Chapter 38 Uterovaginal displacements, damage and prolapse
UTERINE DISPLACEMENTS
The uterus is an organ that normally pivots about an axis formed by the cardinal ligaments at the level of the internal cervical os. In 90% of women the uterus is anteflexed and anteverted, lying on the urinary bladder and moving backwards as the bladder fills. In 10% of women the uterus is retroflexed and may be retroverted (Fig. 38.1). This is a developmental occurrence. The uterus is mobile and can be moved by inserting a finger in the posterior vaginal fornix. In spite of anecdotal statements, a mobile retroverted uterus is not a cause of infertility, abortion or backache.
Acquired uterine retroversion may occur, but is less common. It is associated with endometriosis of the uterosacral ligaments or the cul-de-sac; with adhesions resulting from pelvic inflammatory disease; or caused by a tumour in front of the uterus pushing it backwards.
Symptoms
Developmental retroversion is symptomless; only when the retroverted uterus is ‘fixed’ may symptoms occur. These include the symptoms associated with the underlying cause. In addition, the woman may complain of dyspareunia on deep penetration, pelvic pain and low backache. A few women who have chronic pelvic pain and are told by their doctor that their uterus is retroverted, will obtain some relief if the uterus is manipulated to become anteverted. They often remain pain free when the uterus becomes retroverted again, as it usually does.
Diagnosis
A clinical finding that the uterus is retroverted and is accompanied by symptoms should alert the medical practitioner to determine whether the retroversion can be corrected by manipulation (Fig. 38.2). If it can, it is not the cause of the symptoms. If it cannot be manipulated it may be the cause of the symptoms.
Treatment
In most cases the woman needs reassurance that the retroverted uterus is not the cause of any symptoms she may have, and does not require treatment. If the uterus is ‘fixed’ and the woman has symptoms of deep dyspareunia or chronic pelvic pain, surgery may be suggested, but the patient should be told that, although it may correct the position of the uterus, the symptoms may not be relieved permanently. The procedure is aimed at shortening the round ligaments by plication and treating any pelvic pathology at the same time.
UTEROVAGINAL DAMAGE AND INJURIES
Injury to the vulvovaginal area may occur, for example if a girl or woman falls astride some object or is kicked. The vagina may be damaged or a haematoma may form in the vulva (Fig. 38.3). Injury may also occur if a young girl or a postmenopausal woman is sexually assaulted.
During the first sexual intercourse, the hymen is stretched and torn and a small amount of bleeding results; very occasionally more severe bleeding occurs if a large blood vessel is damaged.
Injury resulting from childbirth is discussed on page 81. Occasionally a vaginal tear is not sutured immediately, and the woman attends a medical practitioner some time later. On inspection the vaginal entrance is seen to gape and the perineal muscles are separated (Fig. 38.4
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