It arises with deep penetration of the penis. Women describe the pain associated with intercourse to be as if their husbands had “hit something” with the penis during deep vaginal penetration.
These involved women may note other physical irritations frequently seen with chronic pelvic vasocongestion, a constantly nagging backache, throbbing or generalized pelvic aching, and occasionally, a sense that “everything is falling out.”
These symptoms are made worse in any situation requiring a woman to be on her feet for an exceptional length of time, as a full day spent doing heavy housecleaning or working as a saleswoman in a department store.
Most women lose interest in any regularity of sexual expression when distressed by acquired dyspareunia. Handicapped by constant anticipation of painful pelvic stimuli created by penile thrusting, they also may lose any previously established facility for orgasmic return.
The basic pathology of the syndrome of broad ligament laceration is confined to the soft tissues of the female pelvis. The striking features of the pelvic examination are the position of the uterus (almost always in severe third-degree retroversion) and the particularly unique feeling that develops for the examiner with manipulation of the cervix.
This portion of the uterus feels just as if it were being rotated as a universal joint. It may be moved in any direction, up, down, laterally, or on an anterior-posterior plane with minimal, if any, correspondingly responsive movement of the corpus (body of the uterus).
Even the juncture of the cervix to the lower uterine segment is ill-defined. The feeling is one of an exaggerated Hegar’s sign of early pregnancy, in which the cervix appears to move in a manner completely independent of the attached corpus.
In addition to the “universal joint” feeling returned to the examiner when moving the cervix, a severe pain response usually is elicited by any type of cervical movement.
However, pain is primarily occasioned by pushing the cervix in an upward plane.
In the more severe cases, either in advanced bilateral broad ligament laceration or in a presenting complaint of five years or more in duration even mild lateral motion of the cervix will occasion a painful response.
During examination the retroverted uterus appears to be perhaps twice increased in size. Pressing against the corpus in the cul-de-sac in an effort to reduce the third-degree retroversion (which usually is readily accomplished) also will produce a marked pain response.
When the examiner applies upward pressure on the cervix or pressure in the cul-de-sac against the corpus, the patient frequently responds to the painful stimulus by stating, “It’s just like the pain I have with intercourse.”
A detailed obstetrical history is the salient feature in establishing the diagnosis of the broad ligament laceration syndrome. The untoward obstetrical event creating the lacerations may be classified as surgical obstetrics, as an obstetrical accident, or even as poor obstetrical technique.
Occasionally, women with both the positive pelvic findings and the subjective symptoms of this syndrome cannot provide a positive history of obstetrical trauma, but this situation does not rule out the existence of the syndrome
Many women are unaware of an unusual obstetrical event because they were under advanced degrees of sedation or even full anesthesia at the time.
Precipitate deliveries, difficult forceps deliveries, complicated breech deliveries, and postmature-infant deliveries are all suspect as obstetrical events that occasionally contribute to tears in the maternal soft parts. If these tears are established in the supports of the uterus (broad ligaments) the immediate postpartum onset of severe dyspareunia can be explained anatomically and physiologically.
It is important to emphasize clinically that although a woman may not be able to describe a specific obstetrical misfortune in her past history, she well may be able to date the onset of her acquired dyspareunia to one particular obstetrical event.
Extensive Dilation of The Cervix
Three cases have been seen in which a criminal abortion was performed by extensively packing the vaginal barrel, leading ultimately to dilation of the cervix and expulsion of uterine content. These extensive vaginal packing episodes created tears of the broad ligaments, completely parallel to those occasioned by actual obstetrical trauma.
Each woman, although unaware of the etiological significance, dated the onset of the symptoms of acquired dyspareunia to the specific experience with the vaginal-packing type of abortive technique.
There have been three cases referred as problems of dyspareunia in which individual women were involved in gang-rape experiences. In all three instances there were multiple coital connections, episodes of simultaneous rectal and vaginal mountings, and finally traumatic tearing of soft tissues of the pelvis associated with forceful introduction of foreign objects into the vagina.
Superficial and deep lacerations were sustained throughout the vaginal barrel and by other soft tissues of the pelvis. Included in the soft-tissue lacerations were those of the broad ligaments (in each case only one side was lacerated), but these lacerations were quite sufficient to produce severe symptoms of secondary dyspareunia.
For some years after the rape episodes each of the three women was presumed to be complaining of the subsequently acquired pain with intercourse as a residual of the psychological trauma associated with their raping.
The immediately necessary surgical repair to pelvic tissues had been conducted, but beyond the clinically obvious lacerations of the vaginal barrel, bladder, and bowel, the remainder of the pelvic pathology understandably had not been described at the time of surgery.
Before gaining symptomatic relief by a second surgical procedure, these three women underwent a combined total of 21 years of markedly crippling dyspareunia, involving a total of five marriages.
The only way that broad-ligament lacerations can be handled effectively is by surgery. Operative findings are relatively constant:
- The uterus usually is in third-degree retroversion and enlarged from chronic vasocongestion.
- A significant amount of serous fluid (ranging from 20 to 60 ml in volume) arising from serous weeping developing in the broad-ligament tears is consistently found in the pelvis.
- There may be unilateral or bilateral broad ligament and/or sacrouterine-ligament lacerations.
It is the inevitable increase in pelvic vasocongestion associated with sexual stimulation added to the already advanced state of chronic pelvic congestion in these traumatized women that can elicit a painful pelvic response. Particularly does such a response arise when the chronically congested pelvic viscera are jostled by the vaginally encased thrusting penis.
It is not within the range of this textbook to describe the surgical procedures for repair of the traumatic tears of the uterine supports. The reader is referred to the bibliography for more definitive consideration.
Subsequent to the definitive surgery, the symptoms of acquired dyspareunia, dysmenorrhea, and the sensations of extreme fatigue usually show marked improvement or may be completely alleviated.
These pelvic findings have been described in far more than usual detail for this type of text, primarily to alert examining physicians to the possibility of the broad-ligament laceration syndrome.
When these pelvic findings have been overlooked, the complaining woman frequently has been told by authority that the pain described with intercourse is due to her imagination. The intelligent woman bas grave difficulty accepting this suggestion. She knows unequivocally that coital activity particularly that of deep vaginal penetration is severely painful.
Actually, she finds that with vaginal acceptance of the full penile shaft, pain is almost inevitable.
Even if she has been orgasmic previously, it is rare that she accomplishes orgasmic release of her sexual tensions during intercourse after incurring broad-ligament lacerations, simply because she is always anxiously anticipating the onset of pain.
Any woman with acquired pelvic disability restraining her from the possibility of full sexual responsivity is frustrated. Without orgasmic release with coital connection there will be a marked residual of acute vasocongestion to provide further pelvic discomfort during a long, irritating resolution phase.
Probably the most frustrating factor of all is to have the acquired dyspareunia disbelieved by authority when the pain with penile thrusting is totally real to the woman involved. The vital question for the therapist to ask should be, “Did this pain with deep penile thrusting develop after a specific delivery?”.
If the woman can identify a particular pregnancy subsequent to which the dyspareunia became a constant factor in her attempts at sexual expression, the concept of the broad-ligament-laceration syndrome should come to mind.