A Text-book of Diseases of Women

by Charles B. Penrose

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.