Pathology

Remembering the course of the blood and lymph vessels and nerves that supply the uterus, as they pass between the layers of the broad ligaments, and the distortion and pressure that must ensue when the fundus of the uterus as a whole is turned backward, one would expect some degrees of congestion or inflammation of the uterus itself. So it is. The uterus is enlarged, slightly prolapsed, and the endometrium is in a state of chronic inflammation. This is present in addition to whatever causative pathology that may have preceded the displacement. The chronic congestion or inflammation has extended to the tubes and ovaries also. These may be dragged backward and downward with the fundus. Adhesions being prominent among the causative factors are often seen. When not an etiological factor they may later develop from pressure, irritation, congestion and inflammation of the opposed peritoneal surfaces. Pressure of a deeply retroflexed fundus has been known to cause gangrene of the posterior vaginal wall.

Symptoms

Menstrual disturbances are common. Menorrhagia and metrorrhagia whether due to the secondary congestion and chronic endometritis or directly to the displacement, usually promptly disappear when replacement is effected, if no complications are present. The excessive bleeding sometimes leads to severe anemia with its associated symptoms. The presence of a retro-displacement may delay the occurrence of the menopause. The early reappearance of menstruation during lactation is sometimes due to a retro-displacement. Leucorrhoea is often present as a result of the congestion and chronic endometritis. Dysmenorrhoea is not a prominent symptom.

An obstructive constipation may ensue from pressure of the fundus upon the rectum. This may also give rise to a feeling of fullness in the rectum and occasionally may be an element in the production of hemorrhoids Irritability of the bladder evidenced by frequent and painful urination is an occasional symptom. Retro-displacements may so distort the ureters as to cause kinks, leading to their partial occlusion. They are so frequently associated with inflammatory affections of the upper part of the urinary tract that the connection can hardly be always accidental.

A peculiar and rather distinctive sacral backache is often present in retro-displacement, and be sides this there may be an ordinary lumbar ache. Pains and weakness in the legs are not uncommon. A sense of weight and heaviness, a bearing down sensation in the pelvis is frequently present. This is easily aggravated by exertion, or standing, and is most common in the cases with complications. Pains and soreness about the ovaries result from the distortion of the blood vessels supplying them and the consequent congestion or inflammation.

Sterility is not so frequent as in anteflexion. It is in some cases apparently due to the displacement, though in most cases doubtless due to the complicating congestion and inflammation. Abortions frequently occur in retro-displacements. When pregnancy does occur and goes to term a spontaneous cure of the displacement sometimes occurs, if proper attention is given the patient.

The general nutrition suffers from the anemia and reflex gastro-intestinal or other disorders.

Diagnosis

The diagnosis must be made from the physical findings upon bimanual palpation. On passing the two fingers of the right hand into the vagina, the cervix may rarely be found in its normal position and pointing in its normal direction in a case of retroflexion. Usually it is anterior to its normal position, is low and points downward, occasionally forward and in extreme cases of retroversion may be directed upward and be difficult to reach. If the finger is now passed to the posterior surface of the cervix and directed upward a mass will be felt of the general size, shape and consistency of the body, and apparently continuous with the cervix. In some cases this tumor will be found below the level of the cervix in the retro-uterine fossa. As a mass in this position may be caused by other conditions it is necessary to determine the absence of the fundus from its normal position. This is done by bimanual palpation, the fingers of the abdominal hand and those within the vagina being approximated anterior to the cervix and the absence of the body of the uterus noted. The diagnosis may often be verified by a rectal examination, especially in fleshy individuals, by feeling the fundus through the anterior rectal wall.

Ordinarily the diagnosis of a retro-displacement is not difficult. Thorough acquaintance with the normal feel of the organ, familiarity with its size, shape, position, consistence, tenderness, and mobility, is indispensible. Certain conditions may, however, prove confusing.

A fibroid tumor occurring in the posterior wall of the uterus, or if pedunculated and behind the uterus or even when in the anterior wall of the uterus and displacing the organ backward, may re quire careful examination to make the diagnosis.

An enlarged and prolapsed ovary may be mis taken for the retro-displaced fundus. The characteristic tenderness and the presence of the fundus in its normal position will make the diagnosis clear. An enlarged and prolapsed uterine tube usually has a sausage shaped outline, and if filled with fluid, fluctuation can usually be detected.

An inflammatory mass back of the cervix is usually tender and lacks the distinct outline of the displaced fundus and presents a history of an acute inflammation. A hematoma or other product of an ectopic gestation, has its distinctive history and lacks the outline and consistence of the fundus. A fecal mass in the rectum is of putty-like consistence, can be indented upon pressure, is practically insensitive, is in the course of the rectum and can be removed by a properly administered enema.

Sometimes the use of a sound to determine the direction of the uterine canal may be necessary.