Sex, Pelvic Syndromes
One of the most obscure of pelvic pathological syndromes, yet one of the most psychosexually crippling, is traumatic laceration of the ligaments supporting the uterus. This syndrome was described clinically. Five women have been referred to the Foundation for relief of subjective symptoms of dyspareunia after referral sources had assured the husbands that there was no plausible physical reason for the constant complaint of severe pain with deep penile thrust.
These 5 postpartum women had severe broad ligament lacerations and were relieved of their distress by definitive surgical approaches, not by psychotherapy. Therefore, they do not represent a component of the statistical analysis of treatment for sexual dysfunction.
Three women reflecting the onset of dyspareunia after criminal abortion techniques also have been seen in consultation and are not reflected in the statistics of the sexual inadequacy study. Three more women have been seen in gynecological consultation for acquired dyspareunia after gang-rape experiences.
They also have not been an integral part of the sexual-dysfunction study. These clinical problems will be mentioned in context. When first seen clinically, women with traumatic lacerations of the uterine supports, acquired with delivery or by specific criminal abortion techniques, present complaints that commonly accrue from pelvic vasocongestion, dyspareunia, dysmenorrhea, and a feeling of being excessively tired.
These complaints are secondary or acquired in nature. The traumatized women consistently can relate the onset of their acquired dyspareunia to one particular obstetrical experience even from among three or four such episodes.
The basic intercourse distress 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 and 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 and 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 the examination, the retroverted uterus appears to be perhaps twice increased in size.
Pressing against the corpus in the cul-de-sac to reduce the third-degree retroversion 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 a 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 a 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 history, she well may be able to date the onset of her acquired dyspareunia to one particular obstetrical event.
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.