DIAGNOSIS AND PROGNOSIS.—The displacement is recognized by digital touch, which discloses the anterior wall of the uterus parallel to the anterior wall of the vagina, with the fundus close to the symphysis and the cervix elevated. Conjoined examination will show the size, shape, hardness, and degree of fixation. Exaggerated anteversion of the healthy uterus is not necessarily pathological in its results. This is illustrated by the anteversion of early pregnancy. The prognosis is therefore good if the causes can be removed.
TREATMENT.—Inasmuch as exaggerated anteversion is the position taken by the uterus in chronic metritis, it follows that the treatment is often that of chronic metritis. For the treatment of metritis, perimetritis, fibroids, menorrhagia, etc. the reader is referred to the special literature of those subjects. Irritable bladder, which is often a mechanical result of the displacement and enlargement, may sometimes be relieved by means of an Albert Smith or Hodge pessary, which lifts the organ to a higher level away from the bladder. In thus elevating the uterus the anteversion may be rather increased than diminished, which proves that the symptoms were dependent not upon the anteposition, but rather upon descent and antelocation. Should the parts be too sensitive to tolerate the hard-rubber pessary or a flexible rubber ring, the daily application of medicated pledgets of cotton will give support to the uterus and decrease the tenderness until the more permanent instrument can be worn. The numerous anteversion pessaries designed to elevate the corpus by direct pressure on the anterior wall of the uterus generally irritate the organ, and thereby aggravate the inflammatory complications. They are therefore to be used with extreme caution.
Pathological Anteflexion.
DEFINITION.—The normal forward bending of the corpus upon the cervix uteri when the bladder is empty makes an angle of which the approximate physiological limits are between 45° and 90°: the flexure would generally be pathological if less than 45° or more than 90°. Furthermore, if the flexure, whether it be normal or abnormal in extent, does not disappear upon filling the bladder, but remains constant under all conditions, the rigidity makes the flexure pathological. Anteflexion is therefore pathological if the mobility at the angle of flexure is increased or diminished or absent.
ETIOLOGY AND PATHOLOGY.—Anteflexion may be congenital or acquired. By congenital is meant not defective foetal development, but failure of the immature child uterus to develop at puberty, a failure which usually pertains alike to the uterus, Fallopian tubes, ovaries, and vagina. In congenital anteflexion the uterus is bent upon itself almost double, the body and cervix both pointing in the direction of the pelvic outlet, with the cervix somewhat elongated and situated in the long axis of the vagina. (See Fig. 23.)
| FIG. 23. |
| Congenital Anteflexion. Both cervix and body are flexed forward. |
Acquired anteflexion may be simply an exaggeration of the normal flexure, due either to increased weight of the corpus from the presence of the uterine fibroid near the fundus or to unequal growth of the uterine walls or to unequal involution. A very frequent cause of anteflexion is thickening of the posterior wall of the uterus from the products of inflammation, and a corresponding atrophy of the anterior wall from prolonged pressure at the angle of flexure. Post-uterine cellulitis and peritonitis involving the utero-sacral ligaments is a frequent and discouraging complication. Sometimes the inflamed ligaments contract and drag the anteflexed uterus upward and backward, where it may be permanently fixed by peritoneal adhesions. (See Fig. 24.)