A Text-book of Diseases of Women

by Charles B. Penrose

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.