PROLAPSE OF THE UTERUS.
Prolapse of the uterus means a falling of that organ below its normal
level. The condition is popularly spoken of as “falling of the womb.”
There are an infinite number of degrees of prolapse of the uterus,
between the slightest descent on the one hand and complete protrusion
of the organ from the body on the other hand. The term “complete
prolapse” should properly be applied to the entire protrusion of the
uterus outside of the vulva. This condition, however, is most unusual.
The term is generally used to designate those cases in which the cervix
alone, or the cervix and part of the body of the uterus, protrude
from the vulva (Fig. 66). In any case of prolapse of the uterus it is
best to describe in detail the extent of the prolapse and the other
conditions present. Thus, some of the various kinds of prolapse may be
described as follows: “Prolapse of the uterus, the cervix resting on
the pelvic floor;” “prolapse of the uterus, the cervix presenting at
the vulvar cleft;” “prolapse of the uterus, the cervix protruding about
two inches from the ostium vaginæ, with elongation of the supra-vaginal
cervix,” etc.
Injury to the pelvic floor that allows air to enter the vagina destroys
the normal equilibrium of the pelvic contents and exposes the uterus to
a direct abdominal pressure from above, which is not counterbalanced by
an equal force from below, but is opposed by the strength of the uterus
and its attachments and the retentive power of the abdomen. Most cases
of prolapse occur in women in whom the perineum has been injured at
childbirth.
[Illustration: FIG. 66.--Prolapse of the uterus, the cervix protruding
from the vulva. There is a bilateral laceration of the cervix.]
There are a number of predisposing causes of uterine prolapse
that permit the descent to progress after the uterus has begun to
fall--namely: Relaxation of the uterine ligaments that results from too
frequent parturition, from old age, or from tissue-weakness which is
part of a general condition, the uterine ligaments sharing the general
feebleness of the other tissues and structures of the body; relaxation,
loss of rigidity, or muscular weakness of the abdominal parietes,
which diminishes the retentive power of the abdomen; diminution of
the cellular tissue and the fat of the pelvis, such as occurs in
wasting disease or in old age. Anything that suddenly increases the
intra-abdominal pressure, such as lifting a heavy weight, may cause
acute prolapse of the uterus. In some cases the uterus has suddenly
protruded from the body as a result of heavy lifting. In cases of this
character it is probable that the muscular supports of the perineum
have been weakened from some cause, or that the sudden increase of
abdominal pressure drives the uterus downward before the perineal
muscles have time to contract and close the vaginal outlet. In such
cases there is also present rupture of the uterine ligaments. Constant
violent coughing has produced uterine prolapse in a similar way.
Extreme uterine prolapse sometimes occurs in a nulliparous woman in
whom the perineal supports are naturally weak. In such women there
exists a condition of relaxation identical in results with subcutaneous
laceration of the perineum.
Anything that increases the specific gravity of the uterus will make
it sink somewhat lower in the pelvis. Subinvolution, congestion from
inflammation, or retroflexion may do this. In such cases, however,
the prolapse never becomes extreme, rarely extending beyond a slight
sinking of the uterus.
In most cases uterine prolapse takes place slowly. Sometimes many years
are necessary for the development of complete prolapse. The equilibrium
of the pelvic contents is destroyed by one of the causes already
mentioned. The uterus falls through a certain distance before the
uterine ligaments become suspensory. Then, however, its further descent
is impeded.
If the original cause continues to act, the uterine ligaments become
stretched and the descent of the uterus gradually progresses, impeded
to a varying degree also by the retentive power of the abdomen and the
cellular tissue and other pelvic attachments.
As the uterus descends, the vaginal walls attached at the cervix are
dragged down with it, so that when the prolapse becomes complete the
vagina is turned inside out (Fig. 67).
When the perineum has been injured so that the lower portion of the
vagina loses its support and the equilibrium of the pelvic contents is
destroyed, two distinct phenomena occur: The uterus falls as already
described, and at the same time the lower part of the vagina begins to
fall, so that there appear a prolapse of the anterior vaginal wall, or
a cystocele, and a prolapse of the posterior wall, or a rectocele. The
condition finally produced will depend upon which prolapse takes place
the more rapidly--that of the vagina or that of the uterus.
[Illustration: FIG. 67.--Complete prolapse of the uterus.]
If the prolapse of the lower vagina progresses faster than that of the
uterus, then the vagina will begin to drag upon the cervix, to which it
is attached, and under these circumstances the uterus will be subjected
to two downward forces--intra-abdominal pressure from above, and
traction of the vaginal walls acting from below.
[Illustration: FIG. 68.--Prolapse of the vagina and the vaginal cervix,
with great elongation of the supra-vaginal cervix.]
As the traction is exerted upon the lower part of the cervix, and
the body of the uterus is sustained by the uterine ligaments, which
resist the downward traction, the isthmus, or point of junction of the
body and cervix, is dragged out or stretched, so that in some cases a
very marked elongation of the supra-vaginal cervix, or the part of
the cervix above the vaginal junction, appears. This elongation is
sometimes so great that the length of the uterine cavity from external
os to fundus measures six or eight inches. Such elongation of the
cervix is usually found to a greater or less degree in every case of
marked prolapse of the uterus caused by injury to the perineum. Such a
condition should be described as prolapse of the uterus with elongation
of the supra-vaginal cervix (Fig. 68). In many cases the prolapse
of the vagina and the elongation of the cervix are the most marked
features, the body of the uterus falling but slightly below its normal
level. The cervix will be found protruding some distance from the
vulva; the vagina will be found turned inside out; while the fundus
may be felt approximately at its normal level in the pelvis, and the
presenting cervix and the body of the uterus are connected by a round,
cord-like structure about the size of the little finger, which is the
stretched, attenuated supra-vaginal cervix.
[Illustration: FIG. 69.--Prolapse of the vagina and cervix, with
elongation of the supra-vaginal cervix.]
As a result of the traction upon the cervix the blood-flow from the
infra-vaginal cervix is impeded, and passive congestion results in
hypertrophy. This hypertrophy is increased by irritation of the
infra-vaginal cervix from friction against the clothing and from urine,
etc. In such cases the presenting cervix becomes much larger than
normal, sometimes measuring two or two and a half inches in diameter.
It will be seen that very pronounced structural changes are present
in old cases of prolapse of the uterus. The uterine ligaments and
the pelvic attachments become so stretched and atrophied that they
can never become functionally useful again. The normal shape and
size of the uterus become very much changed from elongation of the
supra-vaginal cervix and hypertrophy of the infra-vaginal cervix. The
vaginal canal becomes patulous and stretched several times beyond its
normal dimensions, and the delicate mucous membrane, from exposure,
becomes tough and cutaneous in character. The large protruding mass of
uterus and inverted vagina stretches the genital outlet far beyond its
normal dimensions, and the muscular supports that may have remained
after the original perineal injury undergo atrophy from pressure.
[Illustration: FIG. 70.--Prolapse of the vagina and the vaginal cervix,
with elongation of the supravaginal cervix. Extensive ulceration.]
Accompanying the prolapse of the uterus is usually prolapse of the
bladder and of the anterior wall of the rectum, producing a condition
already described under Cystocele and Rectocele.
Women who do hard manual labor are those who suffer with the most
marked forms of uterine prolapse. The form of prolapse accompanied by
elongation of the supra-vaginal cervix is usually characteristic of the
hard-working woman. Such prolapse of the uterus is common among the
Western Indian women, who return immediately after delivery to hard
labor and horseback-riding.
[Illustration: FIG. 70, _A_.--Elongation of supra-vaginal cervix (St.
Bartholomew’s Hospital Museum).]
Many cases of prolapse would be avoided, even though there might be
serious perineal injury, if women remained in bed a sufficient time
after delivery. By rising too early prolapse is favored, for a variety
of reasons. The uterus is large and heavy; the uterine ligaments are
elongated, and the abdominal walls are weak; consequently the retentive
power of the abdomen is poor; the vagina is flabby and much larger than
normal; the genital outlet has not contracted, and the muscular and
fascial supports which may not have been torn are stretched and relaxed.
The subjective =symptoms= of prolapse vary greatly and are not
characteristic. A woman in whom the uterus has descended but slightly
below the normal level may suffer so much with backache, weakness of
the legs, and a feeling of pelvic weight, or “bearing down,” that her
life will be rendered useless; while, on the other hand, a woman with
complete prolapse of the uterus may suffer no inconvenience except from
the presence of the protruding mass. In fact, the lesser degrees of
prolapse seem to cause more suffering than the extreme degrees.
The first subjective symptoms of injury to the supports of the pelvic
floor that appear when the woman leaves her bed are those referable to
beginning prolapse of the uterus. Backache is the most common symptom,
and occurs here as in almost every other disease of the uterus. The
pain, a dull ache, is situated in the upper part of the sacrum. It
is increased by standing, by walking, or by manual labor. It often
disappears entirely when the woman lies down and the intra-abdominal
pressure is removed from the uterus. Headache situated in the occipital
region or the vertex is also usually present, and varies in severity
with the severity of the backache.
Pain extending down the posterior aspect of the thighs, and a dragging
feeling of loss of support in the pelvis, may also be present. The
rectal and bladder symptoms occur later, when rectocele and cystocele
appear.
There is often very marked general physical weakness, much of which
may be referred directly to the loss of the muscular support of the
perineum. Almost every effort that the woman makes is accompanied by
increase of intra-abdominal pressure, and she feels keenly the loss of
the accustomed perineal support which normally resists any increased
abdominal pressure. In the sound woman the perineal muscles contract
and the vagina is more tightly closed to meet the increased pressure
incident to a muscular effort. In the injured woman the vagina is
open and the pressure is resisted by weak vaginal walls and uterine
supports. She feels that her point of resistance is gone. The best
proof of the profound effect of injury to the perineum upon the general
strength of a woman is given by the operation of perineorrhaphy. The
repair of this apparently slight lesion restores the woman to her
former strength.
The =diagnosis= of prolapse of the uterus is readily made by
examination. In the extreme cases the cervix and the greater part of
the body of the uterus are found outside the vulva. In less marked
cases the cervix is seen presenting at the vaginal orifice as soon
as the labia are separated. In other cases the cervix is felt by the
vaginal finger resting on the pelvic floor. It should be remembered
that every case of prolapse is greater when the woman is standing than
when she is being examined upon her back. Sometimes the cervix will
present at the vulva, where it may be felt when the woman is erect; but
when she lies down and intra-abdominal pressure is removed, it retreats
beyond inspection except through the speculum. In order to determine
the full extent of prolapse, therefore, when the woman is examined on
her back she should be directed to strain or bear down, when much more
marked descent of the uterus and vaginal walls will become apparent.
The lesser degrees of prolapse, in which the cervix has not yet fallen
enough to rest on the pelvic floor, are more difficult to recognize by
bimanual examination. It will be found that the upward range of motion
of the uterus is greater than normal, and vaginal examination when the
woman is erect will make the condition more apparent.
Extreme prolapse of the uterus, in which we find protruding from the
vulva a pear-shaped tumor at the apex of which is the opening of
the cervical canal, should not be mistaken for any other condition.
Inversion of the uterus and a uterine polyp resemble it only in shape,
and in no other particular. If there is any doubt, it may be dispelled
by placing the woman in the knee-chest position, when the prolapse may
readily be reduced and the normal anatomical relations restored.
=Treatment.=--As prolapse of the uterus is usually caused by injury to
the pelvic floor, treatment should be directed in the first place to
the restoration of the perineum.
In slight cases of prolapse that are seen early, restoration of the
perineum by Emmet’s operation is sufficient for cure.
In cases of long duration, however, we have to deal with a variety of
secondary conditions. These are as follows: Hypertrophy of the uterus
from subinvolution or congestion; elongation of the cervix; hypertrophy
of the cervix; elongation of the uterine ligaments; stretching of
the vagina; stretching of the genital outlet; and atrophy of all the
structures of the perineum from pressure. The atrophic changes give the
most difficulty. The prognosis, therefore, depends upon the duration of
the case.
In cases of prolapse in which the cervix has reached or has passed the
ostium vaginæ, rest in bed in the recumbent position should always be
prescribed for two to four weeks before any operative procedure. The
woman should be placed in the knee-chest position and the prolapse of
the uterus and vagina should be reduced. Reduction of this kind should
be practised as often as the prolapse returns--as, for instance, after
straining at stool. It may be performed by the woman herself or by
the nurse. It is well for the woman to assume the knee-chest position
three or four times a day, for five to fifteen minutes at a time. One
or two hot vaginal douches of a gallon of 1:4000 bichloride solution
should be administered daily. The intestinal contents should be kept
soft by laxatives. As a result of such preparatory treatment the uterus
will diminish very much in size, and the vagina and the vaginal outlet
will contract, so that at the time of operating the amount of tissue
to be removed may be more accurately determined. The diminution in the
length of an elongated cervix as a result of rest is most striking,
and demonstrates the truth of the explanation of the etiology of this
condition that has already been given. A uterine canal that measures
five or six inches in length may be reduced to three or four inches
after traction on the cervix has been removed by rest in bed.
Ulceration of the cervix, which is often present as a result of
friction from exposure, readily yields to this treatment of rest and
douches.
From the considerations already referred to it will be seen that the
operative treatment of any case of uterine prolapse varies according to
the special conditions present.
Perineorrhaphy is always necessary. Emmet’s operation is usually
the best one. The denudation in the lateral vaginal sulci should be
extended well up the posterior vaginal wall, in order to diminish the
caliber of the overstretched vagina. One of the operations already
described should also be performed for the cure of the cystocele and
to diminish the area of the anterior vaginal wall. The best of these
operations are Sims’ and Dudley’s (Figs. 59 and 60). After all plastic
operations for the cure of prolapse the woman should be kept in bed for
three or four weeks--the longer the better--so that the perineal and
vaginal structures and the ligaments of the uterus may contract and
regain strength.
In some cases of long standing it is impossible, by operation, to
restore the integrity of the pelvic floor, and to restore the shape,
size, and direction of the vaginal canal so that the normal equilibrium
of the pelvic contents will be re-established. In such cases operators
have attempted to build a direct mechanical support for the uterus.
Le Fort’s operation is an ingenious method of attaining this object.
The uterus should be replaced, and a longitudinal strip of tissue,
about one-half to one inch in breadth and two to two and a half inches
in length, should be denuded on the anterior vaginal wall, extending
from a point near the vulva, where the two vaginal walls are in contact
when the uterus is in place, up toward the cervix. A similar strip
should be denuded on the posterior wall. These two denuded areas should
be brought into apposition by interrupted sutures passed transversely.
Perineorrhaphy should also be performed.
In those cases in which the vagina and the vaginal outlet have become
very much stretched by the protruding mass of prolapsed structures,
Emmet’s operation seems to be insufficient. In such cases the following
operation is useful. This consists in denuding a triangular area on
the posterior vaginal wall (Fig. 77), the apex of the denudation being
immediately below the cervix, and the base at the ostium vaginæ. The
denudation should extend well on to the lateral vaginal walls. The
denuded area is then closed by sutures passed transversely.
[Illustration: FIG. 71.--Prolapse of the vagina and of the
infra-vaginal cervix. The sound showed the internal uterine length to
be 5½ inches. An erosion appears on the posterior margin of the os
uteri.]
Judgment, derived from experience, is necessary in choosing and
performing the various plastic operations for prolapse of the uterus.
In every case of prolapse a certain degree of retroversion of the
uterus is present. In fact, the uterus could not escape from the vagina
unless the fundus were turned somewhat backward. The operation of
ventro-fixation of the uterus is therefore a useful adjunct in some
cases of uterine prolapse. The operation is not intended to furnish
a mechanical support to the uterus, but only to keep it in a position
of anteversion, so that it will less readily escape through the vaginal
canal. The plastic operations and the ventro-suspension may all be done
at the same sitting.
[Illustration: FIG. 72.--Amputation of the hypertrophied cervix: _A._
The cervix has been split laterally. _B._ The posterior lip is being
amputated.]
[Illustration: FIG. 73.--The posterior lip has been amputated.]
[Illustration: FIG. 74.--_A._ Both lips have been amputated and the
sutures have been introduced. _B._ The sutures have been secured by the
perforated shot.]
[Illustration: FIG. 75.--_A._ The anterior vaginal wall is pushed
backward by the staff, while on each side of the median line portions
of mucous membrane are grasped by tenacula and brought together in
order to determine the position of the strips to be denuded. _B._
Denudation on the anterior vaginal wall (Sims’ operation).]
[Illustration: FIG. 76.--_A._ The sutures have been introduced. The
prolapsed vagina and cervix have been reduced. The cystocele is
pushed upward by the staff, so that the denuded strips may be brought
into apposition. _B._ The sutures are secured. The cystocele has
disappeared. The area of the anterior vaginal wall and the caliber of
the vagina have been much diminished.]
[Illustration: FIG. 77.--_A._ A point on the median line of the
posterior vaginal wall, about an inch below the cervix, has been seized
by the tenaculum. This marks the apex of a triangle the base of which
is at the ostium vaginæ and the sides of which are on the lateral
vaginal walls. _B._ The triangle has been denuded. The sutures have
been introduced.]
Whenever there is hypertrophy of the infra-vaginal cervix, this
structure should be amputated in addition to the other operations.
[Illustration: FIG. 78.--The sutures in the posterior vaginal wall have
been secured. The caliber of the vagina has been very much diminished.
A strong sling or band of tissue has been formed immediately above
the ostium vaginæ, which supports the lower portion of the posterior
vaginal wall. The operation is completed.]
In those very rare cases of incurable prolapse that have resisted all
conservative treatment the operation for the removal of the uterus
may be considered. The writer has never resorted to it. The operation
consists in supra-vaginal hysterectomy followed by fixation of the
cervical stump by sutures to the abdominal wall.
This operation, however, should not be proposed hastily. The surgeon
should not become discouraged by one or even two failures of the more
conservative methods of treatment. Though the first plastic operation
may fail to retain the uterus inside the body, yet something is always
accomplished by it, and when supplemented by a second or a third
operation, cure will often result.
The operative procedures required in a case of prolapse of the vagina
and of the infra-vaginal cervix, with hypertrophy of the infra-vaginal
cervix and elongation of the supra-vaginal cervix, are illustrated in
Figs. 71-78.
The condition represented in Fig. 71 is that which is commonly spoken
of as “prolapse of the uterus.” It is the usual form of prolapse. It
may be cured in the very great majority of cases by the operations
which are here depicted.
A great number of mechanical devices have been introduced for the
relief of prolapse of the uterus. Every vaginal pessary has been used
for this condition. None of these implements cure the disease. All of
them, if used continuously, produce ulceration of the vagina and of the
cervix from pressure, and must be abandoned until such lesions heal.
In those cases of prolapse in which pessaries remain in the vagina
and support the uterus, without producing ulceration, operation would
effect a cure.
[Illustration: FIG. 79.--Braun’s colpeurynter.]
Mechanical supports of this kind are only indicated in women in whom
operation is contraindicated on account of old age or for some other
reason. Perhaps the best instrument for supporting the uterus in such
cases is Braun’s colpeurynter (Fig. 79). The uterus should be reduced,
and the colpeurynter, well greased and containing about an ounce of
water, should be introduced in the vagina and then distended with air.
This instrument takes its support evenly from all parts of the vaginal
outlet, and is therefore less apt to produce ulceration from pressure
than the various pessaries. It should be removed at night.