Polyethylene sling for procidentia.
Authors: F. Welsh
Journal: BMJ (1967)

A woman aged 86 was referred as a case of rectal prolapse. She complained of being unable to walk because of her passage coming down and of dribbling incontinence when standing. The patient, a sturdy, heavily built woman had had four children and suffered from prolapse, for which she had worn a ring for many years. She had difficulty in defaecation and took 15 sennapods every night. Even with this aid she passed small motions and had to empty the bowel by digital pressure. She thought that both passages came down. Examination, supine and standing, revealed a con siderable degree of uterovaginal prolapse. The anterior vaginal wall with the urethra was very lax and was displaced downwards and backwards. There was no distinct cystocele. The posterior vaginal wall was also very lax and the rectum bulged forwards into the vagina. The cervix was low but no procidentia occurred during examination. The uterus was of normal size. The anal sphincters and canal were normal and there was no evidence of prolapse of the rectum through the anus. A diagnosis was made of severe uterovaginal prolapse associated with weakness of all the pelvic connective tissues, including the rectovaginal septum. At operation on 13 December 1966 at the General Hospital, Birmingham, under general anaesthetic, the patient was placed in the lithotomy position with legs supported as for combined abdominoperineal operation. Traction on the cervix at once produced a complete eversi?n of the vagina and revealed an area of superficial ulc?ration surrounding and including the cervix and about 6 cm. in diameter. Cystoscopy and catheterization of both ureters were carried out, the catheters being left in position. On either side of the cervix about 2.5 cm. from the middle line a vertical incision 1 cm. long was made through the vaginal fornix. A trans verse incision in the abdominal wall 8 cm. long was then made above the pubis to expose both external abdominal rings. A steel 8/10 olive-headed bougie was then manipulated through the inguinal canal and its point made to pass downwards extraperitoneally along the pelvic wall and medially towards the cervix. Without much difficulty the point was made to protrude through the small vertical incision on one side of the cervix. A nylon suture was tied round the bougie, which was then withdrawn, bringing up the suture with it to the suprapubic wound. One end of a polyethylene tube 3 mm. in diameter was tied to the vaginal end of the suture and the tube pulled up into the suprapubic wound (Figs. 1 and 2). In the same way the other end of the tube was threaded through a tunnel from the first to the second small vaginal wound and up the other pelvic wall to the suprapubic wound. The tube was stitched firmly to the cervix with nylon. When the ends of the tube were pulled together the cervix and vaginal vault were raised to an estimated normal position, and the ends of the tube were knotted together and stitched. The abdominal wound was closed and a few fine catgut stitches were used to close the small vaginal wounds. The rectocele was corrected by plicating the posterior wall of the vagina with a single continuous vertical suture of nylon. The patient recovered quickly from the operation, which was bloodless and required no removal of tissue. Walking and urinary continence were re-established within 24 hours, and normal defaecation was also restored by the time the patient left hospital two weeks later. She would have left hospital earlier, but elected to stay in for Christmas. She was seen one month after the operation, when she walked into the clinic. Her only complaint was frequency of micturition. Examination showed no incontinence, no descent of the cervix, and well-healed abdominal and vaginal wounds.