238 THE INDIAN MEDICAL GAZETTE [May, 1948 Public Health Section AN ANALYTICAL STUDY OF 1,450 Bengal with consequent laxity of ligamentary CASES OF RETROVERTED UTERUS supports, lack of proper supervision during labour and and WITH SPECIAL REFERENCE postnatal period to the general or reluctance to follow the TO TREATMENT ignorance principles of social hygiene. In Western countries one out By KEDAR NATH DUTT, m.b. of six possesses a retroverted uterus, while in House Surgeon, Eden Hospital Bengal, it is found in one out of four examined. and JStiology.?Many women are born with a retroverted uterus. This is ascribed to PTTDHTR CHANDRA ROSE, n.sc., M.n? improper of and also f.r.o.s. (Edin.), f.k.c.o.g. development ligamentous supports sometimes to of uterine Professor of Clinical Midwifery, Medical College, under-development musculature. This Calcutta congenital type comprised about 30.5 per cent of our cases and deficiency uterus lies in of proper diet and exercise made the condition Introductory.?The normally ' ' an anteverted and slightly anteflexed position worse. This is also called uncomplicated type in the pelvis. In erect position, the fundus of of retroversion as there are no signs of disease the uterus lies nearly horizontal, below a in other pelvic organs. plane connecting the sacral promontory to the In contrast to the above variety, many top of the pubis and the external os reaches the instances of retroversion are met with, where the level of ischial spines. position is acquired. Associated pelvic lesions Apart from the tone of its own musculature are present in many cases. Three clinical types and the intra-abdominal pressure acting on its of acquired retroversion are generally en- posterior wall, this position is maintained countered. primarily by the strong ligamentary supports, After childbirth there is a of a ' tendency radiating outwards from . the cervix. The heavy bulky uterus to fall' backwards. There musculo-fascial layers of pelvic diaphragm act is often subinvolution with a mild degree as secondary reinforcement or buttress. of infection. This is noticed particularly in The uterus is retroverted when the fundus patients after a difficult or instrumental' delivery falls behind this normal anatomical plane. If or who are generally asthenic. The laceration of the body also bends backwards at the level of soft parts and subsequent infection complicate is both internal os, the uterus retroverted and the picture. They comprised no less than 39.5 retroflexed. Both these conditions are often per cent cases in our series." Lack of proper found associated. Once retroversion begins it postnatal supervision and the present system becomes gradually pronounced as the line of of discharging a puerperal mother too early action of abdominal pressure is transferred to its from the hospital have materially increased the anterior surface. So, in a late case the infra- number of these cases. of cervix is directed vaginal portion upwards As a result of aftermath of and forwards and of the uterus pelvic peritonitis, body occupies tuberculous infection or endometriosis, the uterus the Retropronation or retro- ' ' posterior pouch. may be pulled back by or cession of uterus should be as a adhesions?flimsy recognized to the nature of infection. In where the uterus is dense?according separate entity, pushed recent times, owing to the introduction of backwards as a whole and often it is anteflexed and antibiotics and to the awaken- and chemotherapy under-developed. ing of better knowledge about personal hygiene, There are few in which subjects gynaecology there is a definite fall in the number of these have attracted so much controversial arguments cases. Even then they include 22 per cent of as that of a retroverted uterus. There are our cases. many who believe that a retroverted uterus Uterus may be found retroverted due to the per se does not produce any symptom and presence of blood or any exudate so any treatment for such a condition is tumour, fluid, in front of the when it is never a uterus, simply unwarranted; while others leave 1 ' back. This was noted in 8 cent retroverted uterus as such as they attribute all pushed per of our cases. It is whether a the symptoms in the patient to this condition. questionable normal uterus can deviate backwards due to a In this paper observations made on a study of heavy fall on the back, many 1,450 cases of retroversion, attending Eden though appeared with this story. Hospital, during a period of 5 years, are presented. Pathology.?Under-development of uterus Incidence.?The incidence of retroverted uterus along with other signs of endocrine imbalance is far greater in Bengal than that in America or may be found in some cases of congenital retro- in Western countries. This is mainly due to the version. In this series one woman out of four, general lowered health of the womenfolk of who belonged to this type, presented this picture, May, 19481 RETROV ERTED UTERUS : DUTT & BOSE 239 In acquired variety the uterus is often bulky, Various orthopaedic conditions may be the cause congested and hypertrophied. This was noticed of pain felt in the small of the back and so a in nearly every case where history dated from proper diagnosis of the underlying cause should a difficult labour. Moreover, this type of be made before one launches to correct a retro- One should consider retroverted uterus may be the first stage of pro- verted uterus. the mental lapse. The uterus was definitely displaced make-up of a woman while eliciting this backwards in 90 cent of who attended While Howard Kelly and others per women, symptom.' for in its call a pessary?an obsolete instru- hospital genital prolapse?even ' vaginal earliest stage. ment we have found its application a useful Along with a retroverted uterus the ovaries adjunct in determining whether backache is the are often found prolapsed in the posterior result of retroversion proper. When its applica- cul-de-sac. These ovaries showed evidence of tion is possible, if pain be relieved by its and small forma- employment, all causes other than retroversion congestion, enlargement cyst ' can . tion in about 62 per cent of the cases. The be ruled out. With this Pessary Test' we discovered in cause ovarian ligaments were elongated in many that about 18 per cent the instances. of backache was anything but a retroverted As a result of abnormal circulation and uterus. increased congestion the pelvic veins may be Functional disturbances of menstruation either tortuous and dilated. Broad ligament varix was of the nature of menorrhagia, dysmenorrhea or were noticed in 30 per cent of women who had to be polymenorrhea the main complaints in operated for retroversion. about 61 per cent of our patients. Menorrhagia In most cases of retroversion the bladder is at is due to the abnormal or hyperactivity of the ovaries to a lower level and adhesions may form if the increased pelvic congestion and also to uterus be fallen back for a long time. The probably the presence of congested and (edematous endometrium. In uterosacral ligaments may be tense and tender acquired variety on palpation in many instances. dysmenorrhea is of congestive type when pain Diagnosis.?The diagnosis of this condition is dull and premenstrual in character. Correction with does not present much difficulty. Mistakes can pessary often relieves many of the occur if the bladder and bowel are not emptied symptoms. during examination. The infravaginal portion In an under-developed congenital retroverted of the cervix is directed upwards and forwards uterus, oligomenorrhea, hypomenorrhea, spas- but this should not be always counted as modic type of dysmenorrhea and sometimes the index of retroversion. During bimanual inter-menstrual pain were the various symptoms noted in this series. were due to the examination there is a feeling of emptiness in They the anterior pouch in between the examining underlying imbalance of the sex hormones and fingers and fundus is found when palpation is not to retroversion proper. made posteriorly. When the result of vaginal Dyspareunia was present in 12 per cent of examination becomes doubtful simple rectal or the cases. In nearly every case either one or abdomino-recto-vaginal palpation will greatly both ovaries was easily palpable in the pouch of and seemed help in the diagnosis. Anjesthesia may be Douglas slightly enlarged. Leucorrhea is included as one of the main necessary in a fat subject to demonstrate the of retroversion. This was in mobility of the organ. Sounding the uterine symptoms present two women who attended cavity as an aid to diagnosis is not recommended out of three hospital. cases for there are definite risks of trauma and They belonged in most to the acquired infection. variety. But along the pelvic congestion, ascending of infection Instances are common when a retroverted associated endocervicitis, low grade or infec- uterus is discovered as a matter of coincidence in the corpus, signs of chronic pelvic tion was in of these and does not produce any symptom or discom- present many patients. when a in women with fort in the 28 per cent of the Leucorrhea, symptom patient. Nearly showed total number of cases in this series did not uncomplicated retroversion, sometimes other of ovarian exhibit any of the of retro- signs dysfunction. typical symptoms trace version. They belonged mostly to the congenital In none of the cases could we_ per- manent sterility to be a result of simple retro- variety. either the male Symptomatology.?Backache is the most version. In most instances was at fault or there were manifesta- common symptom of retroversion. This was the partner tions of endocrine imbalance or association of complaint in 80 per cent of women who appeared other lesions.