Congestion of the uterus consequent upon obstruction in the stretched and displaced veins is often so extreme as to induce a state analogous to erection. Measurements by the probe just before and a few minutes after replacement generally show an appreciable decrease in the length of the uterine canal. If the prolapse has been of the third degree, the difference may amount to one or even two inches. It is important not to confound the enlargement of congestion with increase in the solid constituents of the organ.
SYMPTOMS AND COURSE.—A dragging sensation and pelvic and abdominal pain are generally present. Rectocele and cystocele and rectal and vesical catarrh often cause painful and severe functional disturbances of the rectum and bladder. In descent of the third degree excoriations of the exposed vagina and cervix sometimes cause extreme suffering. The course is ordinarily chronic, but attacks of acute vaginitis and pelvic peritonitis are not uncommon. The peritonitis sometimes effects a spontaneous cure by peritoneal adhesions which fasten the uterus in an elevated position and hold it permanently. The symptoms of descent may be so severe as to necessitate absolute rest in bed. In other cases they are often attended with very little discomfort.
DIAGNOSIS is by inspection, palpation, and exploration. The prolapsed uterus may be distinguished from cystocele, rectocele, inverted uterus, and fibroid tumor by the presence of the os externum. The sound may be passed through the urethra into the cystocele, and the finger through the anus into the rectocele. The length of the uterus may be determined by the sound, the size, shape, position, extent of descent, and difficulty of replacement by conjoined manipulation.
PROPHYLAXIS.—This requires such measures during labor as may be necessary to prevent long and powerful pressure upon the pelvic floor. After labor any injury to the perineum should be promptly repaired. The vagina should be kept clean by irrigations. The urine, if necessary, should be regularly drawn and the bowels moved daily without straining. If conditions be present likely to induce subinvolution—such, for example, as pelvic inflammation or laceration of the cervix—they should receive treatment at the proper time. Undue relaxation of the pelvic floor necessitates a more prolonged rest in bed, the use of astringent douches, and the application of a pessary when the patient resumes the upright position.
TREATMENT.—The first indication is replacement, which in the first and second degree of descent is not difficult unless the uterus be held down by cicatrices or by a tumor. Complicating pelvic cellulitis and peritonitis may render replacement dangerous or impossible, and may for a time contraindicate all direct treatment. Replacement of the organs from the third degree of prolapse is accomplished in the inverse order of their descent: first, the posterior vaginal wall, then the uterus, and last the anterior vaginal wall. Not infrequently the completely prolapsed uterus and pelvic floor, hernia-like, become strangulated. Then taxis will usually suffice if supplemented by hot applications, elastic pressure, anodynes, and the knee-chest position. Should these fail anæsthesia may be required.
Undue pressure from above should if possible be removed. The clothing should be loose, and the weight of the skirts supported from the shoulders either by straps or preferably by buttoning them upon a waist made for the purpose. This waist is a good substitute for the corset, which under all circumstances and in all its forms is injurious. Increased uterine weight from subinvolution or congestion is to be overcome by appropriate means. Enlargement of the uterus when due to hypertrophy or hyperplasia is generally incurable. Amputation of the cervix for what was formerly considered circular hypertrophy and hypertrophic elongation is now seldom or never required for the purpose of decreasing uterine weight. Amputation except for malignant disease has given place to the operation of trachelorraphy. Tumors exerting pressure above or traction below should if possible be removed. Regulation of the bowels and general tonics are usually necessary. The knee-chest position assumed several times a day causes the uterus to gravitate toward the diaphragm, and thereby gives temporary rest to the overburdened supports. While in this position the patient should separate the labia, so that the air may rush in and the vagina become expanded. The measures enumerated above, together with rigid care of the diet and of such other hygienic requirements as the individual case may demand, are essential as adjuvants to the more special treatment which almost every case requires.
In exceptional cases of sudden descent, even to the third degree, replacement alone is sometimes followed by permanent relief; but if the descent has been gradual it always recurs immediately after replacement. Measures are therefore required for the maintenance of the uterus in its normal location and position. This indication is fulfilled by pessaries and by operations.
Pessaries.—The function of the pessary is not only to maintain the uterus on the health level in its normal location, but also, if possible, in its normal position, which requires the cervix to be about one inch from the sacrum. The cervix being thus placed, the organ cannot turn back into retroversion, because in so doing the fundus would encounter the sacrum. The direction of least resistance would then be forward into the normal anterior position. The application of the pessary is then based upon the general proposition that if the cervix be normally placed the body of the uterus will in the absence of complications take care of itself. Since the vagina at its upper extremity is attached to the cervix, displacement of the latter is clearly impossible if the upper extremity of the vagina be sustained in its normal location. The pessary restores and maintains the relations of the relaxed vaginal walls by crowding the posterior vaginal cul-de-sac backward into the hollow of the sacrum. It thereby also holds the attached cervix within a proper distance of the sacrum. The Hodge pessary or some modifications thereof fulfils this purpose in ordinary cases more satisfactorily than any other.