Malpositions of the Uterus

Indications for Uterine Suspension

Fluhmann stated that primary suspension of the retroverted uterus is not necessary for adequate gynecologic practice. Uterine suspension is most often indicated in connection with such conservative operations as those done for endometriosis or tubal pregnancy, or in microsurgical tubal reconstruction procedures for relief of infertility. To leave the uterus of an infertile patient in the cul-de-sac, where tubal adhesions may recur, while performing other conservationistic procedures would be to do incomplete surgery that may not completely relieve the primary problem.

Certainly, the mere presence of uterine retrodisplacement alone in an asymptomatic patient is not an indication for prophylactic uterine suspension. However, there are a few young women in whom the symptoms of uterine retroversion are clear-cut and severe. In such a patient, a test with a Smith-Hodge pessary should be tried. The uterus is first brought to an anterior position by manual manipulation. A pessary of proper size is then inserted to hold it in position, allowing the pressure of intra-abdominal organs to become reoriented to the posterior surface of the uterine corpus. After several months, if the symptoms are relieved and the uterus stays in the anterior position after the pessary is removed, no further action is required. If the uterus returns to a retroverted position and the symptoms return, one may have a reason to do a primary uterine suspension. In practice, there are very few occasions when this is necessary. Primary uterine suspension has almost completely disappeared from the operative schedule in most hospitals.

Uterine retroversion may be present in a patient with severely symptomatic anatomic vaginal wall relaxation and uterine descensus. In almost all such cases, when childbearing is complete and symptoms are severe, vaginal hysterectomy and repair are appropriate. However, for women with prolapse who want more children, there is still a place for intra-abdominal uterine suspension. it must be recognized that this will be a temporary solution to the problem. The prolapse is likely to recur after the next delivery and will eventually require a more definitive operation for final solution.