These redundant vaginal structures usually disappear and contraction takes place after the operation of perineorrhaphy. In some cases, however, when the vagina is very much larger and more relaxed than normal, it is advisable to remove some of the excess of tissue by a plastic operation on the anterior wall similar to that described for the relief of cystocele. CHAPTER VIII. THE POSITION OF THE UTERUS AND THE MECHANISM OF ITS SUPPORT. The uterus normally lies with its anterior surface in contact with the posterior aspect of the bladder, no intestines intervening. The absolute and relative positions of the uterus depend upon the degree of distention of the bladder and the position of the woman. The uterus is pushed backward and the fundus is turned upward by distention of the bladder. When the woman is erect the uterus lies at a slightly lower level than when the woman is on her back, and the intra-abdominal pressure acting upon the posterior surface of the fundus turns the uterus more forward, so that the fundus lies nearer the symphysis pubis. Fig. 61 shows about the normal range of position. [Illustration: FIG. 61.--Normal range of position of the uterus, depending upon the distention of the bladder.] It may be said that in the normal woman the long axis of the uterus is approximately perpendicular to the long axis of the vagina (Fig. 62). [Illustration: FIG. 62.--Median sagittal section of the normal female pelvis.] The uterus does not surmount the vagina with the axes of the two structures in the same line, as is shown in some anatomical plates. The cervix looks backward toward the coccyx, from the tip of which it is situated 0.6 to 1.2 inches. The uterus is maintained in position by a variety of factors. The ligaments, which have been described, are eight in number--broad ligaments, round ligaments, utero-sacral and utero-vesical ligaments. With the exception of the round ligaments, which are muscular structures, the uterine ligaments are formed by peritoneal folds, including connective tissue, blood-vessels, lymphatics, and a small amount of unstriped muscle. When the woman is erect the insertions and origins of the various uterine ligaments lie in the same horizontal plane. The insertion of no ligament is higher than its origin in the uterus; therefore these ligaments do not act as suspensory ligaments when the uterus is in its normal position. The truth of this fact is repeatedly demonstrated at operations. If the cervix be caught with a tenaculum when the woman is on her back, the uterus may, with but very little force, be drawn downward toward the ostium vaginæ to the extent of one or two inches; and similarly, by a slight digital pressure on the cervix, the uterus may be pushed upward from one to two inches above its normal position.