Prolapse of the Vagina in Association with Rectal Procidentia ~ JosEet-I C. AMINO, M.D., A. YV. NIARa'IN MARLX'O, JR., M . D . From T k e Brooklyz>Cumberland Medical Ce~zter alzd tke Slate University of N e w Yorh, Downstate ,Medical Ce~tter, Brooklyn, .Vew t'o~t~

PROLAPSE of t h e v a g i n a l v a u l t o c c u r r i n g c o n c o m i t a n t l y w i t h p r o l a p s e of the r e c t t t m is a r a r e p h e n o m e n o n . ~vgatson,a in r e p o r t i n g a case i n 1958, o b s e r v e d t h a t , " I n 3() years of g e n i t a l p r o l a p s e w o r k in S y d n e y a n d d u r i n g five e x t e n d e d o v e r s e a s tours, d u r i n g w h i c h all c o n t i n e n t s w e r e visited, n o i n s t a n c e of tile precise c o m b i n a t i o n of c o n d i t i o n s . . . has b e e n e n c o u n t e r e d . . . . " In o u r s e a r c h of w o r l d m e d i c a l l i t e r a t u r e d a t i n g b a c k to 1920, we h a v e n o t b e e n a b l e to find a n o t h e r r e p o r t e d i n s t a n c e of the c o e x i s t e n c e of these c o n d i t i o n s . I ) u r i n g the s a m e p e r i o d t h e r e h a v e b e e n s c a t t e r e d r e p o r t s of the c o m b i n a t i o n of prolapse of the u t e r u s a n d r e c t a l p r o c i d e n t i a b u t , to the best o f o u r k n o w l e d g e , the case w h i c h is t h e s u b j e c t of t h i s p r e s e n t a t i o n is o n l y t h e s e c o n d r e p o r t e d i n s t a n c e of pro-

Fw,. 1. Vaginal prolapse is well dcmonstrated.

l a p s e of t h e v a g i n a l v a u l t in a s s o c i a t i o n w i t h rectal procidentia. Report

of a Case

A 55-year-old white woman was first seen in November 1961 with a chief complaint of stress incontinence. Past history revealed one pregnancy in 1932, which terminated in a traumatic delivery and death of the infant a few hours postpartum. Four }ears later, in 1936, prolapse of the uterus developed; this was treated by surgical attachment to the anterior abdominal wall. The operation was unsuccessful, the uterus continued to prolapse and, in addition, the rectum began to protrude. For 25 years the patient replaced the prolapsed organs manually and used vaseline applications to palliate and prevent ulceration. She consulted one of us (jCA) and an attempt was made to correct tile prolapsed uterus surgically, it being intended to correct the prolapsed Read at the meeting of the American Proctologic Society, New Orleans, Louisiana, April 17 to 19, 1967.

FIG. 2. Rectal procidentia is demonstrated.

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AMICO AND MARINO

Fro. 3. At the time of surgery, the round ligament and part of the broa(I ligaments are demonstrated. Long sponge forceps is placed in defect caused by the prolapsed vagina.

Fro. -t. The round ligament and part of broad ligaments have been retracted anteriorly: vaginal prolapse has been reduced manually and is held under tension l)y Allis forceps.

rectum at a subsequent (late. A vaginal hysterectomy and anterior, vagi)ml repair were performed in May 1963. \Vithin three months, however, the vaginal vault began to descend and within six months it was completely prolapsed. The problem, therefore, had become more complicated and consisted of a prolapsed vaginal vault and procidentia of the rectum (Figs. 1 and 2). The patient's symptoms were due solely to the prolapsed organs. She had no stress incontinence and cystoscopy revealed good bladder support. On May 7, 196-t, laparotomy was performed through a suprapubic midline incision. Exploration revealed a clean pelvis, free of adhesions. Examination of the pelvic floor revealed that the round and broad ligaments were attached to each other across the vault of the vagina, but they provided no support to the prolapsed vagina (Fig. 3). Both ovaries appeared normal and the hladder was in good position. The hand of the assistant was introduced into the vagina to reposition the vault in the pelvic cavity (Fig. 4). The rectum was mobilized posteriorly and laterally, and the sacrum and spinous ligament between L5 and S1 were exposed by incising the overlying posterior parietal peritoneum (Fig. 5). With the vagina under tension, interrupted silk sutures were placed at the vault and laterally from the vault to the uterosacral ligaments (Fig. ,5). In this manner these ligaments were partially reapproximated anterior

to tile rectmn. A strip of Teflon mesh 3~" wide was then affixed to the sutures previously placed in the vagina (Fig. 7). extendc(l to the long spinous ligament under supporting tension (Fig. 8), and anchored with three silk sutures (Fig. 9). The w~gina was well supported l)y the Teflon prosthesis (Fig. 10). The peritoneal coat of the mobilized rectum and rectosigmoid was sutured to the Teflon so that this portion of the terminal bowel was fixed posteriorly and supported intra-abdominally (Fig. 11) . Finally, the al)domen was closed in layers. \Vith the patient in the lithotomy position, and utilizing anesthesia, examination revealed that the vagina was firmly supported. Although the follow-up period has been relatively brief (three years) this patient appears to have been managed successfully (Fig. 12). The

most common

cause of p r o l a p s e of

the vagina after vaginal or abdominal terectomy

is

the

actual enterocele.

neglected

potential

hysor

As this d e f e c t descends,

it c a r r i e s w i t h it t h e v a u l t

of the vagina

a n d , if n e g l e c t e d , w i l l c o m p l e t e l y e v e r t it. Normally,

there

is a d i s t i n c t

posterior

ct'rvature o r the rectum conforming i~.oiiow o f t h e s a c r n m ,

in

to tb, e

cases of proci-

PROI,APSE OF T H E VAGINA

117

Fro. 5. Peritoneum overlying the long spinous ligaments over 1.5 anti S1 has been incised and three silk sutures have been introduced. Mobilized rectosigmoid is retracted to the left.

l"u;. 6. Silk sutures have heen introduced from the vault of the vagina and uterosacral ligaments. Partial re-approximation of thcse ligaments is shown antermr to the rectum.

Fro. 7. Strip of Teflon has been affixed to the vagina.

Fro. 8. Teflon mesh extends across the pelvic floor.

dentia, this curve is lost, and increased intra-abdominal pressure tends to force the rectum anteriorly through a defect in the pelvic floor.

Teflon mesh, as used in this case, served to suspend the vagina. At the same time, the attachment of the uterosacra! ligaments seaied off the potential or actua! enteroceie.

118

AMIGO e\ND MARINO

Y i:??' )!L

Fro. 9. Prosthesis is affixed to long spinous ligament by three silk sutnres. Posterior parietal peritoneum is retracted to t h e left.

Fro. 10. Prosthesis in place. Rectosigmoid is retracted toward the patient's left.

Fro. 11. Completed procedure. Rectosigmoid has been afficed to cephalad portion of the prosthesis which is partially hidden by overlying colon. In this picture it can he seen that partial reperitonealization has been accomplished.

FIG. 12. Three years postoperatively, no detectable vaginal or rectal prolapse.

A p e l v i c floor w a s t h u s c r e a t e d . T h e a t t a c h ment oi the rectosigmoid to the 'Teflon prost h e s i s s e r v e d t o s u s p e n d t h e r e c t u m a n d to fix it i n t h e h o l l o w of t h e s a c r u m , t h u s

r e s t o r i n g tile n o r m a l p o s t e r i o r c u r v e . N o w , increased intra-abdominai pressure forces the rectum in a posterior than anteriorly.

direction

rather

PROLAPSE OF THE VAGINA

119

Discussion

Summary

W i t h few exceptions, the a p p r o a c h to correction of a prolapsed vaginal vault is t h r o u g h the vagina. O n the other hand, m a n y surgical procedures (both a b d o m i n a l and rectal) have been described to correct rectal procidentia. Ripstein and Lanter, 2 in a series of cases of rectal prolapse, at first utilized a strip of fascia e x t e n d i n g f r o m the vagina to the sacrum to create a pelvic floor and to s u p p o r t the rectum. Later they f o u n d that "Teflon mesh was preferable. I n 1963, Lane~ reported a simple technic for s u p p o r t i n g a prolapsed vagina by extending Teflon f r o m the vault of the vagina to the sacrum. By m o d i f y i n g his technic and e m p l o y i n g the principles developed by Ripstein and L a n t e r we a t t e m p t e d to correct b o t h conditions at the same time.

A. case of c o n c o m i t a n t vaginal prolapse and rectal procidentia has been presented. X,Ve believe this is only the second r e p o r t e d instance of this c o m b i n a t i o n . C o m b i n e d treatment utilizing a Teflon prosthesis a n d result after a follow-up period of three years are described. T h e simplicity of application and tile g o o d result obtained make this a desirable procedure. References 1. Lane, F. E.: Repair of posthysterectomy vaginalvault prolapse. Obstet. Gynec. 20:72, 1962.

2. Ripstein, C. C. and B. Lanter: Etiology and surgical therapy of massive prolapse of the rectum. Ann. Surg. 157: 259, 1963~ 3. Watson, A. L.: Recurrent rectal and vaginal prolapse, with faecal and urinary stress incontinence. M. J. Australia. i: 145, 1958.