position anomalies. Anomalies of the gender of the zhpo Other diseases from the group Diseases of the genitourinary system

- violations of the shape, size, localization, quantity, symmetry and proportions of the internal and external genital organs. The cause of occurrence is unfavorable heredity, intoxication, infectious diseases, early and late gestosis, hormonal disorders, occupational hazards, stress, poor nutrition, poor ecology, etc. The diagnosis is established on the basis of complaints, anamnesis, external examination, gynecological examination and the results of instrumental research. Therapeutic tactics is determined by the characteristics of the malformation.

General information

Anomalies of the female genital organs - violations of the anatomical structure of the genital organs that arose during the period of intrauterine development. Usually accompanied by functional disorders. They make up 2-4% of the total number of congenital malformations. More than 40% of cases are combined with anomalies of the urinary system. Patients may also have lower gastrointestinal tract malformations, congenital heart defects, and musculoskeletal anomalies.

The frequent combination of anomalies of the female genital organs with other congenital defects necessitates a thorough comprehensive examination of patients with this pathology. Congenital malformations of the external genital organs are usually determined at birth. Anomalies of the internal genital organs can be detected during menarche, during a routine gynecological examination, when contacting a gynecologist with complaints of dysfunction of the reproductive system (for example, infertility) or during the gestation period. Treatment is carried out by specialists in the field of gynecology.

Classification of anomalies of the female genital organs

Taking into account the anatomical features, the following types of congenital defects of the female reproductive system are distinguished:

• Absence of an organ: complete - agenesis, partial - aplasia.
• Violation of the lumen: complete infection or underdevelopment - atresia, narrowing - stenosis.
• Change in size: decrease - hypoplasia, increase - hyperplasia.

An increase in the number of whole organs or their parts is called multiplication. Doubling is usually observed. Anomalies of the female genitalia, in which individual organs form an integral anatomical structure, are called fusion. With an unusual localization of the organ, they speak of ectopia. According to the severity, there are three types of anomalies of the female genital organs. The first is the lungs, which do not affect the functions of the genitals. The second is of moderate severity, having a certain effect on the functions of the reproductive system, but not excluding childbearing. The third is severe, accompanied by gross violations and incurable infertility.

Causes of anomalies of the female genital organs

This pathology occurs under the influence of internal and external teratogenic factors. Internal factors include genetic disorders and pathological conditions of the mother's body. These factors include all kinds of mutations and burdened heredity of unclear etiology. Relatives of the patient may have malformations, infertile marriages, multiple miscarriages, and high infant mortality.

The list of internal factors that cause anomalies of the female genital organs also includes somatic diseases and endocrine disorders. Some experts in their studies mention the age of parents over 35 years old. Among the external factors contributing to the development of anomalies of the female genital organs, indicate drug addiction, alcoholism, taking a number of medications, poor nutrition, bacterial and viral infections (especially in the first trimester of gestation), occupational hazards, household poisoning, unfavorable environmental conditions, ionizing radiation , being in a war zone, etc.

The direct cause of anomalies of the female genital organs are violations of organogenesis. The most gross defects occur with adverse effects in the early stages of gestation. The laying of the paired Mullerian ducts occurs in the first month of gestation. At first they look like strands, but in the second month they transform into channels. Subsequently, the lower and middle parts of these canals merge, the rudiment of the uterus is formed from the middle part, and the rudiment of the vagina is formed from the lower part. At 4-5 months, the body and cervix are differentiated.

Fallopian tubes, originating from the upper, not merged part of the Müllerian ducts, are laid at 8-10 weeks. Tube formation is completed by 16 weeks. The hymen originates from the lower part of the fused ducts. The external genitalia are formed from the skin and the genitourinary sinus (anterior part of the cloaca). Their differentiation is carried out at 17-18 weeks of gestation. The formation of the vagina begins at week 8, its increased growth occurs at week 19.

Variants of anomalies of the female genital organs

Anomalies of the external genitalia

Malformations of the clitoris can manifest as agenesis, hypoplasia and hypertrophy. The first two defects are extremely rare anomalies of the female genital organs. Clitoral hypertrophy is found in congenital adrenogenital syndrome (congenital adrenal hyperplasia). Severe hypertrophy is considered as an indication for surgical correction.

Anomalies of the vulva, as a rule, are detected as part of multiple malformations, combined with congenital defects of the rectum and lower urinary system, which is due to the formation of these organs from the common cloaca. There may be such anomalies of the female genital organs as hypoplasia of the labia majora or infection of the vagina, combined or not combined with the infection of the anus. Often there are rectovestibular and rectovaginal fistulas. Operative treatment - plastic of the labia, plastic of the vagina, excision of the fistula.

Anomalies of the hymen and vagina

Anomalies of the ovaries and fallopian tubes

Quite common anomalies of the fallopian tubes are congenital obstruction and various types of tube underdevelopment, usually combined with other signs of infantilism. Anomalies of the female genital organs that increase the risk of developing an ectopic pregnancy include asymmetric fallopian tubes. Rarely, malformations such as aplasia, complete doubling of the tubes, splitting of the tubes, blind passages and additional holes in the tubes are detected.

Anomalies of the ovaries usually occur with chromosomal disorders, combined with congenital defects or disruption of the activity of other organs and systems. Ovarian dysgenesis is observed in and Klinefelter's syndrome. Agenesis of one or both gonads and complete duplication of the ovaries are extremely rare anomalies of the female genital organs. Ovarian hypoplasia is possible, usually combined with underdevelopment of other parts of the reproductive system. Cases of ovarian ectopia and the formation of additional gonads adjacent to the main organ are described.

The development of pregnancy in an abnormal fallopian tube is an indication for urgent tubectomy. With normally functioning ovaries and abnormal tubes, pregnancy is possible by in vitro fertilization of an egg taken during puncture of the follicle. In cases of ovarian anomalies, it is possible to use reproductive technologies with fertilization

Chapter 18

Chapter 18

The incorrect position of the genital organs is characterized by persistent deviations from the physiological position, arising under the influence of inflammatory processes, tumors, injuries and other factors.

(Fig. 18.1)

The physiological position of the genital organs is provided by several factors:

The presence of the ligamentous apparatus of the uterus (suspension, fixation and support);

Own tone of the genital organs, which is provided by the level of sex hormones, the functional state of the nervous system, age-related changes;

The relationship between the internal organs and the coordinated functioning of the diaphragm, abdominal wall and pelvic floor.

The uterus can move both in the vertical plane (up and down), and in the horizontal. Of particular clinical importance are pathological anteflexia (hyperanteflexia), posterior displacement of the uterus (retroflexia) and its prolapse (prolapse).

Rice. 18.1. Physiological (normal) position of the genitals

Hyperanteflexia- pathological inflection of the uterus anteriorly, when an acute angle is created between the body and the cervix (<70°). Патологическая антефлексия может быть следствием полового инфантилизма, реже это результат воспалительного процесса в малом тазу.

Clinical picture hyperanteflexia corresponds to that of the underlying disease that caused the abnormal position of the uterus. The most typical complaints are menstrual dysfunctions of the type of hypomenstrual syndrome, algomenorrhea. Often there are complaints of infertility (usually primary).

Diagnosis established on the basis of characteristic complaints and vaginal examination data. As a rule, a small uterus is found, sharply deviated anteriorly, an elongated conical cervix, a narrow vagina and flattened vaginal vaults.

Treatment hyperanteflexia is based on the elimination of the causes that caused this pathology (treatment of the inflammatory process). In the presence of severe algomenorrhea, various painkillers are used. Antispasmodics are widely used (no-shpa ♠, meta-mizole sodium - baralgin ♠, etc.), as well as antiprostaglandins: indomethacin, phenylbutazone and others, which are prescribed 2-3 days before the onset of menstruation.

Retroflexion of the uterus characterized by the presence of an angle between the body and the cervix, open posteriorly. In this position, the body of the uterus is tilted backwards, and the cervix is ​​forward. In retroflexion, the bladder remains uncovered by the uterus, and loops of intestine exert constant pressure on the anterior surface of the uterus and the posterior wall of the bladder. As a result, prolonged retroflexion contributes to the prolapse or prolapse of the genital organs.

Distinguish mobile and fixed retroflexion of the uterus. Mobile retroflection is a consequence of a decrease in the tone of the uterus and its ligaments during birth trauma, tumors of the uterus and ovaries. Movable retroflexion is also often found in women with an asthenic physique and with pronounced weight loss due to general severe diseases. Fixed retroflexion of the uterus is observed in inflammatory processes in the pelvis and endometriosis.

Clinical symptoms. Regardless of the retroflexion option, patients complain of pulling pains in the lower abdomen, especially before and during menstruation, dysfunction of neighboring organs and menstrual function (algomenorrhea, menometrorrhagia). In many women, retroflexion of the uterus is not accompanied by any complaints and is detected by chance during a gynecological examination.

Diagnostics retroflexion of the uterus usually does not present any difficulties. A bimanual examination reveals a posteriorly deviated uterus, palpable through the posterior fornix of the vagina. Mobile retroflexion of the uterus is eliminated quite easily - the uterus is transferred to its normal position. With fixed retroflexion, it is usually not possible to remove the uterus.

Treatment. With asymptomatic retroflexion of the uterus, treatment is not indicated. Retroflection with clinical symptoms requires treatment of the underlying disease that caused this pathology (inflammatory processes, endometriosis). In severe pain syndrome, laparoscopy is indicated to clarify the diagnosis and eliminate the cause of pain.

Pessaries, surgical correction and gynecological massage, which were previously widely used to keep the uterus in the correct position, are not currently used.

Omission and prolapse (prolapse) of the uterus and vagina. The prolapse of the uterus and vagina is of the greatest practical importance among the anomalies in the position of the genital organs. In the structure of gynecological morbidity, prolapse and prolapse of the genital organs account for up to 28%. Due to the anatomical proximity and commonality of supporting structures, this pathology often causes anatomical and functional failure of adjacent organs and systems (urinary incontinence, anal sphincter failure).

There are the following options for prolapse and prolapse of the genital organs:

Omission of the anterior wall of the vagina. Often, along with it, a part of the bladder drops out, and sometimes a part of the bladder falls out - a cystocele (cystocele;

rice. 18.2);

Prolapse of the posterior wall of the vagina, which is sometimes accompanied by prolapse and prolapse of the anterior wall of the rectum - rectocele (rectocele; fig.18.3);

Omission of the posterior fornix of the vagina of varying degrees - enterocele (enterocele);

Rice. 18.2. Cystocele: a - defect of the pubocervical fascia; b - scheme

Rice. 18.3. Rectocele (rectovaginal septal defect - scheme)

Incomplete prolapse of the uterus: the cervix reaches the genital slit or goes outside, while the body of the uterus is within the vagina (Fig. 18.4);

Complete prolapse of the uterus: the entire uterus extends beyond the genital gap (Fig. 18.5).

Often, with the omission and prolapse of the genital organs, there is an elongation of the cervix - elongation (Fig. 18.6).

Rice. 18.4. Incomplete prolapse of the uterus. Decubital ulcer

Rice. 18.5. Complete prolapse of the uterus. Decubital ulcer on back lip

Rice. 18.6. Elongation of the cervix

A special group is posthysterectomy prolapses- omission and prolapse of the stump of the neck and stump (dome) of the vagina.

The degree of genital prolapse is determined using the International classification according to the POP-Q (Pelvic Organ Prolapse Quantification) system - this is a quantitative classification based on the measurement of nine parameters: Aa - urethrovesical segment; Ba - anterior wall of the vagina; Ap - lower part of the rectum; Bp - above the levators; C - Cervix (neck); D - Douglas (rear vault); TVL is the total length of the vagina; Gh - genital gap; Pb - perineal body (Fig. 18.7).

According to the above classification, the following degrees of prolapse are distinguished:

Stage 0 - no prolapse. Parameters Aa, Ar, Ba, Bp - all - 3 cm; points C and D - ranging from TVL to (TVL - 2 cm) with a minus sign.

Stage I - Criteria for Stage 0 are not met. The most distal part of the prolapse is >1 cm above the hymen (value > -1 cm).

Stage II - the most distal part of the prolapse<1 см проксимальнее или дистальнее гимена (значение >-1 but<+1 см).

Rice. 18.7. Classification of genital prolapse according to the POP-Q system. Explanations in the text

Stage III - the most distal part of the prolapse > 1 cm distal to the hymenal plane, but no more than TVL - 2 cm (value<+1 см, но

Stage IV - complete loss. The most distal part of the prolapse protrudes more than TVL - 2 cm.

Etiology and pathogenesis. Prolapse and prolapse of the genital organs is a polyetiological disease. The main cause of genital prolapse is rupture of the pelvic fascia due to pathology of the connective tissue under the influence of various factors, including the failure of the pelvic floor muscles and increased intra-abdominal pressure.

It is generally accepted that the three-level concept of support for the pelvic organs is Delancey(Fig. 18.8).

Risk factors for developing genital prolapse are:

Traumatic childbirth (large fetus, prolonged, repeated childbirth, vaginal delivery operations, perineal ruptures);

Failure of connective tissue structures in the form of "systemic" insufficiency, manifested by the presence of hernias of other localizations - connective tissue dysplasia;

Violation of the synthesis of steroid hormones (estrogen deficiency);

Chronic diseases, accompanied by a violation of metabolic processes, microcirculation.

Clinical symptoms. Prolapse and prolapse of the genital organs develops slowly. The main symptom of prolapse of the uterus and vaginal walls is detected by the patient herself. the presence of a "foreign body" outside the vagina. The surface of the prolapsed part of the genital organs, covered with a mucous membrane, undergoes keratinization, takes the form

Rice. 18.8. Three-level pelvic support concept Delancey

Rice. 18.9. Prolapse of the uterus. Decubital ulcer

dull dry skin with cracks, abrasions, and then ulcerations. Subsequently, patients complain of feeling of heaviness and pain in the lower abdomen, lower back, sacrum, aggravated during and after walking, when lifting weights, coughing, sneezing. Stagnation of blood and lymph in the prolapsed organs leads to cyanosis of the mucous membranes and swelling of the underlying tissues. On the surface of the prolapsed cervix, a decubital ulcer is often formed (Fig. 18.9).

Uterine prolapse is accompanied difficulty urinating, the presence of residual urine, stagnation in the urinary tract and then infection, first of the lower, and with the progression of the process, of the upper parts of the urinary system. Long-term complete prolapse of the internal genital organs can be the cause of hydronephrosis, hydroureter, obstruction of the ureters.

Every 3rd patient with genital prolapse develops proctological complications. The most frequent of them is constipation, moreover, in some cases it is the etiological factor of the disease, in others it is a consequence and manifestation of the disease.

Diagnosis omission and prolapse of the genital organs are put on the basis of data from a gynecological examination. After examination for palpation, the prolapsed genitals are set and a bimanual examination is performed. At the same time, the condition of the pelvic floor muscles is assessed, especially m. levator ani; determine the size and mobility of the uterus, the condition of the uterine appendages and exclude the presence of other pathologies. A decubital ulcer must be differentiated from cervical cancer. For this, colposcopy, cytological examination and targeted biopsy are used.

With a mandatory rectal examination, attention is paid to the presence or severity of the rectocele, the state of the rectal sphincter.

Rice. 18.10. Options for uterine pessaries (a-c)

With severe urination disorders, it is necessary to conduct a study of the urinary system, according to indications, cystoscopy, excretory urography, urodynamic study.

Ultrasound of the pelvic organs is also shown.

Treatment. With small omissions of the internal genital organs, when the cervix does not reach the vestibule of the vagina, and in the absence of dysfunction of neighboring organs, conservative management of patients is possible using a set of physical exercises aimed at strengthening the muscles of the pelvic floor (Kegel exercises), physiotherapy exercises, wearing a pessary (Fig. .18.10).

With more severe degrees of prolapse and prolapse of the internal genital organs, surgical treatment is used. For the treatment of prolapse and prolapse of the genital organs, there are various types of surgical operations (more than 200). The vast majority of them today are only of historical interest.

At the present level, surgical correction of descents and prolapses of the genital organs can be carried out by various approaches: vaginal, laparoscopic and laparotomic. The choice of access and method of surgical intervention in patients with prolapse and prolapse of the genital organs is determined by:

prolapse of the internal genital organs; the presence of concomitant gynecological pathology and its nature; the possibility and necessity of maintaining or restoring reproductive, menstrual functions; features of dysfunction of the colon and rectal sphincter, age of patients; concomitant extragenital pathology, the degree of risk of surgical intervention and anesthesia.

In the surgical correction of genital prolapse, both the patient's own tissues and synthetic materials can be used to strengthen the anatomical structures. Currently, preference is given to synthetic materials.

We list the main operations used by most gynecologists in the treatment of prolapse and prolapse of the genital organs.

1. Anterior colporrhaphy - plastic surgery on the anterior wall of the vagina, which consists in cutting out and excising a flap from

excess tissue of the anterior wall of the vagina. It is necessary to isolate the fascia of the anterior wall of the vagina and sutured it with separate sutures. In the presence of a cystocele (diverticulum of the bladder), the fascia of the bladder is opened and sutured in the form of a duplicate (Fig. 18.11).

Anterior colporrhaphy is indicated for prolapse of the anterior vaginal wall and/or cystocele.

2. Colpoperineolevathoroplasty- the operation is aimed at strengthening the pelvic floor. It is performed as the main benefit or as an additional operation for all types of surgical interventions for prolapse and prolapse of the genital organs.

The essence of the operation is to remove excess tissue from the posterior wall of the vagina and restore the muscular-fascial structure of the perineum and pelvic floor. When performing this operation, special attention must be paid to the selection of levators. (m. levator ani) and linking them together. With a pronounced rectocele, diverticulum of the rectum, it is necessary to suture the fascia of the rectum and the fascia of the posterior wall of the vagina with dip sutures (Fig. 18.12).

3. Manchester operation- recommended for omission and incomplete prolapse of the uterus, especially with elongation of its neck and the presence of a cystocele. The operation is aimed at strengthening the fixing apparatus of the uterus - the cardinal ligaments by stitching them together, transposition.

The Manchester operation includes several stages: amputation of the elongated cervix and shortening of the cardinal ligaments, anterior colporrhaphy and colpoperineolevatoroplasty. Amputation of the cervix, performed during the Manchester operation, does not exclude future pregnancy, but vaginal delivery after this operation is not recommended.

4. Vaginal hysterectomy consists in removing the latter by vaginal access, while anterior colporrhaphy and colpoperineolevathoroplasty are also performed (Fig. 18.13). The disadvantages of vaginal extirpation of the uterus when it prolapses include the possibility of recurrence in the form of an enterocele, the cessation of menstrual and reproductive functions in patients of reproductive age, a violation of the architectonics of the small pelvis, the possibility of progression of violations of the function of neighboring organs (bladder, rectum). Vaginal hysterectomy is recommended for elderly patients who are not sexually active.

5. Two-stage combined operation in the modification of V.I. Krasnopolsky et al. (1997), which consists in strengthening the sacro-uterine ligaments with aponeurotic flaps cut from the aponeurosis of the external oblique muscle of the abdomen (performed extraperitoneally) in combination with colpoperineolevatoroplasty. This technique is universal - it can be used with a preserved uterus, with recurrence of prolapse of the stump of the cervix and vagina, in combination with amputation and extirpation of the uterus. Currently, this operation is performed by laparoscopic access using synthetic materials instead of aponeurotic flaps.

Rice. 18.11. Stages of anterior colporrhaphy: a - suturing of the bladder fascia by applying a purse-string suture and b - 2nd floor of interrupted sutures; c - suturing the vagina with interrupted sutures

Rice. 18.12. Stages of colpoperineolevathoroplasty: a - separation of the mucous membrane of the posterior wall of the vagina; b - separation and isolation of the muscle that raises the anus; c-d - suturing on m. levator ani; e - suturing the skin of the perineum

6. Colpopexy(fixation of the dome of the vagina). Colpopexy is performed on women who are sexually active. The operation can be performed with different accesses. With vaginal access, the dome of the vagina is fixed to the sacrospinous ligament (usually on the right). With laparoscopic or abdominal access, the dome of the vagina is fixed to the anterior longitudinal ligament of the sacrum using a synthetic mesh. (promontofixation, or sacropexy). Such an operation can be performed both after extirpation of the uterus and after its supravaginal amputation (the dome of the vagina or the stump of the cervix is ​​fixed).

7. Operations of suturing (obliteration) of the vagina(operations of Lefort-Neigebauer, Labgardt) are non-physiological, exclude the possibility of

Rice. 18.13. Stages of vaginal extirpation of the uterus: a - circular incision of the vaginal wall; b, c - dissection and ligation of cardinal ligaments and vascular bundles; d - suturing the peritoneum of the pelvis with a purse-string suture; e - stitching the stumps of the cardinal ligaments and the stumps of the uterine appendages together

life, relapses of the disease also develop. These operations are performed only in old age with complete prolapse of the uterus (if there is no pathology of the cervix and endometrium) or the dome of the vagina. These operations are extremely rare.

8. Vaginal extraperitoneal colpopexy (TVM operation - transvaginal mesh) - a system for the complete restoration of a damaged pelvic fascia using a synthetic prosthesis. Many different mesh prostheses have been proposed, the most versatile and easy-to-use system for restoring the pelvic floor Gynecare prolift(Fig. 18.14). This system completely eliminates all anatomical defects of the pelvic floor according to a standardized technique. Depending on the location of the defect, the procedure can be performed as a reconstruction of the anterior or posterior sections or a complete restoration of the pelvic floor.

For plasty of a cystocele, a transobturator approach is used with fixation of the free parts of the prosthesis behind the distal and proximal parts of the tendinous arch of the pelvic fascia (arcus tendineus). The posterior wall of the vagina is reinforced with a prosthesis passed through the sacrospinal ligaments. Being located under the fascia, the mesh prosthesis duplicates the contour of the vaginal tube, reliably eliminating prolapse without changing the direction of the vector of the physiological displacement of the vagina (Fig. 18.15).

The advantages of this technique are in the versatility of its application, including recurrent forms of prolapse in previously operated patients, patients with extragenital pathology. In this case, the operation can be performed in combination with a hysterectomy, amputation of the cervix, or with preservation of the uterus.

Rice. 18.14. mesh prosthesis Gynecare prolift

Rice. 18.15. Scheme of installation of the prosthesis: 1 - the front part of the prosthesis, installed under the bladder; 2 - dome of the vagina; 3 - the back of the prosthesis, installed above the wall of the rectum; 4, 5 - flaps of the prosthesis, brought out through the obturator opening in the region of the inguinal folds; 6 - in the buttocks

18.1. Urinary incontinence

Urinary incontinence (involuntary urination) - a pathological condition in which volitional control of the act of urination is lost. This pathology is a social and medical-hygienic problem. Urinary incontinence is a disease that occurs both in young and old age and does not depend on living conditions, the nature of the work or the ethnicity of the patient. According to European and American statistics, about 45% of the female population aged 40-60 years, to one degree or another, have symptoms of involuntary loss of urine. According to domestic studies, symptoms of urinary incontinence occur in 38.6% of Russian women.

The normal functioning of the bladder is possible only with the preservation of innervation and the coordinated work of the pelvic floor. When the bladder is full, resistance increases in the area of ​​the internal opening of the urethra. The detrusor remains relaxed. When the volume of urine reaches a certain threshold, impulses are sent from the stretch receptors to the brain, triggering the urination reflex. In this case, a reflex contraction of the detrusor occurs. In the brain is the urinary center associated with the cerebellum. The cerebellum coordinates the relaxation of the pelvic floor muscles, as well as the amplitude and frequency of detrusor contractions during urination. The signal from the urethral center enters the brain and is transmitted to the corresponding center located

in the sacral segments of the spinal cord, and from there to the detrusor. This process is controlled by the cerebral cortex, which exerts inhibitory influences on the center of urination.

Thus, the process of urination is normally an arbitrary act. Complete emptying of the bladder occurs due to prolonged contraction of the detrusor while relaxing the pelvic floor and urethra.

Urinary retention is influenced by various external and internal factors.

External factors - pelvic floor muscles that contract when intra-abdominal pressure rises, compressing the urethra and preventing involuntary leakage of urine. With the weakening of the visceral fascia of the pelvis and the muscles of the pelvic floor, the support they create for the bladder disappears, and pathological mobility of the bladder neck and urethra appears. This leads to stress incontinence.

Internal factors - muscular membrane of the urethra, sphincters of the bladder and urethra, folding of the mucous membrane, the presence of α-adrenergic receptors in the muscular membrane of the urethra. Insufficiency of internal factors occurs with malformations, estrogen deficiency and innervation disorders, as well as after injuries and as a complication of some urological operations.

There are several types of urinary incontinence in women. The most common are stress urinary incontinence and bladder instability (overactive bladder).

For diagnosis and treatment, the most difficult cases are those with complex (in combination with genital prolapse) and combined (combination of several types of urinary incontinence) forms of urinary incontinence.

Stress urinary incontinence (stress incontinence - SUI)- uncontrolled loss of urine during physical effort (coughing, laughing, straining, playing sports, etc.), when the pressure in the bladder exceeds the closing pressure of the urethra. Stress incontinence may be due to dislocation and weakening of the ligamentous apparatus of the unchanged urethra and urethrovesical segment, as well as insufficiency of the urethral sphincter.

clinical picture. The main complaint is the involuntary leakage of urine during exercise without the urge to urinate. The intensity of urine loss depends on the degree of damage to the sphincter apparatus.

Diagnostics consists in establishing the type of urinary incontinence, the severity of the pathological process, assessing the functional state of the lower urinary tract, identifying possible causes of urinary incontinence and choosing a correction method. During perimenopause, the frequency of urinary incontinence increases slightly.

Patients with urinary incontinence are examined in three stages.

Stage 1 - clinical examination. Most often, stress urinary incontinence occurs in patients with prolapse and prolapse of the genital organs, so the patient should be examined in the gynecological chair (as

the ability to detect prolapse of the genital organs, assess the mobility of the bladder neck during a cough test or straining, the condition of the skin of the perineum and the mucous membrane of the vagina); in severe forms of urinary incontinence, the skin of the perineum is irritated, hyperemic, sometimes with areas of maceration.

When collecting an anamnesis, risk factors are ascertained: among them are the number and course of childbirth (large fetus, perineal injuries), heavy physical exertion, obesity, varicose veins, splanchnoptosis, somatic pathology accompanied by an increase in intra-abdominal pressure (chronic cough, constipation), previous surgical interventions on the pelvic organs.

Laboratory examination methods include a clinical analysis of urine and urine culture for microflora.

The patient is advised to keep a urination diary for 3-5 days, noting the amount of urine released per urination, the frequency of urination per day, all episodes of urinary incontinence, the number of pads used and physical activity. Such a diary allows you to evaluate urination in a familiar environment for a sick person.

For the differential diagnosis of stress urinary incontinence and an overactive bladder, it is necessary to use a specialized questionnaire and a table of working diagnoses (Table 18.1).

Table 18.1. List of working diagnoses for differential diagnosis

2nd stage - ultrasound; is carried out not only to exclude or confirm the presence of pathology of the genital organs, but also to study the urethro-vesical segment, as well as the condition of the urethra in patients with stress urinary incontinence. Ultrasound of the kidneys is also recommended.

During abdominal scanning, the volume, shape of the bladder, the amount of residual urine are assessed, and the pathology of the bladder (diverticula, stones, tumors) is excluded.

3rd stage - combined urodynamic study (CUDI)- an instrumental research method using special equipment that allows you to diagnose the type of urinary incontinence. Especially KUDI

Rice. 18.16. Vaginal cones and balls to strengthen the pelvic floor

indicated for suspected combined disorders, when it is necessary to determine the predominant type of urinary incontinence. Indications for mandatory CUDI are: lack of effect from ongoing therapy, recurrence of urinary incontinence after treatment, discrepancy between clinical symptoms and research results. KUDI allows you to develop the right treatment tactics and avoid unnecessary surgical interventions.

Treatment. Numerous methods have been proposed for the treatment of stress urinary incontinence, which are combined into groups: conservative, medical, surgical. Conservative and medical methods:

Exercises to strengthen the muscles of the pelvic floor;

Replacement hormone therapy in menopause;

The use of α-sympathomimetics;

Pessaries, vaginal cones, balls (Fig. 18.16);

Removable urethral obturators.

Surgical methods. Of all the known surgical techniques for the correction of stress urinary incontinence, sling operations turned out to be the most effective.

Sling (loop) operations consist in imposing a loop around the neck of the bladder. At the same time, preference is given to minimally invasive interventions using freely located synthetic loops (TVT, TVT-O, TVT SECUR). The most common and minimally invasive sling operation is transobturator urethrovesico-pexy with a free synthetic loop (Transobturator vaginal tape - TVT-O). During the operation, a synthetic prolene loop is inserted from an incision in the anterior vaginal wall in the area of ​​the middle urethra through a

Rice. 18.17. Synthetic loop for TVT-O

foramen magnum on the inner surface of the thigh - retrograde

(Fig. 18.17, 18.18).

Periurethral injections are a minimally invasive method of treating bladder sphincter insufficiency, which consists in introducing special substances into the tissues that facilitate the closure of the urethra with an increase in intra-abdominal pressure (collagen, autofat, Teflon).

Conservative methods of treatment are possible with a mild degree of urinary incontinence or the presence of contraindications to the surgical method.

Difficulties in choosing a method of treatment arise when urinary incontinence is combined with prolapse and prolapse of the genital organs. Plastic surgery of the anterior wall of the vagina as an independent type of surgery for cystocele and stress urinary incontinence is ineffective; it must be combined with one of the types of anti-stress operations.

The choice of surgical treatment for uterine prolapse depends both on the age of the patient, the presence and nature of the pathology of the internal genital organs (uterus and its appendages), and on the capabilities of the surgeon performing the operation. Various operations can be performed: vaginal hysterectomy, vaginal extraperitoneal colpopexy using synthetic prostheses, sacrovaginopexy. But all these interventions must be combined with one of the types of sling (loop) operations.

Detrusor instability, or an overactive bladder manifested by urinary incontinence. In this case, patients experience involuntary urination with an imperative (immediate) urge to urinate. The characteristic symptoms of an overactive bladder are also frequent urination and nocturia.

The main method for diagnosing an overactive bladder is a urodynamic study.

An overactive bladder is treated with anticholinergic drugs - oxybutynin (driptan ♠), tolterodine (detrusitol ♠),

Rice. 18.18. Scheme of installation of synthetic loop TVT-O

trospium chloride (Spasmex♠), solifenacin (Vesicar♠), tricyclic antidepressants (imipramine), and bladder training. All postmenopausal patients simultaneously undergo HRT: suppositories with estriol (topically) or systemic drugs, depending on age.

With unsuccessful attempts at conservative treatment, adequate surgical intervention is necessary to eliminate the stress component.

Combined forms of urinary incontinence(a combination of detrusor instability or its hyperreflexia with stress urinary incontinence) present difficulties in choosing a treatment method. Detrusor instability can also be detected in patients at different times after anti-stress operations as a new urination disorder.

test questions

1. What factors contribute to the occurrence and progression of genital prolapse?

2. Give a classification of prolapse and prolapse of the genital organs.

3. In what cases of genital prolapse are conservative methods of treatment indicated?

4. List the most commonly used operations in the treatment of prolapse and prolapse of the genital organs.

5. Physiology of the act of urination.

6. Types of urinary incontinence in women.

7. What are the clinical features of stress urinary incontinence and overactive bladder?

8. Indicate methods for diagnosing the causes of urinary incontinence.

9. List the treatments for stress urinary incontinence.

10. Therapeutic tactics for overactive bladder.

Gynecology: textbook / B. I. Baisova and others; ed. G. M. Savelyeva, V. G. Breusenko. - 4th ed., revised. and additional - 2011. - 432 p. : ill.

Under normal conditions, the uterus is located in the center of the small pelvis and has a certain physiological mobility. With an empty bladder, the bottom and body of the uterus are directed forward; the front surface looks forward and down; the body of the uterus forms an angle with the cervix, open anteriorly. The position of the uterus changes during pregnancy, with a full bladder or rectum.

The reasons for the incorrect position of the uterus (bends, displacements - backwards or to the side (left, right), omissions, twisting and kinks) are most often inflammatory processes in the pelvic tissue, which occur with diseases not only of the internal genital organs, but also of the intestine. Incorrect position of the uterus can also occur with: abnormalities of its development; neoplasms localized in various parts of the reproductive system; multiple pregnancies and childbirth; birth injuries of the muscles and ligaments of the perineum; hypodynamia, leading to weakening of the muscles and ligaments of the abdomen and pelvis.

Prolapse and prolapse of the uterus. Prolapse of the uterus called a condition in which the uterus or the walls of the vagina fall down without going beyond the genital gap. Uterine prolapse characterized by its partial or complete protrusion from the labia majora. The causes of these conditions are: violation of the integrity of the pelvic floor (unsewn perineal ruptures after childbirth); weakness of the abdominal muscles (especially in women who have given birth many times or in multiple pregnancies).

With the prolapse and prolapse of the uterus, changes in the vaginal mucosa are noted, which are expressed by dryness, smoothing of folds, the formation of trophic ulcers in the cervical region, and pseudo-erosion. In addition, the genitourinary system is involved in the pathological process: prolapse of the posterior wall of the bladder is noted; the structure of the rectum is disturbed - omission of its anterior wall is noted, which is accompanied by insufficiency of the anal sphincter: hemorrhoids develop.

There are three degrees of this disease: I degree - the uterus is displaced downward, the cervix is ​​​​located in the vagina; II degree - the body of the uterus in the vagina, the external pharynx of the cervix in the vestibule of the vagina or below it - "partial prolapse"; III degree - prolapse of the entire uterus and, to a large extent, the walls of the vagina outside the genital gap - "complete prolapse".

clinical picture. It is characterized by pulling pains in the lower abdomen, in the lumbar region and sacrum; violation of urination - complete or partial urinary incontinence during coughing, during physical exertion, lifting weights; the development of constipation. At III degree, urination is difficult. The general condition worsens, the ability to work is lost for a long time.

"Risk group" are: primiparous women with postpartum injuries of the perineum of the second degree; primiparous women who had a large fetus, especially with a breech presentation; women who completed childbirth by surgery.

Treatment. May be conservative or operative. As a rule, conservative treatment is effective in grade I. General strengthening procedures are used to increase the tone of the uterus, pelvic floor muscles and abdominal muscles. The leading place is occupied by physical exercises performed according to traditional and non-traditional methods, and massage (especially gynecological). At II and III degrees, surgical treatment is used.

Curvature of the uterus backwards or anteriorly. Retrodeviation is associated with a violation of the tone of the uterus and a change in the angle between its neck and body, overstretching of the ligamentous apparatus, and weakness of the pelvic floor muscles. The cause of the development of this disease may be the consequences of inflammatory diseases of the female genital organs, which caused the formation of adhesions. The mobility of the uterus decreases, which can cause spontaneous abortions, infringement of the pregnant uterus. The backward bend of the uterus often causes infertility.

With posterior bends of the uterus, fixed by adhesions, therapeutic exercises are used in combination with physio- and balneotherapy, gynecological massage.

Among the anomalies in the position of the genital organs, the most common pathology is prolapse and prolapse, which in the structure of gynecological morbidity is up to 28%. As a rule, the disease begins in the reproductive age and is always progressive. Omissions and prolapse of the internal genital organs refer to anomalies in the position of the genital organs.

Anomalies in the position of the internal genital organs of women can be congenital and acquired. This or that position of the internal genital organs is always associated with the position of the uterus, which is the central organ of the small pelvis in anatomical and topographic terms, so it is necessary to study the various positions of the uterus in physiological and pathological conditions.

What is the normal position of the uterus in the pelvis?

The normal (typical) position of the uterus in the small pelvis is called the position when the uterus, with the bladder and rectum empty, is in the middle of the small pelvis, the bottom is not higher than the plane of the entrance to the small pelvis, the vaginal part of the cervix is ​​at the level of the plane of the narrow part of the small pelvis. The bottom of the uterus is turned upwards and anteriorly, the vaginal part of the cervix is ​​downwards and backwards (Fig. 13.1). The angle formed by the cervix and body of the uterus is obtuse, open anteriorly (anteflexio uteri). The angle formed by the axis of the uterus and the so-called axis of the pelvic inlet (restored in the middle

Rice. 13.1. Normal position of the uterus in the pelvis

not the entrance to the small pelvis, the perpendicular, which, being continued downward, crosses the coccyx, and continued upward, crosses the navel), - anteversio uteri, while the cervix faces the sacrum, and the bottom of the uterus - to the bosom. The typical position of the uterus in the pelvis is denoted by the term "anteflexio - anteversio uteri".

What factors contribute to the normal position of the uterus in the pelvis?

The following factors contribute to the normal position of the uterus in the pelvis:

Own tone of the genital organs, depending on the proper functioning of all body systems, in particular the state of the nervous system, circulatory conditions, the level of sex hormones;

The relationship between the internal organs, the coordinated activity of the diaphragm, abdominal wall and pelvic floor;

Suspension, fixation and support apparatus of the uterus.

What is the classification of anomalies in the position of the genital organs?

There are displacements of the uterus along the horizontal and vertical planes, around the longitudinal axis.

What are the types of displacement of the uterus along the horizontal plane?

The displacement of the uterus in the horizontal plane can be as follows:

The entire uterus is displaced anteriorly (antepositio uteri);

The entire uterus is displaced backwards (retropositio uteri);

The uterus is displaced to the right (dextropositio uteri);

The uterus is displaced to the left (sinistropositio uteri).

What are the forms of displacement of the uterus around the longitudinal axis?

The displacements of the uterus around the longitudinal axis are as follows:

Rotation of the uterus (body and cervix) half-turn around the vertical axis - from right to left or, conversely, the rotation of the uterus (rotatio uteri);

Torsion of the uterus (torsio uteri)- rotation of the body of the uterus along the vertical axis more than 180? in the region of the isthmus with a fixed neck.

What are the types of displacement of the uterus along the vertical axis

(relative to the planes of the small pelvis)?

The displacements of the uterus along the vertical axis are as follows:

The uterus is displaced upward (elevatio uteri);

Prolapse of the uterus (descensus uteri);

uterine prolapse ( prolapsus s. procidentia uteri).

What is uterine prolapse?

Uterine prolapse (prolapsus uteri) sometimes incomplete (prolapsus uteri partialis) and complete ( prolapsus uteri totalis). In case of incomplete prolapse, when the patient strains, only the cervix comes out of the genital slit (Fig. 13.2), with complete prolapse, the cervix and body of the uterus go beyond the genital slit, which is usually accompanied by an eversion of the walls of the vagina; this situation is called a gynecological hernia - hernia genitalis(Fig. 13.3).

Rice. 13.2.Incomplete uterine prolapse

Rice. 13.3.Complete prolapse of the uterus

What is uterine inversion (inversio uteri)?

With this anomaly, the serous membrane of the uterus is located inside, the mucous membrane is outside, the body of the uterus is located in the vagina below the cervix (the uterus turned out like a finger of a glove) (Fig. 13.4). Such a situation is possible only in the third stage of labor, when they try to isolate the placenta with an unseparated placenta.

Rice. 13.4. Eversion of the uterus

What is the etiopathogenesis of anomalies in the position of the female genital organs?

In the occurrence of anomalies in the position of the female genital organs, the following factors play a role:

Congenital failure of the ligamentous and supporting apparatus of the uterus and connective tissue diseases (connective tissue dysplasia, CTD);

Injuries of the perineum during childbirth;

Anomalies in the development of the Mullerian (paramesonephric) ducts;

A large number of births;

Adhesive process in the small pelvis;

Tumors and tumor-like formations in the pelvis;

Chronic constipation;

flat feet;

Smoking (chronic bronchitis);

Obesity or, conversely, a sharp weight loss;

Hard physical labor, professional sports;

General asthenia, senile age.

What anomalies in the position of the female genital organs have the most important clinical significance?

These anomalies include:

Pathological anteflexia of the uterus (Fig. 13.5);

Retrodeviation of the uterus;

Prolapse and prolapse of the uterus and vaginal walls.

Rice. 13.5. Pathological anteflexia of the uterus

What is the characteristic of pathological anteflexion of the uterus?

Pathological anteflexia of the uterus (hyperanteflexio)- one of the manifestations of sexual infantilism. At the same time, an acute angle between the body and the cervix, the small size of the uterus and an elongated conical cervix are revealed. The basis of this pathology is the insufficient development of the internal genital organs as a result of various intoxications in childhood (infections, helminthic invasions, etc.).

What is the clinic of pathological anteflexia of the uterus?

Painful menstruation, infertility, decreased libido, menstrual irregularities like hypomenstrual syndrome, late onset of menstruation, and frequent urge to urinate are characteristic.

What is characteristic of retrodeviation of the uterus?

Retrodeviation of the uterus develops mainly in adulthood. She can be mobile. (retroversio - retroflexio mobile) or fixed (retroversio - retroflexio fixata) due to the presence of strong adhesions that cause fusion of the uterus with the back wall of the pelvis.

What changes in the uterus are observed during its retrodeviation?

With retrodeviation of the uterus, its blood circulation is disturbed, the uterus becomes edematous, chronic metritis, hyperplastic endometritis may develop, the uterus increases in volume, acquires a rounded shape, its consistency is dense - uterine hypertrophy is observed due to the development of connective tissue (Fig. 13.6).

Rice. 13.6. Retrodeviation of the uterus

What is the clinic of retrodeviation of the uterus?

Possible dull pains in the lower abdomen, in the sacrum with irradiation to the thighs, menstrual disorders such as menorrhagia, algomenorrhea, leucorrhoea, infertility, although often there are no complaints, so there is an alternative point of view, according to which retrodeviation is a variant of the norm, occurring in 20% of healthy women. But at the same time, retrodeviation of the uterus should be differentiated from the Alain-Masters syndrome, adenomyosis.

What are the risk factors for prolapse and prolapse of the uterus and vaginal walls?

1. Failure of the ligamentous apparatus of the uterus and pelvic floor (which can be caused by congenital connective tissue dysplasia, birth trauma, estrogen deficiency, age-related changes in muscle and connective tissue, some extrageni-

metabolic disorders such as diabetes mellitus).

2. Increased intra-abdominal pressure, which, in turn, can also be the result of several causes (heavy physical labor, chronic lung diseases, constipation, etc.).

What is the mechanism for the development of omission

and prolapse of the uterus and vaginal walls?

Under the influence of a constant or sharp increase in intra-abdominal pressure, internal organs descend not only in women who already have pelvic floor muscle failure and weakness of the ligamentous apparatus, but also in women with intact anatomical and functional structures of the pelvic floor.

The force of intra-abdominal pressure is balanced by the resistance of soft tissue structures that fill the space between the pelvic bones. Normally, the resistance provided by soft tissues is sufficient to withstand intra-abdominal pressure without tearing and insufficiency of the pelvic floor.

At present, the theory has received the greatest recognition and scientific confirmation, according to which the main anatomical cause of prolapse is the occurrence of defects (ruptures) in the pubocervical (Galban's fascia - Fig. 13.7) and rectovaginal (Denonville's fascia - Fig. 13.8) fascia , as well as their separation from the walls of the pelvis.

Fig.13.7. Fascia Galban

Fig.13.8.Fascia Denonvilliers

Prolapse of the genitals as a result of ruptures of the fascia can be compared with rotten floorboards in a hut (Fig. 13.9).

What causes a pelvic floor defect?

The defect of the pelvic floor can be due to two reasons: the excess of the acting force of the strength of the unchanged structures of the pelvic floor and the presence of weak points that could not withstand even the usual force of impact. These causes - overuse and anatomical weakness - are often combined. The location of the defect (defects) determines which organs will prolapse.

Rice. 13.9.Genital prolapse model

Rice. 13.10.The prolapse of the walls of the vagina. Moderate cysto- and rectocele

What is a cystocele?

This is a prolapse of the anterior wall of the vagina along with the bladder, and the course of the urethra and the bending of its upper section downwards change (Fig. 13.10)

What is a ureterocele?

This is a prolapse of the proximal urethra, which is more common in combination with a cystocele.

What is a rectocele?

This is a prolapse of the posterior wall of the vagina with the anterior wall of the rectum.

What is an enterocele?

This is the omission and eversion of the posterior fornix of the vagina, and then its posterior wall or dome of the vagina after hysterectomy with the formation of a hernial sac containing loops of the small intestine.

What is the clinic of prolapse and prolapse of the uterus?

With this pathology, the following symptoms are observed: pulling pains in the lower abdomen and in the lower back, which are aggravated by physical exertion, dysuria, chronic constipation. With complete prolapse, patients feel a foreign body in the vulva that interferes with walking, difficulty urinating, which is sometimes impossible if the prolapsed uterus is not filled, blood discharge from ulcerated areas of the cervix (decubital ulcer). With the onset of menopause as a result of estrogen deprivation, a decrease in the overall tone of the body and changes in tissue trophism, the disease begins to progress rapidly.

What changes in the genital organs are observed during their prolapse and prolapse?

The fallen walls of the vagina become dry, rough, calloused, edematous, the folds of the vagina are smoothed out, the mucosa acquires a whitish color. On the mucous membrane of the vagina and cervix, trophic ulcers are formed with sharply defined edges and a purulent coating on the bottom. They note the difficulty in the outflow of venous blood, its stagnation, which leads to edema and an increase in the volume of the vaginal part of the cervix. With incomplete prolapse of the uterus, the cervix often elongates. (elongatio colli uteri), as a result of which its length along the probe reaches 10-15 cm with the usual length of its body

(Fig. 13.11).

What are the diagnostic methods for this pathology?

Diagnosis of prolapse and prolapse of the internal genital organs is not difficult. The diagnosis is made on the basis of anamnesis, characteristic complaints, gynecological examination when the patient is straining, data from a bimanual examination and palpation of the prolapsed genitals.

Rice. 13.11.Hypertrophy and lengthening of the cervix

What are the therapies?

1. Conservative treatment - general strengthening therapy, good nutrition, water procedures, therapeutic exercises (Kegel), changing working conditions, uterine massage.

2. Orthopedic methods. Currently, pessary treatment, which was previously common, is rarely used due to the threat of bedsores, ascending infection, and the necessary systematic medical supervision. Various kinds of belts, bandages are used, however, all these methods have a strictly limited application - only if it is impossible to perform a surgical operation, for example, severe somatic pathology or old age. All conservative methods are palliative.

3. Surgical methods.

What is the indication for surgical treatment of this pathology?

1. The degree of prolapse of the internal genital organs.

2. Anatomical and functional changes in the organs of the reproductive system (the presence and nature of concomitant gynecological pathology).

3. The possibility and necessity of maintaining or restoring reproductive, menstrual functions.

4. Features of dysfunction of the bladder and rectum.

5. Age of patients, sexual function.

6. Concomitant extragenital pathology and the degree of risk of surgical intervention and anesthesia.

What operations are most often performed in this pathology?

The most rational in the systematization of operations used for genital prolapse is their classification proposed by V.I. Krasnopolsky et al. (1997), which combines them into 7 groups. As the main sign of division into groups, the author uses an anatomical formation used to strengthen and correct the position of the internal genital organs.

Group I- operations aimed at strengthening the muscles of the pelvic floor, - colpoperineolevathoroplasty, as well as anterior colporrhaphy.

Group II- operations using various modifications to shorten and strengthen the round ligaments of the uterus, as well as operations to fix the uterus using round ligaments. The most typical and frequently used interventions are shortening of the round uterine ligaments with their fixation to the anterior wall of the uterus, shortening of the round ligaments of the uterus with their fixation to the posterior wall of the uterus (according to Webster-Baldi-Dartig), shortening of the round ligaments through the inguinal canals (according to Alexander-Adams ), ventrosuspension of the uterus (according to Dolery-Gilliams) and ventrofixation of the uterus (according to Kocher).

Group III- operations aimed at strengthening the fixing apparatus of the uterus and transferring the position of the body of the uterus to the state hyperanteflexio by suturing the cardinal or sacro-uterine ligaments to each other and transposing them to the anterior wall of the cervix with a non-absorbable Fothergill suture. This group includes the Manchester operation and its more complex modification - Shirodkar cervicopexy. Preservation of a prolapsed uterus is especially indicated for young women who wish to maintain fertility.

Group IV- operations with rigid fixation of the internal genital organs (usually the vaginal fornix) to the walls of the pelvis - the pubic bones, sacrum, sacrospinous ligament, etc. (sacrovaginopexy, fixation of the dome of the vagina to the sacrospinous ligament).

Group V- operations using alloplastic materials to strengthen the ligamentous apparatus of the uterus and fix it.

Group VI- operations aimed at almost complete or partial obliteration of the vagina (median colporrhaphy of Neugebauer - Lefort, vaginal-perineal colpoclesis - Labgardt's operation).

Group VII- radical (organ-removing) operations performed by various surgical approaches (abdominal, laparoscopic, vaginal).

In a separate group, surgical treatment aimed at restoring pelvic floor defects can be distinguished. To such types of operations

transvaginal installation of a mesh implant of the PROLIFT system? for reconstruction of the pelvic floor - anterior, posterior, total (Fig. 13.12, 13.13).

Fig.13.12.Scheme of fixation of the mesh implant of the PROLIFT system? in the pelvis

Fig.13.13.The layout of the mesh implant of the PROLIFT system? in the pelvis

What is the modern concept of surgical treatment of genital prolapse?

The modern concept of surgical treatment of genital prolapse should consist of "replacing" the old torn (destroyed) pelvic fascia with a new one with its fixation to the anatomically strong structures of the small pelvis (for example, sacrospinous ligament, tendinous arch).

The pelvic floor in a figurative representation is like floors, which over time need not cosmetic (patching individual holes), but major repairs. The entire floor needs to be replaced at once. It is this concept that corresponds to the TVM technology (transvaginal mesh insertion) that has quickly entered surgical practice using the PROLIFT system for the reconstruction of the anterior and posterior sections of the pelvic floor.

The presented operation (Fig. 13.12, 13.13) is pathogenetically justified precisely due to the creation of a neofascia instead of the destroyed one: it eliminates its multiple defects (central, distal, transverse, paravaginal, etc.) and performs its reliable fixation to the strong structures of the small pelvis, which prevent subsequent protrusion of the walls of the vagina with an increase in intra-abdominal pressure.

The absence of tension in the vaginal mucosa when using a polypropylene mesh (Gynemesh TM, Gynecare®, Ethicon®) minimizes the risk of developing its dystrophic disorders. Accordingly, the number of postoperative purulent-inflammatory processes, erosions, vaginal stenoses, as well as the risk of postoperative rejection of the mesh is reduced.

What is the prevention of this pathology?

Of great importance are the prevention of diseases in childhood and puberty, proper nutrition, the development of correct posture (pelvic inclination), dancing, sports (skating, rollerblading, swimming, rhythmic gymnastics), the role of physical exercises during pregnancy and after childbirth, helping to strengthen the muscles of the pelvic floor (Kegel exercises). It is necessary to carefully conduct childbirth, to carry out preventive measures to combat birth injuries. Timely surgical correction is important for prolapse of the walls of the vagina and uterus in order to prevent prolapse of the uterus.

The only effective method of treatment - surgical - should be applied at a young age after the completion of the childbearing function, and with a decrease in the quality of life - at any stage of a woman's life path without limiting the lower and upper age limits.

13.1. URINARY INCONTINENCE

What are the normal functional features of the act of urination?

The bladder is a hollow smooth muscle organ that serves as a reservoir for urine and is involved in its arbitrary excretion. The normal functioning of the bladder is possible only with the preservation of innervation and the coordinated work of the pelvic floor. When the bladder is full, resistance increases in the area of ​​the internal opening of the urethra. The detrusor remains relaxed. When the volume of urine reaches a certain threshold, impulses are sent from the stretch receptors to the brain, triggering the urination reflex. In this case, a reflex contraction of the detrusor develops. in the head

the brain is the urethra center, located in the bridge and associated with the cerebellum. The cerebellum coordinates the relaxation of the pelvic floor muscles, as well as the amplitude and frequency of detrusor contractions during urination. From the bridge, the signal is transmitted to the corresponding center located in the sacral segments of the spinal cord, and from there to the detrusor. This process is controlled by the cerebral cortex, which exerts inhibitory influences on the center of urination. Thus, normally the process of urination is an arbitrary act. Complete emptying of the bladder occurs due to prolonged contraction of the detrusor while relaxing the pelvic floor and urethra.

How are the urinary tract innervated?

The urinary tract is innervated by sympathetic, parasympathetic, and motor nerves. The sympathetic nervous system controls the retention of urine, while the parasympathetic nervous system controls its excretion. The motor nerves innervate the sphincter of the urethra, as well as the pelvic floor.

The lower urinary tract receives sympathetic innervation mainly from the spinal cord (at the level of Th 10 - L 2 segments). The mediator of preganglionic fibers is acetylcholine, postganglionic - norepinephrine. The urethra and bladder neck contain α-adrenergic receptors, and β-adrenergic receptors in the rest of the bladder. Stimulation of a-adrenergic receptors increases the tone of the urethra and contributes to its closure. Stimulation of β-adrenergic receptors reduces the tone of the bladder walls.

The parasympathetic nervous system regulates detrusor contraction and bladder emptying. Long preganglionic fibers originate in the sacral spinal cord (S 2 -S 4) along with motor nerves innervating the pelvic floor muscles, urethral sphincter and external anal sphincter. Impulses from the receptors of the perineum pass into the same segments of the spinal cord. The mediator of pre- and postganglionic fibers is acetylcholine, which acts on M-cholinergic receptors.

What factors affect urinary retention?

All factors affecting urinary retention are usually divided into external and internal.

External factors - the muscles of the pelvic floor, which contract with an increase in intra-abdominal pressure, squeezing the urethra-

channel and preventing involuntary leakage of urine. When weakening the visceral fascia of the pelvis or m. levator ani the support they create for the bladder disappears, pathological mobility of the bladder neck and urethra appears, which leads to stress incontinence.

Internal factors - the muscular membrane of the urethra, sphincters of the bladder and urethra, elastic fibers, folding of the mucosa and the presence of α-adrenergic receptors in the muscular membrane of the urethra. Insufficiency of internal factors occurs with malformations, estrogen deficiency and innervation disorders, as well as after injuries and as a complication of some urological operations. Eliminate urinary incontinence in case of insufficiency of internal factors is much more difficult than with pathological changes in external ones.

What are the main classification units and causes of urinary incontinence in women?

1. True urinary incontinence:

a) stress urinary incontinence (stress incontinence - leakage of urine during physical exertion: during coughing, laughing, running without imperative urge to urinate):

Pathological mobility of the bladder neck (the main reason is pelvic floor insufficiency);

Pathology of the sphincter of the bladder (may be congenital or acquired due to injuries or lesions of the sacral spinal cord);

Combined pathology;

b) urge urinary incontinence (urinary incontinence - leakage of urine due to an uncontrollable urge to urinate):

1) bladder hyperreflexia:

Idiopathic (detrusor instability);

Neurogenic (detrusor overactivity);

2) urethral instability (associated or not associated with bladder hyperreflexia, involuntary urethral relaxation);

c) mixed urinary incontinence.

2. Paradoxical ischuria (urinary incontinence from overflow, the main reason is a decrease in the contractile activity of the detrusor due to infravesical obstruction of any origin, lesions

sacral spinal cord, after operations on the pelvic organs, etc.).

3. Diverticula of the urethra.

4. Malformations of the urethra.

5. Uncontrolled relaxation of the urethra.

6. Transient (transient) urinary incontinence (main causes: acute cystitis, atrophic urethritis or vaginitis, alcohol intoxication, taking diuretics, long-term use of anticholinergic drugs - antihistamines, antidepressants, anti-psychotics, antiparkinsonisms, taking a-blockers, calcium antagonists , bowel obstruction).

7. False urinary incontinence:

a) congenital:

Ectopic ureter;

Bladder exstrophy;

Other malformations;

b) acquired:

Ureteral fistula;

urinary fistula;

Fistula of the urethra;

Complex fistulas.

What is stress urinary incontinence characterized by?

Stress urinary incontinence (stress incontinence) urine stress incontinence) occurs when intra-abdominal pressure increases, which can be caused by sneezing, coughing, or exercise. In this case, the pressure in the bladder exceeds the closing pressure of the urethra, which leads to loss of urine. The main cause of stress urinary incontinence in women is the failure of the pelvic floor muscles, when the support for the bladder disappears, resulting in pathological mobility of the bladder neck and urethra.

How are patients treated for urinary incontinence?

Patients are carefully examined, revealing the true cause of complaints. To do this, they collect an anamnesis, conduct a physical examination (including assessing the condition of the pelvic floor), functional tests (pad test, cough test, stop test, bladder filling test), evaluate the clinical analysis of urine and the results

its crops, if necessary, conduct a cytological examination of urine, measure the volume of residual urine, record the volume and frequency of urination (diary of urination), examine urodynamics (cystometry, profilometry, determination of the threshold pressure of urinary incontinence).

What are the approaches to the treatment of stress urinary incontinence?

With stress urinary incontinence, conservative treatment is carried out (elimination of aggravating factors - obesity, smoking, correction of the volume of fluid consumed; HRT in peri- and postmenopause; the use of α-agonists, Kegel exercises), but often it is impossible to do without surgical treatment.

The literature presents the following division of surgical interventions depending on the access into the following types (D.V. Kan).

1. Operations that restore normal vesicourethral anatomy through transvaginal access.

2. Various options for retropubic urethropexy.

3. Operations that correct the vesicourethral anatomy and fix the musculoskeletal apparatus with a combined approach.

4. Various modifications of loop or sling operations. To do this, apply: anterior colporrhaphy with the obligatory

levatoroplasty, retropubic and transvaginal urethropexy (Marshall-Marchetti-Krantz, Burch, Pereyra operations), looping around the neck of the bladder (so-called sling operations), as well as palliative operations (looping, partially obstructing the urethra, implantation of an artificial sphincter etc.). If stress urinary incontinence is combined with a paravaginal defect and excessive mobility of the bladder neck (hypermobility), then a correctly performed reconstruction using the PROLIFT system? allows you to stabilize the bladder neck in a normal position and eliminate stress urinary incontinence in more than 98% of cases.

It is important to note that the patient can present complaints of stress incontinence not only with pelvic floor failure. Differential diagnosis should be carried out with urgent UI, OAB and urethral diverticula, therefore, with

On the one hand, it is impossible to operate on women with urinary incontinence only on the basis of their complaints, on the other hand, urinary incontinence in the absence of complaints is not a basis for refusing surgical intervention.

What is an overactive bladder?

Under hyperreflexia of the bladder detrusor instability, unstable detrusor(GMP) - understand involuntary contractions of the detrusor due to disinhibition of the urination reflex. With this pathology, there is predominantly urinary incontinence (involuntary urination with an imperative urge). OAB can be neurogenic or idiopathic. The diagnosis of OAB is made on the basis of the patient's complaints of frequent urination and urinary incontinence, objective examination data and special research methods. Special methods include cystometry. At the same time, a periodic increase in detrusor pressure is recorded already in the bladder filling phase, associated with imperative urge to urinate and accompanied by urinary incontinence.

What is the differential diagnosis of bladder hyperreflexia from stress urinary incontinence?

Table 13.1.Differential diagnosis of bladder hyperreflexia

It should be emphasized that the main difference between OAB and stress urinary incontinence is the presence/absence of an imperative urge to urinate.

Can an overactive bladder be combined with pelvic floor pathology?

OAB can also be combined with pelvic floor pathology. In this case, the process can be both associated with the insolvency of the pelvic floor (eng. pelvic floor insufficiency) and prolapse of the genitals, and with a parallel process.

What are the treatments for overactive bladder?

OAB is treated with a combination of medication and behavioral therapy. The main endogenous stimulator of detrusor contraction is acetylcholine, therefore, all medicinal substances that relax the detrusor are M-cholinergic blockers: hyoscyamine, Driptan (oxybutynin hydrochloride), dicycloverine (1-cyclohexylcyclohexanoic acid β-diethylaminoethyl ether), oxybutynin, propaneline bromide. The term "behavioral psychotherapy" refers to the formation of a urination regimen. Thus, the patient trains her bladder to empty only voluntarily. When combined with GMF with pelvic floor insufficiency, complex conservative and surgical treatment is carried out.

The normal position of the female genital organs is provided by a suspension, fixing and supporting ligamentous apparatus, mutual support and regulation of pressure by the diaphragm, abdominals, and own tone (hormonal influences). Violation of these factors by inflammatory processes, traumatic injuries or tumors contributes to and determines their abnormal position.

Anomalies in the position of the genital organs are considered to be such permanent states that go beyond the limits of physiological norms and violate the normal relationship between them. All genital organs are interconnected in their position, therefore, abnormal conditions are mostly complex (at the same time, the position of the uterus, cervix, vagina, etc.) changes.

Classification is determined by the nature of violations of the position of the uterus: displacement along the horizontal plane (the entire uterus to the left, right, forward, backward; incorrect relationship between the body and the cervix in terms of inclination and severity of bending; rotation and twisting); displacements along the vertical plane (omission, prolapse, raising and eversion of the uterus, prolapse and prolapse of the vagina).

Offsets in the horizontal plane. The displacement of the uterus with the cervix to the right, left, forward, backward occurs more often with compression by tumors or with the formation of adhesive processes after inflammatory diseases of the genitals (Fig. 19). Diagnosis is achieved by gynecological examination, ultrasound and radiography. Symptoms are characteristic of the underlying disease. The treatment is aimed at eliminating the cause: surgery for tumors, physiotherapy and gynecological massage during the adhesive process.

Pathological inclinations and bends between the body and the neck are considered simultaneously. Normally, according to bends and inclinations, there can be two options for the position of the uterus: inclination and bending anteriorly - anteversio-anteflexio, inclination and bending backwards - retroversio-retroflexio (Fig. 20). The angle between the cervix and the body of the uterus is open anteriorly or posteriorly and averages 90°. In the standing position of the woman, the body of the uterus is almost horizontal, and the cervix at an angle to it is almost vertical. The fundus of the uterus is at the level of the IV sacral vertebra, and the external cervical os is at the level of the spinal plane (spina ischii). In front of the vagina and uterus are the bladder and uregra, and behind is the rectum. The position of the uterus can normally vary depending on the filling of these organs. Pathological inclinations and bends of the uterus occur with infantilism at an early age (primary) and as a result of inflammatory and adhesive processes of the genitals (secondary). The uterus can be movable or immobile (fixed).

Rice. 19.

: a - anteriorly by the myomatous node; b - to the left with a tumor of the right ovary; c - posteriorly with adhesions resulting from pelvioperitonitis.

Fig.20.

: a - anteflexio-anteversio; b - retroflexio-retroversion.

Rice. 22.

(a) and pathological posterior uterine inflection (b).

Rice. 23.

to the left (a) and posterior displacement of the uterus (b).

Rice. 24.

: a - appearance; b - scheme.

Hyperanteversia and hyperanteflexia of the uterus is a position where the anterior inclination is more pronounced, and the angle between the body and the cervix is ​​sharp (
Hyperretroversion and hyperretroflexia of the uterus is a sharp deviation of the uterus backwards, and the angle between the body and the cervix is ​​​​acute (
Inclination and bending of the uterus to the side (to the right or to the left) is a rare pathology and determines the inclination of the uterus and the bend between its body and the neck to one side (Fig. 23).

The clinical picture of all variants of horizontal displacement of the uterus has much in common, it is characterized by painful sensations in the lower abdomen or in the sacrum, algomenorrhea, and prolonged menstruation. Sometimes there are complaints of dysuric phenomena, pain during defecation, increased leucorrhoea. Since this pathology is a consequence of inflammatory processes or endocrine pathology, it can be accompanied by symptoms of these diseases, be the cause of infertility and the pathological course of pregnancy.

Diagnosis is based on data from gynecological and ultrasound examinations, taking into account the symptoms.

Rice. 25.

: a - appearance; b - scheme.

Rice. 26.

: a - appearance; b - scheme.

Treatment should be aimed at eliminating the causes - anti-inflammatory drugs, correction of endocrine disorders. FTL, gynecological massage are used. In case of severe pathology, surgical intervention can be indicated, with the help of which the uterus is removed from adhesions and fixed in the position of anteversio-anteflexio.

Uterine rotation and torsion are rare, usually due to uterine or ovarian tumors, and corrected at the same time as the tumors are removed.

Offset of the genital organs along the vertical axis. This pathology is especially common in women of the perimenopausal period, less often in young women.

Prolapse of the uterus is a condition when the uterus is below the normal level, the external os of the cervix is ​​below the spinal plane, the bottom of the uterus is below the IV sacral vertebra (Fig. 24), but the uterus does not come out of the genital slit even when straining. Simultaneously with the uterus, the anterior and posterior walls of the vagina descend, which are clearly visible from the genital gap.

Prolapse of the uterus - the uterus is sharply displaced downwards, partially or completely exits the genital slit when straining. Incomplete prolapse of the uterus - when only the vaginal part of the cervix comes out of the genital slit, and the body remains above the genital slit even when straining (Fig. 25). Complete prolapse of the uterus - the cervix and body of the uterus are located below the genital gap, at the same time there is an eversion of the walls of the vagina (Fig. 26). Omission and prolapse of the vagina occurs most often simultaneously with the uterus, due to the anatomical connection of these organs. When the vagina is lowered, its walls occupy a lower position than normal, protrude from the genital gap, but do not go beyond it. Vaginal prolapse is characterized by a complete or partial exit of its walls from the genital slit with the location below the pelvic floor. Omission and prolapse of the vagina are usually accompanied by prolapse of the bladder (cystocele) and the walls of the rectum (retrocele) (Fig. 27). When the uterus prolapses, the tubes and ovaries simultaneously descend, the location of the ureters changes.

The main factors of prolapse and prolapse of the genital organs: traumatic injuries of the perineum and pelvic floor, endocrine disorders (hypoestrogenism), hard physical labor (lifting weights for a long time), stretching of the ligamentous apparatus of the uterus (multiple births).

The clinical picture is characterized by a protracted course and steady progression of the process. Prolapse of the genital organs is aggravated by walking, coughing, lifting weights. There are pulling pains in the groin, sacrum. Possible violations of menstrual function (hyperpolymenorrhea), the function of the urinary organs (incontinence and urinary incontinence, frequent urination). Sex life and pregnancy are possible.

Diagnosis is carried out according to the anamnesis, complaints, gynecological examination, special research methods (ultrasound, colposcopy). When examining the mucous membrane of the vagina and the cervix of the prolapsed uterus, trophic (decubital) ulcers are often noted due to injury and changes in the flora (Fig. 28).

Fig.27.

1 - pubic bone; 2 - bladder, 3 - uterus; 4 - rectum, 5 - descended bowel loop, 6 - prolapsed back wall of the vagina; 7 - vagina.

Treatment for prolapse and prolapse of the genital organs can be conservative and surgical. Conservative treatment is reduced to the use of a set of gymnastic exercises aimed at strengthening the muscles of the pelvic floor and abdominals. It can be valid only with unexpressed prolapse of the uterus and vagina. It is very important to comply with the regime of work (the exclusion of hard physical work, lifting weights), a diet rich in fiber, urination "by the hour", and the exclusion of constipation. These conditions must be observed in both conservative and surgical treatment. With contraindications to surgical treatment (old age, severe concomitant pathology), the introduction of pessaries or rings into the vagina is indicated, followed by teaching the woman the rules for their processing and insertion. The patient should regularly visit a midwife or a doctor to monitor the condition of the mucous membranes of the vagina, cervix (prevention of inflammation, bedsores, trophic ulcers). Treatment of trophic ulcers and bedsores consists in the use of anti-inflammatory and antibacterial local therapy (levomekol, dimexide, antibiotics in ointments and suspensions), healing ointments (actovegin, solcoseryl), drugs with estrogens. Desirable position of the genital organs.

There are many methods of surgical treatment, and they are determined by the degree of pathology, age, the presence of concomitant extragenital and genital diseases. When treating young women, methods that do not violate sexual and reproductive functions should be preferred. In the presence of old perineal tears, an operation is performed to restore the pelvic floor. The prolapse of the vaginal walls can be eliminated by plastic surgery of the anterior and posterior walls with the strengthening of the levators. If necessary, the sphincter of the bladder is strengthened, an operation is performed to fix the uterus to the anterior abdominal wall or raise it by shortening the round ligaments.

In the elderly, with omission and prolapse of the uterus, vaginal hysterectomy with plastic surgery of the vagina and levators is used. If an elderly woman is not sexually active, then vaginal closure surgery is recommended. After the operation, you can not sit down for a week, then for a week you can only sit down on a hard surface (stool), the first 4 days after the operation, general hygiene, diet (liquid food), taking a laxative or cleansing enema on the 5th day, treating the perineum 2 times a day are necessary. day, removal of sutures on the 5-6th day.

Eversion of the uterus is an extremely rare pathology, occurs in obstetrics at the birth of an unseparated placenta, in gynecology - at the birth of a submucosal myomatous node of the uterus. In this case, the serous membrane of the uterus is located inside, and the mucous membrane is outside (Fig. 29).

Treatment consists in taking urgent measures to anesthetize and reduce the everted uterus. In case of complications (massive edema, infection, massive bleeding), surgical intervention is indicated to remove the uterus.

The elevated position of the uterus (Fig. 30) is secondary and may be due to the fixation of the uterus after surgical interventions, tumors of the vagina, accumulation of blood in the vagina with atresia of the hymen.