Resection of the presacral nerve for dysmenorrhea

RESECTION

OF THE PRESACRAL DYSMENORRHEA

NERVE FOR

BASED ON FAVORABLE RESULTS IN A SERIES OF TWENTY/ONE CASES* JOSEPH L.

DE

COURCY,M.D.

CINCINNATI,

T

HE idea of reIieving peIvic pain by aboIishing the function of certain nerves entered the minds of chnicians many years ago. As far back as 1898, JabouIayl suggested paralyzing the sacra1 sympathetic nerves in cases of intractabIe peIvic neuraIgia. Some fifteen years Iater, Rochet2 attempted to mitigate the distress occasioned by tubercuIosis of the bIadder, by sectioning the nerve suppIy to the vesica1 ends of the ureters, approaching them by the transperitonea1 route. The pain was reIieved, but as the operation brought on compIete retention of urine, the method had to be discarded. Later a number of Continenta workers deveIoped hypogastric and periarterial sympathectomy. This did not interfere with bIadder function, and very soon one of them, Cotte, put forward a method of section of the presacra1 nerve which has since found wide appIication in various forms of pelvic pain. In his origina communication made in 1925, Cotte3 Iisted six indications for the use of his method: (I) peIvic neuraIgia; (2) vaginismus; (3) dysmenorrhea, resistant to ordinary measures adopted for its reIief; (4) hypopIasia of the uterus, accompanied by insuffrcient and painfu1 menstruation; (5) metrorrhagia of ovarian origin; and (6) sexua1 neuroses, such as masturbation, nymphomania, etc. The origina appIication seems to have been whoIIy in the fieId of gynecoIogy. Later Cotte apphed presacral nerve section to painful vesica1 conditions, returning to the earIier conceptions of JabouIay and Rochet, and the operation, with various

0.

modifications, has been used quite extensiveIy in this country as we11 as in Europe by those interested in vesica1 pathoIogy. OddIy enough, however, few American gynecologists have taken any interest in Cotte’s work, and a survey of Iiterature shows practicaIIy nothing written in EngIish concerning this method of treating obstinate dysmenorrhea. The first resection of the presacra1 nerve for dysmenorrhea to be done in this country appears to have been that performed at the Cincinnati Genera1 HospitaI by Dr. Louis G. Herman. Because of this extreme paucity of data, I have decided to present my own cases of presacra1 nerve resection, which are now twenty-one in number. As I have been interested in the procedure no Ionger than six months, there is not yet sufficient Iapse ‘of time to permit me to give fina statistics. Nevertheless, the favorabIe immediate resuits seem to me to warrant such an earIy presentation, inasmuch as others may be stimulated to make reports of their own work, and an added interest in the operation and its use in conditions demanding reIief of peIvic pain thus be aroused. ANATOMICAL

BASIS

THE

PROCEDURE

The presacra1 nerve is a part of the prevertebra1 sympathetic chain, which, in turn, originates in the inferior mesenteric ganghon. At the site of bifurcation of the iIiac arteries from the aorta, some fibers are given off from this gangIion which follow the course of these bIood vesseIs and their branches. The greater part of the fibers, however, continue over the anterior surface of the Iowest Iumbar vertebra,

* From the Department of Surgery, De Courcy Clinic. 408

OF

and eventualIy unite to form the presacra1 nerve. The course of the presacra1 nerve lies across the left iliac vein and over the promontory of the sacrum. It is then subdivided into the two hypogastric nerves, which in their turn pass downward beneath the peritoneum unti1 they arrive at the retrorecta1 space. From this space the hypogastric nerves extend into the superior and posterior cornu of the hypogastric gangIion, which Iies externa1 to, and beIow the ureterosacraI Iigaments. Into this ganglion, aIso, the Iumbar and sacra1 sympathetic gangIia extend afferent branches. In addition it receives anterior branches from the second and third sacral nerves, the fibers of which reunite on either side so as to form a trunk, designated by Cotte as the sacral erector nerve of Maret. This nerve trunk conveys to the hypogastric plexus fibers which are apparently homoIogous to the viscera1 fibers of the pneumogastric. Thus, the hypogastric pIexus contains not onIy eIements from the sacral bundIe in this sacra1 erector nerve, but aIso branches coming from the abdomina1 sympathetic nerves, which have their origin in the inferior mesenteric gang&on. Experimental surgery has demonstrated that section of the afferent fibers of this sacra1 erector nerve aboIishes the power of erection in the maIe and causes disturbance of bIadder and recta1 contro1 in both sexes. None of these disturbances of function has foIlowed section of the presacra1 nerve. Investigators at the Mayo CIinic stimuIated the presacra1 nerve during operations upon human subjects, by appIication of a faradic current. Careful observations of the resuIts were made by a cystoscopist. These were: (I) cIosure of the ureteroyesica.I orifices; (2) contraction of the trigone ; (3) contraction of the internal sphincter; (4) contraction of the musculature of the prostate gIand; (5) contraction of the muscuIature of the ejacuIatory ducts and semina1 vesicles; (6) contraction of the blood vessels of the trigone, and (7) sen-

sations of pain, felt in the region of the bladder. These same investigators found that

FIG.

1.

experimenta section of the presacral nerve diminished the tonus of the internal vesica1 sphincter, but increased its expuIsive power. It was also noted that while section of the motor nerves of the bladder always produced incontinence in mare subjects, in femaIes the ext,ernaI sphincter does not seem to have the same functiona importance, and its motor nerves may be divided without entaiIing loss of vesicaI control. This is an observation of great importance when considering the appIication of presacra1 nerve section to cases of obstinate dysmenorrhea. MECHANISM

OF

THE

PRODUCTION

OF

DYSMENORRHEA

The term dysmenorrhea means IiteraIIy “difficult menstruation,” but is generaIIy accepted as indicating severe pain at the period of menstrual flow. The use of the word ought really to be confined to those

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De Courcy-Dysmenorrhea

cases of severe pain during menstruation for which no organic nor pathoIogic cause can be demonstrated. In the majority of cases there is an entire absence of gross pathoIogic Iesions in the peIvis. Novak4 says, “The probIem of the cause of primary dysmenorrhea is stiI1 unsoIved, and it remains one of the big questions stiI1 confronting gynecoIogists.” He is incIined, however, to favor the popuIar conception that an “infantiIe” state of the generative apparatus is responsibIe for the “painfu1 periods ” so frequentIy seen in girIs and young women. After puberty the uterus normaIIy undergoes steady deveIopment, unti1 when fuIIy mature, its structure shows a great preponderance of muscIe over connective tissue. In the undeveIoped uterus, before puberty, on the other hand, the proportion between connective tissue and muscuIar tissue is aImost as two to one. Examination of the structure of uteri from subjects past the age of puberty who suffered from dysmenorrhea has shown that these “infantiIe” conditions of structure had reguIarIy persisted. When the norma hyperemia of menstruation brings about engorgement of the uterine vessels, this dehciency of muscIe tissue in the uterine waI1 permits the bIood to stagnate in the uterine vesseIs. The engorged veins press upon the uterine nerves, and thus stimulate the spasmodic contractions which cause the characteristic menstrua1 pain. It is, of course, difficult, if not impossibIe, in many cases, to demonstrate that the peIvic organs, especiaIly the uterus, which appear normaI, are actuaIIy structuraIIy undeveloped. And even when such demonstration is possibIe, and examination shows the generative apparatus to be undeveIoped, the cIinician is in no way aided in reheving the sufferings of his patient. In the past various measures have been put into practice with more or Iess success. As it has Iong been observed that marriage and pregnancy often serve to aboIish dysmenorrhea which has previousIy resisted a11 therapeutic attack, the most

popuIar method adopted for permanent reIief has been diIatation of the cervix. This procedure is based upon the theory that some form of obstruction is responsibIe for the pain, but it is more IikeIy that the good resuIts which have undoubtedIy often foIIowed this intervention are due to the stimuIation of uterine deveIopment. The same mechanism is probabIy operative when pessaries and drains have been used. Anything which stimuIates an underdeveIoped uterine waI1 to assume adult characteristics wiI1 promote proper circuIation of the bIood at the time of menstruation, and thus do away with intrauterine pressure and its painful effects. There wiI1 remain to be deaIt with, however, a Iarge group of cases where it is impossibIe or inadvisabIe to make use of any of these measures, and it is here that the operation first instituted by Cotte has its chief vaIue. The indications shouId be cIear, and the procedure undertaken onIy when other, more usua1, methods have proved unavaiIing. It must not be forgotten that a fair proportion of these “painfu1 period ” cases are psychogenic, or even hysterica in origin, and for these section of the presacra1 nerve wouId certainIy be inadvisabIe. If there is intermenstrua1 pain associated with rupture of the Graafian foIIicIe, or pain which invoIves the interna ovarian (spermatic) pIexus, the operation is contraindicated. The gynecoIogist who has thoroughIy investigated his cases, and is famiIiar with the menta1, as we11 as the physioIogica1 characteristics of his patients, shouId have no diffrcuIty in differentiating between the cases based upon some physica disabiIity, however and those dependent upon a obscure, neurosis. Yet it is quite possibIe that both factors might enter into a given case. Cannon5 performed Cotte’s operation upon a highIy neurotic unmarried woman of twenty&e, upon whom diIatation and curettage, mobihzation and resection of diseased ovaries, and irradiation of the pituitary out in vain. gIand, had b een carried

NEW SERIES Vol.. XXIII. No. 3

De Courcy-Dysmenorrhea

FoIIowing resection of the presacra1 nerve this patient was perfectIy free from pain, and the excessive Aow which had previousIy been present was reduced to normal. She continued, nevertheIess, to suffer from anxiety symptoms and other evidences of a neurosis. Cannon expIains this resuIt by the hypothesis that the dysmenorrhea, and perhaps the ovarian dysfunction, resuIted from a primary fauIt in the nerve mechanism controIIing the normal rhythm of menstruation. He cites Menge as having observed that the norma physioIogica1 contraction waves which occur during menstruation, whiIe unnoticed by women physicaIIy and mentaIIy sound, become acuteIy painfu1 in those who are of a neurotic d&position, or whose nervous system is depressed from any cause. But against this expIanation it shouId be noted that histoIogica1 examination of some of the specimens removed by Cotte has actuaIIy shown infIammatory change in the presacra1 nerve itself, which led him to beIieve that possibIy a germina1 neuritis of this nerve might be the primary cause of the dysmenorrhea. TECHNIQUE

OF

OPERATION

In his origina communication Cotte outIined at considerabIe Iength his method of exposing and severing the presacra1 nerve. This practice has been foIlowed by numerous gynecoIogists in France, by Cannon in IreIand, and so far as I am aware, by a11 the EngIish-speaking surgeons who have undertaken the operation, either for the relief of dysmenorrhea or for disturbance of vesica1 function. In the 21 cases of my own series, the procedure, in brief, has been as foIIows: Th e patient being anesthetized and pIaced upon the tabIe, the cervix is diIated. She is then pIaced in the TrendeIenburg position, and a Ieft rectus incision made cIose to the midIine, extending from the pubic bone to a point about one inch above the umbiIicus. Packing is pIaced to keep the intestines upward, but the sigmoid is

Amencan

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of Surgery

411

retracted to the Ieft. The uterus and ovaries should be inspected, and if any pathoIogic conditions, such as cysts or retroversion, are in evidence, correction is undertaken before proceeding with the nerve section. UsuaIIy, as soon as the promontory of the sacrum is uncovered, it is possible to see the fibers of the presacra1 nerve crossing the Ieft iIiac vein. The posterior parieta1 peritoneum is next opened by an incision bisecting the peIvic triangIe which Iies between the right iIiac artery and the Ieft iIiac vein. AI1 the fibers in this triangle are picked up upon a Iigature carrier or other suitabIe impIement, and entireIy stripped away, care being exercised not to omit any fiber however insignificant. There is IittIe or no bIeeding, but any points which are evident shouId be Iigated. The peritoneum is then cIosed. It is my routine practice to remove the appendix, if present, after which the abdomen is sutured in the usua1 manner. POSTOPERATIVE

RESULTS

The immediate resuIts of this procedure have been exceIIent, and in no instance has the pain faiIed of reIief. Menstruation reguIarIy takes pIace within forty-eight to seventy-two hours after operatio_n, no matter what time in the menstrua1 cycle it has been performed. Most of the patients have had to be catheterized for two or three days, but the inhibition of bIadder function has been no more marked than after any other gynecoIogic operation. Cotte cIaims that in the majority of his cases, which at the Iatest reports numbered over a hundred, micturition was easier and the output of urine greater than is usua1 after any sort of peIvic procedure. None of my patients have had any diffIcuIty with the bIadder afterward, aIthough the possibility of some interference with vesica1 function has aIways been kept in mind. Several of my patients have since become pregnant, demonstrating that there is no interference with chiId-bearing.

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American

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of Surgery

De Courcy-Dysmenorrhea

In November rg3 I, Cotte pubIished an account of the remote resuhs observed in patients whom he operated upon during the years 1924 and 1923, 36 cases in aII. In one group consisting of 22 patients no pathoIogic conditions of any kind had been found to account for the peIvic pain. In the remaining 14 patients there were Iesions of the genita1 apparatus, which had demanded some intervention upon the ovaries or tubes at the time the nerve was resected. In his very first case, a smaI1 foIIicuIar cyst of the ovary had been removed, and he had aIso taken out a norma appendix. This gir1, aged twenty-three, had had pulmonary hemorrhages and was convaIescent from tubercuIosis. Two months after resection of the presacra1 nerve she had gained I I Ib. in weight, and had experienced no pain at any of her menstrua1 periods. Six and a haIf years Iater, she wrote that she never suffered menstrual pain at any time, that she was married and had had one pregnancy with deIivery at fuI1 term. Of the other patients Cotte was abIe to foIIow up compIeteIy, a11 but one had been absoIuteIy reIieved from pain for five or six years. Th ere were three pregnancies, a11 going to fuI1 term and terminating happily. The one woman who had not been fuIIy relieved of pain cIaimed that she suffered much Iess, and as he had not been abIe to make a persona1 examination of her present condition, Cotte was incIined to beIieve that other factors, perhaps unrelated to the nerve section or the origina cause of dysmenorrhea, might have entered in. My own series is too recent to permit any generaIizations concerning remote resuIts. The gratitude expressed by the young women who have been Iightened of a monthIy burden which was often weIInigh insupportabIe bears strong testimony to the vaIue of this reIativeIy simpIe maneuver. The case histories have been so uniformIy simiIar that I wiI1 append but a single one to iIIustrate the genera1 trend of results.

hIARCH, 193-1 CASE

REPORT

CASE I. V., aged eighteen years. This patient presented herself for examination five months ago. At that time her mother, who accompanied her, stated that she suffered such intense pain at each menstrua1 period that it was aImost unbearabIe. She was aIways confined to her bed for the first two days of the period, and during this time was frequentIy subject to attacks resembIing epiIepsy, during which she would become rigid and comatose. Examination revealed no IocaI cause for the dysmenorrhea, and it was decided to resect the presacra1 nerve. The operation presented no di&uIties, and convaIescence was absoluteI? uneventfu1. RecentIy interviewed, she states that she has not had any pain whatsoever since leaving the hospita1. She has Iost no time from her work, and is apparentIy perfectIy norma so far as her menstrua1 function is concerned. She is naturaIIy very enthusiastic over this happy resuIt.

Other patients simiIar reports.

operated

upon have made

CONCLUSION

In concIusion, I wouId strongIy recommend this procedure for the reIief of obstinate cases of dysmenorrhea which have proved resistant to ordinary measures. The technique is somewhat deIicate, and requires a discriminating eye. Good judgment in the seIection of suitabIe cases is a prime requisite. But given the right conditions, it offers a means of aiding a Iarge cIass of women who must otherwise suffer a monthIy martyrdom and be compeIIed to drag out the greater part of their time in partia1 disabiIity with a genera1 Iowering of physica and menta1 efficiency. REFERENCES I. JABOULAY. Le traitement

de la nevralgie pelvienne par la paralysie du sympathetique sack I-yon &d., 96: 102, r8gg. 2. ROCHET. V.. and LATARJET, A. Etude sur Ies voies d’aboid chirurgical du pI&us hypogastrique et de son ganglion, Lyon cbir., IO: 425; 548, 1913. 3. COTTE, G., and DECHAUME, M. Technique et indications op&atoires des interventions sur la sympathique peIvien (sympathectomie p~riart~rielle hypogastrique: section du nerf presacrk) en gynecologie. J. de cbir., 25: 653, 1925. [For Remainder of References see p. 479.1

Smiththat the abscess be incised and drained; it shouId be treated just as though a fist& had been present for a Iong period of time. To carry infected tissue and pus about in the perirectal tissues is not onIy a dangerous procedure from the standpoint of foca1 infection but, where the condition is Iong negIected, it wiIl Iead inevitabIy to an inffammatorv stricture of the rectum and chronic inv&idism. CONCLUSIONS

I. AnorectaI fistuIae are inflammatory openings from the anus or rectum, either bIind or connecting the anus or rectum with some other peIvic organ or with the skin of the buttocks. 2. Their point of origin is within the rectum or anus, the commonest site being in a crypt of Morgagni. they are subacute 3. PathoIogicaIIy, or chronic abscesses, originating from an acute pararecta1 abscess which has ruptured or has been incised. 4. The infecting organism usualIy is The tubercre baciIIus the staphyIococcus. rareIy is a direct etiologic factor.

REFERENCES

-FistuIae

*Continued

Journnl

of Surgery

4-C)

3. There is no fixed relationship as to Iocation between the externa1 and the interna openings of a fistula. 6. The success of an operation depends upon Iocating and obIiterating the internal opening of a fistuIa and upon giving free drainage to the infected tissue by its partia1 excision. 7. Suturing of the tissues after operation is not performed. The wound is aIIowed to remain oDen and to fiI1 in from its base with EranuIation tissue. 8. The wound is never packed. 9. True incontinence does not foIIow division of the sphincters in the course of an operation, for true incontinence is the resuIt of spina cord disease. If no packing is used after operating, the ends of the cut muscIe wiI1 be joined by scar tissue and not even Ieakage of Iiquid feces and flatus wiI1 resuIt, as a rule. I o. Operations for fistuIa-in-ano shouId be performed earIy both because of the dangers from foca1 infection and because the spreading of the infection in the perirecta1 tissues wiI1 Iead to an inflammatory stricture of the rectum.

OF DR.

Traitement de Ia dysmtnorrhke par Ia resection du nerf p&sac&. Lyon mkd., 149: 29, 1932. ResuItats &loign(l de r§ions du nerf pr&sacr& faites en 1924-1925 pour dysmknorrhke. Lyon cbir., 29: 112, 1932. AIterations du sympathique peIvien et dysmknorrhCe. Lyon cbir., zg: 252, 1932. 4. NOVAK, E. Menstruation and Its Disorders. GynecoIogicaI and Obstetrica monographs. N. Y., Appleton, 1931 (Chap. xx). 5. CANNON, D. J. Resection of the presacra1 nerve for intractabIe dysmenorrhea complicated by severe

Americzln

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bIeeding. lrisb J. M. SC, s. 6, p. 150, 1932. For use in vesica1 conditions refer aIso to: 6. LEARMONTH, J. R. The vaIue of neurosurgery in certain vesica1 conditions. Trans. A. M. A., Sect. UrOI., p. 73, 1931. 7. VAN DUZEN, R. E. Effect of resection of the presacra1 nerve on vesica1 function. Southern M. J., 25: 964, ‘932. 8. LEARMONTH, J. R., and BRAASCH, W. F. Resection of the Dresacral nerve for disease of the bladder: experience in 24 cases. Trans. Am. Assn. Genito&in. Sllrg., 25: 313, 1932. from p. 412.