Traumatic injuries of the female genital organs. Isolated injuries of the female genital organs
Almost all genital injuries occur in men and include damage to the testicles, scrotum, and penis. Female genital mutilation (the removal of the clitoris, preserved in some cultures) is viewed by many as a trauma to the genitals and a form of child abuse.
Most testicular injuries result from blunt trauma; penetrating injuries are less common. Blunt trauma can cause a hematoma or, if severely injured, rupture of the testicle.
Injuries to the scrotum can be caused by infection, burns, or avulsion.
The mechanisms of damage to the penis are varied. Possibly the most common cause of damage is from pants zippers. Penile fractures (ruptures of the cavernous bodies) most often occur during intercourse, and may be accompanied by damage to the urethra. Other types of damage include amputation (inflicted by the patient himself, or when clothes get caught in the mechanisms at work) and infringement (the most common cause is the use of rings to enhance erection). Penetrating injuries, including animal bites and gunshot wounds, are less common and usually associated with urethral injury.
These lesions may be complicated by the development of Fournier's gangrene (necrotizing fasciitis) caused by a mixed aerobic-anaerobic infection. Predisposing factors include alcohol abuse, diabetes mellitus, prolonged bed rest, immunodeficiency, and chronic bladder catheterization. Complications of genital injury include erectile dysfunction, infection, tissue loss, and urethral stricture.
Symptoms and diagnosis of genital injuries
Injuries to the testicles and scrotum may not manifest, or they may present with swelling and tenderness. Hematocele, painful on palpation, may develop when the albuginea is ruptured; with a rupture of the vaginal membrane, bruising is possible in the groin and perineum. Penile fractures present with severe swelling, hemorrhage, and sometimes visible and palpable deformity. Necrotizing infection of the scrotum initially presents with pain, swelling, and hyperthermia and progresses rapidly.
Diagnosis of external injuries of the scrotum and penis is based on clinical data. Testicular injury is diagnosed by ultrasound of the scrotum. Retrograde urethrography should be performed in all patients with genital trauma due to the high risk of associated urethral injury.
The clinical course of necrotizing gangrene of the scrotum is rapidly progressive, accompanied by skin necrosis and even septic shock. Diagnosis is based on physical examination findings. At the beginning of the disease, the scrotum is edematous, tense, with hemorrhages, then blisters, darkening and crepitus appear. In the early stages, patients have systemic manifestations of sepsis, the severity of which is disproportionate to the local manifestations of the disease.
Treatment of genital injuries
Patients with penetrating testicular injury or testicular rupture require surgical treatment; patients with suspected testicular rupture but not confirmed by ultrasound still require surgical exploration. All tears and penetrating injuries of the penis also require surgical revision and correction. In case of viability of the amputated segment of the penis, its microsurgical replantation is indicated. If the trousers are damaged by the zipper, after lubricating it with oil and performing local anesthesia, you can make one attempt to unzip the zipper. If this fails, the zipper lock is bitten with powerful wire cutters, and it easily diverges.
- different in origin and severity of damage to the skin, spongy and cavernous bodies, subcutaneous tissue, fascia, muscles and albuginea of the penis. Symptoms of penile injury depend on the type of injury and may include swelling, pain, bleeding, hematoma, hematuria, urinary problems. Penile injuries are diagnosed on the basis of history, examination, palpation, and ultrasound. First aid for injuries of the penis is to stop bleeding, PST wounds, removal of foreign bodies; further tactics is determined by the type and severity of damage.
General information
Injuries of the penis - damage to the integumentary tissues and internal structures of the penis that occurs when exposed to mechanical and thermal factors. Penile injuries account for 2.2% of all injuries and 30-50% of cases of trauma to the genitourinary organs. Approximately 1% of cases of damage are combined with injuries of the scrotum. Most often, penile injuries occur in men aged 15-40 years. In urology and andrology, penile injuries are classified as urgent pathology and require urgent surgical care.
Classification
First of all, penile injuries are divided into closed (80%) and open (20%). Closed (blunt) injuries include bruises, infringements, dislocations and fractures of the penis. Open (penetrating) injuries include superficial, scalped, bitten, gunshot, stab wounds of the penis. In addition, patients with burns, frostbite, traumatic amputation of the penis (penectomy) are often encountered in traumatology. Injuries of the penis can be both isolated and combined with damage to the scrotum, bones and pelvic organs.
Depending on the severity, the European Urological Association distinguishes the following types of penile injuries:
- I degree- damage to integumentary tissues, bruising of the penis
- II degree- damage to the Buka fascia surrounding the spongy and cavernous bodies
- III degree- tissue ruptures (glans penis, urethra, cavernous body) with a defect length of less than 2 cm
- IV degree- rupture of the urethra, cavernous body with a defect length of more than 2 cm; partial amputation of the penis
- V degree- complete traumatic amputation of the penis.
Types of injury
Penile injury
Bruises are the most common type of penile injury. Most often, bruises occur with direct blows during sports and fights, cycling, etc. Light bruises of the penis are accompanied by painful sensations that subside within 10-15 minutes after the blow. For more severe injuries of the penis, accompanied by tearing of the albuginea, increased pain, swelling of the penis, formation of a subcutaneous hematoma, which gives the penis a blue-purple color, difficulty walking, impaired urination, are characteristic. Strong targeted blows to the penis can lead to a fracture of the cavernous body and the development of internal bleeding. In this case, up to 0.5 liters of blood can accumulate under the skin of the penis in 15 minutes, which is why the penis becomes huge and blue-black in color. The blood accumulating in the subcutaneous tissue spreads to the pubis, scrotum and inner thigh. With severe trauma to the penis and severe blood loss, traumatic shock may develop.
Infringement of the penis
This injury usually occurs when the skin of the penis gets caught in the zipper mechanism of the trousers. In this case, a small wound is formed on the surface of the penis, causing severe pain. Less commonly, the cause of infringement of the penis is pulling the trunk of the penis with a thread, rubber band, putting on it various annular objects. These damages can be inflicted as a result of childish pranks, mental disorders, or in order to maintain an erection, to prevent urinary incontinence.
Infringement of the penis is accompanied by the development of tissue edema and pain; when the urethra is compressed, acute urinary retention occurs. Prolonged disruption of blood circulation in the tissues of the penis can lead to skin necrosis and gangrene of the penis.
Dislocation and fracture of the penis
Dislocation of the penis is the result of a rupture of the ligaments that hold the penis to the pelvic bones. With this type of penile injury, the cavernous bodies are displaced under the skin of the thigh, perineum, scrotum, and the penis itself is palpated in the form of an empty skin sac.
Fracture of the penis in most cases occurs during rough intercourse and is the result of a sharp inflection of the erect penis. Such an injury to the penis is accompanied by a rupture of the cavernous bodies and can be combined with damage to the urethra and spongy body. Usually, at the time of the fracture, a characteristic crack is clearly heard, which patients compare with the crunch of broken glass. At the same time, an attack of acute pain occurs and an erection stops. The consequence of the onset of internal bleeding is the appearance and rapid growth of a hematoma, increased pain intensity, and shock phenomena. When the urethra is damaged, urinary retention occurs. A fracture of the penis is a dangerous type of injury, the long-term consequences of which can be infectious complications, curvature of the penis, painful erections, impotence.
Open injuries of the penis
Superficial wounds of the penis include injuries resulting from excessive friction, tears, and ruptures of the frenulum brenus. Such injuries may be accompanied by external bleeding of varying intensity, scarring. The reason for the formation of scalped wounds of the penis is the penetration of the penis into various kinds of moving mechanisms. In this case, extensive wound defects of the skin are formed, often passing to the scrotum, intense pain, bleeding, and traumatic shock occur.
Bite wounds of the penis are the result of the manifestation of aggression of domestic animals or the deliberate actions of a sexual partner. Despite the small area of damage and minor bleeding, penis bites are usually always infected, so such wounds tend to heal for a long time. Bites inflicted by animals carry the risk of contracting rabies.
Treatment
At the prehospital stage, victims with penile injuries need competent emergency care. As a priority, it is necessary to take measures to temporarily stop bleeding (apply ice, a pressure aseptic bandage on the penis, a tourniquet), splint the penis in case of its fracture, start anti-shock measures (adequate anesthesia, infusion therapy). The hospital performs PST of wounds (including the burn surface, gunshot wound, infected wound), removal of foreign bodies, drainage of post-traumatic hematomas, revision of the wound and the final stop of bleeding. Patients with bite wounds must be vaccinated against rabies; with other wounds - tetanus toxoid is administered, according to indications - antigangrenous serum.
Treatment of penile infringement consists in the removal of squeezing objects. In case of dislocation of the penis, its open reduction is carried out with suturing on the torn ligaments and fixing the cavernous bodies to the pelvic bones. With a fracture of the penis, an operative opening of the hematoma is performed with the removal of blood clots; hemostasis, suturing of defects of the albuginea and cavernous bodies, wound drainage. Penile frenulum tears require frenuloplasty. Elimination of extensive wound defects is carried out using skin plasty methods, for which the skin of the scrotum (Reich operation), pubic area, abdomen, and free skin flaps are used. Treatment of thermal injuries of the penis is carried out according to the general principles of the treatment of burns and frostbite.
If the urethra is damaged, an epicystostomy is applied. Restoration of the continuity of the urethra is carried out by performing an anastomotic urethroplasty or other types of urethral plastics. The penis amputated due to negligence must be preserved, since during the first 24 hours after the injury, its microsurgical suturing into the stump is possible. To maintain the viability of the organ, it is washed and stored in a sterile container filled with sodium lactate solution on ice. If reimplantation is not possible, reconstructive phalloplasty is performed.
Forecast and prevention
Penile injuries are serious injuries that require urgent medical attention, comprehensive diagnosis and qualified assistance. Long-term consequences of unrecognized injuries of the penis can be cavernitis, abscesses, shortening and deformities of the penis, erectile dysfunction, urethral strictures. Protecting the genitals during traumatic sports, avoiding dangerous positions in sex, increasing the level of sexual culture and sex education, and careful handling of pets will help prevent damage to the penis.
What is Genital Injuries in Girls
Injuries of the genital organs in girls are observed mainly at the age of 2 to 11 years, mainly as a result of falling on blunt and sharp objects, violent, iatrogenic and transport injuries are less common.
The severity of injuries varies from small abrasions to injury to neighboring organs and injuries penetrating the abdominal cavity. The external genital organs are often damaged (ruptures of the labia minora, clitoris, vaginal walls, hematomas of the external genitalia).
Rupture of the posterior commissure may be limited to the skin, but may also extend to the muscles of the perineum with a violation of the integrity of the external sphincter and the rectal mucosa. The rupture of the labia minora sometimes captures the area of the clitoris and urethra. Injuries to the genital organs can be combined with injuries to the urethra, bladder and pelvic fractures.
Damage to the genital organs, as a rule, is accompanied by bleeding, although there are injuries without violating the integrity of the mucous membrane and skin with the occurrence of hematomas of various sizes. The hematoma may not grow, but if the artery is damaged, it may increase. Large hematomas from the external genitalia can spread to the thighs, buttocks, and anterior abdominal wall.
Injury to the genitourinary organs is one of the most severe injuries. In most cases, such an injury does not pose a serious threat to life, but the constant excretion of urine or feces from the genital fistula and the lack of independent urination with urethral strictures cause severe physical suffering, disrupt menstrual and reproductive functions, create a difficult environment in everyday life, and depress the psyche of patients. Obliteration of the vagina, leading to the formation of hematocolpos and (or) hematometers, often requires urgent surgical intervention, and in the case of infection and the development of pyocolpos, a radical operation with loss of reproductive function.
Symptoms of Genital Injuries in Girls
The consequences of trauma to the genitourinary organs are very diverse, due to the localization of damage (vagina, urethra, bladder), structural and anatomical form of pathology (strictures, fistulas), as well as comorbidity. As a rule, patients with urethral strictures and/or urogenital fistulas complain of leakage of urine from the vagina and lack of spontaneous urination. Pubertal girls with vaginal obliteration are concerned about cyclically recurring, increasing pain in the lower abdomen associated with the formation of hematocolpos and (or) hematometers. Over time, patients with urogenital fistulas develop severe forms of colpitis as a result of urinary irritation of the vaginal mucosa, sometimes with the formation of urinary stones in the fistula area.
Diagnosis of Genital Injuries in Girls
Diagnosis of trauma to the genital organs is based on the results of a comprehensive examination, including data from anamnesis, examination of the external genitalia, palpation and percussion of the abdomen, vaginoscopy. If it is difficult to determine the localization and extent of damage, then the examination is carried out under anesthesia. Bladder catheterization allows you to clarify the injury of the bladder and urethra. In a rectal-abdominal examination, the integrity of the rectum, the condition of the pelvic bones, and the presence of hematomas are determined. Vaginoscopy gives an idea of the condition of the walls of the vagina and vaults. An x-ray examination is performed with suspicion of fractures of the pelvic bones, a penetrating wound of the abdominal cavity. In case of injuries as a result of rape, the data of a gynecological examination are especially carefully described, the severity and localization of injuries are determined. Smears are taken from the vulva and from the vagina for gonococcus, spermatozoa. The girl's clothes and underwear are handed over to the investigating authorities.
Ultrasound after urogenital damage helps to diagnose simple forms of vaginal obstruction - isolated low vaginal strictures with obligatory hematocolpos. However, it is not possible to accurately determine the localization and extent of the vaginal defect without hematocolpos according to ultrasound data. In such a situation, magnetic resonance imaging of the pelvic organs is indicated. Information about the location of genital fistulas and strictures of the urethra is not provided by both ultrasound and MRI. The simultaneous use of vaginal and cystourethroscopy makes it possible to identify almost all forms of urogenital pathology. The information content of cystourethrovaginography is also quite high, with the help of which it is possible to diagnose not only urogenital fistulas, but also concomitant pathology - a decrease in capacity and deformation of the bladder, vesicoureteral reflux.
Treatment of Genital Injuries in Girls
At the initial stage, the primary treatment of the wound is carried out according to the generally accepted method. The amount of assistance depends on the severity of the injury. With superficial abrasions, the genitals are treated with antiseptics. With a progressive hematoma, cold is prescribed to the area of \u200b\u200bthe hematoma, and then resolving therapy. A large hematoma with the formation of cavities should be opened, clots removed, sutures placed on the bleeding vessel, followed by drainage of the cavity.
Sewing ruptures of the vagina, perineum, rectum, bladder, primary urethral suture and plastic surgery of genital fistulas in the "acute" period after injury cannot be considered justified due to their low efficiency. These operations do not lead to the desired result and end with cicatricial obliteration and stenosis of the vagina and urethra, re-formation of genital fistulas. There is no doubt that each repeated unsuccessful operation on the perineum reduces, and often minimizes, the possibility of reconstructing the vagina or urethra in the future due to the abundance of scars and the inevitable shortage of tissues in the area of the forthcoming operation. In the "acute" period after massive destruction of the genitourinary organs (as a result of an autotrauma or a fall from a height), crushing of the tissues prevents the imposition of a primary suture, so operations on the vagina and urethra are advisable after the completion of scar formation. After an iatrogenic injury in the "acute" period, ruptures of the vagina, urethra, and bladder can be sutured, as tissues with normal reparative capabilities are sutured, which ensures good healing of the defect. The consequences of urogenital damage can be eliminated in one or more stages. One-stage operations are indicated for isolated injuries and multiple injuries, if the reconstruction of the vagina simplifies the plasticity of the urinary tract. If one-stage reconstruction with multiple urogenital injuries is too traumatic, then they are eliminated in two stages. When correcting the consequences of urogenital injuries, the principles of plastic surgery are observed: excision of scars and connection of healthy tissues, elimination of tension by mobilization and fixation of the stitched areas, use of atraumatic suture material. Particular importance is attached to the maximum lengthening of the anastomosis line.
After the reconstruction of the genital tract, a tampon with vaseline oil and an aqueous solution of chlorhexidine is inserted into the vagina on the 3-5th day, which is changed daily for 3-4 days, while sanitizing the vagina with antiseptic solutions. From the 6-7th day, it is necessary to treat the suture line with folliculin ointment, from the 10-12th day to perform prophylactic bougienage of the vagina. After correction of urethral strictures and urogenital fistulas, a urethral catheter is inserted into the bladder or a cystostomy is applied for a period of 3 to 16 days (depending on the type of operation).
With significant blood loss, transfusion of blood components and blood substitutes is indicated, and further general strengthening therapy is carried out.
Efficiency and forecast. The above methods of examination and surgical treatment are effective in 91.2% of patients and create prerequisites for the restoration of menstrual and reproductive functions, as well as for the social adaptation of patients.
Which doctors should you contact if you have Genital Injuries in Girls
Gynecologist
Promotions and special offers
medical news
20.02.2019
Chief pediatric phthisiologists visited the 72nd school in St. Petersburg to study the reasons why 11 schoolchildren felt weak and dizzy after they were tested for tuberculosis on Monday, February 18
Viruses not only hover in the air, but can also get on handrails, seats and other surfaces, while maintaining their activity. Therefore, when traveling or in public places, it is advisable not only to exclude communication with other people, but also to avoid ...
Returning good vision and saying goodbye to glasses and contact lenses forever is the dream of many people. Now it can be made a reality quickly and safely. New opportunities for laser vision correction are opened by a completely non-contact Femto-LASIK technique.
Cosmetic preparations designed to care for our skin and hair may not actually be as safe as we think.
How are traumatic injuries of the female genital organs classified?
Foreign bodies.
Fresh wounds and damage to the genital organs:
Fresh injuries, depending on sexual intercourse;
Fresh injuries, not dependent on sexual intercourse;
Injuries caused by cutting and stabbing objects and firearms;
Old injuries of the genital organs and their cicatricial changes:
Injuries (ruptures) of the perineum and vagina;
Uterine damage. Urogenital and intestinal-genitourinary fistulas.
What are the most common complaints of foreign body ingestion?
The most common complaints are pain, leucorrhoea (usually fetid), spotting.
Under what circumstances can foreign bodies enter the vagina?
Foreign bodies can get into the vagina in the following cases:
When providing patient medical care (uterine rings, pessaries, gauze and cotton swabs);
When using contraceptives - male and female condoms;
With the introduction of various objects into the vagina for the purpose of abortion, masturbation, etc.
How is the recognition of foreign bodies in the vagina?
Recognition of foreign bodies in the vagina is based on a gynecological examination using mirrors, as well as a digital examination and does not present difficulties.
What are the main principles of treatment?
Treatment consists in removing the foreign body, prescribing weakly disinfecting douches with a solution of potassium permanganate 1:4000-1:6000 or other antiseptics.
When do fresh wounds and injuries of the genital organs most often occur?
Fresh injuries and damage to the genital organs most often occur during childbirth or during induced abortion, so they are presented in the course "Obstetrics", but the urogenital organs can be damaged during intercourse, gynecological operations (Fig. 14.1) and violent acts.
Rice. 14.1. Perforation of the uterus: A - curette; B - with the introduction of the IUD
What is the damage to the hymen during the first sexual intercourse called?
Damage to the hymen occurs, as a rule, during the first sexual intercourse - defloration (defloration). Tears of the edges of the hymen in this case are shallow and are accompanied by minor bleeding.
What are the causes of its pathological rupture?
Sometimes during the first sexual intercourse, the rupture of the hymen reaches its base and is accompanied by profuse bleeding. The reasons for such a pathological rupture are excessive strength (rigidity) of the hymen, its fleshiness, underdevelopment of the genital organs, as well as excessive physical impact during rudeness and violence.
Damage to the vagina occurs due to underdevelopment, a decrease in elasticity, or excessive softening of the walls.
Where does vaginal rupture usually occur?
The vaginal walls are usually torn in the upper third in the region of the posterior or one of the lateral arches. With a deep rupture of the lateral wall of the vagina, the pelvic tissue is exposed. It is extremely rare that a rupture of the vaginal fornix is accompanied by a violation of the integrity of the peritoneum lining the recto-uterine cavity (Douglas space). In such cases, prolapse of intestinal loops may occur.
What are the symptoms of genital ruptures?
Symptoms of genital ruptures in connection with sexual intercourse are pain and bleeding, sometimes very profuse. Causes of bleeding - torn veins, cavernous lacunae, arterial branches.
What is the diagnosis of such gaps based on?
Diagnosis of ruptures is not difficult if we take into account the characteristic anamnesis and the availability of damaged organs for examination.
What is the tactics of surgical treatment in infected and non-infected cases?
Treatment in non-infected cases is surgical: ligate bleeding vessels and suture the edges of torn tissues. If the bleeding vessel is not found, then a submerged catgut suture is applied to the bleeding area. If a fresh rupture of the vaginal wall penetrates deeply, then the wound must be sutured in layers and sequentially. In case of damage to the intestines, abdominal surgery is indicated.
In infected cases, it should be limited only to ligation of bleeding vessels or stitching of the corresponding area without suturing the edges of the wound; wound surfaces are treated with antiseptic solutions and infiltrated with antibiotics.
What is the prognosis with proper and timely treatment?
The prognosis with proper and timely treatment is favorable.
What can be attributed to accidental injuries during medical manipulations?
This group includes injuries caused during various medical procedures: with a deep expansion of the cervical canal with metal dilators, accidental injuries of the bladder, ureter, uterus during operations.
What is the most common cause of blunt trauma to the external genitalia?
Blunt trauma occurs due to the impact of blunt objects (bruise) or indirectly (in case of damage to the bone pelvis, with a gunshot wound, etc.). As a result of such injuries, a hematoma most often develops, which, depending on the site of the injury, can form in the vulva, perineum, or vagina.
What are the symptoms of a vulvar hematoma?
Pain appears at the site of injury, sometimes unbearable; urination becomes frequent and painful. With the spread of the hematoma in the peri-intestinal and peri-vaginal tissue, tenesmus, difficulty in urination and defecation appear. The swelling at the site of the bruise acquires a bluish-black or bluish-red color. When the hematoma spreads through the fiber, the phenomena of acute anemia come first, despite the absence of external bleeding.
What is the diagnosis of vulvar hematoma based on?
Hematoma is recognized by examining the external genital organs and a digital examination of the vagina.
What are the basic principles of treatment of vulvar hematoma?
First of all, treatment should be aimed at stopping bleeding, at maintaining the integrity of the hematoma integument in order to avoid infection, and at reducing pain. For this purpose, rest is prescribed,
painkillers, ice pack. If the hematoma grows along with the symptoms of anemia, then it is opened with a wide medial incision, clots are removed, bleeding vessels are stitched. The hematoma cavity is drained. Antibiotics are prescribed prophylactically. With significant blood loss, the volume of the BCC is replenished.
Why do clitoral injuries require emergency surgical treatment?
Injuries to the clitoris due to the saturation of this organ with blood vessels are extremely dangerous, as they are accompanied by severe bleeding, and therefore require emergency surgical treatment.
What is the surgical treatment of clitoral injuries?
Treatment consists of applying hemostatic sutures.
How is a vaginal injury diagnosed?
The diagnosis is established after examination of the vagina with the help of mirrors.
What is the tactics of surgical treatment of wounds of the vagina?
Treatment consists of primary surgical debridement and suturing. In case of violation of the integrity of the peritoneum, bladder and intestines, abdominal dissection is indicated.
What are the main causes of burns of the vulva, vagina and cervix?
Burns of the vulva, vagina and cervix appear as a result of vaginal douching with hot water or an overdose of disinfectants.
What is the treatment for genital burns?
Treatment does not differ from the methods generally accepted in surgery for body burns.
When do cervical ruptures most often occur?
The cervix is most often damaged during childbirth and less commonly during abortion.
What can cause scarring of the cervix?
Cicatricial deformity of the cervix occurs in cases where the ruptures were not sutured or when they were healed by secondary intention (Fig. 14.2).
Rice. 14.2. Cicatricial deformity of the cervix: 1 - after unilateral rupture; 2 - bilateral; 3 - multiple (star scar)
What symptoms can occur with a deformity of the cervix?
Symptoms of old cervical ruptures are leucorrhea, infertility, miscarriage, menstrual irregularities, pain in the lower abdomen and lumbar region.
What are the "generally accepted" surgical methods for the treatment of scarring of the cervix?
These methods include the Emmett operation, cone-shaped amputation according to Sturmdorf and wedge-shaped amputation according to Schroeder, high amputation of the cervix, cervical plastic by the method of dissection according to V.I. Yeltsov-Strelkov.
What is the advantage of surgical treatment of cicatricial deformity of the cervix according to the method of V.I. Yeltsov-Strelkov?
This reconstructive plastic surgery allows, along with the removal of all scar tissue, to completely restore the shape and function of the cervical canal and cervix (see Chapter 6).
What is a fistula?
fistula (fistula) called an artificial passage formed between two adjacent hollow organs or hollow organs and the outer skin.
What fistulas are distinguished?
Distinguish:
Vesical fistulas: vesico-vaginal, vesico-uterine, vesico-adnexal;
Ureteral fistulas: ureteral, ureteral-moisture, uretero-uterine;
Urethrovaginal and urethrovesical-vaginal fistulas;
Combined fistulas: urinary, urinary.
Complex urogenital fistulas (Fig. 14.3).
Rice. 14.3. Genitourinary fistulas: 1 - vesicovaginal; 2-vesicouterine (cervical); 3 - urethrovaginal; 4 - ureterovaginal
What are the main causes of fistulas?
The causes of fistulas are varied. These include:
Birth injury;
Injury inflicted on the genitourinary organs and intestines during operations and manipulations;
Anomalies of development;
Malignant tumors in the stage of tumor decay;
radiation damage;
A breakthrough of pus or other pathological product from the uterine appendages into the urinary organs, vagina or intestines;
Tuberculous process in the lower intestine;
Accidental injuries with damage to the walls of each of the organs adjacent to each other.
What fistulas are most common?
Genitourinary fistulas are much more common than enterogenital fistulas due to the fact that the urethra and isthmus of the bladder are located behind the pubic arch, are easily pressed against it by the fetal head inserted into the small pelvis, while the sigmoid and rectum are in more favorable conditions, since they are protected from fetal head pressure.
What are the main symptoms of fistulas?
The main symptoms of a fistula include:
Urinary and fecal incontinence;
Inflammatory processes in the external genitalia, vagina, bladder, in the overlying parts of the urinary system - the ureter, renal pelvis, kidney parenchyma;
With fistulous openings between the cavity of the abscess (pyosalpinx, abscess of the recto-uterine cavity, etc.) and the vagina; pus flows out of the latter.
What is the diagnosis of fistula based on?
Already when collecting an anamnesis, it is possible to establish the presence of a fistula and its nature, localization, size.
If urine is continuously leaking, but spontaneous urination is also possible, a ureterovaginal or very small vesicovaginal fistula should be assumed.
A fistula with a large diameter is also detected with a simple examination using mirrors or a two-handed vaginal examination. You can apply the probing of the fistulous passage through the vagina, the test with the filling of the bladder. For this, about 200 ml of a sterile coloring disinfectant is injected (rivanol 1:1000, methylene blue 1:2000, potassium permanganate 1:1000). When examining the vagina with the help of mirrors, fluid leakage from the fistulous opening is detected, and its location and size are determined. The presence of a fistula, its location and size can be determined using cystoscopy and chromocystoscopy. In the presence of combined fistulas, it is possible to use an X-ray examination using water-soluble contrast agents (fistulography).
What method of treatment is applicable for this pathology?
Treatment is only surgical (Fig. 14.4). The operation is carried out not earlier than in 4-6 months. after fistula formation. The principle of the operation of suturing the urinary fistula is to separate the fistula of the vaginal wall from the wall of the bladder and give it mobility.
Rice. 14.4. Options for suturing the intestinal-vaginal fistula: I - with dissection of the external pharynx: a - incision line (1 - external pharynx; 2 - fistula); b - the muscular membrane is highlighted; c - the first row of sutures (musculoskeletal); g - the second row of sutures (on the mucous membrane); II - without dissection of the external pharynx: a - incision line (1), fistula (2); b - the first row of sutures (musculoskeletal); in - the first row of seams, covered with a flap of the back row
After that, the edges of the wound are connected with interrupted, separate sutures in such a way that the ligatures pass transversely through the muscular layer of the bladder. The second row of interrupted sutures is placed on the tissue of the bladder, and the third - on the wall of the vagina. In the postoperative period, a permanent catheter is inserted, the bladder is washed with solutions of antiseptics, antibiotics.
Fecal fistulas are sutured through the vagina - the edges of the fistulous opening are excised and layered sutures are applied to the edges of the fistulous passage without piercing the intestinal mucosa.
What is the prevention of the occurrence of fistulas of the female genital organs?
Prevention consists in the proper organization of obstetric care and proper management of childbirth, timely treatment of patients with tumor processes in the genital organs, careful surgery on the pelvic organs and qualified management of patients and puerperas in the postoperative and postpartum periods.
What are the features of female genital trauma in girls?
The features of injuries in girls are injuries of the vulva and vagina due to falling on sharp, cutting and stabbing objects, as well as burn injuries due to the carelessness of parents (boiling water, open fire).
What are the features of treatment tactics in girls?
Features of medical care for girls are effective pain relief, prevention of shock, and closure of tears with atraumatic needles.
The causes of damage to the female genital organs can be bruises, falls, violent
actions, etc. In addition, damage to the genital organs often occurs during pathological childbirth or
operational aids in childbirth.
Conventionally, damage to the female genital organs can be divided into:
- damage to the external genitalia and vagina;
- uterine damage.
Damage to the external genitalia.
Most often occurs in girls when falling on blunt and sharp objects, less common
violent or traffic injuries.
The cause of injuries of the external genital organs can be pathological and operational
childbirth. Ruptures of the vagina, cervix, perineum, vulva most often occur in women in labor with
narrow pelvis, large fetus, abnormal presentation of the fetus, etc. Tears of the external genitalia
often accompanied by operative childbirth - the imposition of obstetric forceps, extraction of the fetus by
pelvic end. Prevention of birth traumatism will be an individual approach to delivery,
qualified midwifery.
With bruises and falls, hematomas, tissue ruptures, complicated
bleeding. When falling on sharp objects, penetrating wounds occur with damage to the vaults
vagina, urethra.
When raped, extensive ruptures of the walls of the vagina can occur with abundant
bleeding.
In transport accidents, there are combined injuries with damage to the pelvic bones,
pelvic organs, etc.
With damage to the external genital organs, the leading symptoms are pain and
bleeding. Pain can range from minor to traumatic shock. Bleeding from
moderate discharge to heavy bleeding, accompanied by hemorrhagic shock. Diagnostics
damage to the external genital organs is based on the data of anamnesis and objective examination.
Examination of the patient must be carried out with full anesthesia, which will allow
determine the exact location of damage. After establishing the nature and extent of damage,
start therapeutic measures that include anti-shock measures,
surgical restoration of damaged tissues, replenishment of blood loss. First aid
consists in applying a pressure bandage to the bleeding area, applying cold. According to indications
intravenous administration of anti-shock and blood-substituting fluids is performed.
Uterine damage. Perforation of the uterus is the most common
during an abortion. The most dangerous perforation of the uterus with dilators or a curette, as this often occurs
damage to internal organs. If a complete perforation of the uterus is suspected, it is best to perform
diagnostic laparoscopy for a thorough revision of the state of internal organs. After confirmation
diagnosis of perforation, it is necessary to suture the wound of the uterus.
After the operation, women with a scar on the uterus should be
dispensary registration in the antenatal clinic. Pregnancy is excluded within the next year, such
time is needed for scar formation. Contraception is selected individually, taking into account age and
contraindications. The patient needs to undergo rehabilitation therapy, including
anti-inflammatory drugs, physiotherapy treatment aimed at prevention
formation of adhesions in the small pelvis. In patients planning pregnancy,
examination to clarify the condition of the scar on the uterus. In subsequent pregnancies, careful
observation, planned hospitalization at critical times and 2 weeks before the expected birth,
individual approach to the method of delivery.
