A Text-book of Diseases of Women

by Charles B. Penrose

The pessary should not be used when there is a laceration of the cervix uteri, for traction upon the posterior lip of the cervix increases the eversion.

The pessary is contraindicated in all cases in which there are pelvic adhesions restraining the uterus, in those cases in which there is inflammatory disease of the Fallopian tubes, and in cases where there is prolapse of the ovary, which may be pressed upon by the upper bar of the pessary.

Before making any attempt to replace a displaced uterus the physician should always make a careful bimanual examination to determine the existence of any acute or chronic inflammation of the Fallopian tubes or the ovaries. Such inflammation is a contraindication to the use of the pessary and to any of the manipulations for replacement of the uterus that have already been described.

If the uterus is adherent, the pessary should not be used. Cure of the retroversion by it is practically impossible, and operative treatment is safer and more certain.

Operative Means of Treating Retrodisplacement of the Uterus.—A great many kinds of operation have been introduced for curing retrodisplacement of the uterus. The fundus has been attached to the anterior abdominal wall by passing a needle and a suture into the uterus and thrusting it through the uterine wall and the anterior abdominal wall; the uterine cornua have been sutured to the anterior parietes; the round ligaments have been shortened by folding each upon itself, and fixed in this position by suture; the round ligaments have been drawn back through openings made in the broad ligaments and attached by suture to each other and to the posterior surface of the uterus; the utero-sacral ligaments have been shortened; the uterus has been held forward by sutures applied through the anterior vaginal fornix.

The two operations that have deservedly met with the greatest favor are ventro-suspension of the uterus, in which the abdomen is opened and the fundus is sutured directly to the anterior abdominal wall, and Alexander’s operation, in which the uterine displacement is corrected by shortening the round ligaments as they emerge from the inguinal rings. The latter operation is designed to be extra-peritoneal. The following is the method of performing Alexander’s operation:

The uterus should first be replaced as already described, and held in position by a gauze or cotton pack. A two-inch incision is made from the pubic spine in the direction of the inguinal canal. The external inguinal ring is opened without wounding the pillars. The thin layer of fascia over the ring is divided, the fat is separated, and the round ligament is sought with a blunt hook. If the ligament is not found here, the canal may be opened to the internal ring. When one ligament has been found, it is secured with forceps and the wound is protected while the other ligament is secured in a similar way. The ligaments are then gently drawn out until they become tense. If the inguinal canal has been opened, it should be repaired by a catgut suture.

The ligament should be sutured to the pillars of the ring by two or three sutures. The excess of the ligament, sometimes amounting to two or three inches, should be cut off. The incision should then be closed.

The field of this operation is very limited. It is not applicable when there are adhesions nor when there is disease of the tubes or ovaries requiring operative treatment.

Many of the cases of retroversion of the uterus that require operative treatment are complicated by salpingitis and pelvic adhesions, though these extra-uterine conditions are very often not recognized by bimanual examination before the abdomen is opened.