Prolapse of the Vagina Following Hysterectomy

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					1726                                            S.A.     MEDICAL JOURNAL                                  11 November 1972

    Prolapse of the Vagina Following Hysterectomy*

       PROFESSOR DR K. RICHTER, Department of Obstetrics and Gynaecology, Landeskrankenhaus,'
                                 Bruck a.d. Mur, Austria

                          SUMMARY                                     FORM AND POSITION OF THE VAGINA
                                                                           AFTER HYSTERECTOMY
  In life, the vagina describes a strong perineally-directed
  course. The fornix lies near the sacrum above the un-             If the vagina is not sutured in the course of the hyste-
  paired levator plate, where it is held in place by the            rectomy but left open as in the Viennese method, the
  powerful paracolpium. After hysterectomy the corners of           corners of the vaginal vault are pulled into two points
  the vault of the vagina are pulled into 2 points. In cases        by the powerful paracolpium. Its course is not changed:
  of prolapse of the vagina after hysterectomy, a distinction
  must be made between prolapse of parts of the vagina
  and prolapse of the vaginal vault. The former presents no         PROLAPSE OF THE VAGINA, AND 'TRUE'
  particular therapeutic problem, while the latter is often         PROLAPSE FOLLOWING HYSTERECTOMY
  considered incurable. The 'true' prolapses of the vaginal
  vault have in common the fact that the corners of the vagi-       If the vaginal wall protrudes from the vulva after a
  nal vault are also prolapsed. They appear very similar, but       hysterectomy, it is generally spoken of as a vaginal pro-
  differ clinically as well as pathologically and anatomically.     lapse following hysterectomy. There is, however, a fun-
  Four types may be distinguished: prolapses of the vaginal         damental difference, depending on whether only a part
  vault of the cytocele, enterocele, rectocele and mixed            of the vagina prolapses and the vault remains in place,
  types. The different types may best be seen with the              or whether the vault prolapses. If the vault has not pro-
  colpocystorectogram of Bethoux and co-workers. With the           lapsed, there are no particular therapeutic problems. The
  vaginal vaginae fixatio sacrospinalis, one corner of the          prolapsed part of the vagina is, according to the particular
  vaginal vault is fixed via the rectal pillar in the area of the   anomaly present, a cysto-, recto- or enterocele and is to
  so-called sacrospinal ligament. A strong scar is thus form-       be treated as such. On the other hand, prolapse of the
  ed which replaces the inadequate paracolpium. Thus the            vault is a certain sign of a complete inadequacy of the
  vagina obtains a natural perineal curve, with the vault in        paracolpial attachment. The vault ceases to resemble a
  a normal position, near the sacrum over the unpaired              floating boat tied up to the dock, held fast by the para-
  levator plate. The results of surgical treatment by the           colpium above the unpaired levator plate near the sac-
  method described, which has been performed 25 times               rum, but instead lies above the hernia orifice of the hia-
  with excellent results, are discussed.                            tus levatoris ani and is pressed outward from the same,
                                                                    upon increase in intra-abdominal pressure.'" This results
  S. Afr. Med. J., 46, 1726 (1972).                                 in a serious abnormality which many authors even con-
                                                                    sider incurable. In order to make a meaningful distinc-
                                                                    tion, as well as for urgent clinical and therapeutic rea-
 NORMAL FORM AND POSITION OF THE                                    sons, the terminology must clarify the difference between
            VAGINA                                                  the 'simple' prolapse of the vagina accompanying a sur-
                                                                    gical defect of the uterus, and the 'true' prolapse of the
In the standing position, the vagina normally follows               vault following hysterectomy.
distally a nearly vertical, and proximally a nearly hori-
zontal course. The change of direction occurs in the area
of the 'levator threshold', where the vagina twists around          CLINICAL ASPECTS OF THE PROLAPSE OF
the M. levatoris ani, and so describes a perineal curve.'           THE VAGINAL VAULT ('TRUE' PROLAPSE
The curve is sharpened upon lifting of the levator and                   FOLLOWING HYSTERECTO~
decreased by pressure.' The vagina is included in the vis-
ceral sac, in which it is suspended. The proximal part of           Outwardly, the true prolapses of the vaginal vault are
the vagina is held away from the hernia orifice of the              very similar. The completely everted vagina protrudes
hiatus levatoris ani by the tension of the pgracolpium              from the vulva, with the corners of the vault outwards.
and is kept in its hereditary place above the "non-paired           Exact bimanual, rectovaginal, cyctoscopic and X-ray ex-
levator plate near the sacrum.                                      aminations, however, allow 4 different types of prolapse
                                                                    to be distinguished: the cystocele (Fig. 1), the rectocele,
• Date received:   15 May 1972.                                     enterocele (Fig. 2) and mixed types' (Fig. 3). The various
11 November 1972                          S.-A.     MEDIESE TYDSKRIF                                                  1727

types may best be seen with B6thoux's colpocystorecto-        has evolved into tendinous fibres (Fig. 4). Embryologically
graphy.' The distinction is therapeutically important. The    the M. coccygeus is a homologue of the abductor caudae
examination shows, for example, whether in the preced-        ventralis of the caudate mammals."
ing operation a high peritonization, such as a bladder
sigmoid roof, has· held or not, or whether a cystocele is
present and must be repaired.

                                                                Fig. 2. Vaginal vault prolapse of the enterocele type (45
                                                                years old, para 2).

                                                              Technique of the Vaginae Fixatio Sacrospinalis
                                                                 According to the prolapse type involved, the vaginal
                                                              fixation is combined with a cystocele, enterocele or rec-
                                                              tocele operation. A complete operation, as must be per-
  Fig. 1. Vaginal vault prolapse of the cystocele type with   formed for a vault prolapse of the cysto-entero-rectocele
  hour-glass bladder (62 years old, para 4).
                                                              mixed type, begins with a midline incision over the an-
                                                              terior and posterior vaginal wall, and preparation of the
                     TREATMENT                                flaps of the vaginal wall. Then follow:
                                                                 The elimination of the enterocele. Opening of Douglas's
A wide variety of abdominal and vaginal surgical pro-         pouch. When indicated, removal of the adnexae. A high
cedures are available for the treatment of the prolapsed      peritonization, with a high union of the bladder with the
vault. Seventy-five years ago the prolapsed vagina was        rectum or sigmoid. Eight or more centimetres of the
variously fixed via the sacral route (Zweifel), and via       bladder peritoneum, and up to 15 cm of the peritoneum
the vaginal route to the sacrospinal ligament or the          of Douglas's pouch, are thus excluded from the perito-
sacrotuberal ligament.··· Amreich" proposed for the treat-    neal cavity.
ment of the true prolapsed vault a method imitating              Elimination of the cystocele. Further lateral separation
nature, i.e. a sacral or a vaginal fixation of the vault on   of the flaps. The neck of the bladder is completely gath-
the sacrotuberal ligament. As the sacrotuberal ligament       ered together, when necessary with 2 sagittal rows of
cannot, for anatomical reasons, be reached vaginally, we      stitches, beginning from below and proceeding up the
perform a vaginal vaginae fixatio sacrospinalis. With this    neck. Thus a sort of fork or 'V' is created, which lifts
procedure one corner of the vault is fixed in the area of     the neck of the bladder. Resection of the vaginal wall as
the so-called sacrospinal ligament, which corresponds to      necessary. Closure of the wound in the anterior vaginal
the dorsal and proximal part of the M. coccygeus, which       wall, but not over its entire length.
 1728                                       S.A.    MEDICAL JOURNAL                                    11 November 1972

                                                                A balloon catheter is inserted in the bladder and the
                                                                vagina is packed with gauze. The end of the bed should
                                                                be elevated for thrombosis prophylaxis. The patient gets
                                                                up the next day and is discharged after 2 - 3 weeks.

                                                                  Fig. 4. Schematic presentation of the vaginae fixatio
                                                                  sacrospinalis vaginalis. One corner of the vaginal vault
                                                                  is fiud about 1 - 1,5 cm medially from the ischial spine
  Fig. 3. Vaginal vault prolapse of the mixed type: Cysto-        in the area of the so-called sacrospinal ligament. Thus
  enterocele with stones in the hour-glass bladder without        the end of the vagina, and often the vagina itself, is
  pressing down (50 years old, para 2).                           pulled to one side. A tough scar is thus formed, which
                                                                  replaces the inadequate paracolpium and gives the vagina
   Vaginae fixatio sacrospinalis. In order to fix the corner
of the vault to the sacrospinal ligament, a way must be
made through the rectal pillar into the pararectal space.
To tbis end, a colpoperineal plastic with triangular in-
cision (Hegar's method) is performed. The preformed                The external genitalia appear normal (Fig. 5). The vagi-
rectovaginal space is entered and the rectum is separated       na which is capable of intercourse has a perineal curve.
from the rectal pillar. A hole is formed through the right      The deviation of the vagina decrease~ to a greater or
pillar and the iscbial spine is located. The spot for attach-   lesser degree with time (Fig. 6). At the point of fixation,
ment is located 1 - 1,5 cm from the iscbial spine. Three        the palpating finger feels a scar, as after Wertheim's or
No. III chrome catgut sutures are passed through the            Schauta-Amreich's radical operation. This replaces the
point of attachment and the right (or left) corner of the       paracolpium and gives the vagina a hold, even when
vault. The vasa pudenda intema and the N. levatoris ani,        the operation is only unilaterally performed.
as well as the branches of the plexus sacralis, may easily
be avoided if the field is presented for view with a
Breisky speculum. The vaginal wall is resected in the                                  RESULTS
upper posterior vaginal region and sutured. The fixation
sutures are then knotted. The vault falls into place and        Between 1959 and the end of 1971, this operation has
disappears from view.                                           been 'performed 25 times by the author. In some cases
  Elimination of the rectocele. The rectal pillar-s are uni-    up to 3 unsuccessful abdominal and/or vaginal opera-
ted medially; resection from the posterior vaginal wall.        tions had been performed previously. All patients have
The anatomically displayed levators are joined in the           been cured; and among the most grateful, are those who
middle. with I - 3 sutures. Suture of the vaginal-perineal      are often young and who in many cases had suffered from
wound follows, to create a medium high, strong perineum.        prolapse for many years.
 11 November 1972                           S.-A.     MEDIESE       TYDSKRIF                                                     1729

                                                                  Fig. 6. Silicone (Sta-Seal) cast of the vagina after vaginae
                                                                  fixatio sacrospinalis vaginalis. The deviation of the vagina,
                                                                  which is capable of intercourse, decreases to a greater or
                                                                  lesser degree with time. From left to right: 25 days after
                                                                  surgery (57 years old, para 1), 2 months after surgery
                                                                  (63 years old para 4), 3 years after surgery (65 years old,
                                                                  para 5), 3 years after surgery (43 years old, para 2).

                                                                  I should like to thank Or K. Hausegger for his excellent
                                                                co-operation in this work.

                                                                I. Richter, K. (1966): Geburtsch. u. Frauenheilk., 26, 1213.
                                                                2. Bethoux, A., Bory, S., Huguier, M. and Lan Cheao Seang (1965):
                                                                   Ann. Radiol. (Paris), 8, 809.
                                                                3. Richter, K. (1967): Geburtsh. u. Frauenheilk., 27, 941.
                                                                4. Randall, L. C. and Nichols, D. H. (1971): Obstet. and Gynec., 38,
                                                                5. Amreich, 1. (1951): Wien. klin. Wschr., 63, 74.
                                                                6. Holl, M. in Bardeleben, K., .ed. (1897): Handbllch der Anatomie des
  Fig. 5. Result of operation as seen in the external genita-      Menschen, vol. VII, No. 2, p. 171. Jena: Fischer.
  lia 28 days after surgery.                                    7. Richter, K. (1968): Gebunsh. u. Frauenheilk., 28, 321.

                               Boeke Ontvang: Books Received
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    Muscular Dystrophy Association of America in Cleveland,        Planned Parenthood Physicians, Kansas City, Missouri,
    Ohio, October 1970. Ed. by B. Q. Banker, R. J. Przbylski,      April 1971. Ed. by A. J. Sobrero, M.D. and R. M. Harvey.
    J. P. van der Meulen and M. Victor. Pp. v + 474. Illu-         Pp. viii + 215. Oil. 52,00. Amsterdam: Excerpta Medica.
    strated. Oil. 105,00. Amsterdam: Excerpta Medica. 1972.         1972.

Shock in Low- and High-Flow States. Proceedings of a Sym-       Calcium, Parathyroid Hormone and the Calcitonins. Proceed-
    posium at Brook Lodge, August, Michigan, USA, June              ings of the 4th Parathyroid Conference, Chapel Hill, USA,
    1971. Ed. by B. K. Forscher, R. C. Lillehei and S. S.           March 1971. Ed. by R. V. Talmage, and P. L. Munson.
    Stubbs. Pp. ix + 314. Illustrated. Amsterdam: Excerpta          Pp. 560. Illustrated. Oil. 120,00. Amsterdam: Excerpta
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