The patient is placed in the lithotomy position and a retractor is inserted in the anterior cul-de-sac in order to elevate the anterior vaginal wall: Fig. 34 shows the appearances then seen. The left forefinger or some gauze packing is placed in the rectum and a double triangular space is denuded by means of sharp-pointed scissors, the base line of the double triangle being formed by the hymen. Two tenacula are inserted as indicated in the drawing (Fig. 34, _t_, _t_). The mucous membrane is now removed from the M-shaped space, great care being taken to penetrate deeply into the lateral sulci. After all bleeding has been arrested in the usual manner, the sutures should be passed. On the left-hand side of the figure these are indicated as inserted, not tied, whereas on the right they are tied and cut. Subsequently the somewhat quadrilateral raw surface which is left is brought together by five deep sutures, and the operation is complete. A Y-shaped cicatrix will be the result. [Illustration: FIG. 35. REPAIR OF A LACERATED PERINEUM, WITH NON-UNION OF THE SPHINCTER ANI, BEFORE A PLASTIC OPERATION. (_From a photograph._) _a._ Ununited sphincter ani. _b_, _c._ Buried ends of torn sphincter. ] =Cases in which the perineum is apparently intact, but in which the sphincter is not united= (Figs. 35, 36). These are the cases in which a complete laceration of the perineum is apparently completely healed after operation, but the patient finds that she has incontinence both of flatus and fæces. On inspection of Fig. 35 this will be well explained. The patient is lying on her back in the lithotomy position: _a_ represents the sphincter which has been torn through; the two cut ends, _b_ and _c_, are represented by two dark circular, somewhat depressed spots. The rectal orifice gapes; there is no sphincteric power present. The perineum anterior to the anus is firmly healed. =Operation.= The most certain and effectual method in these cases is to split up the healed perineum antero-posteriorly and treat the case as one of complete laceration of the perineum (see p. 128). This has been carried out in the case represented in the illustration (Fig. 35), and Fig. 36 shows the result: the patient entirely recovered power over the sphincter ani and the sustaining power of the pelvic floor was much improved. [Illustration: FIG. 36. REPAIR OF A LACERATION OF THE PERINEUM AFTER A PLASTIC OPERATION. (_From a photograph._) _a._ Repaired sphincter ani. _b._ Anus. _s._ Resutured perineum. ] CHAPTER XIII OPERATIONS UPON THE URETHRA AND BLADDER EXTIRPATION OF A URETHRAL CARUNCLE =Indications.= A urethral caruncle is a bright red, tender tumour, usually on the posterior portion of the urethral orifice. The symptoms requiring interference are pain on micturition, dyspareunia, bleeding and discomfort on movement, and, occasionally, retention of urine which is probably due to apprehension of pain rather than to any mechanical obstruction.