Where cystocele exists it is important that the bladder be completely emptied when the patient urinates; to accomplish this she may assume the genu-pectoral position, and at the same time push the tumor up into the vagina. If after this urine remains in the bladder, a catheter should be employed.
If in any form of vaginal displacement the means which have been alluded to fail, then some form of support or some surgical procedure will be necessary. In very fleshy women considerable benefit is sometimes obtained by means of an abdominal band with a perineal pad attached to it. Pessaries, which have been heretofore quite generally depended upon, are now considered as of secondary importance. Sometimes, however, when the hernia is not of great size or when associated with uterine displacement, a pessary proves of service. A Hodge's pessary with a cross-bar, or the one devised by Skene of Brooklyn, will often prove of great benefit in cystocele. For either cystocele or rectocele the most serviceable form of pessary is one like Cutter's or McIntosh's cup pessary, which is retained within the vagina and supported in position by external attachments. To effect a radical cure in either cystocele or rectocele, especially in the latter, some surgical procedure generally becomes requisite.
Of the different operations which have secured the general approval of gynecologists, the most common is perineorrhaphy: this is the name given to the operation for a torn perineum. Another operation sometimes performed with success is colporrhaphy or elytrorrhaphy, which consists of lessening the calibre of the vagina by removing a portion of the mucous membrane and bringing the edges of the wound together by sutures. This can be performed on either the anterior or posterior wall, depending on which seems to demand it the most; and if the operation on one wall is not likely to be sufficient, it should be made on both. Not unfrequently the most perfect success can be attained by a surgical procedure designated as colpo-perineorrhaphy, which combines the two operations that have been mentioned. Full descriptions of these different operations and the best modes of performing them can be found in all late standard works on surgical gynecology.
Cicatrices.
Cicatrices of the vagina may occur in consequence of lacerations or injuries received in childbirth, surgical operations, wounds from accident, or the use of caustics about the uterus. If any of the causes named excite inflammation, there may be more or less sloughing of the parts, and, as healing must take place by granulation, cicatrices of various dimensions are formed. These cicatrices may be sufficient to cause partial or complete atresia, or they may be merely in the form of projections or bands, dragging the uterus out of its normal position or interfering with its natural mobility, and cause dyspareunia and other discomforts.
Recently, since attention has been directed to the reflex symptoms produced by cicatricial tissue in the neck of the uterus, there has been a growing belief that similar symptoms are often caused by cicatrices in the vagina. Thus it is the opinion of some who have investigated this subject that many cases of remote neuralgia and other nervous disturbances may often be caused in this way.6
6 Vide Skene on "Cicatrices of the Cervix Uteri and Vagina," Amer. Gynæc. Soc., vol. i., 1876.
TREATMENT.—This is of necessity surgical, although some cases can be successfully treated without having recourse to cutting operations, but are treated by pressure. One method is to tampon the vagina with cotton or marine lint previously saturated with carbolized glycerin. The tampon can be left in position four or five days, when the vagina may be washed out and again tamponed. Another method of treating with pressure is by means of a Sims's dilator, either worn continuously or a few hours at a time. Generally a quicker and more effectual mode of treatment is to nick the bands with scissors or a knife in several places sufficiently for the vagina to assume its natural shape, and then insert the dilator. In some instances it is advisable to cut away portions of the adventitious membrane. On account of the tendency to hemorrhage after operations in the vagina the physician should avoid cutting more than is requisite, and must use a finger as a guide in cutting, to inform him when he has cut sufficiently.
If there is considerable hemorrhage it may be necessary to use a styptic, but usually the glass dilator, by putting the walls on the stretch and by pressure, will check the bleeding. It is important that the dilator be worn for several hours each day after the nicking, for fear that there will again be contraction. After each removal of the dilator the vagina should be syringed out with warm carbolized water or a very weak solution of permanganate of potassium (gr. ss ad fluidounce ij), that no septic matter may be retained and so that healing of the cuts may be more rapid.