Symptoms

The symptoms arising from pelvic adhesions may vary according to the location and severity of the primary attack and the amount of destruction of tissues and function it has caused, all the way from a slight local indisposition to chronic invalidism. This is easily appreciated when one considers the varied pathology which a given case may present. The area involved may be slight or it may be enormous. The degrees of intensity may vary as greatly. Then, too, the functional importance of the affected part will intensify the symptoms. Because of the enormous nerve supply the reflex or constitutional symptoms are fairly constant.

The victim of adhesions usually has the appearance of invalidism. She looks tired, worn and prematurely aged. She complains of fatigue and nervousness. She is depressed, irritable or even hysterical

Pain or some degree of discomfort is usually present. This may be constant, definite and localized. It is often complained of in one or both of the iliac fossae. Again it is an indefinite and general pain throughout the pelvis. Such pains may be reflected to the back or down the legs. The so-called "bearing down pain" which is so commonly complained of is frequently due to adhesions. It is often caused by the pull or the drag of the pelvic organs upon the adhesions rather than by any prolapse of these organs. Such pains are often bitterly complained of when no prolapse is discernable. Again the pain may be intermittent and caused by exertion of some kind. Standing, walking, jolting, the use of a sewing machine or any overexertion may cause the pain to appear. Whatever the character of the pain it is usually increased just before or at the menstrual period. This is because of the increased pressure upon the nerve terminals from the congestion attending this function.

Disordered menstrual function is frequent. It may be profuse in the more recent cases to later become scanty or irregular from the general atrophic changes caused by the constriction of blood vessels and nerves. Dysmenorrhoea is common. It may occur as a general deep ache throughout the pelvis with an increase of the backache, legache and bearing down pains. A localized ovarian pain is often manifest at this time. The menstrual flow is often dark and clotted.

Leucorrhoea is present in many cases. In some of the cases of long standing it may not be a noticeable symptom. Atrophic changes have supervened in the meantime and the excessive flow has ceased. Occasionally there may be the emptying of a hydro-salpinx or a pyo-salpinx through the uterine end of the tube, accompanied by a profuse gush of serum or pus from the vagina.

Sterility is almost inevitable. The tubes are often occluded by stricture, adhesions or the accumulation of serum or pus within them. The ovaries may be covered by adhesions or have become the seat of a severe ovaritis.

Constipation is common in women ordinarily, but some cases are due to adhesions constricting the colon, rectum or interfering with peristalsis in the colon.

Diagnosis

Pelvic adhesions are diagnosed by bimanual palpation only after one has become familiar with the contents of the normal pelvis, their location, size, consistency, sensibility and normal mobility.

One of the first steps in diagnosis is to test the mobility of the uterus. In nearly every case this is diminished. It may be but slightly so, or in severe cases it may seem as fixed as though it had been set in cement. In these extreme cases further palpation of the pelvic organs is almost, or quite, impossible. Sometimes by a recto-abdominal examination by getting the finger in the rectum above the mass of adhesions some additional information may be obtained. When the uterus is movable, the pain or discomfort that may be caused by an attempt to move it is of some diagnostic importance. Suppose on moving the uterus toward the right wall of the pelvis, the patient in response to an inquiry says that pain is felt on the left and if at the same time motion is restricted toward the right, one would strongly suspect adhesions in the left side of the pelvis. If now with the hand on the abdomen and the middle finger of the intra-vaginal hand the uterus is pressed toward the right side of the pelvis the tightened adhesive band can be felt with the index finger of the intra-vaginal hand. By approximation the two hands, keeping the uterus toward the right, the adhesions can be definitely located and their size, rigidity and tenderness determined. This applies particularly to adhesions arising in the connective tissues lateral to the cervix and in the broad ligament. If on the other hand when the uterus is pressed toward the right and pain is caused on that (the right) side it is evident that some inflamed or sensitive organ is being pressed upon. Look now for an inflamed ovary or a growth of some nature. These symptoms and conditions are of course reversed when the uterus is pressed toward the left, if there is similar pathology on that side.

It sometimes happens that adhesions and inflammation or a growth occur on the same side of the pelvis. An inflamed ovary or tube may exist coincident with adhesions. In such instances pain is caused both by pressing the uterus from the affected side and stretching the adhesions and by pressing it toward the affected side and compressing the inflamed tissues or growth.

If on pressing the uterus upward and forward mobility is restricted and pain is elicited toward the back or rectum, adhesions along the course of the sacro-uterine ligaments are to be suspected. Their presence can be positively determined by palpating them between the fingers of the two hands.

After the mobility of the uterus is tested in all directions and the causes of decreased mobility determined, the ovaries and tubes are next palpated.

This is done in the manner indicated in the chapter on Examination. On one or both sides a mass may be felt in which it may be impossible to differentiate the organs and tissues composing it. This mass is usually separate from the uterus, but may be closely adherent to it. Oftentimes the tortuous, nodular or sausage shaped tube may be felt and traced back to the cornua of the uterus. Again only an enlarged and tender ovary, perhaps displaced downward and backward even to the bottom of the recto-uterine excavation, will be found. These conditions may be found on one or both sides of the pelvis. Sometimes the tubes and ovaries of both sides are found prolapsed and adherent in a single mass in the posterior part of the pelvis.