A system of practical medicine. By American authors. Vol. 4

by Unknown

Displacements of the vagina are usually secondary, either in consequence of relaxation of the walls or of some form of uterine displacement. Prolapsus of the vagina is usually associated with prolapsus of the uterus, yet it may exist independently. It may be present for some time without prolapse of the uterus, or exceptionally it may be the exciting cause.

DEFINITION.—When the tonicity of the vaginal walls is from any cause impaired and they protrude downward in the direction of the vulva, the condition is called prolapsus.

SYNONYMS AND CLASSIFICATION.—Owing to the anatomical arrangement, it is impossible, with one exception, for any form of prolapsus of the vagina to occur without the coincident prolapse of some viscera. The single exception is the rare occurrence of prolapsus of the posterior wall without the rectum being similarly displaced. These displacements of the viscera with prolapsus of the vagina are commonly described by medical writers as vaginal herniæ, of which there are three different forms, as follows: cystocele vaginalis, rectocele vaginalis, and enterocele vaginalis or hernia vaginalis posterior.

ETIOLOGY.—The causes of displacements of the vagina and the different varieties of vaginal herniæ can very properly be considered together, as they are identical. Laceration of the perineum, an enfeebled condition of the vaginal structure, and a retarded involution of the vagina and uterus in consequence of pregnancy or childbirth are the most frequent causes. Other occasional causes may be mentioned, as former distension of the vagina from repeated childbirths or by tumors, and senile atrophy.

PATHOLOGY.—Following childbirth, the vagina, like the uterus, undergoes a process of involution, but if this is retarded from any cause the vagina is rendered more capacious, its tonicity is impaired, and the uterus, being heavy, crowds down upon it and causes it to be displaced. If the vaginal sphincters or the posterior wall are torn or enfeebled or the perineum lacerated, in addition to the presence of a heavy uterus, prolapsus of the vagina, associated with some form of vaginal hernia, is quite sure to follow.

There is a condition which acts as a common cause in producing vaginal and uterine displacements that has failed to receive on the part of medical authors the notice it deserves—namely, a relaxed condition of the vaginal walls and the perineum, in which there may be observed, in many instances, all of the disturbances caused by a laceration, and yet a careful examination fails to reveal where any tearing has taken place. The continuance of this excessive relaxation and atony of the vaginal walls and the perineum for a long time after parturition is, doubtless, due to subinvolution.

SYMPTOMATOLOGY AND COURSE.—The patient will complain of a bearing-down sensation in the vagina, with a sense of fulness and heat in that locality, sometimes extending to the vulva. These symptoms are aggravated by any muscular exertion, particularly by walking. A physical examination will show the presence of an elastic, globular tumor between the labia. In case it protrudes beyond the vulva, it is not unusual to find scattered over its mucous surface excoriated patches of various sizes. Sometimes these become ulcerated. In other instances the tumor has a smooth, shining appearance. Where there is simply prolapsus of the vagina without the coexistence of a hernia, it will, as a rule, be found that it is the posterior wall. If there is a prolapsus of either the anterior or posterior wall with a hernia, there will be additional symptoms to those above mentioned, which will be referred to in connection with cystocele and rectocele.

Cystocele Vaginalis, or Cysto-Vaginal Hernia.

This is sometimes designated as prolapsus of the bladder, and consists of a descent of the bladder and the anterior wall of the vagina, the two being closely adherent to each other. In consequence of such a descent a pouch is formed which becomes filled with urine. The pouch is in the outset quite small, but gradually becomes larger, so that it is not unusual for one to become of sufficient size to protrude beyond the vulva. In consequence of the pouching of the bladder only a portion of the urine is evacuated by the effort of micturition, and, remaining in the bladder, it decomposes, causing cystitis or vesical catarrh.