Symptoms

The most prominent symptoms of anteflexion are, dysmenorrhoea, sterility, irritable bladder and reflex nervous disturbances.

The cause of the dysmenorrhoea in these cases has not been positively determined. That it is due to an obstruction to the egress of the flow by the bend in the cervico-uterine canal is denied by those who claim that a sound can easily be passed under these conditions, showing an absence of obstruction. There is a vast difference, however, between passing a rigid sound from without the uterus inward and the passage of fluid from within the uterus outward. In some of these cases the similarity of the pains to labor pains almost convinces one that this miniature labor is due to some obstruction. Yet the propnents of the no-obstruction theory declare these characteristic pains occur when the uterus is perfectly empty and even hours before the flow passes from the blood vessels into the uterine cavity. Doubtless enough attention has not been given to the rigid and unyielding tissue at the point of flexion, and the pressure upon nerve terminals by the congestion preceding and accompanying the flow. When this congestion is relieved by a copious discharge of menstrual blood, the pain is relieved. Certainly sufficient importance has not been accorded the part that irritation of the "pelvic brain," the cervico-uterine ganglion, plays in the dysmenorrhoea and other disturbances arising in this condition.

Sterility is common in cases of anteflexion.

That it is due to an obstruction to the passage of spermatozoa through a passage that allows free egress of the menstrual flow does not seem reasonable. Some degree of endometritis with an accompanying leucorrhoea is often present and doubtless has something to do with the sterility. Ovaritis and salpingitis are not infrequent especially in the cases due to inflammatory adhesions. These, too, may play a part in causing the sterility. Yet more important in my opinion, is some trophic disturbance from involvement of the cervico-uterine ganglion, either affecting the mucous membrane of the uterus so that it does not afford the normal favorable condition for the lodgement of the fertilized ovum, or affecting the vitality of the ovum itself so that it fails to become fertilized.

Irritability of the bladder is not quite so common as are the foregoing symptoms. It is usually expressed by frequent urination and tenesmus. This may be due occasionally to the pressure of the ante-flexed fundus; though more often to traction on the bladder walls through their intimate connection to the cervix, as the latter is pulled backward and upward by the contracting inflammatory adhesions. The relationship through blood and nerve supply is very intimate and the disturbance of these accounts for some of the bladder symptoms.

Some degree of rectal disorder may be present if contractured adhesions along the course of the sacro-uterine ligaments draw the uterus backward, and constrict or irritate the rectum.

The nervous disturbances are varied. There are almost innumerable paths they may take. They usually follow the path of least resistance, that is, to some reflexly connected organ whose nerves have been previously affected by some disturbed spinal innervation. So we may find headaches, disturbed vision, dyspepsia, epigastric pain, backache, etc.

Anteflection predisposes to abortion and to excessive nausea and vomiting should pregnancy occur.

Diagnosis

In no case should a diagnosis be made from the direction in which the cervix is pointing, which is usually in the direction of the axis of the vagina, as either a cervical or a cervico-corporeal anteflexion is most frequent. Without further examination it might be mistaken for a retroversion. By careful bimanual palpation the fundus will be located and the angle between it and the cervix will be found to be more acute. In stout women this change in the cervico-corporeal angle can be more easily and distinctly palpated with the patient in Sim's position.

In cases due to contracture along the sacrouterine ligaments the cervix is higher than normal, forward mobility especially is impaired and on careful bimanual or recto-abdominal examination the cicatricial bands can be felt.

A small fibroid in the anterior uterine wall (Fig. 20) may closely resemble an anteflexion and when bimanual examination does not make the diagnosis clear, the passing of a sound into the uterus may do so.

Fig. 20. Fibroid in Anterior Uterine Wall Resembling an Anteflexion.

Occasionally inflammation in the connective tissue between the cervix and bladder may prove confusing. This lacks the distinct outline of the fundus and has a causal history. Should abscess formation have occurred fluctuation may be present. Very rarely a hematoma may collect between the uterus and bladder. If recent the history and the fluctuation of the mass will aid in diagnosis. The possibility of malignant infiltration in this region or tumor or disease of the bladder must also be borne in mind.

In cases preceded by extensive inflammation of the pelvic peritoneum or connective tissue a diagnosis may be extremely difficult.

Treatment

The intra-pelvic technic to be employed is especially applicable in those cases due to inflammatory adhesions or cicatricial bands. These are usually attached to the posterior surface of the uterus at or about the junction of the cervix and body and pass backward, outward and upward to the front and sides of the sacrum on either one or both sides. If it is possible such bands should be relaxed. This is best accomplished by placing two fingers of the right hand in the posterior vaginal vault behind the cervix, and then by pressure from above on the abdominal wall insinuate the fingers of the left hand behind the fundus and approximate the fingers of the two hands, (Fig. 21). The uterus is now pulled forward and downward to the point of toleration of the patient, and while the adhesions are thus stretched they are manipulated, transversely, from origin to insertion, by either of the two hands. It often happens that they can easily be manipulated between the fingers of the two hands. The angle of flexion should receive attention. The uterine tissue itself as well as the connective tissue immediately surrounding this point should be manipulated and relaxed as thoroughly as possible. The uterus should be straightened by pressing the apex of the angle forward with the internal fingers, while the fundus is pressed backward by the external hand, (Fig. 22). It should be held in this position for a few seconds, the idea being to make the cavities of the cervix and body a straight line and by over correction, restore as nearly as possible the normal cervico-corporeal angle.

Fig. 21. Replacement of an Anteflexion Caused by Adhesions.

Fig. 22. Straightening an Anteflexion.

It may require several minutes to execute this technic which applies to any form of anteflexion. It may be repeated as scon as the effects of the previous treatment have worn off.

This method of treatment goes far toward relieving any endometritis or metritis present. It restores normal mobility when such is possible. It relieves pressure upon the cervico-uterine ganglion and normalizes circulation by opening blood and lymph channels. It tends to reduce whatever obstruction may be caused by the angulation and in this way often cures the dysmenorrhoea and sterility.