In comparison with those just mentioned, the other causes of vaginal cystocele occur but very rarely. It may happen with prolapsus uteri in women who have never borne children, in consequence of a fall, or of ex cessive exertion, as Malgaigne has observed; or tumors of the vesico vaginiil septum itself may drag it down. It may occur as a vesical diver ticulum, where the corresponding portion of the viscus is weighted with a large calculus, which Ruysch has noticed.' But in most such c,ases the process is reversed.; there is first the cystocele, and only later the forma tion of a calculus. This was so in Gendrow's case, where a woman sixty five years old, and who had had seven children, had a cystocele out of which two stones were spontaneously evacuated. In this category belong also the cases of Eyster and Galabin.
Anatomical Relations.—In slight degrees of this affection the lower part of the bladder is somewhat sunken; in more marked e,ases the viscus is hourglass-shaped (Figs. 21 and 23), being divided int,o an upper and a lower part by the horizontally placed urethra, in which we often find small hypertrophies of the mucous membrane. In the highest grades (comp. Fig. 24, after Schroder), where there is also complete uterine prolapse, the bladder may be so twisted that the orifice of the urethra will be above, and the canal itself extend downwards to the bladder, which is upside down.
When the malady has existed for a long time we find also changes in the bladder walls; they become thicker and more succulent, not from stasis and cedema, but from hypertrophy. (Comp. Fig. 24.) The mucous membrane is sometimes in a condition of chronic hyperremia and catarrh. The dragging upon the fundus vesicle may further cause dilatation of the ureters and hydronephrosis; Philips, Froriep, Virchow, Braiin, etc., have seen this happen. It is of importance to note that the malposition causes the excavatio vesico-uterina to become deeper, and the peritoneum to descend to the vagina. If the prolapse is considerable, coils of the small intestine may descend into it. However, the vesico-uterine excavation is usually closed, and is found as a third cavity when cut into. (See v. Franque.) The symptoms of cystocele vaginalis are partly those of prolapse of vagina and uterus; we will naturally confine ourselves to those caused by the bladder and seen in that org,an itself. Not infrequently there is at first only drawing sensations in the navel region, probable from tension of the superior yesieal ligament; and also anomalies in the urinary secretion, such as dysuria, frequent desire to micturate; they may even be unable to empty the bladder unless they replace the tumor beforehand. I have
found, however, that these difficulties do not occur nearly so often as might be expected; that many women with considerable vesisal dilata tion do not have the least trouble with their urine. And I must confess that in 68 cases of cystocele I have never seen vesical catarrh, which Gold ing Bird says is specially liable to occur in women who are in the climac teric years. I admit that it will occur the more easily the greater the portion of the bladder is which protrudes from the vulva, the longer re tention ramains, and the more frequently the catheter is used.
Ramsbotham found that cystocele might be an obstacle to delivery, es pecially when there is slight contraction of the pelvic outlet. McKee was once called to such a case, in which he could not succeed in catheterizing the prolapsed and over-distended bladder. He therefore punctured it with a lancet; delivery was rapid, and the woman got well. Ramsbotham says that Merriman tells of a case in which a physician mistook the pro lapsed bladder in partu for a hydrocephalus, and punctured it. More recently Brennecke, Dick, More, and Spencer have published accounts of cases of this class. Brennecke believed that the occipito-anterior position of his case was caused by the cystocele, and found that after emptying the bladder with the catheter the violent pains ceased. The furious bear ing-down pains, not coincident with actual delivery, and disappearing after the bladder was evacuated, were characteristic.
But even granted that most vaginal cystoceles do not muse nearly all the symptoms that are generally ascribed to them, it must be admitted that so soon as a catarrhal condition of its inner surface and ammoniacal decomposition of the urine occurs, their results may be much more un pleasant than when they do not occur in a prolapsed bladder; for the in flamed bladder is subjected t,o abnormal pressure and tension, and its evacuation cannot be so perfect as when in the normal condition. If there occur stasis of urine, dilatation of the ureters, and hydronephrasis, nriemic symptoms will not be long wanting. From the tension upon the peritoneum there will occasionally occur suba,cute inflammatory processes in the neighborhood of the bladder; pericystitis, and long-standing pro lapsus when neglected may eventually cause so many adhesions to neigh boring organs that reposition may finally become impossible.