The Results of Operative Treatment of Prolapse 545 Postgrad Med J: First Published As 10.1136/Pgmj.29.337.545 on 1 November 1953

November 1953 BENTALL: The Results of Operative Treatment of Prolapse 545 Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from but where abscesses or fistulae are present, these sary, but whatever is done the chance of recurrence are clear indications for preliminary ileocolostomy is high. with exclusion. It this does not give relief, A follow-up study of 26 cases treated at one resection can be done more safely at a second hospital confirms these generalizations and empha- operation. sizes the problem of the recurrent case. The danger of the ' blind loop ' blowing Gut In the chronic phase surgery should be lirnited following an exclusion operation seems to be more to those cases with clear evidence of obstruction, apparent than real, because the deflection of the perforation, abscess or fistula formation, or severe faecal stream away from the diseased area causes intractibility. the stricture to relent. I wish to thank Professor R. S. Pilcher for his Whatever the form of surgery employed, there assistance in preparing this paper, and also the is no doubt that the recurrence rate is depressingly consultant staff of University College Hospital for high. permission to follow-up their patients. BIBLIOGRAPHY Summary ARMITAGE, G., and WILSON, M. (1950-5i) Brit. Y. Surg., Crohn's disease is a non-specific granuloma of 38, 183. BOCKUS, H. L. (I945), Y. Amer. med. Ass., 127, 449. the gut, commonest in the terminal ileum, some- CHESS, S., CHESS, D., OLANDER, G., BENNER, W, and times involving other parts. COLE, W. H. (I950), Surgery, 27, 221. COOMBE, C., and SAUNDERS, W. (I813), Med. Trans. Roy. An acute form of the disease mimics appendi- Coil. Phys. Lond., 4, I6. citis and is seldom recognized until the belly is CROHN, B. B., GINZBURG, L., and OPPENHEIMER, G. D. (1932), Y. Amer. med. Ass., 99, 1323. opened. Nothing more should be done; appendi- DALZIEL, T. K. (1913), Brit. med. 9'., 2, Io68. cectomy is to be avoided as it may be followed by FELSEN, J. (1936), Amer. Y. Path., 12, 395. a fistula. GARLOCK, J. H. (1946), Amer. 9'. Surg., 72, 875. HADFIELD, G. (I939), Lancet, ii, 773. In its chronic stages the disease presents in HAWTHORNE, H. R., and FROBESE, A. S. (I949), Atnn. Surg.,Protected by copyright. many ways, but its important features are chronic 130, 233. HOMB, A. (1946), Acta. chir. scand., 94, 343. small intestine obstruction and the complications KANTOR, J. L. (I934), 9. Amer. med. Ass., 103, 20I6. of subacute perforation. Operation may be neces- PATEY, D. H. (I949), Proc. Roy. Soc. Med., 42, 769.

THE RESULTS OF OPERATIVE TREATMENT OF PROLAPSE A follow up of 340 cases By A. P. BENTALL, M.A., M.D., M.R.C.O.G., D.C.H.

Assistant Obstetrician and Gynaecologist, Norfolk and Norwich Hospital http://pmj.bmj.com/

Introduction return home, usually with thanks for what has At least twice a week the majority of gynaeco- been done, at the end of three weeks. logists throughout the country come to the stage We do not often see a recurrence and when we in their operating lists where, having taxed them- do the original operation was often done elsewhere selves with the more exacting problems earlier on, and we assume that it was done inefficiently. We on September 29, 2021 by guest. they can sit down to deal with one or two cases of feel justified in thinking that the great majority of prolapse before the hard part of the morning's our own patients get on well and remain eternally work is over. They are justified in expecting that grateful, but in reality we know little of the end the operation, though it may be tedious, especially results of the vast number of operations for to the assistant standing with bent back, will run prolapse which are done throughout the country smoothly and according to the usual routine every year. varied but slightly to suit the particular nature of A study of the literature on the subject is not the case. Their experience teaches them to expect very helpful. Publications on the results have been their patients to have some difficulty in passing surprisingly few in recent years and such as are water for a day or two, to be unable to sit down available give a very varied picture of the success in comfort for about ten days and to be anxious to which may be expected, the picture usually DI Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from 546 POSTGRADUATE MEDICAL JOURNAL November 1953 depending on the thoroughness with which the above the average, being sixty-three and 4.5 years, cases were followed up. respectively. In an attempt to ascertain the degree of success Certain associated medical conditions were which is being achieved the results of 340 cases encountered relatively frequently. Visceroptosis operated upon in the years I948-5I have been of sufficient degree to justify the wearing of a studied; 240 of these cases have been treated in special belt was noted 27 times at the initial an outlying hospital where, in the absence of examination. Functional uterine haemorrhage was a resident medical officer, the day-to-day care has present in 20 cases and fibroids in 6, although been undertaken by local practitioners. The this condition is not common in multiparous reamining IOO who, by reason of their age or women. Prolapsed piles sufficiently severe to some medical complication, were in need of merit surgical treatment were seen in I2 cases. closer supervision, were treated in the main centre. Some degree of hypertension was common, but Certain conclusions have been reached from was sufficiently severe to call for special con- the experience gained in the treatment and follow sideration by the anaethetist on I2 occasions. up of these cases and, in view of the paucity of Diabetes called for special supervision in 9 cases. literature on the subject of this everyday operation, Operation was contraindicated by cardiac failure they have been recorded. in i case and by arthritis so severe as to prevent adequate abduction and flexion of the hips for Symptoms a surgical approach in another. I have only The average age of the 340 patients was fifty- advised against operation on 3 other occasions, one. Although multiparity is usually regarded as and these were cases where the patients' age and a predisposing factor in the production of pro- debility would have prevented their leading a life lapse, large families seem to be increasingly un- of any activity even if the prolapse were cured.

common even in a rural area such as Norfolk and Certain other symptoms deserve considerationProtected by copyright. the average number of children works out at only owing to the frequency with which they are 3-25. encountered. Bleeding from chronic cervicitis, The symptoms of which the patient complains cervical polyp and, particularly, from ulceration vary greatly and bear surprisingly little relation- of the vaginal vault due to the prolonged use of ship to the degree of prolapse or anatomical a ring not infrequently cause the general prac- abnormality which is found on examination. titioner to refer the case as one of post-menopausal Backache, a dragging sensation in the lower bleeding and possible malignant disease. Senile abdomen or a feeling of ' something coming down' atrophy of the uterus predisposes to the condition seem of prolapse and is often accompanied by senile to be the most common presenting symptoms. vaginitis with an atrophic vaginal mucous mem- The complaint of stress incontinence deserves brane, calling for treatment with oestrogens prior special consideration. It was confirmed, as was to operation. One other symptom I have par- emphasized during the discussion on the subject ticularly noticed to be misleading; the soreness at the 13th British Congress of Obstetrics and and swelling resulting from infection of the vagina Gynaecology (Jeffcoate, 1949), that the occurrence with trichomonas vaginalis has resulted in not http://pmj.bmj.com/ of this symptom bears little relationship to the a few patients being told that they require operative degree of prolapse or cystocoele which is present. treatment for prolapse when suitable local treat- Stress incontinence was present to the extent of ment will soon clear up their symptoms without causing notable inconvenience to the patient in any resort to surgery. 132 cases (39 per cent.). This means that in 207, or 6i per cent., of the cases, all of whom had Operative Technique prolapse of sufficient degree to merit surgical The patients are usually admitted to the ward treatment, there was no significant complaint of in the afternoon or evening two days before on September 29, 2021 by guest. stress incontinence. The symptom was severe operation so that they have two nights and one enough to constitute one of the patients' principal day to accustom themselves to their surroundings. complaints in 44 cases (II per cent.). Seventeen Preparation, apart from routine procedures of patients, i.e. 5 per cent. of the total number and cleanliness, shaving, enema, etc., consists of a I2 per cent. of those with any complaint of stress preliminary antiseptic douche, after which a swab incontinence, suffered from this complaint in a soaked in a i in a i,ooo solution of flavine is left severe degree without any demonstrable uterine in the vagina. Only in cases where there has been prolapse or cystocoele. severe and obviously infected ulceration or Complete procidentia, often with accompanying gross oedema from procidentia has any longer ulceration, was present in 41 cases (II per cent.). preparation been undertaken. The age incidence and parity of these cases was The operative procedure adopted follows the November 1953 BENTALL: The Results of Operative Treatment of Prolapse 547 Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from principles of the Manchester type of operation simplified to the utmost degree so that in the majority of cases the operation is not unduly prolonged and the duration of the anaesthetic and the degree of shock, caused to the patient is cut down to the minimum-a point of importance when it is remembered that the majority of the patients are not ideal subjects for operation. The presence of three assistants, at least two of whom are trained in the procedure to be adopted, greatly facilitates the rapid performance of the operation. Preliminary dilation of the cervix and curettage is carried out when there is any history of irregular bleeding or where the age and parity of the patient make carcinoma of the body of the uterus a possibility, but not otherwise. A triangular area of the anterior vaginal- mucous membrane is AK.. removed, the shape of this triangle varying with the degree of prolapse and cystocoele present. The cervix is amputated and descending cervical I branches of the uterine artery ligated on either side. The posterior lip of the cervix is recon- stituted and covered with mucous membrane by three interrupted sutures, the centre one of which Protected by copyright. draws the mucous membrane into the entrance of the cervical canal. The remains of the cardinal Ix ligaments, previously marked by tissue forceps, FIG. ia.-Amputation of the anterior lip of the cervix and the mucous membrane, are brought together only. After reflexion of the flap of anterior vaginal from either side to support and cover the anterior mucous membrane, the upper limit of the wedge lip of the cervix by two interrupted sutures; the to be excised from the denuded anterior lip being anterior colporrhaphy is completed by a single marked with a guiding suture. continuous catgut suture inserted with deep bites so that a firm hold is obtained of the mucous membrane and underlying musculo-fascial tissue on either side. The posterior colporrhaphy is carried out by excision of a triangular area of mucous*membrane K. from the posterior vaginal wall, the base of the triangle being at the perineum; the length of the http://pmj.bmj.com/ incision at the base of the triangle depends on the .. , degree of deficiency of the perineum, while the N distance to which the apex of the triangle is taken up the posterior wall depends on the degree of rectocoele and vault prolapse which is present. When this has been done the perineal muscles, particularly the levatores ani, are exposed and interrupted sutures, usually three, are inserted to on September 29, 2021 by guest. bring them together in the midline. The mucous 4*6 membrane of the posterior vaginal wall is then .t3JI. . brought together by a single continuous suture, the underlying muscular stitches being tied as their level is reached coming down the posterior vaginal FiG. ;ib.- After removal of the wedge from the anterior 'wall. The operation is completed by a few 'inter- lip of the.cervix. rupted sutures of finer catgut to bring together the mucles and skin of the perineal body. Finally a swab soaked in flavine and paraffin is inserted into the vagina to prevent adhesions between the This routine 'procedure is modified in three anterior and posterior suture line. ways accord.ing to circ.umst'ances: Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from 548 POSTGRADUATE MEDICAL JOURNAL November I953 alone elevates the bladder and anterior vaginal wall without corresponding elevation of the cervix; the uterus often remains in its original vertical or retroverted position and is not anteverted as it should be when Fothergill's operation has been well carried out. Indeed, when anterior colporrhaphy alone has been t --PA completed, the cervix often looks more prolapsed than it did before, owing to the elevation of the anterior vaginal wall. Under these circumstances a wedge-shaped area is excised from the anterior lip of the cervix so that the remains of the cardinal ligaments may be brought together in front of the cervix as they are when it has been wholly 0 v 4 amputated. This results in a tidy repair of the a cervix, which is so often lacerated and eroded although it is not markedly prolapsed, and it is elevated and restored to its natural relationship with the repaired anterior vaginal wall (Fig. ia, b and c). (3) In cases of marked stress incontinence I unaccompanied by any very significant cysto- OOMMIN or prolapse, a more through dissection is

coele Protected by copyright. "%%%w'j. xi 111%k made exposing muscular tissue lateral to the 0100 urethra and bladder neck. These structures are then elevated by two or three buried sutures before the anterior colporrhaphy is completed. gp- In this series of cases vaginal hysterectomy and repair has only been carried out where there was some associated abnormality of the uterus, making FIG. Ic.-After repair of the cervix, ready to proceed its removal desirable. In cases where this seemed with the anterior colporrhaphy. likely to be technically difficult owing to little uterine descent, I have had no hesitation in removing the uterus per abdomen after the neces- (i) In cases of marked vault prolapse or sary repair had been carried out from below. enterocoele it is often wise to open the pouch This double operation does not seem to be follQwed of Douglas; the depth of this pouch, which by any undue shock provided the repair is carriedhttp://pmj.bmj.com/ under these circumstances may be regarded as out simply and rapidly as described. (Since a hernial sac, may then be decreased by a purse reading of the operation of ' abdominal colpor- string suture placed as high as possible and the raphy,' as described by MacLeod (1952), this floor supported by bringing the uterosacral double operation has been avoided on several ligaments together in the midline as described occasions with results which at- present seem by Read (949). This type of prolapse is completely satisfactory. It is perhaps worthy of difficult to cure and has been responsible for note that four cases of moderately severe stress the majority of my own failures. It is pointed incontinence, together with other uterine symp- on September 29, 2021 by guest. out in the description quoted above that many toms, appear to have been completely cured by cases of so-called ' recurrent ' enterocoele are this procedure.) not ' recurrent ' but ' neglected ' cases of Worry about the possibility of a further preg- enterocoele and a careful watch for such a con- nancy not infrequently interferes with the com- dition and the adoption of the above procedure plete restoration of physical and mental well-being has resulted in definitely improved results. which might be anticipated after a successful (2) In cases where cystocoele or laxity of the operation for prolapse. In cases where the mother anterior vaginal wall is present without any is already overburdened with the responsibility of marked uterine prolapse, complete amputation a large family or where there is some associated of the cervix is technically difficult and often medical abnormality to contraindicate further seems unnecessary, but an anterior colporrhaphy pregnancies in addition to the contraindication of Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from November I953 BENTALL: The Results of Operative Treatment of Prolapse 549 the risk of a recurrence of the prolapse after a a week they are helped into a bath; thereafter further pregnancy, sterilization may well be bed-pans can be dispensed with. Although the advisable. (In this series a history of severe vari- patient is on her feet for short intervals from an cose veins, often accompanied by thrombo- early stage, a full three weeks in hospital is con- phlebitis, was a common additional contra- sidered essential and, so far as possible, arrange- indication to further pregnancy.) Where there is ments are made so that they do not have to return marked descent of the uterus, it may be an easy to full household duties for two weeks after their matter to open the peritoneum at its reflection discharge. from the bladder to the uterus and excise a portion The patient is encouraged to pass her water of both fallopian tubes from below; where there naturally from the start, but if she is unable to do is not enough prolapse to make this an easy pro- so, a catheter must be passed every eight hours cedure it takes very little longer, and causes much until one is satisfied that the bladder is being less anxiety to the surgeon, to complete the repair properly emptied. In spite of the utmost care, in the usual way and then excise a portion of both a urinary infection is very common and, for this fallopian tubes per abdomen; adequate peri- reason, prophyllactic treatment with a suitable tonealization of the ends of the tubes is much form of sulphonamide is given as a routine for more easily achieved when this is done. the first five days. It is striking that, when these Having seen the extreme discomfort caused by cases are treated as a routine by a nursing staff prolapsed piles during convalescence after opera- accustomed to dealing with cases of prolapse, tion for prolapse, I could not believe that it could natural micturition is established much sooner be any worse if haemorrhoidectomy was carried than when only an occasional case is dealt with. out at the same time; I now follow the repair Early rising is also a help in this respect. operation by haemorrhoidectomy in all cases With such treatment, complications are unusual the be expected to be where severe prolapsed piles are present; and the convalescence may Protected by copyright. discomfort to the patient seems to be very little smooth. An analysis of the complications en- greater than after posterior colpo-perineorrhaphy. countered in this series is given in Table 2. There and the results encourage me to continue with was one death from pulmonary embolism. this practice. Moderately severe secondary haemorrhage requir- The relative frequency with which the various ing packing of the vagina was encountered on 7 procedures described have been employed is occasions. Further treatment for cystitis after illustrated in Table i. the routine prophylactic treatment was completed was required in I2 cases and a febrile reaction TABLE I No. of attributed to chest complications was encountered patients i8 times, but in all cases was rapidly overcome Routine procedure ...... 252 with treatment with penicillin; in only a small Routine procedure with amputation of anterior proportion of these cases were the physical signs lip of cervix only ...... 36 Anterior Colporrhaphy only (usually including sufficiently well defined to warrant a diagnosis of amputation of anterior lip of cervix) .. 7 broncho-pneumonia. In only one case did the Posterior colpo-perineorrhaphy only (usually patient's immediate post-operative condition give http://pmj.bmj.com/ combined with repair of third-degree tear).. 4 rise to grave anxiety; this may have been due to Urethroplasty only ...... I7 excessive blood at the time or to Repair and subtotal hysterectomy .. .. 4 loss of operation Vaginal hysterectomy ...... 20 the use of intravenous pethidene during the Repair accompanied by sterilisation: anaesthetic. Recovery was normal after blood Per abdomen ...... I8 transfusion. Per vaginam ...... 12 Repair accompanied by haemorrhoidectomy .. I2 TABLE 2. POST-OPERATIVE COMPLICATIONS

D. & C. and repair followed by X-ray menopause 6 on September 29, 2021 by guest. Death (pulmonary embolus) .. .. I (0.29%) Secondary haemorrhage . . 7 (2%) Post-Operative Complications Persistent cystitis ...... 2(3.5%) The principles of the post-operative regime in Chest complications ...... I8 (5.3%) these cases are, irt the first place, to secure physical Superficial venous thrombosis .. .. 4 the Pelvic peritonitis (after vaginal hysterec- and mental rest for the patient, which includes tomy in both cases) ...... 2 relief of pain, until healing is complete; secondly Sepsis and superficial breakdown of to encourage the re-establishment of normal perineum ...... 3 function of the bladder and bowel and, thirdly, to encourage clean healing of the wound by such Results means as hot baths and douches. In an attempt to assess the results of the treat- The patients are encouraged to get up for a ment described, a personal letter and question- short time on the third day and by the end of naire was sent to each of the 340 patients, all of Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from 550 POSTGRADUATE MEDICAL JOURNAL -November I 953 whom had their operation at least one year before. These were possibly attributable to the use of a In the first question they were asked if they single continuous suture for the anterior colpor- regarded the operation as a complete success; rhaphy; the incidence is small (less than i per the remaining questions related to any recurrence cent.) and all three cases have been cured by a of the sensation of something coming down and to further relatively minor operation. The risk from micturition symptoms. Every patient whose the use of a single continuous suture therefore answer to the first question was other than ' yes' seems to be slight and is more than outweighed was sent an appointment to be seen again by by the low incidence of post-operative complica- myself. tions which must be partly due to the ease and rapidity of operation, especially in elderly TABLE 3. RESULTS patients. Number traced: 3 I 8 A recurrence of some degree of vault prolapse or high rectocoele in iI cases (3.4 per cent.) is Satisfactory result: 28o (88%) disappointing. In two cases the patient was Patient regards operation as a complete quite unconscious the success ...... 214 of recurrence. No treat- Patient's complaint unrelated to prolapse ment is considered necessary at the present time, and result satisfactory on examination . . 66 but they are being kept under observation in case the condition gets worse. Five patients, all of Unsatisfactory result: 38 (I2%) Death (pulmonary embolus) .. .. whom had a complete procidentia of many years' Recurrence of cystocoele ...... 3 ) standing say that they have been completely free Recurrence of vault prolapse or high k 4% from symptoms since they were fitted with a rectocoele ...... I I J small ring when the recurrence was recognized. Troublesome stress incoAtinence .. 8 Dyspareunia ...... 4 Two cases have undergone further operation with

Pyometra ...... results which at present appear satisfactory andProtected by copyright. Patient did not regard operation as a com- two are still waiting for this to be done. Over half plete success and did not attend for of these recurrences were in patients of over sixty further examination o...... I who had a complete procidentia prior to operation. This point is considered further in the discussion The results of this enquiry are summarized in of the results of procidentia (vide infra). Table 3. Twenty-two patients could not be The total number of recurrences, cystocoele, traced (three of these are known to have died rectocoele or vault prolapse, is therefore 14 (4.3 subsequently from an unrelated cause). These per cent.). It is of interest that, with one excep- patients were omitted from the survey. Two tion, all these recurrences occurred within six hundred and fourteen patients regarded the months of operation. operation as a complete success (many of these One patient complained of attacks of abdominal added a touching word of gratitude, including one pain and intermittent dark brown discharge. who hoped that the surgeon would have a long Examination revealed a pyometra from stenosis life and be spared to carry out this operation for of the cervical canal. Total hysterectomy was many yeats to come !). Sixty-six of the patients undertaken, owing to the difficulty of excludinghttp://pmj.bmj.com/ who did not regard the operation as a success carcinoma of the body of the uterus, and the were seen again; a small proportion of these had patient is in good health. -to be classed as failures,; the great majority had The figure of only four cases of dyspareunia is complaints which were unrelated to prolapse; probably inaccurate. Enquiry regarding this carcinophobia, functional uterine haemorrhage or point was not included in the original question- just a desire to be reassured that everything was naire because, knowing some of the- patients in this area, I felt sure that it a certain going on all right accounted for the greatest would prevent on September 29, 2021 by guest. number. A complaint of persistent backache, number from replying at all. All the patients often due to visceroptosis and relieved by a who were seen again were questioned about this surgical belt, was not classified as an unsatis- point and difficulties were only encountered in factory result unless it was thought to be due to four. In a small proportion of more elderly recurrent prolapse or retroversion after examina- patients with marked vault prolapse, the vaginal tion. Ten patients who did not regard the opera- vault was deliberately overnarrowed; these patients tion as a success but failed to. attend for further were told that complete intercourse might be examination were included in the number of impossible after operation and so might not unsatisfactory results. An unsatisfactory result complain of it afterwards. Although the incidence was found in 38 cases (i2 per cent.). In analyzing of this difficulty is almost certainly higher than these unsatisfactory results a localized recurrence appears from these figures, I have formed the of cystocoele .was found on three occasions. opinion that it is a relatively rare complication Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from November 1953 BENTALL: The Results of Operative Treatment of Prolapse 55' when the posterior repair has been carried out driven to seek advice because they could no with due care. longer get about or because of bleeding from Further information can be gained from these ulceration of the prolapsed mucosa. In none of results if they are analyzed with reference to these cases was there any serious post-operative certain of the presenting symptoms: complication; in ii the results were completely Stress incontinence was present in I32 patients satisfactory; in two there was a slight persistent (39 per cent.) when they were first seen. This enterocoele (already included in the unsatisfactory condition was cured in 68 per cent. and greatly results of operation for complete procidentia). improved in a further 26 per cent. The results Both of the latter were rendered completely free are summarized in Table 4. of symptoms by fitting a small ring. TABLE 4. RESULTS-STRESS INCONTINENCE TABLE 6. RESULTS-AGE INCIDENCE OF OVER 70 Number of patients with an initial complaint Number of cases ...... I3 of stress incontinence ...... I32 (39%) Results: Number traced ...... 123 Completely satisfactory .. .. II Cured according to their own statement 84 (68%) Marked improvement .. .. 2 Still slight stress incontinence . . . . 31I (26%) Still severe stress incontinence ... .. 8 (6%) Discussion Number of patients with severe stress The fact that 88 per cent. of the patients were incontinence unassociated with prolapse I7 satisfactorily cured of their prolapse is gratifying, Cured according to their own statement and no stress incontinence demon- but consideration of the remaining I2 per cent. strated on examination .. .. (65%) shows that there is room for improvement. Still slight stress incontinence after plastic Fletcher Shaw (I934) advocating the employ- operation from below (urethroplasty). . 3 ('7%) ment of an operation, the principles of which Still severe stress incontinence *.. 3 (I7%) are very similar to those here described, for all Protected by copyright. Complete procidentia was encountered in 41 types of prolapse, reports 98.36 per cent. of 664 cases. This was treated by the Manchester type cases ' completely cured.' On the other hand, of operation on 39 occasions, which included Stallworthy (I940), in a very careful study of 268 opening and decreasing the depth of the pouch of cases operated upon by different surgeons, reports Douglas and securing the uterosacral ligaments on a recurrence rate of I3 per cent. (a; quarter of five occasions. Examination of the results shows these being after a further pregnancy). In that some degree of persistent enterocoele was addition to this, io per cent. suffered from present in four cases (io per cent.). Two other severe stress incontinence and io per cent. from cases were unsatisfactory, one being one of the dyspareunia. three cases of recurrent cystocoele previously It is in cases of complete procidentia and entero- mentioned, and one developing a pyometra. Two coele that opinions differ most, and examination cases were treated by vaginal hysterectomy with of the results in the present series shows there satisfactory results. These results are disappoint- was a recurrent of some degree of enterocoele in ing and indicate the importance of looking for I0 per cent. Currie (1952) reports on the result the associated enterocoele and dealing with it of 62 cases of ' massive prolapse ' treated by the http://pmj.bmj.com/ adequately. To my mind the results do not Manchester type of operation with a definite indicate the routine employment of vaginal recurrence in 4.8 per cent. and some bulging of hysterectomy except in those cases where this the vault in a further 8 per cent. procedure is necessary to obtain adequate exposure An alternative method, of treatment for this -and support for the floor of the pouch type of case is vaginal hysterectomy and repair. of Douglas. It is questionable whether this gives any better TABLE 5. RESULTS-COMPLETE PROCIDENTIA results unless special precautions are taken to on September 29, 2021 by guest. Satisflactory Unsatisfactory diminish the depth of the pouch of Douglas and Number of cases .. 41 35 (85-36%) 6 (14.66%) support the pelvic floor. Gniou (1950) reports, Routine operation 34 30 4 a recurrence rate of 6 per cent. in $5 cases treated Routine operation by vaginal hysterectomy, which is no great' plus opening pouch improvement on the figures given here. of Douglas, etc. . . 5 3 2 Vaginal hysterec- The importance of enterocoele and herniation tomy . .. 2 2 0 of the floor of the pouch of Douglas is clearly recognized by Veenbeer and Kooistra (1947), who Examination of the age incidence shows that describe a procedure which gives additional sup- operation was undertaken at the age of seventy or port to this area by utilization of the utero-sacral over in I3 cases. Six of these suffered from long- ligaments after vaginal hysterectomy. They standing complete procidentia and were only report only two failures in I04 cases. Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from 552 POSTGRADUATE MEDICAL JOURNAL November 1953 The observations of Read on this point have demned to the permanent use of a ring or cup already been mentioned (Read, I949). In a series and stem pessary or any similar contrivance. of 139 cases, all of whom were operated upon Stress incontinence is cured in over 6o per specifically for enterocoele (many of them after cent. of cases and greatly improved in a further 25 previous repair procedures), there was a recur- per cent. There remains a small but very definite rence in only one, and 9I per cent. of the patients proportion in whom some more extensive pro- traced were cured and symptom-free. Vaginal cedure is necessary to relieve this complaint. hysterectomy was employed in a very small Cases of complete procidentia can be satis- per centage of these cases. It would seem that factorily cured by the Manchester type of opera- recognition and adequate treatment of the entero- tion, provided that any associated enterocoele is coele is the secret of success whether the uterus exposed and dealt with. It is not essential to is removed or not. employ vaginal hysterectomy in such cases unless A second alternative in the treatment of these adequate exposure cannot be obtained without or cssv^% of severe prolapse with associated prolapse there is some associated uterine disease. of the vaginal vault is the employment of Le The purpose of this investigation has been to Fort's operation. In view of the very satisfactory examine and endeavour to improve upon my own mortality and morbidity figures which can be results. No new principles have been described achieved by the Manchester type of operation (or or new arguments put forward. If it should vaginal hysterectomy), the argument that Le stimulate others to look into their own results Fort's operation is a less serious procedure for an with a critical eye, its purpose will have been elderly patient carries little weight. The oblitera- doubly achieved. tion of the vagina which this procedure entails My thanks are due to Mr. Aubrey Goodwin, could only be justified if the results were definitely Mr. Charles Read and Miss Hetty Player (late superior; in fact, this does not seem to be the theatre sister at Chelsea Hospital for Women), case. Kiihnel (1952), in an analysis of 58 cases who gave me the instruction and courage whichProtected by copyright. treated in this way, reports a recurrence in 5.4 was necessary in the beginning; to the theatre per cent. and a mortality of over 3 per cent. The and ward staff at the Norfolk and Norwich difficulty of investigating and treating any sub- Hospital and the Wayland Hospital, Attleborough, sequent uterine haemorrhage is also emphasized whose co-operation has made the work a pleasure; by Mazer and Israel (I948). and to my patients for the gratification of satisfactory results and the stimulation to improvement Conclusions where the results have been otherwise. A repair procedure based on the principles of the Manchester type of operation may be relied BIBLIOGRAPHY CURRIE, D. W. (I952), Y. Obstet. Gyn. Brit. Emp., 59, 96. upon to produce a satisfactory result in approxi- GNIOU, N. M. (I950), Canad. Med. Ass. J., 63, 147. mately go per cent. of cases of prolapse. JEFFCOATE, T. N. A. (I949), J. Obstet. Gyn. Brit. Emp., 59, 685. The operation is not accompanied by any grave KUHNEL, P. (1952), Acta. Obstet. Gyn. Scand., 31, 151. MAcLEOD, D. (I952), -7. Obstet. Gyn. Brit. Emp., 38, 583. disturbance to the patient and post-operative MAZER, C., and ISRAEL, S. L. (1948), Amer. -7. Obst. Gyn., s6, complications are rare. The number of patients 944- http://pmj.bmj.com/ READ, C. D. (I949), 'Trans. XITth Brit. Cong. Obst. Gyn.,' p. I89. whose age or general condition contraindicates SHAW, W. F. (1934), Y. Obstet. Gyn. Brit. Emp., 4I, 853. operation is small and very few should be con- STALLWORTHY, J. A. (1940), Ibid., 47, 391.

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