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Traumatic laceration of uterine supports
Traumatic Further
EDWIN Palo
Alto.
laceration of uterine supports
observations
V.
of the Allen-Masters
LAWRY,
syndrome
M.D.
California
Twenty-three cases of traumatic laceration of the uterine supports haue been presented. This is a follow-up on a syndrome first described by Allen and Masters. The symptomatology, etiology, clinical, and pathologic findings are discussed. The surgical treatment by repair of the broad ligament or preferably by hysterectomy in appropriate cases is discussed. The results of treatment in general are extremely gratifying. The failures as associated with specific symptoms are presented and discussed.
I N 1 9 5 5 Willard M. Allen and William H. Masters,’ in an article entitled “Traumatic Laceration of Uterine Support,” described a new anatomic and clinical syndrome. This syndrome was characterized by lacerations of the posterior leaf of the broad ligament, usually of obstetric origin, always asrociated with a painful retroversion of the uterus and an abnormally mobile cervix which they described as the “universal joint cervix.” The observations published by Allen and Masters on 28 cases are original in the English literature. I have not been able to find a single reference to isolated tear of the broad ligament without uterine rupture. ‘There is one possible exception in an article on correction of retroversion by Dedman” uteri in which the author suggested the exploration of the broad ligaments for possible defects but did not enlarge upon that statemrnt. In the past 5 or 6 years, I have collected 23 cases of laceration of the broad ligaments. There would be many more, I am sure, but the others werr treated by vaginal hysterectomy and so lost to the series. From
the
Gynecology,
Department Palo Alto
Since 1959, xvhcn Varangot”’ in F~~xnct report4 30 casrs of the Allen-MastcArs syndrome with a critical analysis of etiology, clinical findings, anatomicopatholo+, findings, and therapy, 12 authors have reported in the Foreign litvraturr \ all but 2 in Frc,nch \ on 143 additional cases. This report nlakcs a total of 19-L casts. Allen. in a p~~~~onal communication, says that thev nou h;rvc, a total of approximately 100 cast5. Allen and Masters report uterine retroversion in all of their cases, but WC havtb found that this is not always present. Sarangot and associates’” showed 21 of X! uteri were rf2rovertPc1, and 9 were’ cithcr in a midposition or antevrrted. The onv consistent finding in all the scrics is the abnorm:J mobility of the cer\Gs, “thr universal joint.“ All of the other authors ha\-v heated thix condition by repair of the broad ligament defects and frequently also 1~). round ligamrant uterine suspension. No reft,rvtlct* is made to the a:,Fe and parity of the patients. but I must assume that all fell into a group in which it was thought nvressq to prevrve reproductive function. We have found that most of our cxf’s are effrcti\+ trc~atrd by h~stvrc.toml;. Simple repair also gavl’ cli.iitcx satisfac?wv rcwlts.
of Obstetrics and Medical Clinic.
Material
Presented at the Thirty-fourth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Phoenix, Arizona, Nov. 29-Dec. 2, 1967.
This series consists of 2.7 cases of laceration of the broad ligaments. Not all wert: 315
316
Lawry
diagnosed preoperatively, but the diagnosis was confirmed or established at operation in every case. Three were diagnosed as endometriosis, 2 as pelvic congestion syndrome, and one patient was operated upon for cervical carcinoma in situ, symptomatic lacerations being found at the time of operation. Th e presenting symptoms and findings are not always easy to evaluate, since they resemble other and commoner causes of pelvic pain, notably endometriosis, pelvic inflammatory disease, and pelvic congestion. Because the patients’ complaints far outweigh the apparent clinical findings either by pelvic examination, pelvic pneumography, culdoscopy, or venography, many of these patients are branded neurotic and they drift from doctor to doctor in search of one who will believe them and give them relief. Many have been treated at length with progestational agents. Attempts at relief are sometimes made by holding the fundus anteriorly with pessaries, occasionally temporarily helpful but usually with failure or actual aggravation of their pain. Two cases had been treated by round ligament suspension, also without relief. In Table I the presenting complaints are compared with those in the Allen-Masters report. Dyspareunia is a prominent symptom. This is deep-seated pain, as if something is struck on deep penile penetration, and intercourse is frequently followed by severe pelvic aching. Many patients complain that sexual intercourse is infrequent, if not absent, because of the severity of the pain. Excessive physical fatigue is an equally prominent symptom. Many patients develop a sense of inferiority or inadequacy because they are unable to cope with the daily routine. There is frequent pelvic discomfort associated with low backache and discomfort down the anterior thighs. Jarring movements, riding in a car, and standing for even short periods also cause incapacitating pain. In 6 of our cases specific one-sided pelvic distress could be correlated at operation with broad ligament laceration on that side. Dysmenorrhea was frequent in AllenMasters’ series but much less so in this one.
Table
I. Comparison
of symptoms
Dyspareunia Excessive fatigue General pelvic pain and backache Dysmenorrhea Specifically localized pelvic pain Emotional instability Metrorrhagia Menorrhagia Defecation oain Chronic headaches (occipital) Genitourinary symptoms Leukorrhea
Table II. Comparison
24 24
t9 19
21 22
19 7
19 16 12 5
6 7 3 7
4
4
9 5 5
i 3 1
of obstetric AllenMasters
(28 ClZSC?S)
histories Present series (23 cases)
No positive history of obstetric distress Precipitate delivery Difficult forceps delivery Complicated breech delivery Large infant Severe postpartum hemorrhage treated by uterine packing Criminal abortion
9 7 6 3 1 1 1
” 2 -
-!
Menorrhagia occurred in about one third of our cases but in less than one fifth of the Allen-Masters series. Metrorrhagia was a fairly common symptom, as was emotional instability. Complaints varied from marked mood swings and crying easily to real depression with occasional expression of suicidal intent. The longer the history of distress, the more prominent and frequent the symptoms of emotional instability. Pain on defecation can be a very distressing symptom. The remainder of the complaints have no special significance in association with the syndrome. Etiology All of the patients in this series had histories of pregnancy (Table II). Nineteen gave no history of obstetric difficulty. One
Allen-Masters’
Table III.
Pelvic
pathology
Third
degree
Serous Bilateral
fluid
broad broad
ZJnilateral Right Left
sacrouterine
Bilateral
13
(30 to 80 c.c.)
27
30
? Frequent
laceration
22
17
"I!
ligament
laceration
6
ligament
laceration
,
13
3 IO
4 2
2 I
5 3 2
sacrouterine
ligament
laceration
1 1
patient had her 2 children by elective cesarean section, so labor was not in her case an etiologic factor, One had 3 spontaneous abortions and ‘2 premature deliveries plus 2 term deliveries by the age of 23. Two had difficult forceps deliveries and one had severe postpartum hemorrhage controlled with intrauterine packing. Certainly the vast majority were unable to pinpoint one specific obstetric event as the onset of the problem. Two patients were relieved of symptoms during pregnancy after the first trimester when the uterus had ridden out of the pelvis and was therefore resting on the pelvic brim, with diminished drag on the broad ligaments. anatomy
(Table
111~
Ketroversion of the uterus is found in a large percentage of the cases. It was present in all of the Allen-Masters series, in 21 of Varangot and associates’ series, and in only 13 of the present series. When retroversion is found, the uterus is engorged, violaceous, usually enlarged to at least once again normal size, and quite soft. When brought forward it frequently shrinks in volume as much as one-third. There is usually from 30 to 80 C.C. of serous fluid in the cul-de-sac. Allen and Masters have actually seen this fluid dripping from the peritoneal defect in the broad ligaments and feel that the larger the defect, the greater the amount of fluid.
_. -
Present serifs (23 cases j
21
_----..
-
Pathologic
Varangot and associates (30 cases)
28
of the uterus
ligament
Unilateral Right Left
Allen-Masters (28 cases)
reported
retroversion in pelvis
317
__._.I_-~
---Pathology
syndrome
0 - - .
-
Inspecting the posterior surface of the broad ligaments reveals the fundamental defect, laceration of the base of the broad ligament. This may involve the peritoneum and the underlying fascial layer or the fascial layer alone. The laceration is usually vertical but may be butterfly-like. The edges of the fascial laceration retract laterally toward the pelvic wall and mesially almost to the isthmus of the uterus. The laceration may extend down through the uterosacral ligament. The lacerations are usually bilateral. Prominent and dilated vessels can be seen coursing across the lower portion of the broad ligament defect. Whether the uterus is retroverted or not, there is excessive mobility of the cervis, up and down, side to side, and front to hack. Treatment The treatment is surgical. In the series of Allen-Masters and Varangot and associates and most others it consisted of suture of the defects in the broad ligaments and usually round ligament suspension to correct the retroversion. The technique of broad ligament repair has been well described by Allen and Masters.l They feel that repair of these defects alone will correct the retroversion and believe that round ligament suspension is superfluous. Varangot and associates disagree. They believe round ligament
318
Table
Lawry
IV.
Surgical
procedures __ ----
performed --__ -----.--
Repair of broad ligament lacerations Round ligament suspension Hysterectomy Appendectomy Dilatation and curettage Conization of cervix Repair of sacrouterine ligament laceration Perineorrhaphy Cystocele repair from above Bilateral tubal ligation Cystocele repair from below and
endometrial
..__.... ~_I_.
------
Varangot and associates (30 cases)
Allen-Masters (28 cases)
Procedure
Removal
I
implants
Present series (23 cases)
30 17 0
28 23 0 21 12 8 6 3 2 2 1
4 3 19 12 1
1
(cul-de-sac
ovaries)
1
I
Table V. Results of treatment Allen-Masters
Symfitoms Dyspareunia Excessive physical fatigue Generalized pelvic distress (and/or backache) Dysmenorrhea Specific localization of pelvic distress Emotional instability Metrorrhagia Chronic headaches Menorrhagia Genitourinary symptoms Chronic vagina1 discharge Defecation pain
Present before operation
Varangot
Unrelieved
Present before operation
and
associates
Unrelieved
P resent Present before operation
series
Unrelieved
24 24
2 3
22 22
2 2
I9 19
1 2
21 22
0 9
22
2 2
19 7
2 0
6 7 3 1 7 3 I 4
1 2 0 0 0 0 0 0
19 16 12 9 5 5 5 4
suspension should also be done. Their only 2 failures occurred in cases in which this procedure was omitted. In the reported series the ages and parity of the patients were not mentioned, so I must assume it was deemed important to preserve the childbearing function of all these women. In the present series (see Table IV), only 4 patients were treated by repair of the lacerations in the broad ligaments. Of the remaining 19, all were treated by hysterectomy. The 4 repairs were done in women under 25 years of age. Three of the hysterectomies were in women in their late twenties
whose parity and desire to be sterilized were indications for this operation. Eight were from 30 to 40 and the remaining 8 were in their forties. In personal correspondence with Willard Allen he stated that he now believes in hysterectomy, when appropriate. He also mentioned in passing the need to isolate carefully the ureters to avoid possible damage, as the ureter runs very close to the defect. Results
The results (Table V) are gratifying in the majority of cases. The relief of dyspareunia, pain, fatigue, and emotional in-
Allen-Masters’
stability was striking. Relief of symptoms in al! reported series is about the same, except for dysmenorrhea. In 9 there was failure to rcliel~e this symptom in the Allen-Masters scCes, none in the present series. Varangot and associates had 2 failures in cases in which they did simple repair without round ligament suspension. The two symptomatic failures in our series: manifested by excessive fatigue, pehric distress, and emotional instability, were in 2 women who underwent hysterectomy. These cases were probably not well selected and undoubtedly the patients had a real neurotic component. Marked improvement was observed in the mental state and behavioral pattern in many of these patients after surgical treatment brought r&f of pelvic pain. Comment
Laceration of the broad ligament is a very 1ea1 cause of disabling pelvic discomfort. Sinctx the original article of Allen and Masters.’ in 1955, it has gone unmentioned in the English language literature. I would preSUJW from this that the diagnosis is not made or that the syndrome is not recognized. ‘I’here are, however, several references to the Allen-Masters syndrome in the foreign “A prophet is not without honor, literature. save in his own country.” The syndrome is a specific entity which CaJl be established at surgery. It is difficult to suspect the diagnosis sufficiently to decide U~OJI a surgical approach. There is no ques-
syndrome
3’17
tion that this condition closely resembles other causes of pelvic discomfort. The COI~Iplaints are varied, although consistent, and many of the patients are emotionally unstable, and the physical findings are rnini~nal. so that the tendency is to classify the sulferers as neurotic and to use therapy which is completely ineffective. The kt,y si,cn is extreme mobility of the cervix and pail1 out of proportion to the physical findings. ‘1.1~~ condition can be effecti\,ely treated by SII:gical repair of the lacerations or hystc*rtlctomy. I feel that hysterectomy shoultl he done much more frequently than repail. t+ cause most of the patients in this series WY‘JY of an age or parity 5vhere there was no riced to preserve the uterus. It is notrwurth\, that many of these women volunteer the ini’clrmation that they feel much better than before operation well before the convairscc~~~t twioti is over. If the diagnosis were certain, these patients would lend themselves ideally to treatment by vaginal hysterectomy. ‘I‘hr extremr. JWbility of the cervix and corpus i iIt af)serlce of prolapse) makes this procedure touchnically easy. Since I could not contim the diagnosis in such cases, no patienti: \vith vaginal hysterectomies were included ;II this serws. There are many women, nuw untreated. who can he relieved of their longsLanding disability if more ronsidrration is S$\WI to the possibility of the existenctx of the AIler+ Masters syndrome.
REFERENCES
1. 2. :;
4. 5. 6. 7.
Allen.
W.
M.,
ORST.
&
GYNEC.
and
Masters, 70: 500, Contours mCd.
W. H.: AM. J. 1955. 82: 4531, 1960.
Aubert, L.: (French) Carayon, 1~., Colomar, R., and Resillot, A.: Bull. Sot. mbd. Afr. Noire lang. franq. 9: 524, 1964. (French) Cheshankov, K. H.: Akush. ginek. 4: 240, 1965. (Russian) Comiti. J. and Emery, J.: Marseille chir. 15: 37, 1963. (French) Dedman. H. E.: West. J. Surg. 68: 45. 1960. Desarmenien, J.: Sud med. chir. 99: 11064, 1963. (French)
H. 9. 10. 11. I?. 13. 14.
Ferreira. C. A.: An. brasil. de ginec. .YJ~: 1 I 1. 1963. Gautier, P.. and Vankemmel. M.: Lillr chir. 19: 57, 1964. (French) Joyeux, R., and Colin, R.: ,2nn. < hir. 17: 1475. 1963. (French) Rochet, Y., and Mikaelian, S.: Bnll. Ftd. Sot. gynec. et obst. 17: 449, 1965. (French) Serment, H., Ruf, H., and Felcr, PI.: Marseille chir. 15: 357, 1963. [French) Varangot. J.? et al,: Presse m&~. 67: 1139, 1959. (French) Verne, J. M., et al.: M&II. Acad. c,hir. 85: .5:!3, 1959. (French)
Discussion
H. MORTON, Los Angeles, California. Dr. Lawry has used the criteria and treatment outlined by Allen and Masters and his results have been excellent. The fact that he has been able to collect 23 cases in 5 or 6 years indicates that there is both a high incidence in his area and that he is diligent in making the diagnosis. Very likely many of us miss the diagnosis because a vaginal hysterectomy often is done in a woman with these symptoms and findings. The diagnosis really can be completed only by direct vision at laparotomy. Our concept of the main uterine support is that of a cardinal ligament intimately attached to the uterine vessels and with fanlike spread and attachment to the lateral pelvic wall and to the uterus medially with reflexions to the paravaginal tissues and utero sacral ligaments. We have never found fascia between the anterior and posterior leaves of the broad ligament-only areolar tissue-so we doubt if it is possible to suture fascia here as described. It may be that the main cardinal ligament has been partially torn or stretched, setting the stage for the “universal joint” cervix or the first stage of a prolapse. It would seem that an actual complete tear in the cardinal ligament would inevitably cause serious hemorrhage. We have on occasion attempted a Manchester type of parametrial fixation from above, with some success, but consider it unsatisfactory and there is danger of possible ureteral injury or hemorrhage. The straw-colored free peritoneal fluid is noted to vary from 30 to 80 C.C. and is ascribed to peritoneal irritation from the defect. During my year as a pathology resident in Cleveland, Ohio, Dr. Howard T. Karsner taught us that up to 100 cc. of free peritoneal fluid was normal, and we consider this amount of fluid to be within normal limits. Retroversion is frequently noted and in an earlier day we probably would have blamed the DR.
wide
JOHN
variety
of
pelvic
symptoms
on
uterine
malposition. Also, we would probably have attempted to correct the malposition surgically and would have incidentally corrected the laceration while doing the suspension operation, particularly if we corrected the uterosacral ligaments, as was customary. Dr. Lawry states that he has not found a single reference in English to isolated tear of the broad ligament without uterine rupture. I would like to report 2 acute cases, both treated at the
White Memorial Hospital in Los Angeles by Dr. Elisabeth Larsson who graciously reviewed the cases and granted permission for them IO be reported here. One case could be called an ‘acute traumatic rupture of the uterine support. This patient had had a cesarean section 2 years previously and had sudden severe pain in the right pelvic area during intercourse, followed eventually by shock. At laparotomy a 3 cm. laceration in the upper right broad ligament was found plus 700 C.C. of fresh and clotted blood. The bleeding area was ligated and the rent repaired. The second case could be classified as a subacute traumatic rupture of the uterine support. This woman was 2 months pregnant at the time of operation and had had left lower quadrant pain for 4 weeks, the onset here also being during intercourse. A preoperative diagnosis of ectopic pregnancy was made but at operation an 8 cm. laceration of the left broad ligament base extending from the cul-de-sac to the lateral pelvic wall was found and repaired, with satisfactory recovery. It seems that in the pathogenesis of the Allen-Masters syndrome similar lacerations may have occurred but that serious bleeding and symptoms were not experienced; the train of pelvic and/or symptoms developed other more gradually. Possibly we should call the Allen-Masters syndrome a chronic or old traumatic rupture of the uterine supports in order to distinguish it from the acute and subacute cases which would also include cases of uterine and vaginal rupture accompanied by ligament lacerations. Finally, we should note that there is no classification of the Allen-Masters syndrome in our book of Standard Nomenclature, and when one goes to the record room and asks for reports of such cases one receives only a blank look. Tissue Committees should also be made aware of this syndrome for here is another nonuterine disease which is curable by the removal of a normal uterus. DR.
ROBERT DUNN, Palo Alto, California. Although this condition is a definite structural defect, it is often part of the more general pathologic condition we see in the pelvic congestion syndrome. These are retroverted, subinvoluted uteri, varicosities of the broad and ovarian ligaments, pelvic floor relaxation, and now the Allen-Masters defect. More attention should be paid to this syndrome because we, at least, see many of these women who have gone
Allen-Masters’
from doctor to doctor, gynecologist to gynecologist, without definitive care. The young gynecologist, afraid of the Tissue Committees, often will not treat these patients surgically. To demonstrate how little is really written about this subject, I quote from the fourth edition of Brewer’s Gynecology, published in 1967, upon the subject of pelvic pain. “Pelvic congestive syndrome; treatment consists of medical care, psychological counselling, and in some instances psychiatric management. Presacral nellrcctomy, ovarian resection, oophorectomy and hysterectomy are rarely indicated. Allen and Masters have devised a surgical procedure which relieves 80 to 90yc of the patients.” This author goes from the pelvic congestive syndrome to the Allen-Masters defect without explaining the relationship. I was glad that Dr. Morton mentioned at the end of his discussion that these cvomen arc really pelvic cripples. Some of them
syndrome
321
are neurotic but many of them are neurotic. IN*cause they have so much discomfort and pain trying to perform their daily work. DR. BRUGE B. ROLF, Los Angeles, California. I would like tn cite the instances of 2 y~nq women under 26, in whom the diagnosis was made prcopcratively after they had been ohsrlvcd for a number of years. One of these wtrmpn :~ftc’~ bilateral rcapair has had complete r~hahilitatiorl and two successful pregnancies. Thr other pal ~r’nt, having had two or three pregnancirs was urged to havr a hysterectomy, but because of hcl agc~ she was hesitant. A repair was done 1~11 qhr continued to have symptoms, with pyclour~tr~I~it is, ureteral strictures, and vesical neck tontrac‘rlws. She was prepsychotic and had been under p\vchiatric care both before and after operation. Shv subsequently developed menorrhagia, tinally sui)mitted to hystrrcctomy, and thou,qh vastI) itllprovc,d contmued to have other discasry.
EDWIN Palo
Alto.
laceration of uterine supports
observations
V.
of the Allen-Masters
LAWRY,
syndrome
M.D.
California
Twenty-three cases of traumatic laceration of the uterine supports haue been presented. This is a follow-up on a syndrome first described by Allen and Masters. The symptomatology, etiology, clinical, and pathologic findings are discussed. The surgical treatment by repair of the broad ligament or preferably by hysterectomy in appropriate cases is discussed. The results of treatment in general are extremely gratifying. The failures as associated with specific symptoms are presented and discussed.
I N 1 9 5 5 Willard M. Allen and William H. Masters,’ in an article entitled “Traumatic Laceration of Uterine Support,” described a new anatomic and clinical syndrome. This syndrome was characterized by lacerations of the posterior leaf of the broad ligament, usually of obstetric origin, always asrociated with a painful retroversion of the uterus and an abnormally mobile cervix which they described as the “universal joint cervix.” The observations published by Allen and Masters on 28 cases are original in the English literature. I have not been able to find a single reference to isolated tear of the broad ligament without uterine rupture. ‘There is one possible exception in an article on correction of retroversion by Dedman” uteri in which the author suggested the exploration of the broad ligaments for possible defects but did not enlarge upon that statemrnt. In the past 5 or 6 years, I have collected 23 cases of laceration of the broad ligaments. There would be many more, I am sure, but the others werr treated by vaginal hysterectomy and so lost to the series. From
the
Gynecology,
Department Palo Alto
Since 1959, xvhcn Varangot”’ in F~~xnct report4 30 casrs of the Allen-MastcArs syndrome with a critical analysis of etiology, clinical findings, anatomicopatholo+, findings, and therapy, 12 authors have reported in the Foreign litvraturr \ all but 2 in Frc,nch \ on 143 additional cases. This report nlakcs a total of 19-L casts. Allen. in a p~~~~onal communication, says that thev nou h;rvc, a total of approximately 100 cast5. Allen and Masters report uterine retroversion in all of their cases, but WC havtb found that this is not always present. Sarangot and associates’” showed 21 of X! uteri were rf2rovertPc1, and 9 were’ cithcr in a midposition or antevrrted. The onv consistent finding in all the scrics is the abnorm:J mobility of the cer\Gs, “thr universal joint.“ All of the other authors ha\-v heated thix condition by repair of the broad ligament defects and frequently also 1~). round ligamrant uterine suspension. No reft,rvtlct* is made to the a:,Fe and parity of the patients. but I must assume that all fell into a group in which it was thought nvressq to prevrve reproductive function. We have found that most of our cxf’s are effrcti\+ trc~atrd by h~stvrc.toml;. Simple repair also gavl’ cli.iitcx satisfac?wv rcwlts.
of Obstetrics and Medical Clinic.
Material
Presented at the Thirty-fourth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Phoenix, Arizona, Nov. 29-Dec. 2, 1967.
This series consists of 2.7 cases of laceration of the broad ligaments. Not all wert: 315
316
Lawry
diagnosed preoperatively, but the diagnosis was confirmed or established at operation in every case. Three were diagnosed as endometriosis, 2 as pelvic congestion syndrome, and one patient was operated upon for cervical carcinoma in situ, symptomatic lacerations being found at the time of operation. Th e presenting symptoms and findings are not always easy to evaluate, since they resemble other and commoner causes of pelvic pain, notably endometriosis, pelvic inflammatory disease, and pelvic congestion. Because the patients’ complaints far outweigh the apparent clinical findings either by pelvic examination, pelvic pneumography, culdoscopy, or venography, many of these patients are branded neurotic and they drift from doctor to doctor in search of one who will believe them and give them relief. Many have been treated at length with progestational agents. Attempts at relief are sometimes made by holding the fundus anteriorly with pessaries, occasionally temporarily helpful but usually with failure or actual aggravation of their pain. Two cases had been treated by round ligament suspension, also without relief. In Table I the presenting complaints are compared with those in the Allen-Masters report. Dyspareunia is a prominent symptom. This is deep-seated pain, as if something is struck on deep penile penetration, and intercourse is frequently followed by severe pelvic aching. Many patients complain that sexual intercourse is infrequent, if not absent, because of the severity of the pain. Excessive physical fatigue is an equally prominent symptom. Many patients develop a sense of inferiority or inadequacy because they are unable to cope with the daily routine. There is frequent pelvic discomfort associated with low backache and discomfort down the anterior thighs. Jarring movements, riding in a car, and standing for even short periods also cause incapacitating pain. In 6 of our cases specific one-sided pelvic distress could be correlated at operation with broad ligament laceration on that side. Dysmenorrhea was frequent in AllenMasters’ series but much less so in this one.
Table
I. Comparison
of symptoms
Dyspareunia Excessive fatigue General pelvic pain and backache Dysmenorrhea Specifically localized pelvic pain Emotional instability Metrorrhagia Menorrhagia Defecation oain Chronic headaches (occipital) Genitourinary symptoms Leukorrhea
Table II. Comparison
24 24
t9 19
21 22
19 7
19 16 12 5
6 7 3 7
4
4
9 5 5
i 3 1
of obstetric AllenMasters
(28 ClZSC?S)
histories Present series (23 cases)
No positive history of obstetric distress Precipitate delivery Difficult forceps delivery Complicated breech delivery Large infant Severe postpartum hemorrhage treated by uterine packing Criminal abortion
9 7 6 3 1 1 1
” 2 -
-!
Menorrhagia occurred in about one third of our cases but in less than one fifth of the Allen-Masters series. Metrorrhagia was a fairly common symptom, as was emotional instability. Complaints varied from marked mood swings and crying easily to real depression with occasional expression of suicidal intent. The longer the history of distress, the more prominent and frequent the symptoms of emotional instability. Pain on defecation can be a very distressing symptom. The remainder of the complaints have no special significance in association with the syndrome. Etiology All of the patients in this series had histories of pregnancy (Table II). Nineteen gave no history of obstetric difficulty. One
Allen-Masters’
Table III.
Pelvic
pathology
Third
degree
Serous Bilateral
fluid
broad broad
ZJnilateral Right Left
sacrouterine
Bilateral
13
(30 to 80 c.c.)
27
30
? Frequent
laceration
22
17
"I!
ligament
laceration
6
ligament
laceration
,
13
3 IO
4 2
2 I
5 3 2
sacrouterine
ligament
laceration
1 1
patient had her 2 children by elective cesarean section, so labor was not in her case an etiologic factor, One had 3 spontaneous abortions and ‘2 premature deliveries plus 2 term deliveries by the age of 23. Two had difficult forceps deliveries and one had severe postpartum hemorrhage controlled with intrauterine packing. Certainly the vast majority were unable to pinpoint one specific obstetric event as the onset of the problem. Two patients were relieved of symptoms during pregnancy after the first trimester when the uterus had ridden out of the pelvis and was therefore resting on the pelvic brim, with diminished drag on the broad ligaments. anatomy
(Table
111~
Ketroversion of the uterus is found in a large percentage of the cases. It was present in all of the Allen-Masters series, in 21 of Varangot and associates’ series, and in only 13 of the present series. When retroversion is found, the uterus is engorged, violaceous, usually enlarged to at least once again normal size, and quite soft. When brought forward it frequently shrinks in volume as much as one-third. There is usually from 30 to 80 C.C. of serous fluid in the cul-de-sac. Allen and Masters have actually seen this fluid dripping from the peritoneal defect in the broad ligaments and feel that the larger the defect, the greater the amount of fluid.
_. -
Present serifs (23 cases j
21
_----..
-
Pathologic
Varangot and associates (30 cases)
28
of the uterus
ligament
Unilateral Right Left
Allen-Masters (28 cases)
reported
retroversion in pelvis
317
__._.I_-~
---Pathology
syndrome
0 - - .
-
Inspecting the posterior surface of the broad ligaments reveals the fundamental defect, laceration of the base of the broad ligament. This may involve the peritoneum and the underlying fascial layer or the fascial layer alone. The laceration is usually vertical but may be butterfly-like. The edges of the fascial laceration retract laterally toward the pelvic wall and mesially almost to the isthmus of the uterus. The laceration may extend down through the uterosacral ligament. The lacerations are usually bilateral. Prominent and dilated vessels can be seen coursing across the lower portion of the broad ligament defect. Whether the uterus is retroverted or not, there is excessive mobility of the cervis, up and down, side to side, and front to hack. Treatment The treatment is surgical. In the series of Allen-Masters and Varangot and associates and most others it consisted of suture of the defects in the broad ligaments and usually round ligament suspension to correct the retroversion. The technique of broad ligament repair has been well described by Allen and Masters.l They feel that repair of these defects alone will correct the retroversion and believe that round ligament suspension is superfluous. Varangot and associates disagree. They believe round ligament
318
Table
Lawry
IV.
Surgical
procedures __ ----
performed --__ -----.--
Repair of broad ligament lacerations Round ligament suspension Hysterectomy Appendectomy Dilatation and curettage Conization of cervix Repair of sacrouterine ligament laceration Perineorrhaphy Cystocele repair from above Bilateral tubal ligation Cystocele repair from below and
endometrial
..__.... ~_I_.
------
Varangot and associates (30 cases)
Allen-Masters (28 cases)
Procedure
Removal
I
implants
Present series (23 cases)
30 17 0
28 23 0 21 12 8 6 3 2 2 1
4 3 19 12 1
1
(cul-de-sac
ovaries)
1
I
Table V. Results of treatment Allen-Masters
Symfitoms Dyspareunia Excessive physical fatigue Generalized pelvic distress (and/or backache) Dysmenorrhea Specific localization of pelvic distress Emotional instability Metrorrhagia Chronic headaches Menorrhagia Genitourinary symptoms Chronic vagina1 discharge Defecation pain
Present before operation
Varangot
Unrelieved
Present before operation
and
associates
Unrelieved
P resent Present before operation
series
Unrelieved
24 24
2 3
22 22
2 2
I9 19
1 2
21 22
0 9
22
2 2
19 7
2 0
6 7 3 1 7 3 I 4
1 2 0 0 0 0 0 0
19 16 12 9 5 5 5 4
suspension should also be done. Their only 2 failures occurred in cases in which this procedure was omitted. In the reported series the ages and parity of the patients were not mentioned, so I must assume it was deemed important to preserve the childbearing function of all these women. In the present series (see Table IV), only 4 patients were treated by repair of the lacerations in the broad ligaments. Of the remaining 19, all were treated by hysterectomy. The 4 repairs were done in women under 25 years of age. Three of the hysterectomies were in women in their late twenties
whose parity and desire to be sterilized were indications for this operation. Eight were from 30 to 40 and the remaining 8 were in their forties. In personal correspondence with Willard Allen he stated that he now believes in hysterectomy, when appropriate. He also mentioned in passing the need to isolate carefully the ureters to avoid possible damage, as the ureter runs very close to the defect. Results
The results (Table V) are gratifying in the majority of cases. The relief of dyspareunia, pain, fatigue, and emotional in-
Allen-Masters’
stability was striking. Relief of symptoms in al! reported series is about the same, except for dysmenorrhea. In 9 there was failure to rcliel~e this symptom in the Allen-Masters scCes, none in the present series. Varangot and associates had 2 failures in cases in which they did simple repair without round ligament suspension. The two symptomatic failures in our series: manifested by excessive fatigue, pehric distress, and emotional instability, were in 2 women who underwent hysterectomy. These cases were probably not well selected and undoubtedly the patients had a real neurotic component. Marked improvement was observed in the mental state and behavioral pattern in many of these patients after surgical treatment brought r&f of pelvic pain. Comment
Laceration of the broad ligament is a very 1ea1 cause of disabling pelvic discomfort. Sinctx the original article of Allen and Masters.’ in 1955, it has gone unmentioned in the English language literature. I would preSUJW from this that the diagnosis is not made or that the syndrome is not recognized. ‘I’here are, however, several references to the Allen-Masters syndrome in the foreign “A prophet is not without honor, literature. save in his own country.” The syndrome is a specific entity which CaJl be established at surgery. It is difficult to suspect the diagnosis sufficiently to decide U~OJI a surgical approach. There is no ques-
syndrome
3’17
tion that this condition closely resembles other causes of pelvic discomfort. The COI~Iplaints are varied, although consistent, and many of the patients are emotionally unstable, and the physical findings are rnini~nal. so that the tendency is to classify the sulferers as neurotic and to use therapy which is completely ineffective. The kt,y si,cn is extreme mobility of the cervix and pail1 out of proportion to the physical findings. ‘1.1~~ condition can be effecti\,ely treated by SII:gical repair of the lacerations or hystc*rtlctomy. I feel that hysterectomy shoultl he done much more frequently than repail. t+ cause most of the patients in this series WY‘JY of an age or parity 5vhere there was no riced to preserve the uterus. It is notrwurth\, that many of these women volunteer the ini’clrmation that they feel much better than before operation well before the convairscc~~~t twioti is over. If the diagnosis were certain, these patients would lend themselves ideally to treatment by vaginal hysterectomy. ‘I‘hr extremr. JWbility of the cervix and corpus i iIt af)serlce of prolapse) makes this procedure touchnically easy. Since I could not contim the diagnosis in such cases, no patienti: \vith vaginal hysterectomies were included ;II this serws. There are many women, nuw untreated. who can he relieved of their longsLanding disability if more ronsidrration is S$\WI to the possibility of the existenctx of the AIler+ Masters syndrome.
REFERENCES
1. 2. :;
4. 5. 6. 7.
Allen.
W.
M.,
ORST.
&
GYNEC.
and
Masters, 70: 500, Contours mCd.
W. H.: AM. J. 1955. 82: 4531, 1960.
Aubert, L.: (French) Carayon, 1~., Colomar, R., and Resillot, A.: Bull. Sot. mbd. Afr. Noire lang. franq. 9: 524, 1964. (French) Cheshankov, K. H.: Akush. ginek. 4: 240, 1965. (Russian) Comiti. J. and Emery, J.: Marseille chir. 15: 37, 1963. (French) Dedman. H. E.: West. J. Surg. 68: 45. 1960. Desarmenien, J.: Sud med. chir. 99: 11064, 1963. (French)
H. 9. 10. 11. I?. 13. 14.
Ferreira. C. A.: An. brasil. de ginec. .YJ~: 1 I 1. 1963. Gautier, P.. and Vankemmel. M.: Lillr chir. 19: 57, 1964. (French) Joyeux, R., and Colin, R.: ,2nn. < hir. 17: 1475. 1963. (French) Rochet, Y., and Mikaelian, S.: Bnll. Ftd. Sot. gynec. et obst. 17: 449, 1965. (French) Serment, H., Ruf, H., and Felcr, PI.: Marseille chir. 15: 357, 1963. [French) Varangot. J.? et al,: Presse m&~. 67: 1139, 1959. (French) Verne, J. M., et al.: M&II. Acad. c,hir. 85: .5:!3, 1959. (French)
Discussion
H. MORTON, Los Angeles, California. Dr. Lawry has used the criteria and treatment outlined by Allen and Masters and his results have been excellent. The fact that he has been able to collect 23 cases in 5 or 6 years indicates that there is both a high incidence in his area and that he is diligent in making the diagnosis. Very likely many of us miss the diagnosis because a vaginal hysterectomy often is done in a woman with these symptoms and findings. The diagnosis really can be completed only by direct vision at laparotomy. Our concept of the main uterine support is that of a cardinal ligament intimately attached to the uterine vessels and with fanlike spread and attachment to the lateral pelvic wall and to the uterus medially with reflexions to the paravaginal tissues and utero sacral ligaments. We have never found fascia between the anterior and posterior leaves of the broad ligament-only areolar tissue-so we doubt if it is possible to suture fascia here as described. It may be that the main cardinal ligament has been partially torn or stretched, setting the stage for the “universal joint” cervix or the first stage of a prolapse. It would seem that an actual complete tear in the cardinal ligament would inevitably cause serious hemorrhage. We have on occasion attempted a Manchester type of parametrial fixation from above, with some success, but consider it unsatisfactory and there is danger of possible ureteral injury or hemorrhage. The straw-colored free peritoneal fluid is noted to vary from 30 to 80 C.C. and is ascribed to peritoneal irritation from the defect. During my year as a pathology resident in Cleveland, Ohio, Dr. Howard T. Karsner taught us that up to 100 cc. of free peritoneal fluid was normal, and we consider this amount of fluid to be within normal limits. Retroversion is frequently noted and in an earlier day we probably would have blamed the DR.
wide
JOHN
variety
of
pelvic
symptoms
on
uterine
malposition. Also, we would probably have attempted to correct the malposition surgically and would have incidentally corrected the laceration while doing the suspension operation, particularly if we corrected the uterosacral ligaments, as was customary. Dr. Lawry states that he has not found a single reference in English to isolated tear of the broad ligament without uterine rupture. I would like to report 2 acute cases, both treated at the
White Memorial Hospital in Los Angeles by Dr. Elisabeth Larsson who graciously reviewed the cases and granted permission for them IO be reported here. One case could be called an ‘acute traumatic rupture of the uterine support. This patient had had a cesarean section 2 years previously and had sudden severe pain in the right pelvic area during intercourse, followed eventually by shock. At laparotomy a 3 cm. laceration in the upper right broad ligament was found plus 700 C.C. of fresh and clotted blood. The bleeding area was ligated and the rent repaired. The second case could be classified as a subacute traumatic rupture of the uterine support. This woman was 2 months pregnant at the time of operation and had had left lower quadrant pain for 4 weeks, the onset here also being during intercourse. A preoperative diagnosis of ectopic pregnancy was made but at operation an 8 cm. laceration of the left broad ligament base extending from the cul-de-sac to the lateral pelvic wall was found and repaired, with satisfactory recovery. It seems that in the pathogenesis of the Allen-Masters syndrome similar lacerations may have occurred but that serious bleeding and symptoms were not experienced; the train of pelvic and/or symptoms developed other more gradually. Possibly we should call the Allen-Masters syndrome a chronic or old traumatic rupture of the uterine supports in order to distinguish it from the acute and subacute cases which would also include cases of uterine and vaginal rupture accompanied by ligament lacerations. Finally, we should note that there is no classification of the Allen-Masters syndrome in our book of Standard Nomenclature, and when one goes to the record room and asks for reports of such cases one receives only a blank look. Tissue Committees should also be made aware of this syndrome for here is another nonuterine disease which is curable by the removal of a normal uterus. DR.
ROBERT DUNN, Palo Alto, California. Although this condition is a definite structural defect, it is often part of the more general pathologic condition we see in the pelvic congestion syndrome. These are retroverted, subinvoluted uteri, varicosities of the broad and ovarian ligaments, pelvic floor relaxation, and now the Allen-Masters defect. More attention should be paid to this syndrome because we, at least, see many of these women who have gone
Allen-Masters’
from doctor to doctor, gynecologist to gynecologist, without definitive care. The young gynecologist, afraid of the Tissue Committees, often will not treat these patients surgically. To demonstrate how little is really written about this subject, I quote from the fourth edition of Brewer’s Gynecology, published in 1967, upon the subject of pelvic pain. “Pelvic congestive syndrome; treatment consists of medical care, psychological counselling, and in some instances psychiatric management. Presacral nellrcctomy, ovarian resection, oophorectomy and hysterectomy are rarely indicated. Allen and Masters have devised a surgical procedure which relieves 80 to 90yc of the patients.” This author goes from the pelvic congestive syndrome to the Allen-Masters defect without explaining the relationship. I was glad that Dr. Morton mentioned at the end of his discussion that these cvomen arc really pelvic cripples. Some of them
syndrome
321
are neurotic but many of them are neurotic. IN*cause they have so much discomfort and pain trying to perform their daily work. DR. BRUGE B. ROLF, Los Angeles, California. I would like tn cite the instances of 2 y~nq women under 26, in whom the diagnosis was made prcopcratively after they had been ohsrlvcd for a number of years. One of these wtrmpn :~ftc’~ bilateral rcapair has had complete r~hahilitatiorl and two successful pregnancies. Thr other pal ~r’nt, having had two or three pregnancirs was urged to havr a hysterectomy, but because of hcl agc~ she was hesitant. A repair was done 1~11 qhr continued to have symptoms, with pyclour~tr~I~it is, ureteral strictures, and vesical neck tontrac‘rlws. She was prepsychotic and had been under p\vchiatric care both before and after operation. Shv subsequently developed menorrhagia, tinally sui)mitted to hystrrcctomy, and thou,qh vastI) itllprovc,d contmued to have other discasry.