RESULTS OF LACERATION OF THE PERINEUM.
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.
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.
Fig. 58.—Oval denudation for cystocele: sutures introduced.
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.
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.