A Clinical Lecture ON THE PRECISE RELATIONSHIP OF CYSTOCELE, PROLAPSE AND RECTOCELE, AND THE OPERATIONS FOR THEIR RELIEF: Delivered in the Post-graduate Course at the Manchester Royal Infirmary

W. E. Fothergill
1912 BMJ (Clinical Research Edition)  
THERE is a tendency to uise the words prol0(tpse, cystocele, iiid rectocele rather loosely and witlhouit due respect for the writings of the classical gynaecologists. Buit '. falling of the womb " is so comm1Lnon and causes so iiiucl sufferinlg w%hich can be remedied that clear ideas on the suibject are most desirable. The treatment, if it is to be successful, must be suited to the ineeds of eaclh case, and this can only be done after nice determination of the lesions present. P'lastic
more » ... . P'lastic operations on the vaginal walls and perineum were dlone on 66 patients out of 264 who were treated in the gynaecological wards of the Manchester Royal Infirmary during the year 1911, and this proportion of onie in four was almost the same in previous years. At St. Mary's Hospital 238 patients had vaginal operations for the coniditions nuider consideration during 1911, the total number of patients for the year being 1,137. These tigures clearly show the importance of wNvork of this kind. CYSTOCELE. In cystocele the base of the bladder, the uietlhra. and the anterior wall of the vagina bulge througlh the vaginal orifice and form a rounldedl swelling of w%hich the patient is unpleasantly conscious. The vaginal orifice is always wide, either because the perineum has been torni or l)ecause the cystocele lhas pressed upon .and stretclhed it. In cases of pure cystocele the uterus remliainis anteverted anid near its ordiniary level in the pelvis, even when the patient bears down. The pathological condition whlicl renders cystocele possible is relaxationi of the connective tissue wllich interveines between tlle bladder and vagina anud the upper surface of the pelvic diaphragnm, the tissues wlich support the utertus renmaining iuninjured. PROLAPSE. In cases of classical prol:psits itteri, cystocele is i1ivariably present; but, in addition to tlhis, the uterus is retroverted, and, when the patient bears (down, it descends in the pelvis axis, togetlher with the bladder and anterior vaginal 9.wall. This can be observed in any case of early prolapse, for, oni inspection of the externial genitals, the egg-lilie cy,stocele appears as sooni as the patient strains. If the tip of a finger be placed behind the cervix, and the patient is then requested to strain, tlle uterus is felt to becomiie retroverted (if it is not so already), and to move downwards as she bears downi, the cervix approaclhing the vaginal outlet. In an advanced case the cervix emerges, followed by the posterior vaginal wall; buit the anterior vaginal wall (cystocele) always comes first, the cervix next, and the posterior vaginal wall last. The pathological condition which allows prolapse to occur is relaxation of the connective tissue whichl ilntervenes between the uiterus and the upper surface of the pelvic diaphragm, together with ielajation of the connective tissue which holds in position the bladder and vagina. If the connective tissue rotund the bladder and vagina remains normal, relaxation of the uterinie supporting tissue allows only retroversion to occur -not prolapse, for this demands looseness of vagina and bladder as well as of the uterus. To put this in another way, every case of classical prolapse is clharacterized by both cystocele and retroversion. Cystocele is one thiing retroversion is another. Either may occur alone, but if the two occur together they constitute classical prolapse. Attention must be called to hypertroplhy of the cervix as a complicatiou of the conditions under consideration. In a simple case of hypertroplhy of the vaginal cervix without cystocele or prclapse, the diagnosis is easy and the treat-ment simple-namely, free amputation df the cervix. A loose and elongated uterus often becomes retroverted, descends in the pelvic axis, and inverts the upper part of the vagina. This condition, also, is easily distinguished from classical prolapse by the persistence of the anterior fornix-in other words, by the absence of eystocele. But, when overgrowth of the cervix complicates one of the other conditions, it is not always easy to recognize the true nature of the case. Needless to say, if the cervix requires amputation, this slhould-be done before and in acddition to the operations described below, the uterus being curetted as a preliminary. RECTOCELE. Rectocele is an entirely distinct and separate condition, in which the anterior rectal wall bulges through the vaginal orifice covered by the posterior vaginal wall. It may occur by itself; together w-ith eystocele (but witlhout prolapse), and together with classical prolapse. It is recognized clinically by passing a finger through the anal canal and observing that its tip emerges at the vaginal outlet covered by rectal wvall and vaginal wall. The pathology of rectocele is very interesting. The condition never occurs unless the perineum has been torn. In everv case the anterior rectal wall is more or less abnormally adherent to the posterior vaginal wall. In other words, the recto-vaginal septum in rectocele is two layers of tissue united together and moving as one, while naormally the recto-vaginal septum is two layers united by very loose connective tissue and sliding very freely and easily upon one another. The unduly firm union of the anterior rectal and the posterior vaginal walls in rectocele is caused by the remains of old inflammatory action. There is scar tissue instead of loose connective tissue between the layers of the recto-vaginal septum. The sequence of events is perineal tear at a confinement, infection of the torn surfacas, and then cellulitis in the adjacent connective tissue between the rectal and vaginal walls. The torn perineum heals by granulation, the cellulitis subsides and leaves the anterior rectal wall firmly adherent to the posterior vaginal wall. When this has occurred, constipation and straining at stool produice rectocele. When the rectovaginal septum is not thus altered by old inflammation, constipation and straining do not produce rectocele. This is simply stated as the result of observation, and, like other rules, it may lhave its exceptions, but the writer has not seen one. TREATMENT. In order that the operative treatment of these conditions may be successful certain general rules must be observed. During the fotur or five months after a confinement the parts bleed freely, and are too soft to hold stitches well. Operations should be postponed until the tissues are firm and free from post-partutnt hyperaemia. During the period of waiting the use of pessaries is allowable. It the vagina is in a septic condition, or is ulcerated, a healthy state should be secured before operation by the use of mild antiseptic douches, light vaginal packing, and, if necessary, by rest in bed. The date of operation should be chosen so that menstruation will not occur until healing is fairly well advanced. For the menstrual discharge dilutes the lactic acid containing vaginal secretion, and so favours septic infection. Douching the vagina after plastic operations should be avoided, as a rtule, for the same reason, and also because it irritates the tissues. But if, after an operation, the vagina is found to be infected, mild antiseptic douches should be used. It is not necessary to use silkworm gut or silk sutures within the vagina, aind, if tllese are used, their removal is both troublesome to the surgeon and painful to the patient. Catgut answers every purpose. If fairly thick, plain' catgut, sterilized with iodine or otherwise, lasts long enoughl. If thiin, the catgut should be chromicized or hardened with formalin. Silkworm gut may be used for stitches tied on the perineal surface. The first measure in operating for cystocele is anterior colporrhaphy. Any incision will do, but the anterior vaginal wall must be cut througlh. It is not sufficient to' strip off the vaginal mucous membrane; the whole thick-; ness of the vaginal wall must be freely separated' fromn the bladder wall. The unnecessary portion of the vaginal wall is then clipped away, and the incision is closed from--side -to si;de, so tsto leave the line' of suture running from near the urethr;al aperture to'th& [26761 [ TX BDa8s a K , JoUA I7
doi:10.1136/bmj.1.2676.817 fatcat:4uxdp2ywjfg2tapygn4yytpbve