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Chronic pelvic congestion and pelvic pain
Chronic pelvic congestion and pelvic pain WILLARD St. Louis,
M.
ALLEN,
M.D.
Missouri
Attention is drawn to broad ligament lacerations and pelvic congestion as a cause for incapacitating pelvic pain, backache, and dyspareunia. Surgical repair of the lacerations usually eliminates the symptoms. Hysterectomy should be considered for those patients with the chronic pelvic congestion syndrome in which sterilization is also indicated.
THE SEVENTY-FIRST Annual Meeting of the American Gynecological Society was held at Williamsburg, Virginia, on May 24 to 26, 1948. At this meeting Dr. Howard Taylor3 presented a paper entitled “Vascular congestion and hyperemia: Their effect on structure and function in the female reproductive system.” This thought-provoking presentation produced three points brought out by senior gynecologists who discussed the paper. Dr. W. C. Danforth said, “The essayist’s conservative attitude toward surgery is to be commended. Probably far too many operations are done for conditions of this sort and the essayist’s experience seems to indicate that many of them are unsatisfactory.” Dr. Edward A. Schumann said, “I should like to point out that, while the essayist has noted that major surgery is much decried, in Dr. Taylor’s whole series of patients but one was classified as completely cured and that was by hysterectomy.” Dr. Lugwig Emge said, “The presence of huge pelvic varicosities involving mainly the uterine circulation and the progressive intensification of pelvic symptoms over a period of years hint at an acquired factor.” These three excerpts from the discussion are as pertinent now as they were at the time when the paper was presented before a rather skeptical audience. Our own interest
in this syndrome was aroused by Dr. Taylor’s paper, and our activist approach was induced, in part, at least, by the comments of Drs. Schumann and Emge. The purpose of this paper is to report our experience with the surgical treatment of certain patients with chronic incapacitating pelvic pain who do not have tumors, pelvic infection, endometriosis, or varying degrees of descensus to explain the discomfort. These are the patients who drift from one physician to another seeking help but getting little or no relief from medication. Sooner or later they seek psychiatric help but this, too, gives na help because their pain is real and they have no psychiatric illness. Our initial experience began with a particular patient who had such incapacitating backache that she had to spend a part of each afternoon in bed to “rest up enough” to be able to prepare the evening dinner. In addition, intercourse had become intolerable because of pain. She had been seen by other gynecologists who found nothing other than retroversion of the uterus and pelvic tenderness. The orthopedic consultant found no explanation for the backache. Her family situation, so far as could be ascertained, was stable and satisfying. She had three healthy children, loved her husband, and yet was nearly incapacitated by pelvic pain and backache. Examination of this patient was unrevealing except for the pelvic findings. There was no relaxation of the vaginal walls. The pelvic
From the Department of Obstetrics and Gynecology, Washington University School of Medicine. 198
Volume Number
109 2
floor was intact with good support. The cervix was directed in the longitudinal axis of the vagina, and the corpus lay in the hollow of the sacrum. Any attempt to rapidly move the cervix produced exquisite pain. However, if the cervix was moved laterally very slowly and gently, pain was elicited on the opposite side. Palpation of the adnexal regions gave the impression of fullness, and the pulsations of the uterine arteries were detectable bilaterally. The rectal examination was very revealing. Slight movement of the fundus elicited severe pain, and palpation of the adnexal regions gave the impression that there was little or no supporting tissue on either side of the uterus. There was no palpable evidence of endometriosis or chronic salpingitis. After much discussion, it was decided to carry out an exploratory laparatomy with the intention of suspending the uterus if the uterus appeared normal or to remove the uterus if it appeared abnormal. When the abdomen was opened and the intestines packed away, the first thing noticeable was that the uterus was not visible. It was hidden by the bladder and intestines. When the bladder was retracted and the intestines were displaced upward, the uterus came into view. The fundus lay in the hollow of the sacrum, was somewhat enlarged and soft, and had a peculiar yellow-brown color. When the uterus was elevated, a very striking situation was noted. The cul-de-sac contained about 75 ml. of yellowish fluid. Both ureters were visible from the brim of the pelvis to the point where they disappeared under the uterine arteries. Even the uterine arteries and the dilated parametrial veins were visible, The uterosacral ligaments were inconspicuous, but when the uterus was brought anteriorly the ligaments were noticed as short 3 cm. bands extending posteriorly toward the rectum. The cul-de-sac and the peritoneum between the uterosacral ligaments had the usual gray color, and the underlying tissues were thick enough to conceal the retroperitoneal structures. Laterally, however, there was no normal-appearing peritoneum. The great vessels of the pelvic cavity were visible,
Chronic
pelvic congestion
and pelvic pain
199
and the right obturator nerve could be seen without any dissection. The lateral structures were covered by a thin transparent layer containing tiny blood vessels. There were dilated to the uterus. Both lymphatics adjacent tubes and ovaries were normal but the ovarian veins were tortuous and dilated. Since the uterus appeared to be normal, it was decided to suspend the uterus and attempt repair of the defects in the uterosacral and broad ligaments. The attenuated uterosacral ligaments were grasped with clamps and brought superiorly toward the sacrum. This maneuver caused the fundus of the uterus to assume the normal anterior position and, at the same time, the deep cul-de-sac was brought upward. It was apparent immediately that the retroversion and retrocession of the uterus could be corrected if some tissue near the lateral brim of the pelvis could be found to which the uterosacral ligaments could be attached. Strong fascia was located medial to and beneath the ureters. The uterosacral ligaments were then reunited with this fascia with silk sutures. This maneuver corrected the malposition of the uterus but caused some kinking of the ureters. Consequently, the thin transparent tissue covering the ureters and pelvic vessels was excised by careful dissection. The ureters then retracted from the lateral pelvic walls, the kinks disappeared, and the ureters assumed their normal position adjacent to the reconstructed uterosacral ligaments. At the conclusion of this part of the operation, the uterus was in normal position, but there were deep caverns on each side. The dilated pelvic veins were still as visible as before the reconstruction of the uterosacral ligaments. Lateral tissues beneath the round ligaments and just medial to the external iliac vessels were then brought medially and attached to the lateral side of the uterus and to the reconstructed uterosacral ligaments with interrupted catgut sutures. These maneuvers obliterated the caverns in the lateral pelvic cavity and covered over the ureters and the dilated pelvic veins. The pelvic cavity then appeared to be quite normal. The uterus was in normal position, but a suspen-
200 Allen
sion was carried out by attaching the round ligaments to the anterior rectus fascia lateral to the rectus muscles. The results from the operation were very satisfactory; the low backache, the feeling that “something was falling out,” and the dyspareunia disappeared completely. Another patient with identical symptoms serves to illustrate the family problems which may arise. This young woman had two children, one from each of two previous maralso was about riages. The third marriage to be terminated by divorce because of her chronic disability and dyspareunia. The findings at operation were identical with those of the previous patient. All symptoms disappeared after operation, and the third marriage was salvaged. The results of our experience with this operation on the first 28 patients were reported in 1955.l In most of the patients reported at that time, the symptoms appeared relatively soon after a particular delivery. The results obtained from operation were generally good. For example, there were only 2 failures in 24 patients in which the most significant symptom was dyspareunia. In the past 15 years we have gained much additional experience with this syndrome, and a few additional and practical aspects need to be emphasized. Perhaps the first and most important point is to raise the question of hysterectomy as another method of treatment. The modern tendency to use hysterectomy as a method of sterilization, especially in multiparous patients who have many of the symptoms of the “universal joint” syndmme (called this because of the excessive and unrestricted mobility of the cervix), is commendable. Hysterectomy as a satisfactory method of treatment in patients with special indications was reported by Taylol-4 in 1954. However, the surgeon should not recommend hysterectomy as the only method of treatment since equally good results will be obtained by reconstruction of the broad and uterosacral ligaments without hysterectomy. Little difficulty will be encountered in reaching the proper decision
January 15, 1971 Amer. J. Obstet. Gym.
if hysterectomy is limited to those patients in whom sterilization is indicated. When hysterectomy is indicated, there are several excellent reasons for using the abdominal approach. The foremost reason is that it is relatively easy to reconstruct the utemsacral and broad ligaments and thus secure better support to the vaginal vault than can be achieved by vaginal hysterectomy. Usually it is technically preferable to repair the lacerations before removal of the uterus. This maneuver permits the uterus to be used for upward traction to permit better exposure of the parametrial defects. The uterus is then removed with the use of the intrafascial technique. There is another excellent reason for using the abdominal approach for hysterectomy. In most patients the veins in the parametrium are large, sometimes nearly a centimeter in diameter, and in many patients there is a plexus of large veins anterior to the cervix and just beneath the bladder. Intrafascial abdominal hysterectomy makes it possible to avoid injury to these veins, thereby avoiding excessive bleeding, and if the veins are accidentally traumatized, bleeding can be controlled under direct vision by ligature. Vaginal hysterectomy is fraught with danger because venous bleeding cannot be so readily and safely controlled. In actual fact, vaginal hysterectomy is probably contraindicated also because very few patients need vaginal repair work. We have encountered a few patients in whom ordinary suspension of the uterus had been done elsewhere and in whom there had been only partial relief of symptoms. In these patients the cervix could be moved freely from side to side but any movement of the cervix produced severe discomfort even though the fundus itself was in normal anterior position. Operative reconstruction of the uterosacral broad ligaments relieved the pelvic pain and discomfort. There have been several patients with symptoms of pelvic pain, low backache, and exquisite parametrial tenderness on one side in whom the uterus was in anterior position.
Volume Number
109 2
At operation the varicosities were limited to one side. There have been remarkably few complications from the operation. There has been no instance of intestinal obstruction either in the postoperative period or in ensuing years so far as we know. No injury to the ureters has been sustained despite the necessity to partially mobilize the ureters in most cases. Comment
The etiology of the symptoms falls in the realm of pure speculation. The patient’s subjective feeling that “something is falling out” is satisfactorily explained by the unusual mobility and retmcession of the uterus. The feeling of pressure and dull aching in the pelvis may be caused by dilatation of the pelvic veins in much the sameway that varicose veins in the legs produce aching and soreness. It seems unlikely, however, that venous congestion provides an adequate explanation for the exquisite tendernesselicited by manual movement of the uterus or the severe pain produced by intercourse. One wonders if this severepain may not be due to traction on the uterine arteries. In many cases the primary support to the cervix appears to be the uterine arteries. It is conceivable that arterial spasm occurs when the cervix is moved rapidly by intercourse, by bimanual examination, or by sudden jolts. Whatever the true explanation may be, the fact remains that adequate repair of the broad ligament laceration with correction of the retroversion and retrocession of the uterus eliminates the symptoms. The clear yellowish fluid in the cul-de-sac at operation is probably explained by leaking of serum through dilated venules or capillaries directly into the peritoneal cavity. This may be because of the absence of normal peritoneum covering the lateral retroperitoneal tissues. In reality, the intraperitoneal fluid may accumulate solely becausethe normal seepageof fluid from capillaries is not mechanically confined to the retroperitoneal tkues where lymphatics are abundant. It is probable, too, that the blotchy yellow-brown
Chronic
pelvic congestion
and pelvic pain
201
discoloration of the surface of the fundus is due to superficial staining by the fluid in the cul-de-sac. One wonders, of course, whether the operative repair of the parametrial lacerations does, in fact, reduce the pelvic congestion and eliminate the reappearance of intraperitoneal fluid. A recent study by Hartnett and colleagues2shows that there is marked diminution of pelvic venous congestion as judged by venogram obtained under anesthesia at the beginning and at the conclusion of operation. Two opportunities have occurred to reexplore patients in our own series of cases, one because of myoma uteri and the other becauseof an ovarian cyst. In both cases,the repair had been successfulin that there was no visible pelvic congestion and there was no fluid in the cul-de-sac. The recent paper by Hartnett and colleagues2contains a superb color photograph of the findings at operation in a typical case. His operative technique is quite similar to that described by Allen and Ma.sters,l but in addition a method is described for correcting the fascial defects anterior to the uterus and beneath the bladder which are seen in some cases.This maneuver also improves the support to the bladder adjacent to the cervix. The etiology of the fascial defects is presumably related in some way to pregnancy and delivery since the patients whom we recognize as having the syndrome are parous women. In the small seriesof patients reported in 1955,l we were impressedwith traumatic delivery as the usual cause for the syndrome. However, as we have acquired more experience we wonder if some casesmay not be because of such minor malpresentations of the fetus as a mildly deflexed occiput posterior. These patients are prone to exert expulsive efforts when the cervix is no more than 7 or 8 cm. dilated. Whenever expulsive efforts are made prior to complete dilatation, the head descends,bringing the cervix before it. This inevitiably must produce stretching, and perhaps tearing, of the parametrial tissues and uterosacral ligaments. In fact, as every obstetrician knows, sufficient trauma
202
January 15, 1971 Amer. J. Obstet. Gynec.
Allen
can occur in the parametria, even from spontaneous delivery, to produce extensive retroperitoneal hemorrhage. Another interesting possibility is brought out by Hartnett and associates. They feel that in some instances sudden jolts during pregnancy may produce parametrial lacerations. There seems to be no reliable way of estimating the incidence of the syndrome. The patients of gynecologists who recognize the syndrome and believe in operation are available for appraisal. Patients of gynecologists who do not recognize the syndrome, or who do not believe in operative treatment, will not be counted. The incidence, however, must be quite low. In the past 20 years, on our own gynecologic service there have been about 7,000 major operative cases with about 150 patients operated upon for the universal joint syndrome. During the same period, there have been about 50,000 deliveries. Diagnosis of the syndrome is relatively easy, providing one is not too impressed with the neurotic traits which are so common. Chronic pelvic pain, fatigue, and dyspareunia are important factors in preventing a woman from discharging her daily duties as a housewife and enjoying the sexual requirements of a good marriage. When she can no longer cope with her responsibilities, the tag of neurosis is all too frequently attached
to her; and her physician, while he may listen to her complaints, may not recognize the chronic pelvic congestion syndrome as the primary cause for her complaints. The use of the laparascope, especially in the patient with neuroses, should make a firm diagnosis very easy, as the defects in the broad ligaments should be visible with no difficulty if they are present. Since the advent of the contraceptive pills, many women with vague pelvic complaints are given “ovarian rest” by oral contraceptives. In cases of suspected endometriosis, this treatment may be quite helpful. Ovarian suppression in patients with broad ligament lacerations and pelvic congestion gives no relief whatsoever. In fact, some patients have an increase in symptoms while taking oral contraceptives. This is not surprising since oral contraceptives do increase pelvic congestion. A final question arises regarding the desirability of subsequent vaginal delivery in patients who have had repair of the uterosacral and broad ligaments. We have had a few patients who have been delivered normally of their infants after repair and without reappearance of symptoms. However, it would seem preferable in most instances to deliver the infants of those patients who have had a successful repair by cesarean section.
REFERENCES
1. Allen, W. M., and Masters, W. H.: AMER. J. OBSTET. GYNEC. 70: 500, 1955. 2. Hartnett, L. J., Edwards, O., Knight, W. A., and Woods, R.: Obstet. Gynec. 36: 16, 1970.
3. 4.
Taylor, H. C.: AMER. J. OBSTET. 1177, 1954. Taylor, H. C.: AMER. J. OBSTET. 211, 637, and 654, 1949.
GYNEC.
57:
GYNEC.
67:
M.
ALLEN,
M.D.
Missouri
Attention is drawn to broad ligament lacerations and pelvic congestion as a cause for incapacitating pelvic pain, backache, and dyspareunia. Surgical repair of the lacerations usually eliminates the symptoms. Hysterectomy should be considered for those patients with the chronic pelvic congestion syndrome in which sterilization is also indicated.
THE SEVENTY-FIRST Annual Meeting of the American Gynecological Society was held at Williamsburg, Virginia, on May 24 to 26, 1948. At this meeting Dr. Howard Taylor3 presented a paper entitled “Vascular congestion and hyperemia: Their effect on structure and function in the female reproductive system.” This thought-provoking presentation produced three points brought out by senior gynecologists who discussed the paper. Dr. W. C. Danforth said, “The essayist’s conservative attitude toward surgery is to be commended. Probably far too many operations are done for conditions of this sort and the essayist’s experience seems to indicate that many of them are unsatisfactory.” Dr. Edward A. Schumann said, “I should like to point out that, while the essayist has noted that major surgery is much decried, in Dr. Taylor’s whole series of patients but one was classified as completely cured and that was by hysterectomy.” Dr. Lugwig Emge said, “The presence of huge pelvic varicosities involving mainly the uterine circulation and the progressive intensification of pelvic symptoms over a period of years hint at an acquired factor.” These three excerpts from the discussion are as pertinent now as they were at the time when the paper was presented before a rather skeptical audience. Our own interest
in this syndrome was aroused by Dr. Taylor’s paper, and our activist approach was induced, in part, at least, by the comments of Drs. Schumann and Emge. The purpose of this paper is to report our experience with the surgical treatment of certain patients with chronic incapacitating pelvic pain who do not have tumors, pelvic infection, endometriosis, or varying degrees of descensus to explain the discomfort. These are the patients who drift from one physician to another seeking help but getting little or no relief from medication. Sooner or later they seek psychiatric help but this, too, gives na help because their pain is real and they have no psychiatric illness. Our initial experience began with a particular patient who had such incapacitating backache that she had to spend a part of each afternoon in bed to “rest up enough” to be able to prepare the evening dinner. In addition, intercourse had become intolerable because of pain. She had been seen by other gynecologists who found nothing other than retroversion of the uterus and pelvic tenderness. The orthopedic consultant found no explanation for the backache. Her family situation, so far as could be ascertained, was stable and satisfying. She had three healthy children, loved her husband, and yet was nearly incapacitated by pelvic pain and backache. Examination of this patient was unrevealing except for the pelvic findings. There was no relaxation of the vaginal walls. The pelvic
From the Department of Obstetrics and Gynecology, Washington University School of Medicine. 198
Volume Number
109 2
floor was intact with good support. The cervix was directed in the longitudinal axis of the vagina, and the corpus lay in the hollow of the sacrum. Any attempt to rapidly move the cervix produced exquisite pain. However, if the cervix was moved laterally very slowly and gently, pain was elicited on the opposite side. Palpation of the adnexal regions gave the impression of fullness, and the pulsations of the uterine arteries were detectable bilaterally. The rectal examination was very revealing. Slight movement of the fundus elicited severe pain, and palpation of the adnexal regions gave the impression that there was little or no supporting tissue on either side of the uterus. There was no palpable evidence of endometriosis or chronic salpingitis. After much discussion, it was decided to carry out an exploratory laparatomy with the intention of suspending the uterus if the uterus appeared normal or to remove the uterus if it appeared abnormal. When the abdomen was opened and the intestines packed away, the first thing noticeable was that the uterus was not visible. It was hidden by the bladder and intestines. When the bladder was retracted and the intestines were displaced upward, the uterus came into view. The fundus lay in the hollow of the sacrum, was somewhat enlarged and soft, and had a peculiar yellow-brown color. When the uterus was elevated, a very striking situation was noted. The cul-de-sac contained about 75 ml. of yellowish fluid. Both ureters were visible from the brim of the pelvis to the point where they disappeared under the uterine arteries. Even the uterine arteries and the dilated parametrial veins were visible, The uterosacral ligaments were inconspicuous, but when the uterus was brought anteriorly the ligaments were noticed as short 3 cm. bands extending posteriorly toward the rectum. The cul-de-sac and the peritoneum between the uterosacral ligaments had the usual gray color, and the underlying tissues were thick enough to conceal the retroperitoneal structures. Laterally, however, there was no normal-appearing peritoneum. The great vessels of the pelvic cavity were visible,
Chronic
pelvic congestion
and pelvic pain
199
and the right obturator nerve could be seen without any dissection. The lateral structures were covered by a thin transparent layer containing tiny blood vessels. There were dilated to the uterus. Both lymphatics adjacent tubes and ovaries were normal but the ovarian veins were tortuous and dilated. Since the uterus appeared to be normal, it was decided to suspend the uterus and attempt repair of the defects in the uterosacral and broad ligaments. The attenuated uterosacral ligaments were grasped with clamps and brought superiorly toward the sacrum. This maneuver caused the fundus of the uterus to assume the normal anterior position and, at the same time, the deep cul-de-sac was brought upward. It was apparent immediately that the retroversion and retrocession of the uterus could be corrected if some tissue near the lateral brim of the pelvis could be found to which the uterosacral ligaments could be attached. Strong fascia was located medial to and beneath the ureters. The uterosacral ligaments were then reunited with this fascia with silk sutures. This maneuver corrected the malposition of the uterus but caused some kinking of the ureters. Consequently, the thin transparent tissue covering the ureters and pelvic vessels was excised by careful dissection. The ureters then retracted from the lateral pelvic walls, the kinks disappeared, and the ureters assumed their normal position adjacent to the reconstructed uterosacral ligaments. At the conclusion of this part of the operation, the uterus was in normal position, but there were deep caverns on each side. The dilated pelvic veins were still as visible as before the reconstruction of the uterosacral ligaments. Lateral tissues beneath the round ligaments and just medial to the external iliac vessels were then brought medially and attached to the lateral side of the uterus and to the reconstructed uterosacral ligaments with interrupted catgut sutures. These maneuvers obliterated the caverns in the lateral pelvic cavity and covered over the ureters and the dilated pelvic veins. The pelvic cavity then appeared to be quite normal. The uterus was in normal position, but a suspen-
200 Allen
sion was carried out by attaching the round ligaments to the anterior rectus fascia lateral to the rectus muscles. The results from the operation were very satisfactory; the low backache, the feeling that “something was falling out,” and the dyspareunia disappeared completely. Another patient with identical symptoms serves to illustrate the family problems which may arise. This young woman had two children, one from each of two previous maralso was about riages. The third marriage to be terminated by divorce because of her chronic disability and dyspareunia. The findings at operation were identical with those of the previous patient. All symptoms disappeared after operation, and the third marriage was salvaged. The results of our experience with this operation on the first 28 patients were reported in 1955.l In most of the patients reported at that time, the symptoms appeared relatively soon after a particular delivery. The results obtained from operation were generally good. For example, there were only 2 failures in 24 patients in which the most significant symptom was dyspareunia. In the past 15 years we have gained much additional experience with this syndrome, and a few additional and practical aspects need to be emphasized. Perhaps the first and most important point is to raise the question of hysterectomy as another method of treatment. The modern tendency to use hysterectomy as a method of sterilization, especially in multiparous patients who have many of the symptoms of the “universal joint” syndmme (called this because of the excessive and unrestricted mobility of the cervix), is commendable. Hysterectomy as a satisfactory method of treatment in patients with special indications was reported by Taylol-4 in 1954. However, the surgeon should not recommend hysterectomy as the only method of treatment since equally good results will be obtained by reconstruction of the broad and uterosacral ligaments without hysterectomy. Little difficulty will be encountered in reaching the proper decision
January 15, 1971 Amer. J. Obstet. Gym.
if hysterectomy is limited to those patients in whom sterilization is indicated. When hysterectomy is indicated, there are several excellent reasons for using the abdominal approach. The foremost reason is that it is relatively easy to reconstruct the utemsacral and broad ligaments and thus secure better support to the vaginal vault than can be achieved by vaginal hysterectomy. Usually it is technically preferable to repair the lacerations before removal of the uterus. This maneuver permits the uterus to be used for upward traction to permit better exposure of the parametrial defects. The uterus is then removed with the use of the intrafascial technique. There is another excellent reason for using the abdominal approach for hysterectomy. In most patients the veins in the parametrium are large, sometimes nearly a centimeter in diameter, and in many patients there is a plexus of large veins anterior to the cervix and just beneath the bladder. Intrafascial abdominal hysterectomy makes it possible to avoid injury to these veins, thereby avoiding excessive bleeding, and if the veins are accidentally traumatized, bleeding can be controlled under direct vision by ligature. Vaginal hysterectomy is fraught with danger because venous bleeding cannot be so readily and safely controlled. In actual fact, vaginal hysterectomy is probably contraindicated also because very few patients need vaginal repair work. We have encountered a few patients in whom ordinary suspension of the uterus had been done elsewhere and in whom there had been only partial relief of symptoms. In these patients the cervix could be moved freely from side to side but any movement of the cervix produced severe discomfort even though the fundus itself was in normal anterior position. Operative reconstruction of the uterosacral broad ligaments relieved the pelvic pain and discomfort. There have been several patients with symptoms of pelvic pain, low backache, and exquisite parametrial tenderness on one side in whom the uterus was in anterior position.
Volume Number
109 2
At operation the varicosities were limited to one side. There have been remarkably few complications from the operation. There has been no instance of intestinal obstruction either in the postoperative period or in ensuing years so far as we know. No injury to the ureters has been sustained despite the necessity to partially mobilize the ureters in most cases. Comment
The etiology of the symptoms falls in the realm of pure speculation. The patient’s subjective feeling that “something is falling out” is satisfactorily explained by the unusual mobility and retmcession of the uterus. The feeling of pressure and dull aching in the pelvis may be caused by dilatation of the pelvic veins in much the sameway that varicose veins in the legs produce aching and soreness. It seems unlikely, however, that venous congestion provides an adequate explanation for the exquisite tendernesselicited by manual movement of the uterus or the severe pain produced by intercourse. One wonders if this severepain may not be due to traction on the uterine arteries. In many cases the primary support to the cervix appears to be the uterine arteries. It is conceivable that arterial spasm occurs when the cervix is moved rapidly by intercourse, by bimanual examination, or by sudden jolts. Whatever the true explanation may be, the fact remains that adequate repair of the broad ligament laceration with correction of the retroversion and retrocession of the uterus eliminates the symptoms. The clear yellowish fluid in the cul-de-sac at operation is probably explained by leaking of serum through dilated venules or capillaries directly into the peritoneal cavity. This may be because of the absence of normal peritoneum covering the lateral retroperitoneal tissues. In reality, the intraperitoneal fluid may accumulate solely becausethe normal seepageof fluid from capillaries is not mechanically confined to the retroperitoneal tkues where lymphatics are abundant. It is probable, too, that the blotchy yellow-brown
Chronic
pelvic congestion
and pelvic pain
201
discoloration of the surface of the fundus is due to superficial staining by the fluid in the cul-de-sac. One wonders, of course, whether the operative repair of the parametrial lacerations does, in fact, reduce the pelvic congestion and eliminate the reappearance of intraperitoneal fluid. A recent study by Hartnett and colleagues2shows that there is marked diminution of pelvic venous congestion as judged by venogram obtained under anesthesia at the beginning and at the conclusion of operation. Two opportunities have occurred to reexplore patients in our own series of cases, one because of myoma uteri and the other becauseof an ovarian cyst. In both cases,the repair had been successfulin that there was no visible pelvic congestion and there was no fluid in the cul-de-sac. The recent paper by Hartnett and colleagues2contains a superb color photograph of the findings at operation in a typical case. His operative technique is quite similar to that described by Allen and Ma.sters,l but in addition a method is described for correcting the fascial defects anterior to the uterus and beneath the bladder which are seen in some cases.This maneuver also improves the support to the bladder adjacent to the cervix. The etiology of the fascial defects is presumably related in some way to pregnancy and delivery since the patients whom we recognize as having the syndrome are parous women. In the small seriesof patients reported in 1955,l we were impressedwith traumatic delivery as the usual cause for the syndrome. However, as we have acquired more experience we wonder if some casesmay not be because of such minor malpresentations of the fetus as a mildly deflexed occiput posterior. These patients are prone to exert expulsive efforts when the cervix is no more than 7 or 8 cm. dilated. Whenever expulsive efforts are made prior to complete dilatation, the head descends,bringing the cervix before it. This inevitiably must produce stretching, and perhaps tearing, of the parametrial tissues and uterosacral ligaments. In fact, as every obstetrician knows, sufficient trauma
202
January 15, 1971 Amer. J. Obstet. Gynec.
Allen
can occur in the parametria, even from spontaneous delivery, to produce extensive retroperitoneal hemorrhage. Another interesting possibility is brought out by Hartnett and associates. They feel that in some instances sudden jolts during pregnancy may produce parametrial lacerations. There seems to be no reliable way of estimating the incidence of the syndrome. The patients of gynecologists who recognize the syndrome and believe in operation are available for appraisal. Patients of gynecologists who do not recognize the syndrome, or who do not believe in operative treatment, will not be counted. The incidence, however, must be quite low. In the past 20 years, on our own gynecologic service there have been about 7,000 major operative cases with about 150 patients operated upon for the universal joint syndrome. During the same period, there have been about 50,000 deliveries. Diagnosis of the syndrome is relatively easy, providing one is not too impressed with the neurotic traits which are so common. Chronic pelvic pain, fatigue, and dyspareunia are important factors in preventing a woman from discharging her daily duties as a housewife and enjoying the sexual requirements of a good marriage. When she can no longer cope with her responsibilities, the tag of neurosis is all too frequently attached
to her; and her physician, while he may listen to her complaints, may not recognize the chronic pelvic congestion syndrome as the primary cause for her complaints. The use of the laparascope, especially in the patient with neuroses, should make a firm diagnosis very easy, as the defects in the broad ligaments should be visible with no difficulty if they are present. Since the advent of the contraceptive pills, many women with vague pelvic complaints are given “ovarian rest” by oral contraceptives. In cases of suspected endometriosis, this treatment may be quite helpful. Ovarian suppression in patients with broad ligament lacerations and pelvic congestion gives no relief whatsoever. In fact, some patients have an increase in symptoms while taking oral contraceptives. This is not surprising since oral contraceptives do increase pelvic congestion. A final question arises regarding the desirability of subsequent vaginal delivery in patients who have had repair of the uterosacral and broad ligaments. We have had a few patients who have been delivered normally of their infants after repair and without reappearance of symptoms. However, it would seem preferable in most instances to deliver the infants of those patients who have had a successful repair by cesarean section.
REFERENCES
1. Allen, W. M., and Masters, W. H.: AMER. J. OBSTET. GYNEC. 70: 500, 1955. 2. Hartnett, L. J., Edwards, O., Knight, W. A., and Woods, R.: Obstet. Gynec. 36: 16, 1970.
3. 4.
Taylor, H. C.: AMER. J. OBSTET. 1177, 1954. Taylor, H. C.: AMER. J. OBSTET. 211, 637, and 654, 1949.
GYNEC.
57:
GYNEC.
67: