OPERATIVE TREATMENT OF GENITAL PROLAPSE (IN YOUNG WOMEN)

by

V. N. PuRANDARE* , M.D., F.R.C.S., KuMuD PATIL**, M.D., D.G.O. and RAJANI ARYA***, M.D., D.G.O.

Operative treatment of genital pro­ lapse has to be judged on its own lapse in young women poses two im­ merits; hence it is very difficult to portant problems before the operator. find strictly comparable groups. ( 1) Repair of prolapse by a method Pessary treatment was not possible which will not jeopardise future because of ignorance; moreover the child-bearing. prolapse was of quite a major degree, (2) Recurrence of prolapse follow­ requiring operative correction. ing a vaginal delivery. A simple answer to this question Selection of Cases will be to sterilise the patient at the (1) Age: Only 30 % of the patients time of operation. But many of our were above the age of 30 years. patients with advanced degrees of Fothergill published a series of prolapse are so young and the infant 149 cases in the year 1921; 81% of mortality in this country so high his patients were above the age of that this possibility cannot be con­ 30 years. In England this operation sidered. is done for all patients, irrespective I \ of age, while we do it only for Mat erial and Methods younger patients. For those ap­ With this problem in mind we proaching menopause and past studied 191 cases of genital prolapse menopause the operation of choice is treated by "Manchester Operation" vaginal hysterectomy with plastic (Forthergill' operation) and abdo­ repair; there was not a single post­ ,ninal cervicopexy during the 5 year menopausal case in the present series. period from January 1956 to Decem­ Out of the two groups, cervicopexy ber 1960 in the Gynaecological group comprised a larger number of Department of K.E.M. Hospital, young patients. The average age of Bombay. One hundred and ten a patient at the time of operation was patients were treated with Fother­ 30 years in the Manchester (Fother­ gill's operation and 81 with cervi­ gill) group and 25 years in the copexy. Each case of genital pro- cervicopexy group. (2) Parity: Except for 19 patients, From Department of Obstetrics & all others were parous. Forty-eight Gynaecology, K.E.M. Hospital, Parel, (25.14% ) developed prolapse follow­ Bombay 12. ing a single vaginal delivery. Women Received for publication on 11-10-65. of higher parity were treated with 54 JOURNAL OF OBSTETRICS AND GYNAECOLOCY OF INDIA

Manchester operation (Fothergill') such patients having a utero-vaginal with or without sterilisation. Aver­ prolapse; 18 were treated with cervi- • age parity in Fothergill group was copexy and only one underwent 3.4 while that in cervicopexy group . Manchester operation. In these 2.7, excluding nulliparae. patients cervical supports were weak (3) Type of prolapse: In the and hence they required some addi­ majority of cases the prolapse was of tional help to hold the cervix up. the utero-vaginal type as described There was no appreciable prolapse by Malpas. As the postmenopausal of the anterior or posterior vaginal cases are excluded from this study walls. No enterocele was encounter­ there were not many cases of pro­ ed in this group. lapse due to a failure of the whole of ( 4) Associated vaginal wall pro­ the pelvic floor and particularly the lapse: Table I-b shows that associat­ rectal sling of the pubo-rectalis mus­ ed vaginal wall prolapse with cle. marked cytocele was taken up for It is difficult to get pure utero­ Manchester repair, while the pre­ vaginal prolapse or anterior vaginal sence of a rectocele and enterocele wall prolapse or posterior vaginal did not affect the choice of operation. wall prolapse. They are often as­ Direction of uterine axis did not sociated. affect the line of treatment; 72 % of TABLE I-a Degree of cervical prolapse

Nature of Proce- I III Unknown Total operation II dentia ..,.. Manchester 6 41 (37.37% ) 51 (46.36% ) 5 7 110 Cervicopexy 3 48 (60.00% ) 25 (31.25%) 5 81

TABLE I-b Associated Vaginal Wall Prolapse

Nature of Cystocele Rectocele Enterocele operation No. % No. %

Manchester 84 76.36 51 46.33 3 Cervicopexy .. 45 56.25 37 46.25 2 - -- Table I-a shows the degree of the prolapsed uteri were retrovert­ cervical prolapse. Second degree ed. prolapse was treated more often by ( 5) Length of cervix: When the cervicopexy while for third degree cervix was hypertrophic and elongat­ prolapse the Manchester operation ed the patient was selected for Man­ !' I was preferred. chester operation., Thus out of 110 I Nulliparous prolapse: Cervicopexy patients undergoing this operation, was the operation of choice in nulli­ 90 patients had utero-cervical length parous prolapse. There were 19 between 3!-4-!''; 19 between 4-!--5!" OPERATIVE TREATMENT OF GENITAL PROLAPSE 55 while in one patient the utero-cervi- descending cervical branch of the cal length was 6". Cervix was not uterine artery was found to be the amputated when the utero-cervical most effective method of achieving a length was less than 3!''. There · bloodless amputation. were three such patients. Abdominal cervicopexy: This is a comparatively new operation design- All the patients selected for cervi- ed by B. N. Purandare, in the year copexy had utero-cervical length less 1956, for young women with second than 3!". and early third degree cervical pro­ ilapse (Shaw's classification) where Incidence of Sterility child-bearing is to be preserved. The Table II shows the incidence of steps of the operation are described sterility. in brief. TABLE II Incidence of sterility

Nature of Primary Secondary Total operation No. Per cent No. Per cent No. Per cent

Manchester 1 0.91 62 56.36 63 57.27 Cervicopexy . . 8 9.88 40 49.38 48 59.26

Though only 5% of the patients ( i) A curved transverse incision is selected for cervicopexy had come made in the suprapubic region about with secondary sterility as their chief 4-5 inches in length in the skin crease complaint, the obstetric history of just above the symphysis pubis. these patients revealed a very in­ ( ii) The anterior rectus sheath is teresting fact. There were 49.38 % of incised transversely. The upper flap women with secondary sterility. of the sheath is separated from recti Duration of 3 years was taken as a muscles and from the linea alba by yard-stick for both types of sterility; dissection. 10 % incidence of primary sterility in (iii) The recti muscles are separat­ the cervicopexy group compares ed from each other in the midline; favourably with the incidence in the peritoneum is incised longitudi­ general population. nally (Pfannenstiel incision). (iv) The fundus of the uterus is Operative technique grasped in the fingers and pulled out. Manchester operation: It is our The tubes are tested with saline in­ custom to take an inverted T shaped stillation. incision on the anterior vaginal wall (v) The peritoneum of the utero­ instead of the classical incision of vesical pouch is incised and the Fothergill. Rest of the technique is bladder pushed down from the front similar to one described by John of the cervix and upper vagina (Fig. Hunter. Pouch of Douglas was 1). The uterus is then returned to opened in 31 cases. Ligation of the abdominal cavity. 56 JOURNAL OF OBSTETRICS AND GYNAECOLOCY OF INDIA

(vi) Starting from midline two fundus of the uterus by interrupted strips are made from the low0r edge sutures. The round ligaments of both · of the anterior rectus sheath, about sides are plicated to keep the uterus half an inch broad and cut up to the anteverted. Alternately a Baldy­ lateral border of the rectus muscle. Webster type of suspension can be (Fig. 2). Some operators prefer to done. prepare the strips from the upper (x) If there is an enterocele it is edge of the incised sheath. Dis­ obliterated by taking repeated purse­ advantage of the latter method is that string sutures and the uterosacrals the sheath is under considerable ten­ are approximated in the midline. If sion while suturing. a r ectocele is present, posterior (vii) The uterus is again pulled colporrhaphy is done per vaginam out exposing the bare cervix, the tip after finishing the abdominal pro- __.>-:, of each fascial strip is now caught in cedure. Bonney's round ligament forceps and In the present series Manchester taken beyond the lateral border of operation was combined with vaginal the rectus muscle, after which the sterilisation in 8 cases. Abdominal forceps is directed towards the site cervicopexy was combined with of internal inguinal ring which is colpo-perineorrhaphy in 23 cases and made prominent by traction on the operations on adnexae in 17 cases. round ligaments. The forceps pierces The adnexal operations were of the the transversalis fascia and enters the nature of salpingolysis, salpingo­ broad ligament in between its two tomies, salpingectomies and wedge layers and comes out in front of the resection of ovaries. All the cervices bare cervix (Fig. 3). removed at operation were examined (viii) The two strips are crossed microscopically. No case of un­ in front of the cervix and transfixed suspected carcinoma of cervix was to it on the anterior surface by three found. sutures of unabsorbable material Figs. 4, 5 and 6). Post-operative complications A modification of this step is to ( 1) Mortality: There was one take the strips backwards and fix death in this series due to tetanus on them to the posterior aspect of the the sixth day after operation. cervix. The raw area on the posterior surface is covered by approximating (2) Pyrexia: Nine patients with the uterosacral ligaments over it. Manchester operation had pyrexia This incidentally shortens the liga­ exceeding 100°F., while only 3 ments. Advantage of this technique patients in the cervicopexy group had is that uterus is kept in anteverted fever. The higher incidence in the position, disadvantage being possible first group is due to urinary sepsis. cervical dystocia due to fibrous stdps Many of the patients had difficulty in surrounding the cervix completely. passing urine and residual urine ex­ This method requires longer strips. ceeded 2 ounces. (ix) The bladder peritoneum is (3) Haemorrhage: Three patients advanced and is stitched high on the with Manchester repair suffered from OPERATIVE TREATMENT OF GENITAL PROLAPSE this complication. One of this was a the rectus sheath created by the pass­ mild reactionary haemorrhage notre- age of strips and is particularly liable quiring blood transfusion. to occur in fat patients. Two patients had secondary hae- · (7) Anaesthetic compl~catiom in-· morrhage. One patient had three elude two cases of paresis of lower bouts on 13th, 23rd and 31st post- limbs which made complete recovery. operative days. During the last bout some abdominal operation probably Follow up of the nature of internal iliac artery Table II shows that a total of 87 ligation, was done to arrest the bleed- patients were followed up for 3-8 ing. years. Fifty-four patients came to ( 4) Wound gaping: Two patients outdoor for examination. Informa­ with cervicopexy had wound gaping. tion on the remaining 33 patients was None of them required secondary obtained by letters. As nearly 37 % suturing. of the patients could not be e:2_Camin- (5) Cervical stenosis, enough to ed, more stress is laid on the func­ prevent the passage of the uterine tionaL than on structuraL cure. sound was present in two cases of Manchester series. It did not lead to Relief of Symptoms haematometra. There was not much difference in ( 6) Spigelian hernva: This in- the two groups as far as the relief of teresting complication was present in symptoms is concerned and hence we one patient of cervicopexy. There shall not discuss it. Suffice it to say were bilateral herniae on the lateral that 4 patients developed dyspareunia side of recti muscles. This is due to following Manchester repair (Table ' failure to close completely the gap in III).

TABLE Ill Physiologic Results

MANCHESTER OPERATION CERVICOPEXY Deve- Deve- Symptoma No. of loped No. of .loped patients Cured after patients Cured after suffering opera- suffering opera- tion tion

Prolapse 59 57 21 20 Leucorrhoea 11 10 3 3 Backache 10 6 3 3 2 Dyspareunia 9 9 4 6 5 Stress incontinence 6 5 Dysuria 6 5 1 Constipation .. 6 5 4 - 4 Flour· semlnia 1 Secondary aterili~ 5 4 2

8 56 JOURNAL OF OBSTETRICS AND GYNAECOLOCY OF INDIA

Anatomic results following Manches­ vaginal wall had shortened to 1 ~-2 ter repair inches and posteriorly to 2-2! inches. Recurrence of prolapse: Table IV The posterior vaginal fornix was re- shows that 2 patients out of 35 had . markably shallow and one patient recurrence follownig (Fothergill) had flour seminis. Though it is repair. claimed that Manchester repair cor- TABLE IV Anatomic Results

MANCHESTER OPERATION CERVICOPEXY No. No. Symptoms No. Im- Recur- No. Im- Recur- ,suffer- suffer- cured proved renee cured proved rene\? ing ing Cervical prolapse 36 34 2 18 17 1 Cystocele 28 19 7 2 11 8 2 1 Rectocele 24 10 12 2 9 3 2 Enterocele 1 3

Case No. F 83: A multipara, aged 30 rects retroversion our findings do not years, had 3rd degress cervical ·· prolapse, support this claim. Neither did we cystocele, rectocele and enterocele. Man­ chester operation with ventral suspension find any relation between cure of the was done on lOth October 1960. Prolapse prolapse and correction of retrover­ recurred soon after operation. Anterior sion. The larger number of entero­ colporrhaphy and posterior colpoperineor­ celes at follow up may be due to a rhaphy were done 3 months later (1st careful search for /this particular February· 1961). She gave birth to a pre­ mature still-birth (weight 3 lbs. 12 ozs.) lesion. 1! years after operation. Labour lasted for· 3 days and pitocin drip was given. She Anatomic results following Cervi­ had another full-term normal delivery in copexy operation December 1963. Again pitocin drip was given for cervical dystocia. · Recurrence of prolapse: Only one At the time of follow up she had 3rd patient out of 17 had a recurrence degree cervical prolapse with cystocele, following a vaginal delivery 2 years rectocele and enterocele. after operation (Case No. C 23). Case No. F 102: Recurrence occurred Eollowing a cervicopexy operation, following a full-term vaginal delivery one the cervix is pulled towards the sym­ year after Manchester operation. There physis pubis. This ' broadens the was 3rd degree cervical prolapse with rectocoele and enterocele. - · . pouch of Douglas and gives an erro­ neous impression of an enterocele Following a Manchester operation when the patient is made to strain. cervix was found to be very irregular When the strips are attached low and with a few exceptions was flush down on the cervix the fundus of the with the vaginal vault. It was ex­ uterus falls back in the pouch of tremely painful to locate the cervical Douglas. Hence the strips should be canal and two patients had cervical attached at or above the level of stenosis. In all the cases the anterior the internal os. OPERATIVE TREATMENT OF GENITAL PROLAPSE 59

The sling action of the rectus strips TABLE V could be demonstrated in every case Effect of Manchester operation on fertility except the one with a recurrence. When the patient coughed cervix No. of went up in each case. patients The large number of rectoceles at Sterility of 3 years or more prior to follow up was due to the fact that in operation . . 15 early days of this operation it was not Sterilised at or b 2fore the time of supplemented with a colpoperineor­ operation . . 9 Oligomenorrhoea, anovular dysfunc- rhaphy. tional bleeding 6 The vagina was roomy and there No sexual relations . . 3 was not a single case of post-opera­ Husband responsible for sterility 3 · tive dyspareunia. Fertility unaffected by operation 17 Secondary sterility-conceived after Effect of operation on fertility operation . . 4 Sterility probably attributable to ope- Manchester operation: According ration 5 to Leonard 80 % of women under­ goning Manchester repair become Total 62 sterile; of those who conceived 50 % had premature interruption of preg­ tions. Only one couple was com­ nancy and of those proceding to term pletely investigated and no obvious even a larger percentage had diffi­ cause was detected. Thus in 22.7 % cult and prolonged labours. John of patients operation could be possi­ Hunter also shares the general belief bly blamed for sterility. Another that few patients conceive after Man­ fact to be remembered is that 'pro­ chester repair. In his series of 330 lapse follows difficult, prolonged and cases, there were 32 wo:nen of child­ hence infected deliveries. Thus tubal bearing age who had not practised infection might have been responsible contraception. There were only 3 for sterility in at least some of these pregnancies in his series with one cases. If these women are used as premature live-birth. their own control then incidence of Zoefgen (1936) recommended the secondary sterility prior to operation operation as a sterilising measure. was 56.36 % as mentioned previously. Table V shows that out of 62 There were four patients with second­ patients followed up, there were 22 ary sterility of 3 years or more who young women who had their last de­ conceived shortly after operation. livery within 3 years of operation and All of them had 3rd degree prolapse. hence they were expected to become Clearing of chronic cervicitis and in­ pregnant after operation. Of these, creased frequency of coitus might 17 conceived and 5 failed to conceive, have been responsible for these preg­ thus giving an incidence of 22.7 % of nancies. secondary sterility. It was decided Cervicopexy operation: Table VI to investigate these patients fully but shows the effect of cervicopexy as they had sufficient number of operation on fertility. In this parti­ children they refused any investiga: cular group we were in a better posi- JOURNAL . OF OBSTETRICS AND GYNAECOLOCY OF INDIA

TABLE VI common. Before operation there Effect of cervicopexy operation was one full-term still-birth in 238 - · on fertility pregnancies while after operation No. of · there were three full-term still-births patients in 32 pregnancies. There was one Diseased tubes 3 caesarean section for possible cervi­ Secondary sterility of 4-10 years prior cal dystocia. Some of these patients to operation 3 require special mention. Fertility unaffected by operation 15 Secondary sterility-conceived after Case No. F. 100: Mrs. X, 25 year old, operation . . 4 had two full-term normal deliveries prior Secondary sterility probably attribut- to operation. · She had 2nd degree cervical able to operation . . Nil prolapse with cystocele and rectobeele. Total 25 Uterocervical length was 3 inches. Man­ chester operation was done on 1st Novem­ ber 1960; half an inch cervix was amputat­ tion to evaluate facts because at ed. Following operation she had 3 pain­ operation tubes were examined and less midtrimester abortions. Tightening of tested for patency. There was not a internal os was done per abdomen on 12th single pat!ent in whom the sterility March 1963. At follow up portio vaginalis of the cervix was not felt and utero-cervi-· could be attributed to operation, cal length was 2 inches. Patient was ad­ while four patients with third degree mitted with 36 weeks amenorrhoea and c~rvical prolapse conceived after labour pains on 1st September, 1965. Liga­ operation probably due to increased ture around the internal os was cut, but the frequency of coitus. cervix failed to dilate. Lower segment caesarean section and sterilisation were Outcome of pregnancy and labour done under spinal anaesthesia. Baby following repair of prolapse weight was 5 lbs. Table VII clearly shows that This case is an example of incom­ following Manchester operation petence of internal os due to high abortions increased three times and amputation of cervix. It has been premature deliveries were twice as rightly emphasised by Shirodkar that'

TABLE VU Outcome of Pregnancy and Labour following repair of prolapse

Premature Pregnant at F.T.N.D. Abortion F.T.S.B. F.T.C.S. · delivery the time of follow up Per Per Per Per Per No. No. No. No. No. No. cent cent cent cent cent MANCHESTER REPAIR

Before ~05 16.12 24 10.08 8 3.38 1 0.42 After 16 50 9 28.12 3 9.38 3 9.38 1 3.12 3 ABDOMINAL CERViCOPExY Before 49 83.06 6 10.17 3 5.08 1 1.69 Aftet 18 72 5 20 2 8 2 OPERATIVE TREATMENT .OF . GENITAL PROLAPSE . 61

· · t' 1 f for cord prolapse. Due to extensive adhe- amputabon IS not ~ssen 1a .. or . a sions over the lower segment a classical successful repair provided the:cervl.X caesarean section with sterilisation was is not elongated. undertaken. Case No. F 104: Mrs. M., aged 26, _ h~d • 3 full-term normal deliveries and one s1x From this it is obvious that the in­ months abortion prior to operation. She dication for caesarean section was not had 3rd degree cervical prolapse, cystocele previous operation, but some obste­ and rectocele. Manchester repair was done tric complication. on 13th October 1960. Following operation she had two painless abortions at 4 and 6 months. During her last pregnancy she was Conclusions admitted for repeated threatened abortion A comparative study of the cases and had a premature delivery in April1964. . . of prolapse occuring m young women In a paper read at the 14th British of childbearing age treated by Man- Congress of Obstetrics and Gyna~co- chester repair and abdominal cervi­ logy the high incidence. of aborb~ns copexy was made. It was found that: and premature deliveries follo~m.g ( 1) Majority of our patients are Manchester Operation was statist!- young, average ages being 25 and 30 cally proved; 5% had caesarean sec- years respectively in the two series, tion due to cervical dystocia. There making a conservative operation were two deaths due to rupture of necessary. uterus and a surprisingly high in­ (2) Ten per cent of the women cidence of accidental haemorrhage were nulliparous and 25 % had pro­ was noted. In our series there was lapse following a single delivery. one caesarean section in 20 full-term This emphasises the importance of deliveries giving a similar incidence congenital weakness of supporting of 5% . There was not a single case tissues as a cause of prolapse. of rupture uterus or accidental hae- (3) There was a high incidence of morrhage. . secondary sterility in prolapse cases Nineteen women who conceived ( 53.4% ) possibly due to tubal infec­ after cervicopexy had in all 25 con­ tion and this should be taken into ceptions. Incidence of abnormal de­ account when studying the effect of liveries was not significantly increas­ operation on fertility. ed. There were two caesarean sec­ ( 4) The possibility of prolapse tions. Details are given below. causing sterility through chronic Case No. C 10: Mrs. K. 25 years old, cervicitis and dyspareunia is put for­ married for 7 years had a cervicopexy ward. operation for nulliparous prolapse. She conceived 5 years after operation. At full ( 5) The . claim that Manchester term head was floating and there was some operation causes sterility has been degree of cephalopelvic disproportion. She challenged. was taken for caesarean section after a (6) The incidence of post-opera­ short trial. Lower segment was difficult tive complications such as secondary to approach because of adhesions an~ . a slightly higher incision had to be made on haemorrhage, urinary infection, the lower segment. cervical stenosis and dyspareunia is Case No. C 55: Mrs. Y. was 6th gravida higher after a Manchester repair than and 3rd para. Caesarean section was done after abdominal cervicopexy. 62 JOURNAL OF OBSTETRICS AND GYNAECOLOCY OF INDIA

(7) As far as anatomic and physio­ tion after repair for prolapse is not logic cure is concerned there is not justified. much 'to choose between the two pro- cedures. · _Summary ( 8) After Manchester repair th~re A comparative study of 191 cases is an increased incidence of abortions, of prolapse occurring in young premature deliveries and still-births. women and treated by Manchester There will be a need for more caesa­ repair and abdominal cervicopexy is rean sections if these still-births due presented. to cervical dystocia are to b2 avoided. Technical details of abdominai All the still-births were home deli­ cervicopexy are described. · veries, hence the need of hospital ·Abdominal cervicopexy was found delivery after a vaginal repair. All to be a good operation for 2nd and these are complications of cervical early third degree cervical prolapse amputation and hence this should not (Shaw's classification) with a small be done unless cervix is elongated cystocele. Presence of rectocele considerably. and enterocele required additional (9) Both the caesarean sections operative procedures. after cervicopexy were for indications Abdominal cervicopexy did not in­ other than previous repair. Nev2r­ terfere with fertility and pregnancy. theless. there was difficulty during During labour it did not increase the operation. This can be avoided b'! incidence of operative delivery. The attention to certain details of th~ incidence of recurrence of prolapse technique. after full-term vaginal delivery was (a) Proper peritonisation of the only 6.6%. raw area in front of the cervix at the This operation is not suitable for time of cervicopexy. procedentia, stress incontinence and (b) During caesarean section a large cystocoele. particular attention should be given If is an operation of choice for to bladder which has been advanced; nulliparous prolapse. otherwise it is liable to injury. Acknowledgement (c) The lower segment incision Our thanks to Dr. B. N. Purandare, should be above the level of the strips the Head of the Obstetric and Gynae­ so that the repair is not disturbed. cological Unit of K.E.M. Hospital for ( 10) Following Manchester repair his valuable suggestions and the 16 patients had full-term vaginal Dean of K.E.M. Hospital for allowing deliveries, 3 patients liaving 2 deli­ us to use the hospital data. veries each with recurrence of prolapse, giving an incidence of References 12.5% . Following abdominal cervi­ 1. Fothergill, W. E.: J. Obst. & copexy 15 patients· had full-term Gynec. Brit. Emp. 24: 19, 1913. vaginal deliveries, 3 having two deli­ . 2. Hunter, John: Progress in Gynae­ veries each with one recurrence, cology, Vol. III by Meigs. giving a percenta,ge of 6.6. Thus it is 3. Shirodkar, V. N.: Contributions to apparent that routine caesarean sec,. ,Gyn

t OPERATIVE TREATMENT OF GENITAL PROLAPSE

Fig. 1 Fig. 2

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Fig. 5 Fig. 6