ELONGATION - OF (Review of 90 Cases)

BY K.M. MASANI, M.D. (Lond.); F.R.C.S., (Eng.); F.I.C.S., Hony. Gynaecologist, K.E.M. Hospita1, Hony. Principal Medical Officer, NowToji Wadia Maternity Hospital, Bombay.

Elongation of the cervix has at­ genital prolapse. (2) Elongation of tracted the attention of gynaecolog­ the cervix with prolapse. In the first ists for many centuries, and one of the group, elongation without prolapse, oldest gynaecological operations has there are two distinct clinical types been that of amputation of the cervix. having different retiological and cli­ Elongation of the cervix is a frequent nical features. The two types are: cause of primary as well as 'relative' (a) congenital elongation of the sterility. Congenital elongation of cervix; and (b) acquired elongation the cervix is a recognised cause of of one of the lips of the cervix with primary sterility and is frequently marked hypertrophy of the elongated encountered during routine investiga­ lip in some of the cases. tion. In parous women cervical elon­ The second group, elongation with gation is a common cause of 'relative' prolapse, is also preferably divided sterility. The association of cervical into two clinical types: (1) Elonga­ tears with elongation is common and tion of the cervix with genital pro­ in them muco-purulent cervical dis­ lapse in women of menopausal age charge is an additional distressing or after the menopause. (2) Elon­ symptom. Frequently, there is pro­ gation of the cervix with genital pro­ lapse of the genital organs as well as lapse in young women desiring elongation of the cervix. further childbirth. In this paper, 90 cases of elongated cervix are reviewed, of which 58 Statistical and Clinical Survey of cases were treated at the King Ed­ Congenital Elongation of the Cervix. ward VII Memorial Hospital, Bom­ Among 90 cases were eleven cases of bay, and 32 were treated by me in this type. All the females were private practice. sterile and were between the ages of Clinically, elongation of the cervix 16 and 25. The chief complaint of can be divided into two main groups: all the cases was that they had (1) Elongation of the cervix without noticed something protruding at the ------. In 4 cases there was inability Paper read at the Seventh All India to have normal coitus due to the Obstetric and Gynaecological Congress elongated cervix in the . at Calcutta in December, 1952. Physical examination revealed 294 JOURNAL OF OBSTETRICS AND OF INDIA genital underdevelopment in most of between 20 and 25; 2 between 25 the cases. The vagina was short, the and 30; 1 between 35 and 40; and 2 cervix long and conical, and the were above 50 years of age. of prepubescent size in acutely All the cases occurred in parous anteflexed or retroflexed posit·ion. women. History of previous difficult The fornices were high up in their labour with forceps was obtained in normal position, the entire elongation only 2 cases. In 2 cases, there was being of the vaginal portion of the history of one previous childbirth 5 cervix. , and 7 years ago after which there was All the cases were treated by relative sterility. In one case, there amputation of the cervix. As the were 2 previous full term deliveries; cervix in most of the cases was in two, there were 3 deliveries; and conical, it was not difficult to cover in the remaining two, 6 previous de- '­ the amputated cervix. An anterior liveries had occurred. and posterior suture was sufficient All 7 cases came under observa­ to cover the raw area. Small areas tion for something protruding at the left over on the lateral side were vulva. Five of the women were dis­ covered by one or two sutures. tressed by profuse, sticky, muco­ Four of 11 cases conceived after purulent cervical discharge. amputation and there was no diffi­ The four women below the age of culty in dilatation of the cervix 30 were treated by amputation of during labour. the cervix, and the remaining three An alternative method of pulling parous women nearing 40 by vaginal '. up the elongated cervix is by ventri­ . fixation of the uterus by a single Elongation of the Cervix with suture passed through the abdominal Prolapse. The purpose of separating parieties and the anterior wall of the elongation of the cervix with genital uterus below the round ligament. prolapse into separate types requires Elongation with m· without Hyper­ clarification. In women approaching trophy of One of the Lips of the menopause or after the onset of menopause, genital prolapse with Ce1·vix. There were 7 cases, 7.8 j'~ of elongated, torn or hypertrophied this type. In 5, the anterior lip, and cervix can be treated by any one of in the other 2, the posterior lip was the standard operations, but the same elongated. In 5 cases, the elongated is not the case in younger women in lacerated lip appeared as a long whom the preservation of childbear­ tongue-like structure. In 2 cases, there was marked hypertrophy of ing function is an important factor. There were 72 cases of elongated the anterior lip with elongation which cervix with genital prolapse in this closely simulated a polypus protrud­ 'series of 90 cases: 39 cases were ing from the cervical canal. On spe­ in women above the age of 40, and culum examination the posterior 33 in women below the age of 40. lip was visualised with difficulty in its normal position. Statis'tical and Clinical Survey of The ages of these 7 cases were: 2 39 cases above the Age of Forty. ELONGATIONS OF CERVIX 2"9 5

Age: 18 cases were between the ration. Le Forte's operation has no ages of 40 and 50; 14 between 50 and place in cases of prolapse with elon­ 60; and the remaining 7 were over gation of the cervix. In many cases 60. the elongated cervix is lacerated or hypertrophied and it is contra-indi­ Type of Prolapse: In 6 cases there cated to close the vagina below such was complete procidentia, in 12 an unhealthy cervix. Also, an elon­ there was second degree of uterine gated cervix cannot be elevated high prolapse, and in eleven cases th~re up in the vagina so as to allow a was varying degree of cystocele WIth good vaginal barrier to be fo~me.d elongation of the cervix. The .degr~e below it. Even when the cervix 1s of cervical elongation was: 1 mch m healthy and slightly elongated and 19 cases, 2 inches in 14 cases, 3 Le Forte's has been performed, fur­ inches in 4 cases, and more than 3 ther elongation ·of the cervix pushes inches in 2 cases. the closed vagina in front of it and The cervix was normal in ap­ the cervix is felt, though not seen, as pearance in 16 cases, irregularly a conical structure. For all these lacerated in 6 cases, markedly hyper­ reasons Le Forte's operation was not trophied with ectropion of ~t~ lips done in any of the cases. in 6 cases, and in the remammg 2 All 39 cases were treated by Mayo­ cases there were trophic ulcers of Ward operation. By including vagi­ varying size and in varying situation nal hysterectomy in treating these in the region of the cervix. cases, .risk of carcinoma of the cervix Clinical symptoms for which the as well as the body of the uterus is patients sought relief were varie~. In eliminated, a distinct advantage over 9 cases of procidentia. blood-stamed Manchester operation in which p;:.r) discharge from the ulcers brought of the cervix and the body of the the patient for advice. Micturition uterus is left behind. Spalding­ symptoms in some form were present Richardson composite operation in 33 cases. None of these symptoms which also aims at eliminating the could be strictly regarded as being potential danger of carcinoma of the due to cervical elongation. cervix and the body was not per­ It was an interesting observation formed in any of the cases. that in 23 cases the patients stated In younger women desiring future that the protrusion at the vulva notic­ childbirth, genital prolapse with cer­ ed by them was of short duration, one vical elongation is usually treated by to three months. The genital pro­ Manchester operation or by the lapse and cervical elongation of some recently introduc~d -shirodkar's ope­ vears must have been present, but ration. Manchester operation fre­ involution of the components of the quently defeats the chief object, that pelvic floor caused further descent of of future conceptions and childbirth, the genital organs. in several ways. After Mancliester Treatment. The two operations operation the amputated cervix usually employed are Mayo-Ward usually points directly downwards. operation and the Manchester ope- The backward position favourable for 296 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF lNDli\

conception is seldom obtained. Fre­ even when an amputation is required, quently, the amputated cervix be­ bringing forward the utero-sacral comes flush with the vaginal dam~. ligaments by Shirodkar's method is The gland bearing area of the cervix definitely superior to Manchester from which the cervical mucous is method of bringing forward Macken­ secreted is removed after high ampu­ drodt's ligaments without cutting tation. The vitality of the sperms is them. diminished by the absence of cervical Manchester operation was per­ mucous together with the difficulty in formed in 25 of the 33 cases in this getting access to the amputated series and only 8 were treated by cervix. When conception occurs Shirodkar's operation because this after the Manchester operation there operation was introduced recently. It is considerable risk of repeated has not been possible to follow up all abortion. At full term, cervical the cases, but at least 4 cases treated dystocia is likely due to failure by Manchester operation conceived. of the newly formed fibrosed external One of the four cases caused cervical os to dilate and then caesarean dystocia at term necessitating caesa­ section is required for safe deli;,ery. rean section for delivery and the Shirodkar's operation aims at remaining 3 delivered by the vaginal getting over the disadvantages of the route. One of the 8 cases treated b:v Manchester operation. If the cervix Shirodkar's operation conceived and is heal·thy and elongated not more delivered normally. than 2 inches, amputation is not re­ quired. The utero-sacral ligaments Summary. 90 cases of elongation are widely separated after opening of the cervix are reviewed. They the pouch of Douglas, cut and then are divided into two groups: (1) brought forward in front of the cervix Elongation of the cervix without and stitched. In this manner the genital prolapse, and (2) elongation cervix is pulled up and is directed of the cervix with genital prolapse. backwards. By not amputating the The group of cases of elongation cervix, the gland bearing area from without prolapse is separated into which cervical mucous is secreted two clinical types: (a) congenital is preserved, and the cervix directed elongation of the cervix, and (b) backwards dips into the seminal acquired elongation of one of the pool. All these conditions favour lips of the cervix. conception. Again, the risk of re­ The group of elongation with pro­ peated abortions, as well as cervical lapse is also separated into two dystocia during labour as is present clinical types: (~elongation of the after amputation, is eliminated. cervix with genital prolapse in When the cervix, one or both lips, women of menopausal age or after is hypertrophied, amputation has to the menopause, and (b) elongation be done. Again, a cervix that is lace­ o£ the cervix with genital prolapse in rated has got to be amputated. Thus, young women desiring further child­ indications for Shirodkar's operation birth. without amputation are limited, but There were eleven cases of con- ELONGATIONS OF CERVIX 297 genital elongation of the cervix, all the cervix with prolapse were in occurring in women between the women of menopausal age or after ages of 16 and 25 and all of them · the menopause. Sixteen were com­ sought advice' for something pro- plete procidentia, 12 of second truding at the vulva and sterility. degree, and 11 had elongation with Dyspareunia was an additional cystocele. All the cases were treat­ symptom in 4 of them. All were ed by Mayo-Ward operation. treated by amputation of the cervix. Thirty-three cases of elongation of Four conceived and delivered nor- the cervix with prolapse occurred in mally after amputation. young women desiring future child- There were 7 cases of elongation of birth. Twenty-five were treated by one of the lips. In 5, the elongated Manchester operation and 8 by cervix was thin and in 2 there was Shirodkar's operation. The advan­ marked hypertrophy of the elon- tages and disadvantages of these gated anterior lip which simulated two operations are discussed, and new growth of the cervical lip. more wide use of Shirodkar's opera- Thirty-nine cases of elongation of tion is emphasised.

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