Procidentia Uteri.1 
BY CHARLES P. NOBLE, M.D., 
Surge on-in-chief of the Kensington Hospital for Women, Philadelphia. 
The condition of procidentia uteri 
is of importance to the practitioner 
because of the frequency with which 
it exists, and because of its curability 
when properly treated. Without 
proper treatment it becomes progres- 
sively worse, until finally, in some 
cases, such changes ensue in the 
posterior vaginal wall and pelvic floor 
that its curability is questionable. In 
order to appreciate the treatment of 
procidentia it is necessary to refer to 
the factors engaged in maintaining 
the pelvic organs in their normal rela- 
tions, and also to the causes which 
tend to produce their downward dis- 
placement, and especially to the dis- 
placement of the uterus. The tendency 
is strong to consider the uterus sepa- 
rate and apart from the other pelvic 
organs, especially in relation to the 
causes of its displacement. This ten- 
dency is unphilosophical, and results 
in confusion and in erroneous infer- 
ences. In general, the same factors 
preserve all of the pelvic organs in 
their normal relations, and the same 
factors are at work in the displace- 
ment of each and all of these viscera. 
The influence of atmospheric pressure 
in maintaining the pelvic viscera in 
their normal relations is frequently 
overlooked. The peritoneal cavity is 
a shut sac immediately in relation 
with the thoracic cavity, being sepa- 
rated therefrom by the diaphragm. As 
under normal conditions the urethra, 
vagina, and rectum are closed canals, 
impervious to air, it follows that at- 
mospheric pressure has a very positive 
effect in maintaining the pelvic vis- 
cera at a certain level. This level is 
fairly constant, as the capacity of the 
thorax (which has a free communi- 
cation with the external air) is fairly 
constant. This influence of atmos- 
pheric pressure has been treated of 
by writers, especially by Thomas, 
under the heading of “The Retentive 
Power of the Abdomen.” Atmos- 
pheric pressure is the constant factor 
giving the abdomen retentive power 
Variations in the tonicity of the ab- 
dominal muscles interfere with this 
function; and when the abdominal 
walls become very lax from over-dis- 
tention, or from atrophic changes, 
this factor in maintaining the normal 
status of the pelvic viscera becomes 
largely inoperative. 
Habits of dress also modify the in- 
fluence of the intra-abdominal press- 
ure in maintaining the pelvic viscera 
in position. The use of tight corsets, 
by restricting the excursions of the 
diaphragm, tends to prevent the ascent 
of the pelvic viscera which takes place 
normally with each expiration. Also, 
by displacing the abdominal viscera 
downward and forcing the bowels 
down upon the pelvic organs, tight 
lacing acts by driving downward the 
pelvic contents. Tight lacing kept 
up for a long period of time, acts 
further by inducing an atonic condi- 
tion of the muscles of the trunk, 
1 Read before the Obstetrical Society of Philadel- 
phia, January 4, 1894. 2 
CHARLES P. NOBLE. 
thereby interfering with the normal 
intra-abdominal pressure, and with 
the so-called retentive power of the 
abdomen. 
Another factor which is not much 
dwelt upon is the adipose tissue which 
is present in the pelvis. When a 
woman becomes rather suddenly and 
markedly emaciated, the loss of adi- 
pose tissue in the pelvis favors the 
displacement of the pelvic viscera. 
During and after the time of the 
menopause, when the fatty tissues 
about the genitalia very generally 
undergo absorption, displacement of 
the pelvic viscera often occurs. Prior 
to this time, in many cases, although 
various injuries which favor displace- 
ment may have been sustained, yet, 
owing to the presence of the fatty 
tissue, displacement does not result. 
In these cases, after the atrophy of 
the fatty tissues occurs, prolapse of 
the pelvic viscera takes place. 
Other factors, not directly con- 
nected with the pelvic structures 
themselves, which must be considered, 
are certain habits of patients. Too 
laborious work favors displacement 
of the pelvic organs, especially when 
their proper supports are for any 
reason weakened. As a rule, those 
who are called upon to do laborious 
work have vigorous muscular systems, 
and with intact pelvic organs no harm- 
ful consequences ensue. Such con- 
sequences are most apt to ensue when 
a feeble woman is called upon to do 
extremely heavy work, or when such 
work is performed by one who has 
suffered injury to the pelvic supports. 
Constipation favors prolapse of the 
pelvic viscera for very much the same 
reason as does too laborious work— 
the straining at stool accomplishing 
the same result as the too laborious 
work. Constipation acts also by 
favoring pelvic congestion, which, no 
matter how induced, always favors 
displacement of the viscera by in- 
ducing laxity of the tissues. 
These general considerations are of 
importance, not only as permitting 
the proper appreciation of the causes 
which underlie displacement of the 
pelvic viscera, but also for the very 
great assistance in the curative treat- 
ment of these disorders which a proper 
appreciation of the above facts affords. 
More important, however, than the 
foregoing are the proper supports of 
the pelvic organs themselves. In 
women, as in men, the entire pelvic 
contents are supported by the action 
of the levator ani muscles, the pelvic 
fasciae, the sacro-sciatic ligaments, and 
the pelvic connective tissues. It is 
true that the peritoneum and the con- 
nective tissue which lies under it af- 
fords some additional support from 
above. The bladder, the womb and 
its appendages, the vagina and the 
rectum, and the super-imposed, small 
intestines are all supported by the 
structures referred to. They make 
up the pelvic floor, and upon their 
integrity the normal position of the 
pelvic viscera depends. The connec- 
tive tissue of the peritoneum about 
the bladder and also about the rectum 
and the other organs has a minor in- 
fluence in fixing within certain limits 
these organs. The uterus, more 
especially, receives other support 
than that of the pelvic floor,—the 
utero-sacral, the broad, and the round 
ligaments affording a certain amount 
of support to this organ. The careful 
study of the whole subject, however, 
is convincing that these ligaments 
and the retentive power of the ab- 
domen, brought about by the atmos- PROCIDENTIA UTERI. 
3 
pheric pressure, are of importance, 
rather as maintaining the uterus in 
its normal position of anteflexion 
than in keeping it at a certain plane 
in the pelvis. Undoubtedly, these 
factors have a certain influence in 
preventing downward displacement 
of the uterus, but all combined they 
are not of so much importance as is 
the normal pelvic floor. 
The principal support which main- 
tains the pelvic viscera in their nor- 
mal relations is the pelvic floor, the 
most important structures in which 
are the levator ani muscles and the 
pelvic fasciae. Upon the integrity of 
these structures the support of the 
pelvic viscera depends. When these 
structures no longer perform their 
normal functions, either because of 
atrophy or because of laceration of 
their tissues, downward displacement 
of the pelvic viscera is favored. This 
point cannot be too strongly insisted 
upon; nor can it be made too clear 
that these are the structures of im- 
portance in giving support to the 
rectum, vagina, bladder, and uterus, 
rather than an imaginary structure 
formerly known as the perineal body. 
The old theory that the perineal 
body was the prime factor in pelvic 
support must be definitely abandoned, 
because it is based in error. There is 
no such structure as the perineal body. 
The tissues between the lower end of 
the vagina and the rectum are certain 
slips of the levator ani muscles, the 
transversus perinei muscles, the deep 
and superficial fasciae, connective 
tissue, blood-vessels and nerves, and 
the bulbo-cavernosus muscle. The 
ends of these slips of muscle unite in 
the median line, forming a somewhat 
tendinous union. The amount of 
tissue between the rectum and vagina 
is very much overestimated. Any 
one can demonstrate that this septum 
is scarcely more than a third of an 
inch in thickness if he will examine a 
nulliparous woman, placing the thumb 
in the vagina and the forefinger in 
the rectum. Such an examination 
will dispel from his mind any idea 
which he may have had that there is 
a large wedge-shaped mass of tissue 
situated between these two canals, 
which, in virtue of its size and shape, 
holds up the pelvic organs. 
Women having the greatest amount 
of tissue between the anus and pos- 
terior commissure of the vulva, have 
really the least support for their pel- 
vic organs. This fact, so directly at 
variance with the ancient teaching 
upon this subject, is easily explained. 
When the levator ani muscle, or a 
part of it, has been torn through, the 
pelvic floor drops down, and if the 
skin over the perineum has not been 
ruptured it stretches out. The anus 
drops down toward the feet and back 
toward the coccyx, so that the skin 
between the anus and the vulva is put 
upon the stretch. These facts are 
easily capable of demonstration, and 
any one who doubts them can easily 
satisfy himself of their correctness. 
They show also that visual inspection 
of the perineal region is insufficient 
to test its integrity. Cases which 
have appeared to receive no injury 
may have severe lacerations within 
the vulva; and other cases which ap- 
pear to have been badly torn because 
of the involvement of the skin over 
the perineum may, in reality, have 
escaped without injury to the deeper 
and important structures of the pelvic 
floor. The examination, to be com- 
plete, must include palpation of the 
levator muscles to test their powers 4 
CHARLES P. NOBLE. 
of resistance when drawn upon by the 
palpating fingers. 
The physiology of the support of 
the pelvic viscera appears to be as 
follows: The rectum and vagina re- 
ceive direct support from the levator 
muscles. Their orifices are kept 
closed partly by the action of these 
muscles, and partly by the sphincter 
ani and bulbo-cavernosus muscles. 
The anterior wall of the vagina and 
the bladder are supported upon the 
posterior wall of the vagina ; and the 
uterus and its appendages are sup- 
ported upon these structures. The 
connective tissue attachments of the 
organs named, of course, are of ser- 
vice in limiting their mobility; and, 
in addition, the proper supports of the 
uterus are of much importance. 
When all of the factors concerned 
in maintaining the pelvic- organs in 
their proper relations are normal, 
these organs are retained in their 
proper positions. Their downward 
displacement is due either to in- 
creased pressure from above, or to 
diminished support from below, or to 
both. The influence of heavy lifting, 
of tight lacing, of constipation, and of 
emaciation, in favoring displacement, 
have been considered. Two other 
causes remain: one is retro-displace- 
ment of the uterus, and the other is 
increase in the size and weight of 
the uterus. The influence of the 
second cause in favoring downward 
displacement is so clear that it is un- 
necessary to enlarge upon it. The 
influence of retro-displacement in 
favoring descent of the uterus is 
equally clear, if the anatomical and 
physical relations of the pelvic viscera 
are remembered. The uterus, in its 
normal position of ante-flexion, lies 
with its axis at an acute angle with 
the vagina; indeed, when the bladder 
is empty, the fundus of the uterus 
approaches very close to the ante- 
rior wall of the vagina. In this 
position, when the uterus is forced 
downward, it simply tends to push 
the anterior wall of the vagina against 
the posterior wall, when it meets with 
the resistance of the pelvic floor; 
hence the vagina is not distended. In 
this position the force of the intra- 
abdominal pressure falls upon the 
posterior wall of the uterus, and main- 
tains the uterus in its normal anti- 
flexed position. If, for any reason, 
the uterus becomes retro-displaced, 
its axis becomes parallel, or almost 
parallel, with the axis of the vagina. 
Intra-abdominal pressure falls upon 
the fundus and anterior wall of the 
uterus and the vesico-uterine pouch, 
and tends not to drive the cervix and 
the anterior vaginal wall against the 
posterior vaginal wall, but to drive the 
whole uterus downward along the axis 
of the vagina; thus to a greater or 
less degree, inverting the vagina in 
its descent. In this mal-position of 
the uterus, intra-abdominal pressure, 
instead of being a conservative force 
tending to maintain the uterus at a 
certain level, becomes a factor of evil 
tending to produce procidentia uteri 
and prolapse of the bladder. The de- 
gree to which these displacements are 
carried depends, of course, upon the 
amount of intra-abdominal pressure, 
upon the laxity of the tissues in an 
individual case, and upon the amount 
of resistance met with from the pelvic 
floor. So much for the causes acting 
from above. 
When the pelvic floor becomes 
weakened, either by laceration or 
atrophy of its structures, adequate 
support to the pelvic viscera is no PROCIDENTIA UTERI. 
5 
longer afforded. The pelvic floor 
drops downward and backward, the 
introitus vaginse gapes open, the pos- 
terior wall of the vagina drops away 
from the anterior wall, the rectum 
tends to bulge forward through the 
gaping vulva, constituting a rectocele; 
the anterior wall of the vagina and 
the bladder tend to prolapse into the 
introitus, constituting a cystocele; 
and in turn the uterus tends to come 
down (partly from lack of support, 
and partly through the influence of 
pressure from above), constituting a 
prolapsus or procidentia uteri. 
The proper study of every case of 
procidentia involves a careful investi- 
gation into each of these factors 
which may be concerned in its pro- 
duction, and upon the proper recogni- 
tion of exactly what underlies each 
case depends the scientific and cura- 
tive treatment of the disorder. 
In my experience, by far the most 
important cause of procidentia is 
laceration of the pelvic floor, espe- 
cially lacerations involving the levator 
ani muscle and pelvic fascia. This 
injury is the primary cause of proci- 
dentia in ninety-nine per cent, of the 
cases which come under my observa- 
tion. I see numerous cases of slight 
prolapsus or descensus uteri, where the 
uterus simply descends one inch, or 
an inch and a half, which are due to 
other causes than a torn pelvic floor. 
Such causes as tight lacing, hard 
work, constipation, pelvic congestion, 
etc., can bring this about. But in 
my experience these causes, broadly 
speaking, are incapable of producing 
complete procidentia of the uterus. 
There are exceptions to this rule, but 
only one has come under my observa- 
tion. This was a case of complete 
procidentia in a nulliparous woman 
having lax tissues, who had been com- 
pelled to do laborious work with 
heavy lifting. Her uterus doubtless 
had become retroverted, then pro- 
lapsed, and, finally, had been forced 
down so low that it protruded between 
the labia. This woman had a lax, but 
intact pelvic floor. She was cured by 
changing her occupation, the use of 
tampons for a time, followed by a 
Smith-Hodge pessary. 
Treatment.—As the primary cause 
of procidentia is a torn pelvic floor, it 
follows that if lacerations of the pel- 
vic floor were properly repaired at the 
time of their occurrence, or shortly 
thereafter, that procidentia uteri 
would be prevented. In other words, 
the way to prevent procidentia uteri is 
to do immediate perineorrhaphy in all 
cases of laceration of the pelvic floor 
following labor. It is unnecessary at 
this time to go into the details con- 
cerning the technique of immediate 
perineorrhaphy. I shall simply say, 
that in this operation the sutures 
should be placed just as carefully, 
and in the same manner, as for the 
secondary operation. The patient 
should be anaesthetized, the parts well 
exposed, and the suturing begun at 
the upper angle of the tear, no mat- 
ter how high up this may be. The 
sutures should be tied as they are in- 
troduced, so that when the last suture 
is introduced and tied the operation 
is completed. Immediate perineor- 
rhaphy can be done at any time within 
twenty-four hours after labor, and 
doubtless even later, with complete 
success. If, however, the suturing is 
postponed more than six hours after 
the injury has occurred, it is better to 
freshen the raw surfaces by scraping 
them with a knife. These lacerations 
will be found, almost invariably, to 6 
CHARLES P. NOBLE. 
extend up one or both sulci of the 
vagina. They are never median, un- 
less the tear extends through the 
sphincter ani, and then splits the 
recto-vaginal septum. It is far better 
to postpone immediate perineorrha- 
phy for six, ten, or twenty-four hours, 
and to have proper assistance, than it 
is to attempt the operation at the 
close of labor, when the physician is 
tired out, the patient exhausted, and, 
perhaps, without anaesthesia, because 
no one is present to administer the 
anaesthetic. The practice somewhat 
in vogue of putting in one, two, or 
three sutures from the skin perineum 
cannot be too strongly condemned; 
because all severe lacerations extend 
one, two or three inches up one or 
both sulci of the vagina, and cannot 
be reached by sutures introduced from 
the skin perineum. All that such 
suturing can accomplish is to unite the 
unimportant superficial structures of 
the skin perineum, while the torn 
levator muscles are not included in 
the sutures. 
The other factors which produce 
procidentia are those which increase 
intra-abdominal pressure (such as 
tight lacing and laborious work), 
retro-displacement of the uterus 
(which favors procidentia, because in 
this position intra-abdominal pressure 
tends to drive the uterus along the 
vagina, and parallel with its axis), pel- 
vic congestion, brought about espe- 
cially by constipation, sub-involution 
of the uterus and other pelvic organs, 
and in rare cases the presence of a 
tumor adds to the weight of the 
uterus. A perfect prophylaxis of 
procidentia uteri involves the pre- 
vention or cure of all of these con- 
ditions. 
When procidentia really exists cer- 
tain conditions are always present. 
The uterus prolapses into or through 
the vulva, and its proper ligaments 
are overstretched. The anterior 
vaginal wall and bladder are pro- 
lapsed, and in many cases a large 
cystocele is present. The posterior 
vaginal wall and rectum have dropped 
downward and backward with the 
pelvic floor; and the rectum may, or 
may not, have bulged through the 
open introitus, if so, constituting a 
rectocele. In many cases the uterus 
will be found elongated, constituting 
the condition known as supra vaginal 
elongation of the cervix. This is 
brought about by stretching of the 
cervical tissue, rather than by its 
hypertrophy. In such cases the fun- 
dus uteri occupies a higher plane in 
the pelvis than would appear from the 
position of the cervix. In many such 
cases the uterus measures four, five 
or even more inches; and yet often 
reducing the procidentia and putting 
the woman in the knee-chest posture, 
it will be found to measure only three 
or four inches. 
The method of operating which I 
have followed in treating this class 
of cases is to do a high amputation 
of the cervix, anterior colporrhaphy, 
and Emmet’s perineorrhaphy. The 
amputation of the cervix reduces the 
size and length of the uterus, and 
through the way it is done draws the 
vagina to a higher point in the pelvis. 
The anterior colporrhaphy takes up 
the slack under the bladder and makes 
the anterior vaginal wall a straight 
line from the pubic arch to the cervix, 
as it should be. The perineorrhaphy 
restores the pelvic floor to its normal 
condition, and gives permanent sup- 
port to the bladder and uterus. Nat- 
urally the uterus should be main- PROCIDENTIA UTERI. 
7 
tained in ante-flexion, and if after 
an operation it does not assume this 
position, a Smith-Hodge pessary is 
introduced to maintain the uterus in 
its normal position. Practically, I 
have seldom found this necessary 
even for a short time, and of the very 
many operations which I have done 
for procidentia, so far as I know, not 
a single woman is now wearing a 
pessary. 
In amputatingthe cervix, the woman 
is placed in the lithotomy posture; 
the field of operation made aseptic; 
the cervix is seized with bullet for- 
ceps and drawn down; the vagina is 
cut loose from the cervix ; the blad- 
der is stripped off in front, and the 
sub-peritoneal tissues stripped off be- 
hind. The lateral attachments of the 
cervix (the bases of the broad liga- 
ments) are now ligated and cut away. 
About an inch of the cervix is now 
amputated; then the cut edges of 
the vagina are stitched to the stump 
of the cervix, the mucous membrane 
of the vagina to the mucous mem- 
brane of the cervical canal; thus cov- 
ering in the stump, and securing pri- 
mary union. This operation draws 
up the vagina to the cervix at its new 
level. Also, it very materially re- 
duces the size and weight of the 
uterus, not only through removing 
part of the structure, but by the 
process of involution which it in- 
duces. 
Anterior colporrhaphy is next per- 
formed. In those cases in which the 
bladder has not been markedly pro- 
lapsed a simple oval denudation is 
made, which is closed with a contin- 
uous catgut suture in two layers. In 
marked cases of cystocele Stoltz’s 
operation is done. This consists of 
a circular denudation, with a single 
running suture placed like the draw- 
ing-string of a bag, and tied in the 
same way. The operation is quickly 
done, and secures a firm point of cica- 
tricial union under the bladder. I 
believe that the merit of the opera- 
tion consists not only in the ease and 
rapidity with which it is done, but 
also that it offers a more permanent 
resistance to the descent of the blad- 
der at a future time. 
Emmett’s perineorrhaphy is then 
done, and is that part of the operation 
which makes the cure a permanent 
one. The operations upon the cervix 
and upon the bladder would for a 
time overcome the prolapse of these 
structures, but when the woman got 
about on her feet again, the prolapse 
would simply reappear were not the 
primary cause of the trouble (namely, 
the lacerated pelvic floor) repaired. 
In restoring the pelvic floor I have not 
been content with doing the regular 
Emmett’s perineorrhaphy, but taking 
this operation as a basis, I have made 
the denudation as extensive as possi- 
ble ; in this way not only bringing 
together the sundered structures, but 
in addition making the vagina as nar- 
row as possible, and also sewing up 
the vulva to a certain extent. In this 
way the vagina can be reduced in 
size, so that it scarcely admits more 
than the index finger,—an end to be 
desired in every bad case of proci- 
dentia. 
In doing amputation of the cervix, 
a few heavy silk ligatures are used, 
but most of the operation is done with 
catgut. It is well to have a silk liga- 
ture to pass through each lip of the 
cervix into the cervical canal, so as to 
have two silk ligatures at the point 
where the future os uteri is to be, as 
otherwise the raw edges of the cut 8 
CHARLES P. NOBLE. 
vagina might unite, which would ne- 
cessitate making an external os at a 
later day. The bases of the broad 
ligaments can be tied off with catgut, 
and almost all of the sutures about 
the cervix can be of this material. 
This is a decided advantage, as it is 
not desirable to make traction upon 
the perineum to remove these sutures 
for some weeks after the operation. 
In doing the colporrhaphy, when the 
oval denudation is made, the wound 
is closed usually with a running cat- 
gut suture placed in two tiers. Usually 
one or more silk sutures are intro- 
duced to act as stays. In operating 
upon the pelvic floor, the upper su- 
tures are of catgut and the lower ones 
of silk. This obviates the necessity 
of removing the upper sutures, which 
embrace only the cut vaginal walls, 
and which are used only to help in 
narrowing the vagina. Silk is used in 
suturing the torn ends of the muscles 
and for the external sutures. The 
ones in the skin are removed in a 
week, those in the vagina after two 
weeks. 
It is wise to treat patients having 
procidentia for some weeks prior to 
their operation. The uterus should 
be reposited and kept in its position 
by means of tampons. In order to 
secure this object it is at times neces- 
sary to put the woman to bed. In 
very bad and long-standing cases of 
procidentia, the mucous membrane of 
the vagina loses its proper character, 
and becomes very much like skin. It 
is of decided advantage to reduce the 
procidentia and to treat the condition 
with glycerin tampons, which helps 
to restore the parts to a more nearly 
normal condition. After the opera- 
tion it is best to keep the patient in 
bed for at least two weeks, and prefer- 
ably for three weeks, and then to per- 
mit only a very gradual resumption of 
her ordinary occupation. Such patients 
should be cautioned against straining 
or lifting, and should be informed that 
it requires some weeks for a wound to 
become thoroughly consolidated. 
It is, perhaps, wise, in this connec- 
tion, to say a few words about the use 
of the pessary for procidentia. Ex- 
cepting those rare cases in which the 
procidentia has occurred in spite of 
the fact that the pelvic floor is intact, 
the use of the pessary for this condi- 
tion is clearly illogical. A pessary 
can never restore a torn pelvic floor; 
and if this accident has been the 
cause of the procidentia, any treat- 
ment except the repairing of the in- 
jury is clearly illogical, and can be 
only of temporary value. The pessary 
is a useful instrument in the treatment 
of slight descensus and of retroflexion 
of the uterus when the pelvic floor is 
intact. The pessary should be sup- 
ported from below, partly by the vagina 
itself and largely by the encircling 
slips of the levator muscle. It should 
never get its support from the pelvic 
bones, which is what happens when a 
large pessary is introduced to hold up 
a procidentia when the pelvic floor is 
widely torn. Used under these cir- 
cumstances, a pessary must be large 
in order to be retained, and when it 
is large it invariably presses against 
the pubic bones. It is only necessary 
to point out how illogical this use of 
the pessary is in order that its appli- 
cation may be condemned.