MALPOSITIONS AND MALFORMATIONS OF THE FEMALE BLADDER.
I. Displacement of the Bladder, especially with Vesico-vaginal Fistula; Cystocele Vaginalis.
Displacement upwards only occurs as a rule from traction from above, or pressure from below. Traction may be applied to the vesical wall through its peritoneal covering, which exerts a certain tension when the internal genitals are displaced upwards, or when there is adhesion of the vesical surface to the ovary, the uterus, or the intestine (page 26). Thus again, the pregnant uterus as it enlarges, a growing ovarian tumor, or a coil of intestine, may exert traction. But even without the pelvic organs rising out of the true pelvis they may influence the shape and position of the bladder; thus retro-flexion of the uterus may cause a dragging of the lower bladder wall backwards or upwards (see Fig. 25). Tumors located below the vesical neck, as small ovarian cysts, rectal tumors, and those growing from the pelvic walls, and others, may elevate the blad der. The bladder has been found in largo hernhe, and even partly in the foramen ovale.
All these changes of position are only of importance inasmuch as they dislocate the urethra, compromise its lumen, and cause dysuria and ischu ria, and render the introduction of the catheter more difficult than usual. Remove the cause, and the vesical dislocation usually easily and quickly disappears. If the bladder is attached by adhesions to surrounding parts, careless c,atheterization, too rapid emptying of the organ, a too flat position on the part of the patient, and a failure to close the catheter at the proper time, may cause air to enter the bladder through the instru ment, as we have already noticed in page 22, when discussing the different methods of examining the organ. Air, however, is not so hurtful as Wil8 formerly supposed, since repeated examinations by Rutenberg's method have been made without evil result, And in most cases it is undoubtedly not the air, but the use of unclean instruments, that causes the malady of the mucous membrane.
The longer adhesions between the bladder and surrounding parts exist, Ihe less harm do they do, since the continual traction caused by the alter nate filling and emptying of the viscus continually tends to make them less resistent, longer. more extensile, and less hindersome.
By far the most important anomalies of position is that which is known as vesico-vaginal-prolapse, eystocele vaginalis.
The causes as a rule are to be found in an antecedent pregnancy and child-birth. In this condition the vesico-vaginal septum becomes hy perremie, loosened, lengthened, and is exposed to pressure from above, which pushes down the bladder wall and the tuberculam vaginte, espec ially at the time of delivery. Thus the upper part of the urethra is car ried downwards (Fig. 23); all the structures of the pelvic floor are so stretched, and the introitus vaginfe so dilated, that the other organs de scend for want of an efficient support. This of course occurs t,o its great est extent when the rima vulvis is enlarged by a rupture. Given such predisposing conditions, the direct causes of vesico-vaginal hernia are usually increased abdominal pressure during the lifting and carrying of heavy objects or by efforts at defecation, which latter are especially prone to do damage when the bladder is partly or entirely full. It is easy to convince oneself, by requesting the patient to press down, that when the tubereulam vagiwe descends, tho genital orifice begins to gape, and the tumor that dilates it grows rapidly. As a rule the primary displacement is that of the vesico-vaginal wall, followed by descensus and prolapsus uteri incompletus. But in many cases the reverse occurs. Hypertrophy of the neck of the uterus, or tumors situated upon it or in its walls, drag or press the uterus downwards, and the bladder follows after. Age is especially predisposing; cystocele is most common in the years from thirty to forty. Occupations which involve much standing, lifting, or carrying heavy weights will render even nulliparous women liable to it.