Usually, the uterus and the cervix lie at right angles to the long axis of the vagina and with the body of the uterus inclined slightly for-ward. The uterus is normally freely movable upon examination. Individual variations may result in an anterior, middle, or poste-rior uterine position. A backward positioning of the uterus, known as retroversion and retroflexion, is not uncommon (Fig. 47-5).
If the structures that support the uterus weaken (typically from childbirth), the uterus may work its way down the vaginal canal (prolapse) and even appear outside the vaginal orifice (pro-cidentia) (Fig. 47-6). As the uterus descends, it may pull the vagi-nal walls and even the bladder and rectum with it. Symptoms include pressure and urinary problems (incontinence or reten-tion) from displacement of the bladder. The problems are aggra-vated when the woman coughs, lifts a heavy object, or stands for a long time. Normal activities, even walking up stairs, may ag-gravate the problem.
Pessaries and surgery are two options for treatment. If surgery is the method of treatment used, the uterus is sutured back into place and repaired to strengthen and tighten the muscle bands. In post-menopausal women, the uterus may be removed (hysterectomy). For elderly women or those who are too ill to withstand the strain of surgery, pessaries may be the treatment of choice.
Some problems related to “relaxed” pelvic muscles (cystocele, rec-tocele, and uterine prolapse) may be prevented. During pregnancy, early visits to the health care provider permit early detection of problems. During the postpartum period, the woman can be taught to perform Kegel exercises to strengthen the muscles that support the uterus.
Delays in obtaining evaluation and treatment may result in complications such as infection, cervical ulceration, cystitis, and hemorrhoids. The nurse encourages the patient to obtain prompt treatment for these structural disorders.
Before surgery, the patient needs to know the extent of the pro-posed surgery, the expectations for the postoperative period, and the effect of surgery on future sexual function. In addition, the pa-tient having a rectocele repair needs to know that before surgery, a laxative and a cleansing enema may be prescribed. She may be asked to administer these at home the day before surgery. A per-ineal shave may be prescribed as well. The patient is usually placed in a lithotomy position for surgery, with special attention given to moving both legs in and out of the stirrups simultaneously to prevent muscle strain and excess pressure on the legs and thighs.
Immediate postoperative goals include preventing infection and pressure on any existing suture line. This may require perineal care and may preclude using dressings. The patient is encouraged to void within a few hours after surgery for cystocele and com-plete tear. If the patient does not void within this period and re-ports discomfort or pain in the bladder region after 6 hours, she will need to be catheterized. Some physicians prefer to leave an indwelling catheter in place for 2 to 4 days, so some women may return home with a catheter in place. After each voiding or bowel movement, the perineum is cleansed with warm, sterile saline so-lution and dried with sterile absorbent material if a perineal inci-sion has been made.
After an external perineal repair, several methods are used in caring for the sutures. In one method, the sutures are left alone until healing occurs (in 5 to 10 days). Thereafter, daily vaginal douches with sterile saline solution may be administered during recovery. In another method—the wet method—small, sterile saline douches are administered twice daily, beginning on the day after surgery and continuing throughout recovery. A heat lamp or hair dryer may be used to help dry the area and promote heal-ing. Commercially available sprays containing combined anti-septic and anesthetic solutions are soothing and effective, and an ice pack applied locally may relieve discomfort. However, the weight of the ice bag must rest on the bed and not on the patient.
Routine postoperative care is similar to that given after ab-dominal surgery. The patient is positioned in bed with the head and knees elevated slightly. The patient may go home the day of or the day after surgery; the duration of the hospital stay depends on the surgical approach used.
After surgery for a complete perineal laceration (through the rectal sphincter), special care and attention are required. The blad-der is drained through the catheter to prevent strain on the sutures. Throughout recovery, stool-softening agents are administered nightly after the patient begins a soft diet.
Predischarge instructions includeinformation pertaining to the gynecologist’s postoperative in-structions related to douching, using mild laxatives, performing exercise as recommended, and avoiding lifting heavy objects or standing for prolonged periods. The patient is reminded to re-turn to the gynecologist for a follow-up visit and to consult with the physician about when it is safe to resume sexual intercourse.
The patient is instructed to report any pelvic pain, unusual discharge, inability to carry out personal hygiene, and vaginal bleeding. She is advised to continue with perineal exercises, which are recommended to improve muscle strength and tone.