SYMPTOMS AND COURSE.—The displacement and its complications usually cause bearing-down sensations, a feeling of heaviness in the pelvis, exhaustion upon walking and standing, especially the latter, and constipation. After the puerperium the extreme engorgement of the pelvic organs often produces uterine hemorrhage, which should not be confounded with the returning menstruation. Especially after abortion the hemorrhage often persists for a long time unless cured by treatment. Gradual or sudden replacement may occur spontaneously, or the causes may continue active, and even be enforced by cystocele and rectocele. The displacement may also be complicated by disease and displacement of the ovaries. Organic disease of the uterine walls may induce a superadded retroflexion. The heavy organ may descend along the relaxed subinvoluted vaginal walls even to complete procidentia.
DIAGNOSIS AND PROGNOSIS.—The symptoms outlined in the preceding paragraph indicate the probability of displacement, but the diagnosis depends upon direct examination of the uterus. Conjoined manipulation and the probe will usually show the retroverted organ with the cervix displaced toward the pubes and with the corpus in the hollow of the sacrum. The introduction of the probe is contraindicated by cellulitis and peritonitis. In certain cases of anteflexion, as represented in [Fig. 23], the cervix is bent forward in the vaginal axis as in retroversion. The condition is in reality one of retroversion of the cervix with high anteflexion of the corpus, which may usually be detected by careful conjoined examination. The prognosis with treatment is generally favorable both for speedy relief and ultimate recovery.
TREATMENT.—As in descent, the treatment consists in removing cellulitis, peritonitis, and other complications, in the use of pessaries, and in operations on the anterior and posterior vaginal walls if needed. Inasmuch as the treatment corresponds to that of retroflexion, it will be presented under that subject.
Retroflexion.
ETIOLOGY AND PATHOLOGY.—Retroflexion is that displacement in which the organ is bent backward upon itself. It usually results from, and is associated with, retroversion, but for convenience the double displacement will be termed retroflexion. It may be caused by the great weight of the corpus, the soft flexible state of the uterine walls during and after involution, intra-abdominal forces, downward pressure during defecation, tight clothing, and not commonly by the obstetric bandage.
The ovaries, unless fixed elsewhere by adhesions, are displaced with, and held down on either side of, the corpus, sometimes enlarged from inflammation, often adherent, and always extremely sensitive. Chronic metritis, cellulitis, and peritonitis, with adhesions more or less firm, are usually present, and not infrequently as the result of gonorrhoea, abortion, or injudicious treatment. Peritoneal adhesions between the corpus and the cul-de-sac of Douglas sometimes make replacement impossible. In rare cases the displacement is congenital.
| FIG. 15. |
| Extreme Retroflexion, with Hypertrophy of the Corpus, which impinges upon the rectum and compresses the recto-vaginal wall. |
SYMPTOMS AND COURSE.—Among the most pronounced symptoms are profuse uterine catarrh, menstrual disorders, sterility, abortion, weakness, pain in the back, painful defecation, rectal tenesmus, the symptoms of pelvic inflammation, neurasthenia, and other nervous symptoms. The uterine catarrh is due to an effort on the part of the engorged pelvic organs to relieve themselves by an exaggerated secretion of mucus from the uterus, which upon being increased in quantity becomes vitiated in quality, and therefore pathological. Menorrhagia and abortion may also result from congestion. Dysmenorrhoea and sterility result from the general anæmic condition and from the inflammatory complications, and from the obstruction in the uterine canal or in the blood-vessels at the angle of flexure. (See Pathology of Anteflexion.) The rectal symptoms are caused by the pressure of the corpus uteri upon the rectum, which gives the sensation to the patient of an overloaded bowel.
Should pregnancy occur, the rapid growth of the uterus may induce spontaneous reposition at about the fourth month, when the fundus rises out of the pelvis, but if the corpus be incarcerated under the sacral promontory from adhesions or from any other cause, the uterus will, unless manually replaced, relieve itself by abortion.