectocele and cystocele.]
=Rectocele.=--A rectocele (Fig. 56) is the tumor formed by the
protrusion of the lower part of the posterior vaginal wall into the
vagina or through the ostium vaginæ. The condition is due to a prolapse
of the posterior vaginal wall, and is caused by the loss of the support
of the perineum, usually the result of laceration at childbirth.
Sometimes the mucous membrane of the vagina alone prolapses, the
anterior wall of the rectum remaining in place. Usually, however, the
anterior rectal wall and the posterior vaginal wall protrude together.
If the rectocele is not so extensive as to protrude through the ostium,
the woman may be unaware of its existence. In many cases, however, the
prolapsing vaginal wall protrudes at the vulvar cleft when the woman is
erect, or when she strains at stool or performs work requiring heavy
lifting. The woman often says that under such circumstances the “womb”
protrudes. On account of the accompanying prolapse of the anterior
rectal wall the passage of feces does not take place in the normal
direction, but the fecal mass is forced into the pouch of the anterior
wall of the rectum, and straining efforts push it forward into the
vagina. The woman says she feels as though the passages were about to
take place through the vagina. This discomfort is relieved by pressing
the rectocele back with the finger during defecation. Accumulation of
feces in the rectal pouch may result in inflammation or ulceration.
The condition is readily recognized by introducing a finger into the
rectum, when it will be found to enter the rectocele.
[Illustration: FIG. 57.--Median sagittal section of the pelvis of a
woman in whom there has been a laceration of the perineum in the sulci,
with rectocele and cystocele. The vagina is no longer a closed slit.]
A rectocele is cured by Emmet’s operation, which restores the support
of the perineum and the posterior wall of the vagina.
=Cystocele.=--A cystocele is a tumor formed by the protrusion of the
lower part of the anterior vaginal wall into the vagina or through the
ostium (Fig. 56). The prolapse of the vaginal wall is accompanied by
prolapse of the posterior wall of the bladder. A sound introduced into
the bladder through the urethra will be found to enter the cystocele.
This test, and the soft, reducible character of the cystocele tumor,
enable us to diagnosticate between cystocele and cyst of the anterior
vaginal wall. The condition is caused by a loss of the support of the
anterior vaginal wall that is furnished by the posterior wall and the
perineum.
In a case of cystocele residual urine often remains in the pouch of the
bladder-wall. In some cases the woman learns that, in order to empty
the bladder, it is necessary for her to push the cystocele upward and
forward at every act of micturition. The result of this inability to
empty the bladder is decomposition of the urine and resulting cystitis.
Many cases of so-called irritable bladder and chronic cystitis are
caused primarily by laceration of the perineum, which produces
cystocele or prolapse of the posterior wall of the bladder; and such
cases can be cured only by curing the cystocele.
A cystocele varies much in size. Every long-standing case of laceration
of the perineum in the sulci presents a certain degree of prolapse
of the anterior vaginal wall. The tumor may remain within the vagina
and be rendered prominent only upon efforts at straining, or it may
protrude through the vulva as a mass the size of a duck’s egg.
As a cystocele is caused by laceration of the perineum, it can be
cured only by repair of this laceration. The most important part of
the treatment, therefore, is perineorrhaphy, which should always be
performed. Usually this operation is sufficient. If the anterior wall
of the vagina is supported, the tissues will recover their tonicity and
contract, and the tumor will disappear.
In some cases, however, where the mucous membrane of the
anterior vaginal wall has become much stretched and redundant
in the normal-sized vagina, it is advisable, in addition to the
perineorrhaphy, to perform a plastic operation on the anterior wall
in order to diminish the area of the vaginal mucous membrane. Such an
operation is called anterior colporrhaphy. A variety of operations of
this kind have been invented. The various forms are modified according
to the requirements of the case and the whims of the operator. In one
form of operation an oval area is denuded (Fig. 58), and the edges
are brought together by interrupted sutures passed beneath the whole
denuded surface.
[Illustration: FIG. 58.--Oval denudation for cystocele: sutures
introduced.]
[Illustration: FIG. 59.--Sims’ operation for cystocele.]
As the transverse measurement of the vagina is greater in the upper
than in the lower part, an operation by which a greater amount of the
excess of tissue is taken in above than below is often desirable. Such
an operation is represented in Fig. 59. Two strips, about one-third
to one-half inch in breadth, are denuded on each side of the anterior
wall, extending from the position of the internal urinary meatus upward
toward the lateral vaginal fornices. The length of these strips varies
with the case, and depends upon the size of the upper portion of the
vagina. It is often desirable to carry the denudation to the level
of the external os. The denuded surfaces are brought into apposition
by interrupted sutures. By this operation the whole caliber of the
vagina is narrowed from above downward. The degree of divergence of the
denuded strips may be determined by seizing portions of tissue with
tenacula upon each side and bringing them together, thus determining
the amount of tension which will be put upon the sutures.
[Illustration: FIG. 60.--Dudley’s operation for cystocele (Ashton,
modified from Dudley).]
In Dudley’s operation the denudation is made and the sutures are
introduced as shown in Fig. 60. The advantage claimed for this
operation is that by it the upper end of the vaginal wall is attached
to the bases of the broad ligaments.
The operation of anterior colporrhaphy must always be accompanied by
perineorrhaphy. The anterior operation should be performed first. The
woman should be placed in the Sims or the dorsal position.
=Enterocele.=--Enterocele, or entero-vaginal hernia, is a rare
condition. It consists of a hernia, or prolapse, of the intestine into
the vaginal canal. Two forms of the disease have been described--the
anterior and the posterior. The latter is the more common. In the
posterior variety one or more loops of the intestine, or the omentum,
reach the bottom of Douglas’s pouch and push the posterior vaginal wall
forward, so that it encroaches upon the vaginal canal and in some cases
protrudes from the ostium vaginæ.
The causes of this disease are not known. It is probably favored by
loss of support of the perineum and the vaginal walls. An unusually
deep pouch of Douglas would predispose a woman to this condition.
In the anterior form of the disease the hernia occurs at the bottom of
the vesico-uterine pouch.
The posterior enterocele may be distinguished from rectocele by
introducing a finger into the rectum and one into the vagina, when the
prolapsed intestine or omentum may be felt between the anterior rectal
wall and the posterior vaginal wall. The condition may be distinguished
from vaginal cyst by percussion and palpation.
In the treatment of enterocele any existing injury to the perineum
should be repaired, and the vagina should be narrowed by one of the
plastic operations already described. Great care should be taken not to
injure with the needle the intestine underlying the vaginal wall.
=Subinvolution of the Vagina.=--It should be remembered, in connection
with the subject of prolapse of the vaginal walls as a result of
loss of the perineal support, that there is always present, also, a
condition of subinvolution of the vagina. During pregnancy all the
elements of the vagina undergo a physiological hypertrophy analogous
to that which occurs in the uterus. After labor the vagina normally
undergoes certain changes by which it is again approximately restored
to the dimensions, shape, etc. that existed before pregnancy. This
change is called the involution of the vagina. Anything that arrests
this process of involution produces a state of subinvolution of the
vagina; this structure is then found much larger and more relaxed than
normal, and a certain hypertrophy of all the elements of the vaginal
walls persists. Such subinvolution of the vagina is caused by the
various pelvic lacerations, which, by causing loss of support to the
pelvic vessels, result in a state of passive congestion.
These redundant vaginal structures usually disappear and contraction
takes place after the operation of perineorrhaphy. In some cases,
however, when the vagina is very much larger and more relaxed than
normal, it is advisable to remove some of the excess of tissue by a
plastic operation on the anterior wall similar to that described for
the relief of cystocele.