‫سورة البقرة آيه ‪32‬‬

Old Complete Perineal Tear

It usually results from labor injury of perineum
(Obstetric trauma), which is the commonest cause.
 Clinical Picture
Symptoms:
1. Loss of voluntary control over the passage of
feces and flatus, after sometimes, many women
learn to use there levator ani as sphincter
control of hard stools, but they still incontinent
to fluid stools and flatus.
2. Chronic vaginal infections.
3. Persistent leukorrhea: due to irritation by fecal
matters.
 Clinical Picture
Signs:
1. Perineal tear extending to the anal orifice.
2. Dimples on either sides of anus (Retracted torn
ends of the external anal sphincter).
3. Deficient normally seen radial folds around the
anus, except posteriorly (Retracted anal
sphincter).
4. The index finger passes easily through the anus
without resistance and pain due to absence of
reflex voluntary spasm of anal sphincter.
 Pre-operative preparation
 Improve the patient's general condition. e.g.
treatment of anemia.
 Treatment of any cervical or vaginal
infections.
 Treatment of any intestinal infection.
 Patient is admitted 5 days before operation
for:
 Non-residue diet is given to avoid bulky
stools.
 Pre-operative preparation
 Milk is better avoided to prevent abdominal
distension.
 Intestinal antiseptic: e.g. combined
Sulfaguanidine and streptomycin, or Flagyl
tablets.
 Daily low rectal enema.
 Daily vaginal douche by antiseptic solution
(Bovidine Iodine = Betadine).
 Operation
 H shaped incision at the ano-
vaginal junction.
 The incision is deepened to
expose the various structures of
perineal body
 Separate the vaginal mucosa
from rectal mucosa by blunt
dissection.
 Inverted lambert sutures using chromic catgut
No 2/0 approximate the rectal mucosa
together.
 Operation
 Identification of the torn ends of the anal
sphincter which are then repaired by 1 or 2
stitches of chromic catgut No 1.
 Levator ani muscles are approximated by 2 or 3
stitches of chromic cat gut No1
 The vaginal mucosa and superficial perineal
muscles are closed as usual.
 The perineal skin is closed by chromic catgut
No 1/0.
 Cervical Lacerations
Causes:
 Forceps delivery before full cervical
dilatation.
 Breech delivery before full cervical dilatation.
 Manual dilatation of the cervix during labor.
 Annular detachment of the cervix.
 Precipitate labor.
 Cervical Lacerations
Causes:
 Old cervical scar or amputation of cervix
extended during labor.
 Rupture uterus extending to cervix.
 Forcible dilatation of the cervix under
anesthesia for curettage.
 Types of lacerations
1. Unilateral cervical tear: More common in the
left side due to dextro-rotation of the uterus.
2. Bilateral cervical tears  Ectropion.
3. Stellate lacerations (Multiple lacerations).
 Complications
1. Hemorrhage, if tear extend to the cervical
branch of uterine artery.
2. Infection  Chronic cervicitis.
3. Cervical incompetence  habitual abortions.
4. Cervical metaplasia and dysplasia due to
chronic cervical infections.
 Tracheolorrhaphy
Emmet`s Tracheolorrhaphy:
Done for cervical lacerations without cervical
hypertrophy.
 Under endotracheal anesthesia, the cervix is
dilated to Hegar 12.
 Refreshment of the edges of lacerations by
removing the scar tissue.
 The cut edges are sutured by interrupted
stitches using chromic catgut No 0.0 over
Hegar dilator No 6.
 Tracheolorrhaphy
Bonny`s tracheolorrhaphy:
Done for cervical lacerations with cervical
hypertrophy as ectropion.
 The cervix is dilated up to Hegar 12.
 A wedge shaped area of the cervix is excised
including the tear including the anterior and
posterior lips of the cervix.
 The everted lips of the cervix are inverted
inwards by strong catgut stitches over Hegar
dilator No 6 to cover the raw area.
 Causes
As Vesico-vaginal fistula
(I) Congenital causes: Very rare.
(II) Traumatic causes:
1. Obstetric trauma:
a. Incomplete healing of complete perineal tear
occurs during labor.
b. Necrotic fistula due to obstructed labor.
c. Traumatic instrumental fistula caused by
perforator of crainiotomy.
2. Surgical trauma: Total hysterectomy and
posterior colpo-perineorrhaphy
3. Direct trauma: e.g. defloration injury and
falling on sharp object.
 Causes
(III) Inflammatory causes:
E.g. pelvic abscess, tuberculosis, bilharziasis or
vagina or rectum.
(IV) Neoplastic causes:
Malignant diseases of the vagina or rectum
(V) Post-irradiation Fistula:
Radium needles applied for treatment of cancer
cervix or vagina.
 Diagnosis
(I) Symptoms:
1. Chronic vaginitis and leukorrhea.
2. Symptoms depends upon the site and size of
fistula. there are ;
3. Large fistula:
4. Incontinence over the passage of feces and
flatus.
5. Small fistula:
6. Incontinence over the passage of liquid stools
and flatus.
7. Soreness and pruritis vulva.
8. Psychological troubles.
 Diagnosis
(II) Signs:
Demonstration of the fistulous opening under good
illumination.
1. Small fistula:
 P.R. or combined recto-vaginal examination to
detect its site.
 Passing a blunt probe into the fistulous tract.
 Injection of methylene blue solution to detect
the opening of a very small fistulous opening.
2. Large Fistula:
Seen in the posterior vaginal wall during
examination.
 Treatment
(I) Inflammatory or Malignant fistula:
Treatment of the cause.
(II) Congenital and Traumatic fistula:
Closure of fistula by operation.
The pre and post-operative preparations are the
same as complete perineal tear.
The type of operations depends upon the size and
site of fistula.
 Treatment
(A) Fistula in the lower 1/3 of vagina:
i- Lawsen Tait`s operation:
Indication:
When the fistula is large with deficient perineal
body.
Operation:
The bridge of tissues below the fistula is cut,
converting it into complete perineal tear which
is repaired in layers.
 Treatment
(A) Fistula in the lower 1/3 of vagina:
ii- Vernon-David`s operation:
Indication:
The fistula is small and the perineal body is intact.
Operation:
A circular incision is made around the fistulous
opening in the posterior vaginal wall. The
fistula is dissected and closed in 2 layers.
The levator ani muscles are approximated infront
of the closed fistula.
The vagina closed by interrupted chromic catgut
 Treatment
(B) Fistula in the middle 1/3 of vagina:
By Flap splitting operation done as repair of
vesico-vaginal fistula
(C) Fistula in the upper 1/3 of vagina:
 Done through an abdominal approach,
because the vaginal approach is difficult.
 If fistula is large, a temporary colostomy is
done for 2 weeks before operation followed by
repair of fistula. Colostomy is closed 6 weeks
later after operation.
 Retroversion and Retroflexion
Normally the uterus is anteverted anteflexed.
In about 20% of females the uterus is retroverted or
retroflexed or both i.e. retroverted-flexed
Normal position:
Anteverted:
The cervix bends forward on the
vagina forming an angle of
90 degrees.
Anteflexed:
The body of uterus bends
forwards on the cervix
forming an angle of 160
degrees.
 Retroversion and Retroflexion
Abnormal position:
Retroflexed:
The uterus is curved backwards.
Retroverted:
The cervix is curved backwards.
Retro-position:
The uterus is displaced backwards, but the
direction of its axis remains the same.
 Causes of R.V.F.:
(A) Congenital:
The uterus may be of normal size or slightly
hypoplastic.
(B) Acquired:
I. Puerperal R.V.F.:
Occurring after abortion or labor, due to:
1. Laxity of the supporting ligaments of uterus,
allowing it to rotate backwards.
2. Increased bulk and weight of uterus.
3. Distended bladder, pushing the uterus
backwards.
4. Prolonged stay in bed in the dorsal position
 Causes of R.V.F.:
II. Pelvic lesions:
1. Tumors infront of uterus pushing it
backwards.
2. Adhesions behind the uterus pulling it
backwards.
III. Genital prolapse:
Before uterine prolapse, the long axis of uterus lies
on the long axis of vagina. i.e. retroversion.
 Degrees of retroversion
First degree:
The fundus is directed towards the sacral
promontory.
Second degree:
The fundus of uterus is directed towards the sacral
concavity.
Third degree:
The fundus of uterus is directed towards the tip of
sacrum.
 Clinical picture
(A) Symptoms:
I) Symptoms related to pelvic congestion:
Congestive dysmenorrhea, menorrhagia,
polymenorrhea (Congestion of the ovaries),
and leukorrhea.
II) Symptoms related to abnormal position of
uterus:
1. Backache: Due to pressure of uterus on the
sacral ligaments.
2. Spasmodic dysmenorrhea
 Clinical picture
3. Dysparonia: Due to:
a. Prolapsed ovaries on the douglas pouch.
b. Direct pressure on the uterine fundus.
c. Pelvic congestion.
4. Infertility: Due to ;
a. The cervix is directed forwards away from
the seminal pool.
b. Kinking of the cervical canal.
c. Congestion of endometrium interfering
with ovum implantation.
d. Kinking of fallopian tubes.
e. Congestion of ovaries  Anovulation.
 Clinical picture
(B) Signs:
1. The posterior lip of cervix is first felt.
2. The external os is directed downwards and
forwards.
3. Bimanual examination: The fundus of uterus
is felt through the posterior fornix.
4. Adnexia is felt through the posterior fornix.
5. Uterine sound diagnoses the direction of
uterine cavity.
 Treatment
(A) Prophylactic:
Avoid causes, which promote retroversion during
puerperium.
(B) Pessary treatment:
Indications:
1. Retroversion detected in puerperium.
2. Early pregnancy with retroversion, when the
patient gives history of abortions when no other
causes were detected.
3. Symptomatic retroversion and the patient is
surgically inoperable.
 Treatment
(B) Pessary treatment:
Technique:
A Hodge-Smith pessary is made of plastic or
vulcanite used to correct retroversion by
introducing into the uppermost of vagina.
The broader part stretches the posterior fornix and
the utero-sacral ligaments to maintain the
anteverted position of uterus, while the lower
end behind the symphysis pubis to maintain the
pessary in position.
 Treatment
(C) Surgical treatment:
Indications:
1. Mobile retroversion with marked symptoms
relived by pessary test.
2. Fixed retroversion producing symptoms.
Operations:
Baldy-Webster`s operation:
Silk sutured are attached to the round ligaments
and pulled back under the fallopian tubes, so
that the ligaments are fixed to the back of
uterus.
 Treatment
Gilliam`s Ventro-suspension operation:
The sutures are attached as before, and a loop of
round ligament is pulled through perineum and
rectus muscle fibers, to be sutured to each other
across the rectus abdominus.
 Chronic inversion of uterus
Definition:
The uterus is turned inside out through the cervix.
Degrees:
First degree:
The fundus is depressed (Cubing), so it bulges into
the uterine cavity.
Second degree:
The inverted fundus protrudes into the vagina.
Third degree:
The fundus appears at or protrudes through the
cervix.
 Chronic inversion of uterus
Causes:
1. Senile inversion: Due to weakness of uterine
muscles and laxity of circular muscle fibers of
cervix.
2. Fundal tumors: Attempts of the uterus to expel
intra-cavitary tumors
3. Fundal myoma pulling the uterine fundus
downwards.
4. Malignant tumors of the body of uterus.
5. Puerperal inversion
caused by fundal pressure with traction of the cord
to expel the placenta
 Chronic inversion of uterus
Clinical picture:
 The patient complains of irregular uterine
bleeding, with sensation of something
comings down.
 Examination reveals an infected mass
distending the genital canal.
Differential diagnosis:
Mass protruding from the vagina.
 Treatment
(I) Senile inversion:
Treated by hysterectomy.
(II) Inversion due to fundal tumors:
Fundal myoma:
 If the woman is above 40 years, hysterectomy
is done.
 If the patient is young, vaginal myomectomy
is done with correction of uterine inversion.
Malignant tumors:
The treatment is according to the malignant
condition.
 Treatment
(III) Puerperal inversion:
Conservative treatment:
By applying continuous pressure using the Aveling
S shaped repositor. It may be used if the
patient is unfit for surgery.
Surgical treatment:
(A) Abdominal operations:
1. Huntington`s operation:
Traction on the depressed fundus by volsellum.
2. Dobbin`s operation:
Division of the cervical ring anteriorly and pulling
the fundus.
 Treatment
Surgical treatment:
(A) Abdominal operations:
3. Haultain operation:
Division of the cervical ring posteriorly and pulling
the fundus.
4. Abdominal hysterectomy:
If the patient above 40 years and complete her
family.
 Treatment
(B) Vaginal operations:
1. Spinelli operation:
Division of the cervical ring anteriorly and
correction of inversion.
2. Kustner operation:
Division of the cervical ring posteriorly and
correction of inversion.
3. Vaginal hysterectomy.