A Text-book of Diseases of Women

by Charles B. Penrose

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.