The Urinary Troubles 
Produced by 
Prolapsus of Genital Organs. 
CHARGES GREENE CUIWSTON. I*-0-* 
Boston ,'Twass. 
Reprinted from Annals of Gyneecology 
and P cedi airy. 
BOSTON, 1896. The Urinary Troubles produced by Prolapsus of the Genital Organs. 
A CLINICAL LECTURE DELIVERED ON NOV. 9, 1895, BY 
CHARLES GREENE CUMSTON, M.D., 
Instructor in Clinical Gynaecology, Tufts’ College; Member of the Societe Francaise 
(TElectrotherapie; Corresponding Fellow of the Maine Academy 
of Medicine and Science; Director of the Department 
of Gynaecology, Tremont Dispensary, etc. 
Gentlemen :—We have this morn- 
ing a patient that I am about to 
bring before you, whose case is most 
interesting in many respects. She 
has a prolapsus of the genital organs 
in its initial stage. 
The corpus uteri is found of 
normal size, the culs-de-sac are per- 
fectly free, and nothing but normal 
tubes and ovaries are to be palpated. 
The uterus is very movable, too much 
so, by far, and is inclined to tip back- 
ward on the rectum. 
She is thirty-seven years of age 
and the mother of eight children. 
She has never miscarried and her 
general health has always been excel- 
lent, while after close questioning I 
can obtain no history of any uterine 
or tubo-ovarian lesions. 
This great relaxation of the vaginal 
walls and broad ligaments is in all 
probability due to the repeated 
labors, for remember the patient is 
but thirty-seven and has given birth 
to eight children at term. 
The reason that our patient conies 
to us today is for our opinion regard- 
ing a sensation of hearing down in the 
pelvis and a dysuria. 
In this case two symptoms are 
present, namely, bearing down pains 
in the pelvis and dysuria. 
The prolapsus is only at its debut 
and can be remedied by a plastic 
operation on the vaginal walls, and at 
the same time an Emmet’s operation 
on the cervix must be done. 
On examination, you notice that 
the anterior vaginal wall protrudes 
from the entrance of the genital 
canal, and I would particularly call 
your attention to the meatus, which 
has a decidedly upward direction. 
The patient will be prepared for 
this surgical interference by antisep- 
tic vaginal irrigations, followed by 
packing of the canal with steril 
gauze for about a week, after which 1 
shall perform the operation. 
Introducing the index finger into 
the vagina, 1 come on to the cervix 
at about four centimetres above the 
vulva. It presents a complete bilat- 
eral laceration, but is not hyper- 
trophied. 
The dysuria is a most important 
and neglected symptom of prolapsus, 2 
CHARLES GREENE CUMSTON. 
and with your permission I will take 
up the remainder of the hour with 
some considerations regarding the 
urinary troubles which are produced 
by the condition presented in the 
case before us. 
thus placing it in the axis of the vag- 
ina and facilitating its prolapsus. 
In prolapsus of the vagina it is 
usually the anterior wall that first 
falls; the posterior (reposing on the 
perineal floor) is held in place when 
the latter is not ruptured. Prolapsus 
of the anterior wall is almost always 
followed by that of the posterior wall 
of the bladder, which explains the 
production of the urinary complica- 
tions of which I am going to speak. 
But let me add that there are cases 
in which you will find the cervix at 
the vulva without there being any 
complication in urinating, as for ex- 
ample in cases of hypertrophy of the 
lower segment, as Schrceder has 
described. 
Prolapsus uteri is rarely primary 
and usually follows a prolapsus of the 
vaginal walls. Sometimes it is the 
anterior, as in the case which I have 
just shown you; at others it is the 
posterior vaginal wall or even both at 
the same time, which unfold them- 
selves, so to speak, and by so doing 
draw upon the uterus on which they 
are attached. 
When the broad ligaments are 
sufficiently solid and not relaxed, the 
uterus resists, for a tiine at least, the 
traction exercised on it by the relaxed 
vaginal walls, and will remain fairly 
well up. But little by little the cer- 
vix-reaches the vulva, in which case 
you will often find it hypertrophied, 
while the fundus is normally situated 
in the pelvis. 
As you probably know, this Ger- 
man gynaecologist divided the cervix 
into three sections, each of which may 
become separately hypertrophied. 
The lower segment, being situated 
entirely below the insertion of the 
vagina and having consequently no 
relation to the bladder, may be in a 
high degree of hypertrophy without 
giving rise to bladder symptoms. 
But other than in these rare cases 
urinary symptoms are most generally 
met with in utero-vaginal prolapsus. 
The urinary troubles met with in 
these cases are the same as those 
occurring in prolapsus properly speak- 
ing. 
As you know, vaginal prolapsus is 
produced by too frequent labors, 
rupture of the perineum, etc., or in 
neurasthenia, in which case you will 
probably find other viscera in a state 
of ptosis. There is another factor in 
the production of this affection which 
should also be remembered, and that 
is a permanent and exaggerated re- 
pletion of the bladder, a frequent 
occurrence in females, and which acts 
by pushing the uterus backwards, 
When there is prolapsus, the 
urethra, instead of being directed 
from above downwards and from be- 
hind forwards, as it is in the normal 
condition, may present more or less 
pronounced inflexions, and forms a 
curve with the concavity uppermost 
and especially very flexed at the 
point where it traverses the sub-pubic 
ligament and Wilson’s muscle. PROLAPSUS OF THE GENITAL ORGANS. 
This concavity of the urethra, 
which is just the op]3osite to the 
normal curve, is generally present in 
cystocele as in the patient just shown, 
and when you go to pass a catheter 
into these patients, the proximal end 
of the instrument must always be 
raised very high up in order to entirely 
empty the bladder, a thing which 
you will not always be able to accom- 
plish. 
mention others in which the relations 
of the bladder have become changed- 
Generally speaking the bladder, when 
drawn down by the uterus in pro- 
lapsus, retains its normal relations to 
the latter organ; but it may also 
happen that the uterus slides behind 
the bladder, which remains in its nor- 
mal position, and there consequently 
is a change in the relations of the 
two organs which you must always 
have before your minds in order to 
avoid injuring the bladder during 
surgical interference. 
That portion of the bladder which 
adheres to the upper part of the 
vaginal wall and to the lower part of 
the uterus is drawn down with these 
organs, and may thus present a true 
diverticulum, forming with the prin- 
cipal pouch a, kind of hour-glass blad- 
der. 
On account of the changes in shape 
and situation of the bladder, the 
ureters may also be compressed at 
their lower extremity, and if the com- 
pression is kept up, and is severe, 
dilatation of these canals, extending 
more or less high up may occur, with 
hydronephrosis as an ultimate result. 
In cases of hypertrophic elonga- 
tion of the cervix, the increase in size 
of the neck of the womb compresses 
this vesical diverticulum to such an 
extent that its walls are pressed 
together and so firmly against the 
lower border of the pubis that the 
urine cannot enter the lower pouch; 
when it has been possible to make 
the catheter e’nter this secondary 
reservoir, which is most difficult to 
accomplish, only a very little urine 
or none at all will be withdrawn. 
However, in such cases, which are 
infrequent, it is well to take into 
consideration the general health of 
the subject, which possibly may be 
the factor in the relaxation of the 
ligaments, which at the same time 
that it produces the prolapsus, also 
brought about a slight ptosis of the 
kidneys with a curve in the ureters, 
resulting in a consecutive hydrone- 
phrosis. 
In other cases the urine will 
remain in the diverticulum during 
micturation, and by prolonged stagna- 
tion may set up a vesical catarrh, and 
which latter condition may be the 
means of formation of calculus, as I 
shall soon point out. 
Whatever it may be, the compres- 
sion of the ureters has been often suffi- 
ciently prolonged and serious enough 
to have caused uremia in some pa- 
tients, and which was explained by 
the one fact of compression, as well 
as by a concomitant nephritis follow- 
ing the dilatation of the ureters. 
Beside the cases in which the 
bladder is either displaced or modi- 
fied in shape, I must not neglect to 
According to Perrd this dilatation 4 
CHARLES GREENE CUMSTON. 
of the ureters and pelvis of the 
kidney is always present. The 
former are often abnormal from the 
beginning of the prolapsus, because 
they open in that part of the bladder 
which is just that one which is the 
first to enter into the formation of the 
hernia, and by their means, on account 
of the traction exercised on them, the 
kidneys are drawn down out of their 
normal situation. 
When the prolapsus is complete the 
vaginal wall hangs down between the 
thighs and soon becomes ulcerated. 
The ulcerations may extend to the 
bladder, and cases of perforation of 
this organ are reported. I would 
also mention the prolapsus of the 
mucous membrane of the urethra—in 
medical terms, urethrocele. This is 
formed by the dilatation of the 
urethra, while the bladder may remain 
intact, in which case a small sulcus is 
found between the anterior wall of 
the vagina and the urethra. 
As to the capacity of the bladder 1 
desire to say a few words. The 
researches that have been made up to 
the present time have not given any 
very definite results. According to 
Perrc and Barnes, the capacity of the 
bladder is always increased, while 
others, among whom I may mention 
Courty and de Sinety, believe that 
it is not changed, while some uphold 
that it is smaller than normal on 
account of atrophy of the organ. 
Cystocele and serious troubles in 
urinating due to prolapsus have often 
been reported, but there are cases in 
which they appear early and without 
cystitis, and Guyon insists on the fact 
that they are especially frequent in 
cases of slight prolapsus, giving rise 
to mistakes in diagnosis, especially 
so because the urinary troubles are 
not always in relation to the degree 
of the cystocele ; a cystocele which is 
hardly apparent may sometimes give 
rise to very marked urinary troubles, 
as in the case I have shown you and 
two cases reported by Comar demon- 
strate. 
In a case reported by Duplay and 
Chaput, in which an autopsy was 
made, the bladder contained one hun- 
dred and thirty grammes of urine. 
The same authorities found, out of 
twenty-eight cases, that eleven times 
the capacity was diminished and 
seventeen times increased; the in- 
crease of the vesical capacity often 
augmenting the prolapsus uteri. 
Other than these infrequent cases 
a real cystocele is generally found in 
connection with a utero- vaginal pro- 
lapsus. Duplay and Chaput found it 
present in thirty-three out of thirty- 
seven cases of prolapsus. 
These contradictory opinions in the 
evaluation of the bladder capacity 
are not to be wondered at when we 
recollect that “ the bladder has no 
anatomical capacity, hut a physio- 
logical one," as is most justly pointed 
out by Guyon, and consequently is as 
variable in women having a prolapsus 
as in those without it. 
Often the cystocele represents the 
first stage of the affection; at the 
same time as the vaginal invagination 
it precedes the falling of the womb 
instead of being a complication. 
Usually the entire bladder does not PROLAPSUS OF THE GENITAL ORGANS. 
5 
prolapse; it is first the lower wall 
that comes down. The organ is then 
the so-called hour-glass type; the 
upper part may not only extend 
above, but also behind the uterus, 
when this organ is sufficiently low 
down, while the remaining lower part 
of the bladder is drawn down by the 
vagina and descends, pulled in front 
of the cervix uteri by the upper wall. 
This lower pouch dilates and con- 
tributes to the increase of weight and 
inconvenience that these patients 
complain of in their pelvis, and you 
can readily understand that this dila- 
tation may secondarily invade the 
ureters as I have already pointed out. 
prolapsus is total, and is the cause of 
the ulcerations on the mucous mem- 
brane of the vagina so frequently 
seen. The urine is cloudy and fil- 
amentous, sometimes with a very bad 
smell, and the vesical mucous mem- 
brane becomes the seat of a purulent 
secretion. 
These cases are infrequent, as cys- 
titis is not a common complication of 
prolapsus, and according to certain 
writers it is only found accompanying 
calculi. 
The urine in cystitis contains a 
large quantity of the phosphates (for 
some authorities phosphoric gravel is 
most frequently met with in the 
female), while the difficulty of mictu- 
rition in prolapsus, and stagnation of 
the urine in the fundus, favors the 
formation of phosphatic deposits. 
Cystocele is first noticed by fre- 
quent desire to pass water, the act 
being followed by painful sensations 
and vesical tenesmus. The patients 
will get into various positions to 
urinate and are sometimes obliged to 
directly press upon the hernia formed 
by the bladder in the vaginal canal 
in order to accomplish the act. Some 
writers consider these efforts and 
repeated irritations as the factors in 
the production of fungus growths 
and small polypi of the meatus, a 
typical example of which 1 showed 
the class last spring. 
Uric acid calculi are also to be met 
with in prolapsus. These deposits 
are without doubt as frequent in the 
female as in the male, but usually in 
the former they are passed per ure- 
thram before they have a chance of 
becoming fixed in the bladder, while 
in prolapsus they remain in the di- 
verticulum and give rise to the for- 
mation of calculi. Ruysch has re- 
ported several cases of calculi in the 
diverticuli of the bladder, and Varnier 
mentions thirty cases occurring in 
cystocele. 
Cystitis of the fundus is produced 
by the stagnation of urine in the 
diverticuli of which I have spoken. 
The cystitis is accompanied by a 
thickening of the vesical walls and 
sometimes by fungus growths. 
As you see, vesical calculi, although 
not frequent, are ' certainly not rare, 
and 1 particularly wished to bring 
this complication to your notice, for 
in so good and recent a treatise as 
Keating and Coe, no mention is even 
made of them. 
The symptoms are a frequent de- 
sire to urinate. The urine dribbles 
away over the parts bulging out of 
the orifice of the vagina when the 6 
CHARLES GREENE CUMSTON. 
You should also remember that in 
certain cases of genital prolapsus, a 
general ptosis is often found, which 
would lead you to suspect a slow 
nutrition of Bouchard, the phenomena 
of assimilation and desassimilation are 
no longer in full sway and uric acid 
gravel appears. 
of the organ. Pollakuria may also 
be produced by uric acid gravel. 
Dysuria is easily accounted for by 
the faulty position of the bladder and 
uterus. It may also be characterized 
by the efforts that the patient is 
obliged to make in order to expel the 
few drops of urine that come away. 
It is also characterized by pains, that 
the patients complain of at the meatus 
and urethra, and which are explained 
as burning, pricking, lancing sensa- 
tions, although the most careful ex- 
amination fails to show any cystitis 
or even urethrocele. 
Pollakuria is frequent in prolapsus 
uteri. When the uterus has attained 
a certain degree of prolapsus all its 
weight is borne by the neck "of the 
bladder, in which case the patients 
experience a continual desire to pass 
water, but which is not satisfied by 
the act, because the reflex cause still 
persists. 
Cystalgia is often met with in com- 
bination with dysuria, and is especi- 
ally interesting from the fact that it 
constitutes one of these early forms 
of urinary troubles accompanying pro- 
lapsus uteri. 
The patients repeat the effort 
again and again, and this continual 
straining finally results in a painful 
tenesmus so often seen in these cases. 
This cause of pollakuria appears 
to be the true one if you will consider 
the characters that it has. Now the 
frequent necessity to micturate, 
which takes place when the patients 
stand or walk, disappears under the 
influence of repose and the horizontal 
position. To bring on the desire to 
empty the bladder in these patients, 
fatigue or jarring of a carriage is not 
necessary as in cases of stone ; the 
simple upright position is alone suf- 
ficient, and the pollakuria usually 
disappears entirely when the patient 
lies down or even sits in a chair. 
It is produced by a prolapsus which 
is often hardly visible and it may 
form the only diagnostic element; it 
appears with functional symptoms of 
cystitis, the bladder being void of any 
sign of inflammation and the urine 
free from any pathological change. 
The pain first comes on in an in- 
distinct fashion ; then it increases in 
time, becomes exaggerated by the 
erect position, at first only being felt 
at the time of micturition, thus pre- 
senting the characters of frequency 
and pain that I have already described. 
However, sometimes this cystalgia 
is not accompanied by pollakuria, 
and a most curious thing is that the 
pains, which are charactistic, may 
disappear during a time more or less 
long in spite of repeated fatigue 
while in other cases they persist, no 
The pollakuria often becomes pain- 
ful after a time, especially after vesi- 
cal tenesmus is present, but the pain 
and frequent micturition may also be 
due to a passive congestion of the 
bladder, caused by the displacement PROLAPSUS OF THE GENITAL ORGANS. 
7 
matter what treatment you may em- 
ploy, and if you do not obtain and 
make a most careful examination and 
by a careful and complete interroga- 
tion of your patients, nothing will put 
you on the track of the real cause of 
this cystalgia. This I have seen done 
time and again by experienced prac- 
titioners, as the following case will il- 
lustrate. 
were massed and toned by the faradic 
current, three stances a week, and 
the uterus came back to a nearly nor- 
mal position, which was complete by 
the aid of a well-fitting pessary. 
Incontinence of urine in prolapsus 
is sometimes a false incontinence by 
overdistension occuring when the 
bladder is too full; or in other cases, 
when there is at the same time a 
pollakuria, you have to do with 
another type of false incontinence, 
the bladder being able to retain the 
urine, but its excitability is exagger- 
ated by the continual irritation to 
which it is subjected, either by con- 
gestion kept up by the prolapsus, or 
by the direct contact of the tumor 
formed by the prolapsed organs. 
A young married lady of twenty- 
one consulted me for pollakuria and 
inflammatory symptoms of the blad- 
der. These symptoms had been 
treated before her marriage, about 
one year ago, by a gynaecologist in 
this city, by instillations of nitrate of 
silver,, boracic acid, irrigations, etc., 
all to no avail. 
The family physician being con- 
sulted, immediately and without ex- 
amination diagnosed cystitis, and the 
unfortunate young woman was filled 
with all the new fluid extracts, with 
supposed power for overcoming in- 
flammation of the bladder, in which 
the pharmacopoee of the United States 
abounds. 
Other patients, fewer in number, 
have a real incontinence, which is 
spontaneous and occurring only when 
the subject assumes the erect po- 
sition ; others have a desire to pass 
water and are obliged to satisfy it at 
once or the urine will escape. Laugh- 
ing, coughing, sneezing, will cause an 
involuntary expulsion of urine. The 
continual dribbling away of the urine 
produces itching, excoriations and ul- 
cerations of which I have spoken and 
in some cases finally leads to the 
formation of vesico-vaginal fistulse. 
All these preparations, excellent as 
they may possibly be, failed to give 
the patient any relief. 
On examination I obtained a dis- 
tinct history of a fall from a horse, 
some two years previously, with con- 
secutive incomplete prolapsus of the 
uterus and anterior vaginal wall. 
The bladder symptoms were the 
only ones complained of by the pa- 
tient. I performed an anterior col- 
porrhaphy ; the patient was out of 
bed in fifteen days and now enjoys 
life, all bladder symptoms having 
disappeared. The round ligaments 
The deviation and traction on the 
urethra may also be the cause of in- 
continence. 
Retention may also occur in pro- 
lapsus uteri or in cases presenting an 
hypertrophic elongation of the cer- 
vix. Sometimes it takes place sud- 
denly, as for example when the pro- 
lapsus appears all at once under the 
influence of an effort, the cervical 8 
CHARLES GREENE CUMSTON. 
portion of the uterus hits against the 
symphysis pubis and is followed by 
an instantaneous retention of the 
urine. The retention in other cases 
may be preceded by symptoms of 
vesical irritation with frequent desire 
to micturate. 
Diabetes must not be forgotten and 
its other symptoms searched for. 
The genital organs must be care- 
fully examined for the slightest de- 
gree of prolapsus, and, if found, de- 
mands surgical treatment. 
Pessaries are of little or no use 
when the prolapsus is marked ; they 
may be the means of preventing its 
increase, but they in no way diminish 
the urinary complications. 
You will occasionally meet with a 
voluntary retention on account of the 
pain caused by the passage of the 
urine, or by its contact with the ex- 
coriated vaginal mucous membrane. 
But, gentlemen, these cases are not 
frequent, and when they do occur the 
consequences are numerous, such as 
calculi on their increase in volume 
when they preexist, urinary deposits 
form, becoming the starting point of 
a cystitis; and lastly, the cystocele 
which already exists is increased in 
size by the retained urine and may 
be followed by dilatation of the 
ureters with all the usual sequelae. 
For obstinate cystocele, cystopexy 
has been proposed and performed, 
fixing the bladder to the anterior ab- 
dominal wall, but this operation has 
not given, as might be expected, the 
results hoped for, and in my opinion, 
hysteropexy followed by an anterior 
colporraphy is the operation of choice 
in these cases. I also believe that 
shortening the round ligaments (Al- 
exander’s operation) is decidely con- 
tra-indicated and is worse than useless 
in prolapsus uteri. 
Remember that in these cases the 
passage of the catheter is difficult 
and the reservoir cannot always be 
emptied. 
Hysteropexy and colporraphy are 
indicated in all cases of pronounced 
utero-vaginal prolapsus, but the ques- 
tion that is also to be considered is : 
Should an operation be performed for 
slight prolapsus ? 
When a cystocele is not evident 
and the prolapsus is only slightly pro- 
nounced, you will often only make 
your diagnosis, based on the urinary 
troubles that are present, and in this 
point of view the pollakuria is the 
most important of them all. 
I have pointed out to you that 
there may be serious urinary compli- 
cations even in prolapse of slight 
degree ; now these complications are 
of quite sufficient gravity for the op- 
eration, which is the only therapeutic 
measure that will be effectual. 
You must, however, be careful not 
to attribute all cases of frequent mic- 
turition to a genital prolapse, for the 
pollakuria can be a symptom of 
hysteria, and it is evident that if you 
find stigmates of this neurosis in your 
patient or the symptoms of severe 
neurasthenia, this subject will cer- 
tainly be entitled to a pollakuria. 
Consequently in cases of slight pro- 
lapsus you should operate with the 
view of giving the bladder the sup- 
port that it requires and which is ob- 
tained by a carefully performed colpo- 
perineorrhaphy.