Surgical conditions resulting from childbirth

Surgical conditions resulting from childbirthDuring childbirth, certain injuries to the soft tissues of the birth canal may occur. Many of these are obviated by the use of episiotomy, and many may be repaired immediately after deliv­ery. Some, however, are unavoidable and may appear years after childbirth and may be pro­gressive.

Cystocele is a falling backward and down­ward of the bladder because of injury to the supporting structures of the front of the vaginal wall. This is usually progressive with the increased pressure from above with strain­ing, coughing, sneezing, etc. Cystocele is most often associated with some degree of rectocele and prolapse. This condition may give rise to the symptoms of pelvic pressure and pain, in­continence of urine, and inability to completely empty the bladder, so that bladder infections are common.

Rectocele is a falling downward and forward of the rectum. This is caused by injury to the supporting muscles of the back vaginal wall, by childbirth. This con­dition is likewise progressive and usually is as­sociated with some degree of cystocele and pro­lapse.

Prolapse of the uterus is a descent of the uterus in the vaginal canal caused by a stretch­ing of the ligaments which normally hold the uterus in place. Again the condition is pro­gressive over a period of years.

All of these conditions (cystocele, rectocele, prolapse) are definitively cured only by surgery. For temporary relief or in cases where operation is not feasible, however, the wearing of a vaginal pessary which artificially supports these struc­tures may be used. There are many different kinds of pessaries for such, but these are not curative. In most cases operation is indicated, but should be deferred until after the child­bearing years whenever possible. This is because a repeat operation may be necessary if child­birth follows pelvic repair. When the prolapse is severe, operation usually includes vaginal hys­terectomy. Operation for cystocele is called an­terior colporrhaphy (vagina-repair) and that for rectocele, posterior colporrhaphy. A gen­eral term for plastic repair of the perineal area is perineorrhaphy or perineoplasty. These operations are usually performed in combina­tions.

Retroflexion of the uterus is a bending backward of the uterus, is a tilting backward of the entire uterus, the result of lack of normal ligament support, usually from childbirth. These conditions usually do not give rise to symptoms. In the few cases where symptoms are present a trial with vaginal pessary to hold the womb in its normal position may cause disappearance of symptoms, so that operative replacement may be indicated. Operation for uterine replacement to its normal position is called uterine suspen­sion. This is performed by several methods, most of which are directed at reconstructing or short­ening the supporting ligaments.

Vesicovaginal (bladder-vagina) fistula is an abnormal communication between the bladder and the vagina. Rectovaginal fistula is an ab­normal tract between the rectum and the vagina. These are usually not the result of childbirth injury, but may occur following the use of x-rays or radium for pelvic cancer. These conditions are curable only by surgical methods.

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