The ovary is determined between the doctor's fingers. Inflammation of the ovaries (oophoritis). Causes, symptoms and signs, diagnosis and treatment of the disease. Symptoms of ovarian apoplexy in pain form

Bimanual gynecological examination occupies a central place in the assessment of the condition of the ovaries. Symptoms arising from physiological or pathological processes in the ovaries usually correspond to the findings of a physical examination. Some ovarian diseases are asymptomatic, so physical examination data may be the only information at the first stage of the examination.

For the correct interpretations results of the study, it is necessary to know the palpation characteristics of the ovaries at different periods of life.

AT premenstrual age ovaries should not be palpable. If they can be felt, their pathology should be assumed and further in-depth examination should be carried out.

AT reproductive age normal ovaries are palpable in about half of women. The most important characteristics are: size, shape, consistency (solid or cystic) and mobility. In women of reproductive age taking oral contraceptives, the ovaries are less frequently palpated, smaller and more symmetrical than in women not using these means.

In female patients in postmenopausal age, the ovaries are functionally inactive except for the production of a small amount of androgens. The ovaries no longer respond to gonadotropic stimulation and therefore their superficial follicular activity gradually decreases, ending in most cases within three years of the onset of natural menopause. Women close to the onset of natural menopause are more likely to have residual functional cysts. In general, palpable ovarian enlargement in the postmenopausal period requires more critical evaluation than in younger women, since this age group has a higher incidence of ovarian malignancies.

Approximately 1/4 of all ovarian tumors in the postmenopausal period are malignant, while in the reproductive age only 10% of tumors are malignant. In the past, the risk was considered so great that the detection of any enlargement of the ovary in the postmenopausal period (the so-called palpable postmenopausal ovary syndrome) served as an indication for surgical intervention. The advent of more sensitive diagnostic pelvic imaging modalities has changed routine tactics. Mandatory removal of minimally enlarged postmenopausal ovaries is no longer recommended.

If the patient has a natural menopause lasts 3 to years and transvaginal ultrasound reveals the presence of a simple single-chamber cyst less than 5 cm in diameter, further management of such a patient may consist of repeated ultrasound examinations (including transvaginal) to monitor the condition of the cyst. Masses that are larger or have a complex ultrasound structure are best treated surgically.

Functional ovarian cysts- These are not tumors, but rather normal anatomical variants resulting from the normal activity of the ovaries. They may occur as asymptomatic adnexal masses or be accompanied by symptoms that require further investigation and possibly specific treatment.

When ovarian follicle does not rupture at the end of its maturation, ovulation does not occur and a follicular cyst may occur. The consequence of this will be the lengthening of the follicular phase of the cycle and, as a result, secondary amenorrhea. Follicular cysts are lined internally with normal granulosa cells and contain estrogen-rich fluid.

Follicular cyst becomes clinically significant when it is large enough to cause pain, or when it persists for more than one menstrual period. It is not entirely clear why the granulosa cells lining the follicular cysts persist beyond the time when ovulation is due and continue to function during the second half of the cycle. The cyst may enlarge, reaching a diameter of 5 cm or more, and continues to fill with estrogen-rich follicular fluid coming from the thickened layer of phanular cells. Symptoms caused by a follicular cyst may present with mild to moderate unilateral pain in the lower abdomen and changes in the pattern of the menstrual cycle.

The latter may be the result of both a failed follow-up ovulation. and an excess amount of estradiol produced inside the follicle. Excessive estrogen saturation of the body in the absence of ovulation hyperstimulates the endometrium and causes irregular bleeding. A bimanual gynecological examination may reveal a unilateral painful mobile cystic adnexal mass.

Having received such data during the primary survey. the doctor must decide whether to undertake further in-depth examination and decide on treatment. Ultrasound of the pelvic organs is recommended for patients of reproductive age with a cyst size of more than 5 cm in diameter. This examination reveals a single-chambered simple cyst with no signs of blood or soft tissue elements inside and no signs of growths outside. Most patients do not require ultrasound confirmation. Instead, the woman should be reassured and reassessed in 6 to 8 weeks.

Pain in the abdomen on palpation.

Good afternoon. Age 30 years old, weight 52 kg. Approximately 4 months of pain in the lower abdomen, as if inflammation of the ovaries, and sometimes right under the navel. She was checked in gynecology, did an ultrasound of all the internal organs, no pathologies were found. I began to suspect the intestines, as during palpation in certain places (to the right of the navel and a little higher along the intestinal line) severe pain, though, if you do not touch, there is no pain in those places, only when pressed, I checked with the gynecologist again, the doctor On a manual examination, she said that the intestines give such pains, as she felt the painful areas of the intestine. The therapist referred me to a proctologist. did a colonoscopy

The colon was examined up to the splenic angle, the tone was normal. The rectum is hyperemic, the vascular pattern is clear. External and internal hemorrhoids are noted, in the anal canal a polyp 0.4 cm in diameter. Conclusion — moderately pronounced proctosigmoiditis. Chronic hemorrhoids. They prescribed omez, flax to drink and a diet for a month. Nothing helped.

I passed the analysis of feces: leukocytes 0-1-2vp.z, undigested fiber - in large quantities, muscle fibers 1-2-3 in p.z. everything else is normal.

For dysbacteriosis:

Everything is normal, except for lactobacilli 0 v10^5 and fungi of the genus Candida 10^4.

Blood test in the app. The doctor did not prescribe anything except lactobacilli. I would be very grateful at least for a hint on what else to check, who to contact. Thanks in advance.

P.S. Periodically, pains in the lower abdomen began to be observed three months after the birth (child 1.4 years old), but periodically. and now almost always. Thank you.

Pain and its causes in alphabetical order:

pain in the ovaries

The ovary is a steamy female gonad, the site of the formation of maturation of eggs and the production of hormones that regulate the sex life of women. The anatomical structure, reactions to hormonal stimulation and secretory activity of the ovaries in different periods of life are not the same. In this chapter, the normal physiology of the ovaries is considered as the basis for understanding the pathology of both the ovaries themselves and other organs of the female reproductive system.

What diseases cause pain in the ovarian region:

Causes of pain in the ovarian region:

- Pain in the ovarian region may indicate the presence of an inflammatory process in the ovarian appendages (oophoritis). It is the most characteristic sign of this disease, is localized in the lower abdomen and often radiates to the lumbosacral spine. As a rule, pain in the ovarian region occurs paroxysmal, but may be present and permanent. Hypothermia, physical and mental overwork, decreased immunity against the background of other internal diseases contribute to their emergence and intensification. Such pains are often accompanied by disturbances in the functioning of the nervous system - increased irritability, weakness, problems with sleep, and decreased ability to work.

- Adnexitis, or inflammation of the ovaries. The most common causative agents of inflammatory processes of the internal genital organs, which lead to inflammation of the ovaries (adnexitis) are chlamydia, mycoplasma, ureaplasma, candida. The clinic of chlamydial infection has no characteristic manifestations. Without adequate therapy, the inflammatory process in inflammation of the ovaries (adnexitis) takes a protracted course and leads to infertility. The main symptom of inflammation of the ovaries (adnexitis) is pain in the ovaries and lower abdomen. The pain can radiate to the lower back, and periodic pains almost always predominate. Treatment of inflammation of the ovaries is carried out within 5 days.

- In some cases, pain in the ovarian region occurs when a cyst forms. Until the cystic capsule is small and does not undergo negative changes, this pathology is asymptomatic.

- The cause of constant pain in the ovarian region is a cyst or tumor of the ovary, which has reached a large size. It compresses neighboring internal organs and nerve endings. Not only neoplasms can twist, but also the ovaries themselves. This leads to impaired blood supply and tissue necrosis, inflammation and pain develop.

- Pain in the ovarian region occurs when the pedicle of the cyst is twisted or as a result of a violation of its integrity, which is accompanied by the outflow of liquid contents into the abdominal cavity and causes tissue irritation. In addition to nausea, vomiting and pain, rupture of an ovarian cyst or necrosis of its tissue due to torsion of the leg can provoke inflammation of the peritoneum - peritonitis, which requires immediate surgical intervention. A similar situation can be observed in the presence of a benign or malignant tumor of the ovary.

- Pathological changes in the position of the ovarian appendages are facilitated by their relative mobility in the pelvic cavity, as well as increased physical activity. That is why this pathology is observed, as a rule, in childhood. Among the factors contributing to ovarian torsion, it should be noted drug stimulation of ovulation, pregnancy, as well as any conditions accompanied by an increase in the size of the ovaries. Sharp pain in the ovaries and abdomen may be accompanied by vomiting, palpation reveals a painful swelling. If the tissue of the appendages has undergone irreversible pathological changes, surgical removal of the ovary is performed.

“Sometimes during ovulation, an ovary ruptures, causing bleeding. The ingress of blood into the abdominal cavity provokes pain and threatens with the development of peritonitis, therefore, surgical intervention is indicated, during which sutures are applied and the integrity of the organ is restored. In some women, ovulation itself is quite painful, as indicated by the appearance of pain in the ovarian region on certain days of the menstrual cycle. In addition, acute and chronic inflammatory processes contribute to the formation of adhesions in the ovaries, which in turn often cause pain in the ovarian region.

- Ovarian apoplexy is a sudden hemorrhage in the ovary, which is accompanied by its rupture and bleeding into the abdominal cavity.

Ovarian apoplexy occurs, as a rule, in women under the age of 40, more often in the right ovary, while bleeding and pain in the ovarian region always occur. According to the predominance of one of these signs, anemic and painful forms of the disease are conditionally distinguished. With the same severity of these signs, they speak of a mixed form of apoplexy.

The disease begins acutely with sudden, sometimes very severe pain in the ovaries and lower abdomen, with a predominance on the side of the affected ovary. Pain is often given to the rectum, thigh and lower back. Often the attack is accompanied by nausea and vomiting, as well as fainting.

Body temperature remains normal. With heavy bleeding, a sharp decrease in blood pressure and collapse occurs (a serious condition with severe cardiac weakness, a drop in vascular tone, frequent pulse, and cold sweat). The ovary, when palpated, has a spherical shape and sharp pain.

- Ovulatory pain in the ovarian region occurs in the lower abdomen during the periovulatory period as a result of irritation of the peritoneum with follicular fluid; last from 12 to 36 hours with separate attacks for several hours.

- Ovarian hyperstimulation syndrome can develop in women with infertility when treated with hormones (clomiphene, gonadotropins). The ovaries are enlarged, with multiple follicular cysts, a large cystic corpus luteum, and stromal edema. With a mild form, there are pains in the ovarian region, bloating; weight gain. In severe form, shortness of breath, ascites, pleural effusion, electrolyte imbalance, hypovolemia, oliguria appear.

- Psychogenic factors: with the exclusion of organic causes of pain in the ovaries, it is necessary to examine the woman by a psychotherapist (borderline conditions: hypochondria, depression, hysteria).

- To establish the presence of a large neoplasm of the ovary, palpation of the abdomen and gynecological examination helps. Important information about the condition of the uterine appendages is provided by ultrasound of the pelvic organs and magnetic resonance imaging. Especially valuable is the diagnostic laparoscopy, which allows to identify the adhesive process and foci of endometriosis, localized in the ovaries. Through this technique, you can not only detect, but also eliminate many pathologies of the pelvic organs. Proper diagnosis is the key to effective treatment, which will permanently get rid of pain in the ovaries.

Which doctor should I contact if there is pain in the ovarian region:

Ovarian cancer symptoms and signs | How to identify ovarian cancer

One of the most common female cancers in the world is this disease. In the countries of the former CIS, ovarian cancer does not predominate among oncological diseases, but still remains a common problem. The main problem of the disease is the difficulty of diagnosing even with the help of medical means.

Symptoms of ovarian cancer

This disease, like other female oncologies, rarely causes vivid symptoms. Most often, signs of ovarian cancer and the main manifestations of the disease do not appear until the development of a dangerous stage of the disease. Most often, the symptoms of the disease appear six months or even a year after the onset of the development of the pathogenic process.

Most often, all manifestations of cancer are not caused by tissue destruction, but by the pressure of the tumor on the ovary from the inside or from the side - it all depends on the place of its deployment. However, if the symptoms have already begun, then they will go on increasing. The following signs of the disease in women of different ages are possible.

First, spasmodic pains in the abdomen begin to appear. The pains are not strong, but the sensations are atypical and new. Painful signs of ovarian cancer are not like menstrual pain.

Then pain in the lower abdomen, in the pelvis, in the lower back may begin. They are provoked by the inflammatory process. These pains can be akin to pain during menstruation, but they will only haunt the patient for the whole month. Note that women who suffer from this problem are at a potential risk group for ovarian cancer. So, physical atypical sensations may appear at an early stage, they may not appear until the development of the third stage of cancer.

In parallel with the physical manifestations, there may be a violation of menstruation, weight loss may begin, or vice versa, its growth for no reason, such a reaction can be caused by a hormonal imbalance, which is highly dependent on the ovaries. The presence of spotting bleeding, especially in women after menopause, is always a sign of problems in the reproductive system. This manifestation of the disease should be paid attention first of all.

Bleeding and pain during sports or during sexual intercourse, this is another indication of a malfunction of the ovaries. Physical activity, heaviness, sexual contact - all this can provoke such a symptom of ovarian cancer as bleeding.

Almost always, ovarian cancer provokes the formation of mucous and / or purulent discharge. This is due to the destruction of the lymphatic vessels. Allocations will be uncharacteristic, do not ignore them. Mucous discharge with an unpleasant odor, odorless, with blood, and no color at all. All this can be a sign of cancer and a reaction to inflammatory and destructive processes.

There may be loss of appetite, nausea, a feeling of rejection of food and drink. Due to the refusal of food, weakness and loss of strength appear. In this case, the forces will decrease exponentially.

With the development of the disease, spasmodic pains in the lower abdomen, in the lower back, in the peritoneum will appear.

Ascites as a sign of ovarian cancer

By its nature, ascites is the release of fluid into the peritoneal cavity, which causes inflammation, abscess, necrotic processes and death. What causes ascites in ovarian cancer, and what are the methods of primary diagnosis of the problem?

Ascites causes an increase in tumor formations due to fluid. Fluid occurs due to the destruction of the lymphatic vessels. Partly it remains inside the ovary and the tumor, which threatens to rupture the ovary, partly it simply enters the abdominal cavity.

In the abdominal cavity, the presence of fluid up to 140 ml is not diagnosed by external methods of observation. In large volumes, the doctor finds liquid during palpation and examination. Ascites can be indicated by asymmetrically protruding parts of the peritoneum. A sharp increase in the volume of the patient's abdomen.

Ascites in ovarian cancer can cause severe swelling of the lower abdomen, legs, and genitals. As a rule, edema cannot be ignored and doctors begin prompt action.

Ascites in ovarian cancer can be painless, or it can cause severe pain. In this case, the patient can be pulled into the “embryo” position, as with appendicitis. The pain syndrome is strong, and it is often relieved by the use of drugs to remove fluid from the peritoneum.

The fluid obtained from the peritoneum with ascites is analyzed for composition and the presence of pathogenic flora. Depending on the results, the direction for the treatment of the problem is chosen. Given the fact that this problem can cause the death of the patient, it is treated with great attention.

Specific manifestations of ovarian cancer

Also, ovarian problems can affect the excretory system. Signs of cancer may include diarrhea, constipation, frequent urination, or problems with normal urination.

Flatulence and bloating can also be caused by a problem in the ovaries.

In addition, atypical enlargement of the abdomen, asymmetrical enlargement of the abdomen, bad signs. If a swelling appears on the abdomen that you feel with your hands, then this also clearly indicates the development of a problem in the peritoneal cavity.

As you can see, there are quite a few signs of the disease. The problem is that many do not connect these manifestations with each other, while others attribute them to endometriosis or other chronic diseases.

Why are the symptoms of the disease subtle? The reason is due to the location of the cancerous tumor. In most cases, it is located inside the ovary, which makes it simply invisible in the first, and sometimes in the second stage of the problem. However, if a woman is attentive and knows how to monitor her body, then she will be able to determine ovarian cancer. The tumor will provoke some reactions that only the carrier can notice.

How to identify ovarian cancer yourself?

The most terrible thing in female oncology is diagnostic problems. The fact is that these problems do not have external manifestations in the early stages of development. Because of this circumstance, women are strongly recommended to be diagnosed with ovarian cancer by a doctor and do tests for cellular changes every six months. In this case, the cancer will be detected at a stage accessible for effective treatment.

Unfortunately, the Pap test does not detect ovarian cancer. In order to determine ovarian cancer, a deeper diagnosis is needed. It is worth knowing about the features of the diagnosis in advance. This will help the woman avoid problems in the future. Moreover, after reading the article, it will not be superfluous to talk with your doctor so that he can suggest options for those methods for diagnosing ovarian cancer that are available to him. Perhaps you will be more comfortable using them.

The most correct thing is to do a CA-125 blood test. This test detects tumors on the ovaries. Unfortunately, even he cannot say about the good quality of the tumor. In addition, there are a number of physiological factors that can bring down the accuracy of the analysis. Therefore, it is proposed to use it in case of suspicion and in combination with other studies.

As an addition to the blood test, a transvaginal ultrasound can be used. This diagnostic method allows you to diagnose changes in the size of the ovaries and identify the problem, in the case of atypical bulges, the formation of growths on the outside of the ovary, and so on.

Rectovaginal examination can also be used in the diagnosis of ovarian cancer. However, the doctor must have the skills of this procedure in order to be able to identify the beginnings of the problem.

Diagnosis at an early stage makes it possible to save a woman's life, health and appendages. And this is extremely important, because the treatment of the disease is difficult and complex.

Diagnosis of an ovarian tumor

Manifestations of the disease are characterized by the appearance of pain in the lower abdomen, disorders in the gastrointestinal tract and urinary system. Diagnostic signs of the disease are as follows.

On palpation, it is possible to determine a tumor that comes from the ovary or uterus and, when the leg is twisted, proceeds with a picture of an acute abdomen. Then this tumor is painful, especially when trying to displace it. However, the tumor may not be clearly palpable due to severe pain and tension in the abdominal wall. If the tumor originates from the genital organs, then only its upper pole is usually well palpated, while the lower pole is inaccessible to palpation through the abdominal wall.

It is necessary to determine and note in the history of the disease the localization of the tumor, its size, consistency, the nature of its surface, mobility and soreness. If the patient indicates the presence of a tumor or cyst in the anamnesis, and the tumor is not detected on palpation, and at the same time a picture of an acute abdomen has developed, one can think of a rupture of this formation. Sometimes a palpable formation does not have clear contours and is motionless, then they speak of an infiltrate. This happens with inflammatory tubovarial formations or with malignant formations.

5. Other symptoms a. Murphy's sign: severe pain at the height of inspiration with deep

palpation of the right hypochondrium. The symptom is often positive in acute cholecystitis, but is not pathognomonic for this disease.

b. Rovsing's symptom: the appearance of pain in the right iliac region with deep palpation (or percussion) of the left iliac region. A positive symptom is characteristic of appendicitis, but can also be observed in other diseases.

in. Symptom of the lumbar muscle: the patient lies on the left side, with the extension of the right leg pain occurs in the lower back. It is observed in retrocecal appendicitis and other inflammatory diseases affecting the lumbar muscles - paranephritis, psoas abscess, retroperitoneal hematoma, perforation of the posterior wall of the caecum by a malignant tumor. The same symptom observed when the left leg is extended is characteristic of paranephritis, perforation of the diverticulum and cancer of the sigmoid colon.

d. Symptom of the obturator muscle: the patient lies on his back with his legs bent at a right angle; turning the shins in or out causes pain. The occurrence of pain is due to an inflammatory process involving the obturator internus muscle or localized next to it (pelvic abscess, appendicitis, salpingitis).

e. Kehr's symptom: pain in the shoulder on palpation of the lower abdomen, especially in the Trendelenburg position. The symptom was first described with damage to the spleen. Pain caused by the accumulation of fluid in the subdiaphragmatic space radiates to the shoulder and neck.

6. Sometimes there is increased skin sensitivity over the focus of inflammation. This is an interesting biological phenomenon, but it has no diagnostic value.

G. Examination of the perineum, examination of the genital organs and rectum in case of abdominal pain is mandatory.

Gynecological study.

This study allows not only to determine whether acute pains come from the genital organs, but also to identify the cause of their occurrence.

Examination of the external genitalia. In an acute abdomen, it can provide valuable information if signs of gonorrhea of the lower genital apparatus are detected: vulvitis,

urethritis, gonorrheal spots, purulent discharge, abscess of the excretory duct of the large gland of the vestibule of the vagina.

Examination of the vagina and cervix using mirrors allows you to identify cyanosis, as a sign of pregnancy, the nature of the discharge (dark blood in tubal pregnancy, purulent in the inflammatory process, light in other diseases). Cervical hyperemia and purulent discharge can be with endocervicitis, which was the source of ascending gonorrhea. A sample of secretions from the uterine os is taken for bacteriological examination (bacterioscopy of a Gram-stained smear and culture).

Bimanual study: can be vaginal-abdominal and rectal-abdominal. In a bimanual study, the shape and consistency of the cervix, the state of the uterine os, a feeling of pain when the cervix is displaced are determined. Soreness during displacement of the cervix during a two-handed examination is characteristic of tubal pregnancy, inflammation of the uterine appendages, pelvic peritonitis. In surgical pathology, this symptom is usually absent. Next, you should determine the condition of the vaginal vaults. Usually, the filling of the rectal-uterine cavity with blood or inflammatory effusion is manifested by flattening of the posterior and sometimes lateral arches. However, the lower pole of the tumor or infiltrate can also be determined through the vaults; in these cases, in the picture of an acute abdomen, one can think either of a tubo-ovarian inflammatory formation with microperforation, or of an ovarian tumor. In some cases, the posterior fornix is protruded by a uterine hematoma in an "old" tubal pregnancy.

Then determine the location, size, shape, consistency and degree of mobility of the uterus. During tubal pregnancy, the uterus is softened, somewhat enlarged, very mobile (floating uterus syndrome). In case of inflammation of the appendages, pelvic peritonitis, the uterus is not enlarged, but painful, since it can be involved in the inflammatory process. Soreness on palpation of the knotty uterus, especially against the background of infertility, indicates endometriosis.

With ovarian apoplexy, torsion of the pedicle of the ovarian tumor, with surgical pathology, the uterus does not have any pathological features. An enlarged, tuberous uterus is detected with myoma, while some of its nodes can be sharply painful on palpation, which indicates impaired blood supply and necrosis. Appendages in the normal state are most often not palpable, especially with obesity of the abdominal wall.

In tubal pregnancy, the appendages are thickened, painful and pasty on the one hand, without clear contours, which is explained by the presence of a fetal egg and peritubal hematoma. With inflammation, the appendages are most often thickened and painful on both sides, but they cannot be clearly palpated. A dense, bumpy, motionless and painful formation on one or both sides of the uterus is determined either with tubo-ovarian abscesses or with true ovarian tumors, which, in combination with the clinic of an acute abdomen, may indicate microperforation of these formations. Sometimes a painful band is palpated in the area of the appendages, which may be a twisted leg of a cyst or ovarian tumor. An attempt to displace the tumor causes severe pain. With ovarian apoplexy with hemorrhage, it is palpated as a sharply painful tumor-like formation of an elastic consistency with clear contours. In surgical pathology, the area of the appendages is usually painless.

Sometimes the uterus and appendages cannot be palpated due to severe pain and tension of the abdominal wall. This most often happens with gonorrheal pelvioperitonitis, with diffuse peritonitis, sometimes with a rupture of the tube.

Recto-abdominal examination is resorted to if the patient does not live sexually or in the case when the main pathological formations are palpated through the anus. Such a study will provide more accurate data.

A rectal examination can reveal a symptom of Promptov, which consists in pain on palpation of the recto-uterine cavity and pain when the uterus is displaced to the womb. This symptom is characteristic of acute appendicitis. A rectovaginal examination can be of great help, in which the examiner's fingers are more intimately closer to the uterine appendages and the broad ligament, which makes it possible to identify a pelvic abscess and retrograde metastases to pararectal lymph nodes (often with asymptomatic malignant tumors of the abdominal organs).

Additional research methods.

1. Laboratory research

Laboratory studies can provide significant assistance in the differential diagnosis of an acute abdomen. However, the results of blood and urine tests, as well as the data of radiological studies, by themselves do not allow either to make or exclude any of the options for the diagnosis, and without a detailed history and physical examination, they are meaningless. “The patient should be treated, not his blood test or X-ray.” Laboratory studies that provide valuable information include:

a. Urinalysis is an affordable and inexpensive method for detecting diseases of the kidneys and urinary tract. Hematuria confirms the diagnosis of urolithiasis. Leukocyturia and bacteriuria are indicative of a urinary tract infection. Proteinuria is a nonspecific symptom. The specific gravity of urine allows you to assess the water balance. All these studies can be quickly carried out using test strips. Urinalysis for chorionic gonadotropin (hCG) allows you to differentiate pregnancy from other pathological conditions.

b. General blood analysis. The white blood cell count helps to establish whether abdominal pain is associated with an inflammatory process. Inflammation is characterized by leukocytosis, although there are many exceptions. So, with appendicitis, the number of leukocytes in the blood may be normal. Therefore, the leukocyte formula should be determined, especially in cases where the total number of leukocytes is normal or slightly increased. The shift of the leukocyte formula to the left is a more important diagnostic sign than leukocytosis. With gynecological pathology, an increase in ESR is more pronounced, with surgical pathology - leukocytosis, which rapidly increases in dynamics. A general blood test allows not only to detect anemia (by reducing the absolute level of hemoglobin and hematocrit), which indicates acute blood loss, but also to establish its type (by the morphology of red blood cells).

in. Serum amylase and lipase activity. The diagnosis of acute pancreatitis is always clinical. An increase in amylase and lipase activity confirms the diagnosis. However, it should be remembered that an increase in amylase activity is a non-specific sign that is observed in many other diseases (mechanical intestinal obstruction, intestinal infarction, perforated ulcer, ectopic pregnancy). Since amylase is excreted by the kidneys, its activity in serum also increases in renal failure. In acute pancreatitis, amylase activity usually reaches a maximum in a day and normalizes by the end of 2-3 days. Therefore, to confirm the diagnosis, it is advisable to also determine the activity of lipase. Note that the increase in the activity of both enzymes does not correlate with the severity of pancreatitis. Moreover, in chronic pancreatitis accompanied by pancreatic necrosis, the activity of amylase and lipase may not change. If blood amylase activity exceeds 2000 U/L, calculous pancreatitis should be suspected.

d. Bacterioscopy Analysis of vaginal discharge reveals the presence of an increased content of leukocytes and pathogenic flora, which almost always happens with inflammation of the internal genital organs. However, it should be remembered that these signs can also be detected in other pathologies, including extragenital, if it is combined, for example, with inflammation of the uterus or vagina.

2. Instrumental Research Women X-ray and isotope studies are carried out only after

exclusion of pregnancy.

a. X-ray studies Plain radiography. Referring the patient for X-ray examination

the doctor must be sure that his result will affect the tactics of treatment. For example, a patient with typical appendicitis complaints, right iliac tenderness, abdominal muscle tension at McBurney's point, and mild leukocytosis needs surgery rather than x-ray. In some diseases, the information content of the survey radiography is so small that its implementation is not justified. An x-ray of the abdominal cavity in the supine position allows you to see the distribution of gas in the intestine, determine the cause of bloating (accumulation of gas or fluid), detect fluid-filled bowel loops, soft tissue thickening and calculi. X-rays show 90% of urinary stones (because they contain enough calcium) and only 10% of gallstones. You can see the calcification of the pancreas - a sign of chronic pancreatitis. The focus of calcification in the right iliac region, together with the corresponding complaints and physical examination data, indicates acute appendicitis. The presence of gas in the bile ducts is a sign of vesico-intestinal fistula, which can occur with gallstone intestinal obstruction. The absence of a psoas muscle shadow indicates a pathological process in the retroperitoneal space - bleeding (in case of injury) or inflammation (retrocecal appendicitis, pancreatitis, sigmoid diverticulitis). And finally, the picture allows you to detect the pathology of the spine and pelvis.

A standing abdominal x-ray is used primarily to detect horizontal levels of fluid and gas in loops of the small intestine. With mechanical intestinal obstruction, the fluid levels in adjacent knees of the intestinal loop have different heights.

3. Special methods.

In acute abdominal pain, invasive and non-invasive examinations of the abdominal organs are often necessary.

a. Ultrasound Women with complaints of pain in the lower abdomen are shown transabdominal and transvaginal ultrasound of the small pelvis.

b. Puncture of the abdominal cavity through the posterior fornix of the vagina. It allows you to identify the nature of the liquid contents in the abdominal cavity (pus, serous effusion, blood). Indications for puncture are signs of the presence of free fluid (overhanging arches, dullness of percussion sound, pain when the neck is displaced). If the clinic of internal bleeding or rupture of the pyosalpinx is clear, and the patient's condition requires urgent surgical treatment, then puncture of the posterior fornix is inappropriate, because its result cannot change the patient's management plan. A contraindication to puncture of the posterior fornix is the filling of the recto-uterine cavity with a tumor. If no contents are obtained during the puncture, it is not considered diagnostically significant, since sometimes blood or effusion does not enter the uterus due to the adhesive process.

in. CT (computed tomography) - one of the best methods for diagnosing diseases of the abdominal cavity, retroperitoneal space and small pelvis. With all their

The advantages of the method are not without some disadvantages (high cost, high radiation exposure, allergic reactions to intravenous administration of contrast agents). CT should not replace physical examination or exploratory surgery.

d. Laparoscopy. It is resorted to with questionable results of physical and additional research methods. The study can be performed on a patient under local anesthesia, this is its main advantage over diagnostic laparotomy performed in the operating room. Diagnostic laparoscopy is indispensable in the examination of women with pain in the right iliac region. In this category of patients, up to 30% of appendectomies are erroneous. Laparoscopy can reduce the number of unnecessary surgical interventions and get the most complete picture of the state of the abdominal organs, in addition, laparoscopy can be the method of final surgical treatment.

d .Trial treatment. In some obscure cases of acute abdomen, a trial treatment with dynamic monitoring of the patient is justified. With gonorrheal pelvioperitonitis, acute salpingitis, usually within a few hours, the patient's condition progressively improves, which confirms the correctness of the diagnosis and the chosen method of treatment.

Thus, a methodical and consistent study of the anamnesis and an objective examination of the patient makes it possible to identify all the symptoms of the disease and choose the optimal method of therapy at all stages of observation.

Lead tactics.

If an acute gynecological disease of the abdominal organs is accompanied by collapse, the patient undergoes the following drug therapy: intramuscular injection of 1 ml of a 5% solution of ephedrine or 1 ml of a 1% solution of mezaton, intravenous reopoliglyukin, polyglucin, gelatinol, 5% glucose solution ( 400800 ml), cardiac agents are added to the infusion medium (1 ml of a 0.06% solution of korglucon or 0.3 ml of a 0.05% solution of strophanthin).

The use of painkillers in cases of "acute abdomen" at the prehospital stage is unacceptable! Before the operation, the surgeon should be able to assess the clinical picture, not distorted by the action of narcotic analgesics. But in some cases (for example, when the patient does not allow himself to be examined due to severe pain), the appointment of small doses of analgesics is acceptable in a hospital setting - to alleviate suffering, increase confidence in the doctor and, as a result, to conduct a more complete and sparing examination.

At the prehospital stage

1. Carefully collect anamnestic data and complaints.

2. By examination, palpation, percussion, auscultation of the abdomen and changing the position of the patient, identify symptoms characteristic of an "acute abdomen".

3. Perform a recto-vaginal-abdominal examination.

4. Exclude a somatic disease that simulates an acute pathology in the abdominal cavity (diabetes, renal failure, cirrhosis, hepatitis, intercostal neuralgia, pleurisy, pneumonia, etc.), as well as infectious diseases.

5. Explore respiratory and cardiovascular system.

In the hospital 1. To study and evaluate complaints, anamnesis, objective data.

2. Make a blood and urine test (laboratory tests in dynamics: blood count and leukocytosis, bilirubin, blood clotting, transaminase and alkaline phosphatase, urine diastasis, etc.), analyze the smear for flora and the degree of frequency of the vagina ..

3. Examine the state of the respiratory system, and if necessary, perform a chest x-ray.

4. Explore Function cardiovascular system (pulse, blood pressure, if necessary - ECG).

5. If a urological disease is suspected, it is necessary to take an overview of the kidneys, urography, chromocystoscopy, urine examination, bladder catheterization (if there is no damage to the urethra).

6. Measure rectal and axillary temperatures (an increase in this difference over 1 "indicates an inflammatory process in the abdominal cavity).

7. According to the indications, perform: laparoscopy, laparocentesis (abdominal puncture), separate diagnostic curettage, ultrasound, fluoroscopy and radiography of the abdominal cavity.

In doubtful cases or in the absence of the effect of conservative therapy, indications for diagnostic laparotomy or laparoscopy, which may be therapeutic, should be given.

Acute abdomen in gynecology (main causes and symptoms).

We are talking about a syndrome that develops as a result of an acute pathology in the abdominal cavity and is manifested by sudden pains in any part of the abdomen, peritoneal symptoms and pronounced changes in the patient's condition.

Acute pain in the lower abdomen in women with severe peritoneal symptoms is possible with intra-abdominal bleeding (ectopic pregnancy, ovarian apoplexy; torsion of the ovarian cyst (cystoma); perforation of purulent tubo-ovarian formations; pelvioperitonitis).

Ectopic pregnancy- implantation and development of a fertilized egg outside the uterine cavity. Inflammatory diseases of the uterine appendages, violation of the functional state of the fallopian tubes and ovaries, sexual infantilism, increased activity of the trophoblast, etc. lead to this pathology.

Its most frequent type is pipe (98.5%). Other types of ectopic pregnancy are extremely rare - abdominal (0.4%), ovarian (0.2%). Ectopic pregnancy predominantly occurs at the age of 20-35 years, somewhat more often in the right tube. Termination of an ectopic tubal pregnancy, accompanied by bleeding, occurs at 4-6 weeks due to a violation of the integrity of the fetus.

The main task of the general practitioner is to suspect an ectopic pregnancy in a timely manner and urgently refer the patient to the gynecological or surgical department.

It is practically important to remember that sudden abdominal pain in a young woman, accompanied by signs of acute vascular insufficiency and signs of acute blood loss, are sufficient to diagnose an ectopic pregnancy.

The doctor providing emergency care should not administer painkillers, so as not to distort the clinical picture of the disease, should not prescribe cold or heat on the abdomen and a cleansing enema, so as not to cause increased bleeding.

I. Prehospital stage

The clinical picture of ectopic pregnancy is very complex and diverse. The emergency doctor most often has to deal with its acutely developing forms: internal and external rupture of the tube and tubal abortion.

A well-collected gynecological history is essential for making a correct diagnosis. When questioning, it is necessary to pay attention to the delay in menstruation, infantilism (late onset of menstruation - at 16-17 years old, their soreness and atypicality), past inflammatory diseases of the genital organs, abortions in the past, long intervals between pregnancies. Most often, a woman considers herself pregnant, but in some cases she denies pregnancy. Often a woman is disturbed by slight pains and bloody, dirty, foul-smelling discharge. The clinic of ectopic pregnancy most often develops among full health. There is a sharp paroxysmal cramping pain in the lower abdomen, radiating to the anus, lower back, lower limbs, sometimes the pain radiates to the corresponding shoulder girdle (phrenicus symptom). Often there is a short-term loss of consciousness, dizziness, fainting, nausea, vomiting, hiccups. Urination is usually delayed, but may be frequent. There are urges to defecate, sometimes there is diarrhea. Signs of internal bleeding come to the fore: a sharp pallor of the skin and visible mucous membranes, a pale face, a semi-conscious state, cold sweat, sunken facial features, an expression of fear in the eyes. Body temperature is usually normal, subfebrile or even low.

In the study of such patients, engorgement of the mammary glands is observed, with pressure, drops of colostrum are released from the nipples. Shortness of breath is noted. The pulse is frequent - 100 beats / min or more, small, weak filling, sometimes barely palpable or completely imperceptible. Arterial pressure (maximum and minimum) is reduced and progressively falls.

Palpation of the abdomen and vaginal examination in acute ectopic pregnancy should be carried out with extreme caution. Patients are often in a forced semi-sitting position. The abdomen is moderately swollen. The patient spares him when breathing. Percussion and palpation of the abdomen are sharply painful, especially on the side of the ruptured tube. There is a dullness of percussion sound in sloping areas of the abdomen, which is due to the presence of free blood in the abdominal cavity.

With a two-handed vaginal examination, a sharp soreness is determined at the entrance to the vagina and in the posterior fornix, which is supple and soft. In one of the arches, resistance is usually noted. The uterus is slightly enlarged. Vaginal discharge - spotting, bloody, dark in color.

If an ectopic pregnancy is detected or suspected, the patient should be urgently taken on a stretcher to the gynecological department of the hospital for surgical treatment. It is especially important to create conditions of complete rest during the transportation of the patient. Due to the variety of clinical forms (atypical and obliterated forms), the recognition of ectopic pregnancy is often a difficult task, so most patients are admitted to surgical departments with a diagnosis of "acute abdomen".

II. hospital

Great difficulties in recognizing an ectopic pregnancy occur when peritoneal phenomena predominate in the clinical picture. In the blood taken in the first hours after the attack, anemia is noted, on the part of white blood -

transient leukopenia and thrombocytopenia. ESR is increased with a large blood loss.

Gynecological examination helps to clarify the diagnosis. With an indistinct clinical picture, a puncture of the abdominal cavity through the posterior fornix of the vagina is indicated to establish the presence of free blood in the abdominal cavity.

AT In the diagnosis of ectopic pregnancy, laparoscopy is widely used, which allows you to detect blood in the abdominal cavity, hematosalpinx, hemorrhages in the ovary, as well as to provide the necessary amount of surgical care.

To clarify the diagnosis, it is also possible to use laparocentesis (abdominal puncture) to determine the blood in the abdominal cavity.

With a clear clinical picture and a threatening condition, the patient must be operated on an emergency basis, regardless of the severity of the condition (operative access, either laparoscopy or laparotomy). The fight against shock, blood loss should not delay the operation, but be carried out during the surgical intervention. Anesthesia is general.

After revision of the pelvic organs, the affected tube is found and most often a salpingectomy is performed. In the absence of contraindications, autotransfusion of blood from the abdominal cavity is required.

Discharge from the hospital with a favorable course of the postoperative period on the 7-8th day after the operation.

AT Depending on the place of implantation of the fetal egg, an ectopic pregnancy can be disrupted by the type of tubal abortion and rupture of the fallopian tube.

With a tubal abortion, the fetal egg, not having the appropriate conditions for development, exfoliates from the walls of the fallopian tube and is expelled into the abdominal cavity. Due to the rhythmic contraction of the fallopian tube, blood enters the abdominal cavity periodically.

When the fallopian tube ruptures as a result of an ectopic pregnancy, the villi of the fetal egg completely destroy the thin wall of the fallopian tube, and blood from the damaged vessels flows into the abdominal cavity. Bleeding is usually massive, so signs of intra-abdominal bleeding predominate in the clinical picture of fallopian tube rupture. Rupture of the fallopian tube, as a rule, occurs suddenly against the background of absolute health, with a delay in menstruation by an average of three to four weeks.

Sudden and severe pain in the lower abdomen radiates to the rectum and is accompanied by dizziness, weakness, pallor, fainting. The abdomen participates in the act of breathing to a limited extent, is painful on palpation and percussion, the symptoms of peritoneal irritation are positive, with percussion in sloping places there is dullness. With continued bleeding, signs of hemorrhagic shock and posthemorrhagic anemia come to the fore.

Differential diagnosis is carried out with acute pancreatitis, perforated gastric and duodenal ulcer, acute appendicitis, torsion of the ovarian cyst, etc. Diagnostically important is an indication of delayed menstruation, subjective signs of pregnancy, bloody discharge from the genital tract.

Patients with an ectopic pregnancy need emergency care in a gynecological hospital; in case of diagnostic doubt, hospitalization in a multidisciplinary hospital is indicated. . Signs of intra-abdominal

bleeding requires immediate replenishment of the BCC with any available blood-substituting solution, preferably dextrans, starch preparations. The infusion is continued until the patient is admitted to the hospital.

Ovarian apoplexy(rupture of the ovary, ovarian infarction, ovarian hematoma) - an acute violation of the integrity of the ovary with hemorrhage in its stroma and subsequent bleeding into the abdominal cavity. Ovarian apoplexy occurs more often in women of reproductive age, but also occurs in adolescents. Rupture of the ovary occurs due to congestive hyperemia, varicose, dilated veins or sclerotic vessels, as well as sclerotic changes in the stroma. Bleeding from the ovary is preceded by the formation of a hematoma, which causes severe pain due to an increase in intra-ovarian pressure, followed by rupture of the ovarian tissue.

An important role belongs to dysfunctions of the autonomic and endocrine systems, which leads to an increase in the secretion of luteinizing hormone from the pituitary gland. Apoplexy often occurs during the period of ovulation, as well as in the stage of vascularization and flowering of the corpus luteum.

Ovarian apoplexy is accompanied by intra-abdominal bleeding and pain. According to the predominance of one of them, anemic and painful forms of the disease are conditionally distinguished. It begins acutely, with sudden pain in the lower abdomen, mainly on the side of the lesion. In the painful form, on examination, pain in the lower abdomen is determined, symptoms of peritoneal irritation are mild. In this situation, differential diagnosis with acute appendicitis is necessary. With an anemic form, all signs of intra-abdominal bleeding come to the fore.

Unlike an ectopic pregnancy, with a rupture of the ovary, there are no indications of a delay in menstruation, signs of pregnancy, or spotting from the genital tract. With ovarian apoplexy, hospitalization in a multidisciplinary hospital is necessary. With signs of intra-abdominal bleeding, immediate administration of blood-substituting solutions is required.

Torsion of the legs of a cyst (cystoma) of the ovary- complication of an existing cyst or ovarian cystoma. The onset of the disease is often associated with a sharp change in body position, an increase in intra-abdominal pressure as a result of strong straining, prolonged coughing, hard physical work, as well as a violation of the blood supply to the cyst. Torsion can occur acutely or develop gradually, with a violation of the blood supply with swelling of the cyst, hemorrhage and necrosis of the parenchyma. There are partial (gradual) and complete (sudden) torsion.

With partial torsion, the pedicle changes its position by 90-180°, arterial blood flow is preserved, but venous outflow is difficult due to vascular compression, resulting in venous plethora and swelling of the cyst wall. With complete torsion (up to 360°), arterial blood flow stops, which causes necrobiotic processes in the ovarian cyst and the appearance of peritoneal symptoms, and when the cyst becomes infected, peritonitis. Pain in the lower abdomen from the side of education can be gradually increasing or acute. Nausea, vomiting, flatulence, intestinal paresis, tension of the anterior abdominal wall, symptoms of peritoneal irritation are possible. Differential diagnosis is carried out with acute appendicitis and disturbed ectopic pregnancy. Urgent

hospitalization. At the prehospital stage, treatment is not carried out.

Perforation of purulent formations of the uterine appendages

Inflammatory diseases of the female genital organs occupy a leading place in gynecological practice and remain the most common cause of hospitalization in women of reproductive age. Inflammatory diseases go through several stages, from acute inflammation to complex destructive tissue changes. The main mechanism for the development of inflammation is microbial invasion. At the same time, in the etiology of the purulent process, provoking factors occupy a significant, and sometimes leading place. This is a physiological (menstruation, childbirth) or iatrogenic (abortion, intrauterine contraceptives, surgery, hysteroscopy, in vitro fertilization) weakening or change in the barrier properties of the uterus and genital tract, contributing to the formation of an entrance gate for pathogenic microflora and its further spread. Infection occurs by intracanalicular, ascending, hematogenous and lymphogenous routes.

The clinical picture of inflammatory diseases of the female genital organs, in particular the uterine appendages, is now often erased, oligosymptomatic. Pyosalpinx, tubo-ovarian abscess cause constant pain in the lower abdomen, mainly from inflammation, chills, high fever, weakness, malaise. Pain radiates to the lower extremities, lumbar region. The abdomen is soft, may be moderately swollen. Patients have tachycardia. There are no symptoms of peritoneal irritation, nausea, stool retention, gases are possible.

A purulent discharge sometimes appears from the genital tract.

With perforation of purulent formations, mild symptoms of peritonitis appear already in the first hours, which are superimposed on the clinic of a severe inflammatory process. Pain is intense, sometimes aching, indistinct localization. Chills, fever, tachycardia accompany this stage of the disease. Painful urination, loose stools, and bloating are often noted.

At the prehospital stage, the introduction of analgesics is strictly unacceptable.

Broad-spectrum and long-acting antibiotics are used. Antibiotics should have cross-effectiveness in gynecological, urological, general surgical and other diseases). For example, ceftriaxone 1-2 g IV or IM in combination with metronidazole 100 ml IV drip and amoxicillin 2.4 g IV in combination with metronidazole 100 ml IV are eligible. . required hospitalization and

the main treatment is carried out in a hospital.

Pelvic peritonitis (pelvioperitonitis).

There are primary and secondary pelvioperitonitis. Primary occurs as a result of damage to the peritoneum by microbes that have penetrated hematogenous, lymphogenous or through the fallopian tubes. Secondary peritonitis is much more common and is the result of the spread of the inflammatory process from the organs, as a result of their perforation or inflammation.

Gynecological diseases are most often characterized by local limited pelvic peritonitis. However, with insufficient defense mechanisms, with high virulence of the microflora, with inadequate treatment, inflammation of the peritoneum progresses and diffuse peritonitis occurs. With pelvic peritonitis, against the background of predisposing moments, there are constant increasing pain, malaise, fever, chills, tachycardia, nausea, shortness of breath, dry and

AT premenstrual age ovaries should not be palpable. If they can be felt, their pathology should be assumed and further in-depth examination should be carried out.

The latter may be the result of both a failed follow-up ovulation, and an excess amount of estradiol produced inside the follicle. Excessive estrogen saturation of the body in the absence of ovulation hyperstimulates the endometrium and causes irregular bleeding. A bimanual gynecological examination may reveal a unilateral painful mobile cystic adnexal mass.

Having received such data during the primary survey, the doctor must decide whether to undertake further in-depth examination, and decide on treatment. Ultrasound of the pelvic organs is recommended for patients of reproductive age with a cyst size of more than 5 cm in diameter. This examination reveals a single-chambered simple cyst with no signs of blood or soft tissue elements inside and no signs of growths outside. Most patients do not require ultrasound confirmation. Instead, the woman should be reassured and reassessed in 6 to 8 weeks.

Inflammation of the appendages in women is an infectious pathology, while the process affects the ovaries or fallopian tubes, but not the uterus itself. The penetration of the pathogen into the body occurs in various ways.

The disease can proceed for a long time without symptoms, sometimes characterized by the appearance of pain in the lower abdomen and menstrual irregularities. Treatment is aimed at destroying the pathogen and restoring the function of the uterine appendages.

Causes

Why do women develop inflammation of the appendages, and what is it? In medicine, this disease is called salpingo-oophoritis. If the inflammation affects only the fallopian tubes, then salpingitis is diagnosed. An inflammatory process that affects only the ovaries is called oophoritis.

The development of the inflammatory process in the uterine appendages occurs under the influence of pathogenic and opportunistic microorganisms. There are two types of disease:

specific adnexitis caused by diphtheria bacteria, tuberculosis bacillus, gonococci;
nonspecific salpingoophoritis caused by viruses, fungi, E. coli, streptococci, staphylococci, mycoplasmas, chlamydia and other microorganisms.

The penetration of infection into the uterine appendages can occur in the following ways:

ascending (pathogenic microbes from the vagina enter the uterus, bypassing the cervical canal, into the tubes, and then can enter the ovaries);
descending (there is already inflammation in the abdominal cavity, which gradually passes to healthy tissues);
hematogenous (microbes enter the fallopian tubes and ovaries with blood from other internal organs).

The likelihood of inflammation of the appendages increases with the action of provoking factors on the body:

hypothermia;
weakening of the immune system;
using a contraceptive method such as an intrauterine device;
unprotected sex;
childbirth or abortion.

can take three forms:

acute;
chronic;
latent (asymptomatic, or sluggish).

The disease can be diagnosed at any age. Both young girls who do not live sexually and older women who have gone through menopause turn to doctors for help.

Symptoms of inflammation of the appendages

In the case of the development of inflammation of the appendages in women, the presence of certain symptoms depends on certain factors:

pathogenicity of the ingested microorganism, its type;
from the course of the disease, whether it is an acute process, with pronounced symptoms, or chronic, with erased, barely noticeable symptoms;
the ability of the girl's body to resist microorganisms and fight the inflammatory process, from the state of the immune system.

For acute form women complain of the following symptoms:

tense abdomen in the lower sections;
, giving sometimes to the legs or lower back;
elevated body temperature (it can reach 39 degrees);
change in the menstrual cycle (the occurrence of sudden bleeding or delayed menstruation);
vaginal discharge that is different from normal (they may be greenish-purulent or yellowish, profuse or frothy).

An incompletely cured disease in the acute period can turn into chronic inflammation of the appendages, the symptoms of which depend on the period of remission or exacerbation. Every second woman with chronic adnexitis has the following pathological changes:

menstrual irregularities;
sexual dysfunction;
concomitant diseases of the urinary organs (,), etc.

During the period of exacerbation, all the symptoms characteristic of acute adnexitis resume.

Chronic adnexitis

Chronic adnexitis develops as a result of untimely or poor-quality treatment of the acute form of the disease, it occurs with periodic seasonal exacerbations. This form of inflammation of the appendages is characterized by the presence of dull, aching pain in the lower abdomen, radiating to the vagina and lumbar region. Palpation of the abdomen determines moderate pain.

In connection with the structural and functional transformations in the ovaries (lack of ovulation, hypoestrogenism), chronic inflammation of the appendages in women is accompanied by menstrual irregularities, which is manifested by oligomenorrhea (scanty menstruation), polymenorrhea (abundant menstruation), algomenorrhea (painful menstruation). Also, patients may complain of a lack or decrease in sexual desire, the appearance of pain during intercourse.

Diagnostics

The above symptoms may also be present in other diseases of the genital organs, therefore, only a gynecologist can make an accurate diagnosis after examining the patient, collecting an anamnesis, and the results of laboratory and instrumental studies:

Ultrasound of the uterus and appendages;
PCR diagnostics (vaginal smear), which allows to establish genital infections;
colposcopy (examination of the vagina and its walls);
bakposev;
tomography;
laparoscopy.

Signs of inflammation of the appendages can be determined by the results of a blood test. In inflammatory processes, the blood formula changes significantly,. In addition, during a gynecological examination at a gynecologist's appointment, a woman feels severe pain in the ovaries and uterus.

Effects

Any inflammation of the appendages is dangerous because the following complications are possible:

development into a chronic form;
infertility, as a result of the adhesive process, in which there is obstruction of the fallopian tubes and anovulation;
a fairly high risk of ectopic conception;
purulent complication (tubo-ovarian formation) - purulent fusion of the ovaries and tubes, followed by an abscess.

Prevention

Regularly visit the gynecologist, without resisting the examination on the chair, take smears.
Avoid hypothermia by dressing appropriately for the weather, changing after swimming, avoiding sitting on cold objects.
If abortion is necessary, do it early or with medication or mini-abortion (avoid curettage).
Treat teeth, intestines and other foci of chronic infection.
Use barrier methods of contraception.
Timely treat gynecological diseases.
Follow the rules of a healthy diet.
Follow the rules of intimate hygiene.
Avoid douching.
Avoid stress.

Thus, inflammation of the appendages is a serious disease that requires timely treatment, which involves strict adherence to medical prescriptions.

Treatment of inflammation of the appendages

When diagnosing inflammation of the appendages, treatment in women should be comprehensive: a combination of medications with physiotherapy, gynecological massage, osteopathy, and physiotherapy.

The main point in the treatment of inflammation are antibiotics. They are selected with a wide spectrum of action and a maximum half-life. In addition, the woman herself needs to monitor her lifestyle (proper nutrition, abstinence from sexual activity, physical education, smoking and alcohol should be avoided).

The disease cannot be started, since the inflammatory process soon passes into the chronic stage, which leads to infertility.

Antibiotics for inflammation of the appendages

Antibiotics for inflammation of the appendages is the first and main condition that must be met for a favorable outcome of the disease. How to treat inflammation of the appendages, the dosage and number of doses for each particular woman is determined by a specialist, however, we will give you the most commonly prescribed pairs of medicines:

Nitroimidazole derivatives (for example, Metronidazole) to eliminate anaerobic flora that can live in an anoxic environment, such as gonococci (causative agents of gonorrhea);
Inhibitor-protected penicillins (Amoxiclav), 3rd generation cephalosporins (Ceftriaxone), macrolides (Erythromycin), etc., which affect the aerobic (living in an oxygen environment) flora;
Antifungal drugs (eg Diflucan, Nystatin).

The first three to four days before the condition normalizes, all these drugs are administered as injections. Then you can switch to tablet forms and reduce the dose.

Concomitant treatment

In addition to the appointment of antibacterial drugs, detoxification therapy is carried out (intravenous infusions of saline solutions, glucose, hemodez, rheopolyglucin and others in a volume of 2-3 liters).

Relief of pain, and reduction of the inflammatory process is carried out with the help in the form of tablets. These are Diclofenac, Ibuprofen, Ketarol and other drugs. Be sure to prescribe vitamins C and B, as well as allergy pills.

When removing an acute process and in the treatment of chronic inflammation of the appendages without exacerbation, physiotherapy is widely used: electrophoresis of copper and zinc in the phases of the menstrual cycle, electrophoresis with lidase or iodine, ultrasound, high-frequency pulsed currents (SMT, DDT). Also in the rehabilitation treatment, immunomodulators, autohemotherapy, injections of aloe, FIBS, Longidase and so on are used. In chronic adnexitis, spa treatment is indicated - mud, paraffin, therapeutic baths and douching.

Candles for inflammation of the appendages

To reduce signs such as inflammation, pain, swelling, and temperature, special suppositories are used that can relieve inflammation. They can also prescribe such suppositories that are able to strengthen the immune system, and this is very important for any illness. Also, these drugs cleanse the body of harmful substances.

All candles are prescribed by a doctor, but in any case, such treatment will be additional.

Folk remedies

At home, you can use some folk recipes:

Take 4 teaspoons of finely chopped buckthorn roots, Chernobyl and peony, add 3 teaspoons of burnet roots and elecampane. After that, pour 2 tablespoons of the resulting mixture with half a liter of boiling water. Boil for half an hour on low heat, and then let cool for half an hour. After strain and you can add a little honey for taste. Take the drug should be half a cup 3-4 times a day.
One tablespoon chopped dry grass boron uterus pour a glass of boiling water. Insist 2 hours. Strain. Take 1/3 cup 3 times a day half an hour before meals. The course of treatment is 1 month. After a monthly course of treatment of adnexitis with a pine forest uterus, it is advisable to drink another infusion for 2 months - from the field yarutka grass. 1 st. l. herbs pour a glass of boiling water, leave for 4 hours, strain. Drink 1 tsp. 30 minutes before meals 4 times a day.
Buldenezh should be collected at the very beginning of flowering (until insects have started in them). Tincture of them has excellent antiseptic, anti-inflammatory and analgesic properties. A liter jar is filled with inflorescence balls, filled with vodka and sent for 15 days to a dark, cool place. The lower abdomen is rubbed with this tincture, and the inflorescences are applied in the form of compresses.
Take flowers of coltsfoot, sweet clover, centaury in equal proportions. Mix, pre-grinding, pour boiling water, let it brew for an hour, then strain the broth through gauze and drink half a glass twice a day. During treatment, abstinence from sexual intercourse is recommended.

Remember that folk remedies are only an addition, and in no way can replace drug therapy prescribed by a specialist.

Among all diseases of the female reproductive organs, the ovarian cyst occupies a leading position. This is a fairly common pathology, which belongs to the group of tumor-like diseases. It occurs most often in reproductive age, but can sometimes be detected in girls or in women who are in menopause. When planning a child, a woman must be examined for the presence of tumor formations, as they can prevent the onset of a long-awaited pregnancy. And some cystic formations lead to the formation of adhesions in the pelvis, which can make the dream of motherhood unrealizable.

The cyst is a sac-like formation filled with liquid secretion. The size of the "pouch" can vary from a few millimeters to tens of centimeters, when the formation can fill the entire abdominal cavity. It all depends on the type of cyst.

Why does an ovarian cyst form?

Tumor-like formations are formed in the ovaries due to hormonal imbalance, as a result of inflammatory diseases, blood stagnation in the pelvic area. In this case, there is a gradual accumulation of fluid, stretching of the thin walls of the cyst at the site of formation. Cysts differ from true ovarian tumors in that they increase only due to an increase in the volume of fluid in the cavity. The walls of the formation remain thin. Tumors also increase due to the growth of tissues in the wall itself.

Types of ovarian cysts depending on the place of their formation:

Follicular.
Yellow cyst.
Paraovarian.
Endometrioid.

The most common are follicular cysts. They are diagnosed in more than 70% of cases. The reason for their appearance is the accumulation of fluid in the follicle, which is produced during the menstrual cycle. In a healthy woman, a mature follicle should burst and release an egg. If this does not happen, the follicle grows due to the accumulation of fluid and forms a cyst.

With a corpus luteum cyst, the accumulation of fluid is noted at the site of the bursting follicle. Often accompanied by hemorrhage in the formation cavity. Such formations are often detected only during preventive examinations, since they may not give clinical symptoms and proceed completely unnoticed by a woman. Only a small part of patients have complaints of heaviness in the lower abdomen, pain during intercourse, increased urination or flatulence.

These types of tumor-like formations have a favorable outcome. More often, the doctor chooses expectant tactics for two to three cycles. During this time, the cysts can dissolve on their own and disappear without a trace.

Paraovarian cysts form on the side of the uterus, between the broad ligament that holds the uterus in the pelvis. This type of formation can reach large sizes, filling the abdominal cavity and causing an increase in the abdomen. Most often, such a cyst is found in young girls. It can be asymptomatic, occasionally girls are bothered by abdominal pain and are alarmed by a grown belly. The disease can proceed without disruption of the menstrual cycle. Paraovarian cysts can be complicated by torsion of the pedicle of the formation, causing acute pain in the abdomen. After removal, the prognosis is favorable.

Endometrioid cysts are caused by a condition called endometriosis. With this pathology, islands of growth of tissue similar to the endometrium appear. Such foci can be located on the cervix, ovaries, in the abdominal cavity, the walls of the bladder, etc. There are many theories about the origin of the disease, but not one has received one hundred percent proof. With the location of endometrioid foci in the ovaries and their fusion, they speak of the occurrence of endometrioid cysts. A characteristic feature of them is the color of the secret in brown due to the accumulation of blood. Such cysts in gynecology are called "chocolate".

The main complaint is abdominal pain, aggravated by physical work, as well as during sexual intercourse. Periods become painful, pain appears in the external genitalia and in the pelvic area during intercourse. The earlier a cyst is diagnosed, the greater the chance of successful treatment. Endometrial cysts can develop into a cancerous tumor.

Most often, cysts are discovered by chance during preventive examinations or when planning a pregnancy. Less often, women complain of a violation of the cycle or the appearance of pain in the abdomen. Mandatory and available methods for diagnosing cysts are the following:

Palpation
Laparoscopy

On palpation, the doctor palpates the uterus and its appendages using a two-handed examination, when one hand is in the vagina, and the second is located on the front wall of the abdomen. With small sizes of tumor-like formations, palpation may not give results. If the size of the cyst reaches several centimeters in diameter, then the doctor can feel a soft, rounded formation. With a follicular cyst, it is usually located on the side of the uterus on the right or left side. On palpation, the formation is mobile and painless. The cyst of the corpus luteum is palpated behind the uterus, sometimes it is painful.

Paraovarian cysts are palpable above the uterus on the right or left side. This is a smooth formation with limited mobility, can be quite large, painless.

Cysts in ovarian endometriosis are usually located posterior to the uterus. Their feature is an increase in size after menstruation. The examination of the vagina can be painful due to the presence of adhesions in the pelvis.

Ultrasound examination (ultrasound) of the ovaries allows you to determine the size and number of cysts, their location, wall thickness, consistency of the contents.

Diagnosis of a cyst by the laparoscopic method is the most informative method. The camera on the laparoscope allows you to see the tumor-like formation in its natural form. At the same time, a laparoscope can be used to take a biopsy in order to verify the diagnosis, as well as to perform an operation to remove the cyst. In this case, damage to the soft tissues of the abdominal wall will be minimal.

Possible complications of the cyst and first aid for them

Sometimes complications resemble a picture of an "acute abdomen", in which case a woman with an ovarian cyst is urgently admitted to the surgical department. This can happen when the pedicle of the tumor formation is twisted or ruptured. As a result of torsion of the leg, compression of blood vessels and nerve fibers occurs. This causes acute pain and ischemia in the tumor formation. As a result, necrosis of the cystic formation occurs, and peritonitis may develop. The rupture of the wall of the formation is accompanied by the outpouring of its contents into the abdominal cavity with the development of inflammation, which, with untimely assistance, can be fatal.

First aid in this case consists in the emergency hospitalization of a woman for an operation to remove a cyst or ovary along with a ruptured formation.

The appearance of sharp pains in the abdomen, a decrease in pressure, an increase in temperature, loss of consciousness are symptoms in which it is necessary to call an ambulance.

Long-term complications are the development of chronic inflammation in the ovaries, followed by an adhesive process, as well as malignancy of the cyst (cancerous degeneration).

First of all, planning a child should begin with a visit to the gynecologist. Before the onset of pregnancy, a woman must be sure that everything is in order with her reproductive organs and nothing threatens the health and life of the unborn baby.

If during examinations an ovarian cyst is found in a woman or girl, then the planning of the child should be postponed until a complete cure. Firstly, the presence of cysts can lead to infertility, since often in their presence there is no ovulation and fertilization becomes impossible. Secondly, there is a high risk of developing acute complications of the cyst during childbearing, and then surgery will be needed, which can harm the baby.

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Gynecological examination. Gynecological examination

Gynecological examination is carried out in the gynecological chair in the following order:

Inspection of the external genitalia - examine the pubis, large and small labia, anus. The condition of the skin, the nature of hair growth, the presence of volumetric formations are noted, suspicious areas are palpated. By spreading the labia majora with the index and middle fingers of a gloved hand, the following anatomical structures are examined: labia minora, clitoris, external opening of the urethra, vaginal opening, hymen, perineum, anus. If a disease of the small glands of the vestibule is suspected, they are palpated by pressing on the lower part of the urethra through the anterior wall of the vagina. In the presence of secretions, smear microscopy and culture are indicated. If the anamnesis has indications of volumetric formations of the labia majora, the large glands of the vestibule are palpated. To do this, the thumb is placed on the outside of the labia majora closer to the posterior commissure, and the index finger is inserted into the vagina. On palpation of the labia minora, epidermal cysts can be detected. The labia minora is spread with the index and middle fingers, then the patient is offered to push. In the presence of a cystocele, the anterior wall of the vagina appears at the entrance, with a rectocele - the posterior one, with prolapse of the vagina - both walls. The condition of the pelvic floor is assessed during a bimanual examination.

A special gynecological examination is divided into three types depending on the volume and results of the examination that they can give. These include vaginal, rectal, and rectovaginal examinations. Vaginal and rectovaginal examinations, in terms of their capabilities, provide much more information than one rectal one. More often, rectal examination is used in girls or in women who are not sexually active.

EXAMINATION OF THE EXTERNAL GENITAL ORGANS

In most cases, one of the signs of a normal structure and undisturbed functions of the reproductive system is, as you know, the appearance of the external genitalia. In this regard, the determination of the nature of the pubic hair, the amount and type of hair distribution is important. Examination of the external and internal genital organs provides significant information, especially in women with menstrual irregularities and infertility. The presence of hypoplasia of the small and large lips, pallor and dryness of the vaginal mucosa are clinical manifestations of hypoestrogenism. "Juiciness", cyanosis of the color of the mucous membrane of the vulva, an abundant transparent secret are considered signs of an increased level of estrogens. During pregnancy, due to congestive plethora, the color of the mucous membranes acquires a cyanotic color, the intensity of which is all the more pronounced, the longer the gestational age. Hypoplasia of the small lips, an increase in the head of the clitoris, an increase in the distance between the base of the clitoris and the external opening of the urethra (more than 2 cm) in combination with hypertrichosis indicate hyperandrogenism. These signs are characteristic of congenital virilization, which is observed only in one endocrine pathology,  CAH (adrenogenital syndrome). Similar changes in the structure of the external genital organs with pronounced virilization (hypertrichosis, coarsening of the voice, amenorrhea, atrophy of the mammary glands) make it possible to exclude the diagnosis of a virilizing tumor (both ovarian and adrenal glands), since the tumor develops in the postnatal period, and CAH is a congenital pathology that develops antenatally, during the formation of the external genital organs.

In giving birth, pay attention to the condition of the perineum and genital gap. With normal anatomical relationships of the tissues of the perineum, the genital slit is usually closed, and only with a sharp straining slightly opens. With various violations of the integrity of the pelvic floor muscles, which usually develop after childbirth, even slight tension leads to a noticeable gaping of the genital slit and the descent of the vaginal walls with the formation of a cysto and rectocele. Often, when straining, prolapse of the uterus is observed, and in other cases, involuntary urination.

When assessing the condition of the skin and mucous membranes of the external genitalia, various pathological formations are detected, for example, eczematous lesions and warts. In the presence of inflammatory diseases, the appearance and color of the mucous membranes of the external genital organs are sharply changed. In these cases, the mucous membrane can be intensely hyperemic, sometimes with purulent deposits or ulcerative formations. All altered areas are carefully palpated, determining their consistency, mobility and soreness. After examination and palpation of the external genital organs, they proceed to the examination of the vagina and cervix in the mirrors.

EXAMINATION OF THE CERVICE WITH THE HELP OF MIRRORS

When examining the vagina, the presence of blood, the nature of the discharge, anatomical changes (congenital and acquired) are noted; condition of the mucous membrane; pay attention to the presence of inflammation, mass formations, vascular pathology, injuries, endometriosis. When examining the cervix, pay attention to the same changes as when examining the vagina. But at the same time, the following must be borne in mind: with bloody discharge from the external uterine os outside of menstruation, a malignant tumor of the cervix or body of the uterus is excluded; with cervicitis, mucopurulent discharge from the external uterine os, hyperemia and sometimes erosion of the cervix are observed; cervical cancer is not always possible to distinguish from cervicitis or dysplasia, therefore, at the slightest suspicion of a malignant tumor, a biopsy is indicated.

For women who are sexually active, Pederson's or Grave's, Cusco's self-supporting vaginal mirrors, as well as a spoon-shaped mirror and a lift, are suitable for examination. Folding self-supporting mirrors of the Cuzco type are widely used, since when using them you do not need an assistant and with their help you can not only examine the walls of the vagina and the cervix, but also carry out some medical procedures and operations (Fig. 5-2).

Rice. 5-2. Folding mirror type Cuzco. For examination, the patient chooses the smallest mirror, which allows a full examination of the vagina and cervix. Folding mirrors are inserted into the vagina in a closed form obliquely with respect to the genital slit. Having advanced the mirror to half, turn it with the screw part down, at the same time move it deeper and push the mirror so that the vaginal part of the cervix is between the parted ends of the valves. With the help of a screw, the desired degree of expansion of the vagina is fixed (Fig. 5-3).

Rice. 5-3. Examination of the cervix using a disposable Cuzco speculum.

Spoon-shaped and plate mirrors are convenient when it is necessary to perform any operations in the vagina. First, a spoon-shaped lower mirror is inserted, pushing the perineum backwards, then a flat (anterior) mirror (“lift”) parallel to it, with which the anterior wall of the vagina is raised upward (Fig. 5-4).

Rice. 5-4. Inspection of the emerging submucosal myomatous node with a spoon-shaped mirror and bullet forceps.

During the study, using mirrors, the condition of the vaginal walls is determined (the nature of folding, the color of the mucous membrane, ulceration, growths, tumors, congenital or acquired anatomical changes), the cervix (size and shape: cylindrical, conical; the shape of the external os: round in nulliparous, in the form of a transverse slit in those giving birth; various pathological conditions: ruptures, ectopia, erosion, ectropion, tumors, etc.), as well as the nature of the discharge.

When examining the walls of the vagina and the cervix, if blood discharge is detected from the external uterine os outside of menstruation, a malignant tumor of the cervix and body of the uterus should be excluded. With cervicitis, mucopurulent discharge from the cervical canal, hyperemia, erosion of the cervix are observed. Polyps can be located both on the vaginal portion of the cervix, and in its canal. They can be single or multiple. Also, with a visual assessment of the cervix with the naked eye, closed glands (ovulae nabothi) are determined. In addition, when examining the cervix in the mirrors, endometrioid heterotopias in the form of "eyes" and linear structures of cyanotic color can be detected. In differential diagnosis with closed glands, a distinctive feature of these formations is the dependence of their size on the phase of the menstrual cycle, as well as the appearance of blood discharge from endometrioid heterotopias shortly before and during menstruation.

Cervical cancer during a gynecological examination can not always be distinguished from cervicitis or dysplasia, so it is imperative to make smears for cytological examination, and in some cases, to make a targeted biopsy of the cervix. Particular attention is paid to the vaults of the vagina: it is difficult to examine them, but volumetric formations and genital warts are often located here. After removing the mirrors, a bimanual vaginal examination is performed.

BIMANUAL VAGINA EXAMINATION

The index and middle fingers of one gloved hand are inserted into the vagina. Fingers must be lubricated with a moisturizer. The other hand is placed on the anterior abdominal wall. With the right hand carefully palpate the walls of the vagina, its vaults and the cervix. Any volumetric formations and anatomical changes are noted (Fig. 5-5).

Rice. 5-5. Bimanual vaginal examination. Clarification of the position of the uterus.

In the presence of effusion or blood in the abdominal cavity, depending on their number, flattening or overhanging of the arches is determined. Then, by inserting a finger into the posterior fornix of the vagina, the uterus is displaced forward and upward, palpating it with the other hand through the anterior abdominal wall. Determine the size, shape, consistency and mobility, pay attention to volumetric formations. Normally, the length of the uterus, together with the cervix, is 7-10 cm, in a nulliparous woman it is slightly less than in a woman who has given birth. Reduction of the uterus is possible with infantilism, in menopause and postmenopause. An increase in the uterus is observed with tumors (myoma, sarcoma) and during pregnancy. The shape of the uterus is normally pear-shaped, somewhat flattened from front to back. During pregnancy, the uterus is spherical, with tumors - irregular shape. The consistency of the uterus is normally tight elastic, during pregnancy the wall is softened, with fibromyomas it is compacted. In some cases, the uterus may fluctuate, which is typical for hemato and pyometra.

The position of the uterus: inclination (versio), inflection (flexio), displacement along the horizontal axis (positio), along the vertical axis (elevatio, prolapsus, descensus) - is of great importance (Fig. 5-5). Normally, the uterus is located in the center of the small pelvis, its bottom is at the level of the entrance to the small pelvis. The cervix and body of the uterus form an angle open anteriorly (anteflexio). The entire uterus is somewhat tilted anteriorly (anteversio). The position of the uterus changes with a change in the position of the body, with overflow of the bladder and rectum. With tumors in the area of the appendages, the uterus is displaced in the opposite direction, with inflammatory processes - in the direction of inflammation.

Soreness of the uterus during palpation is noted only in pathological processes. Normally, especially in women who have given birth, the uterus has sufficient mobility. With the omission and prolapse of the uterus, its mobility becomes excessive due to the relaxation of the ligamentous apparatus. Limited mobility is observed with infiltrates of parametric fiber, fusion of the uterus with tumors, etc. After examining the uterus, they begin to palpate the appendages  of the ovaries and fallopian tubes (Fig. 5-6). The fingers of the outer and inner hands move in concert from the corners of the uterus to the right and left sides. For this purpose, the inner hand is transferred to the lateral fornix, and the outer  to the corresponding side of the pelvis to the level of the fundus of the uterus. Fallopian tubes and ovaries are palpated between converging fingers. Unchanged fallopian tubes are usually not detected.

Rice. 5-6. Vaginal examination of the appendages, uterus and fornix.

Sometimes, the study reveals a thin round cord, painful on palpation, or nodular thickenings in the area of the horns of the uterus and in the isthmus of the fallopian tube (salpingitis). The sactosalpinx is palpated in the form of an oblong formation expanding towards the funnel of the fallopian tube, which has significant mobility. The pyosalpinx is often less mobile or fixed in adhesions. Often, during pathological processes, the position of the tubes is changed, they can be soldered adhesions in front or behind the uterus, sometimes even on the opposite side. The ovary is palpated in the form of an almond-shaped body 3x4 cm in size, quite mobile and sensitive. Compression of the ovaries on examination is usually painless. The ovaries are usually enlarged before ovulation and during pregnancy. In menopause, the ovaries are significantly reduced.

If, during a gynecological examination, volumetric formations of the uterine appendages are determined, their position relative to the body and cervix, shape, texture, soreness and mobility are assessed. With extensive inflammatory processes, it is not possible to palpate the ovary and the tube separately; a painful conglomerate is often determined.

After palpation of the uterine appendages, the ligaments are examined. Unchanged uterine ligaments are usually not detected. Round ligaments can usually be palpated during pregnancy and when fibroids develop in them. In this case, the ligaments are palpated in the form of strands extending from the edges of the uterus to the internal opening of the inguinal canal. The sacro-uterine ligaments are palpated after the transferred parametritis (infiltration, cicatricial changes). Ligaments go in the form of strands from the posterior surface of the uterus at the level of the isthmus posteriorly, to the sacrum. The sacro-uterine ligaments are better detected in the study per rectum. The parauterine tissue (parametria) and the serous membrane are palpated only if they contain infiltrates (cancerous or inflammatory), adhesions or exudate.

RECTOVAGINAL EXAMINATION

Rectovaginal examination is carried out necessarily in postmenopause, as well as in cases where it is necessary to clarify the condition of the uterine appendages. Sometimes this method is more informative than the standard bimanual examination.

The study is carried out with suspicion of the development of pathological processes in the wall of the vagina, rectum or rectovaginal septum. The index finger is inserted into the vagina, and the middle finger into the rectum (in some cases, to study the vesicouterine space, the thumb is inserted into the anterior fornix, and the index finger into the rectum) (Fig. 5-7). Between the inserted fingers, the mobility or adhesion of the mucous membranes, the localization of infiltrates, tumors and other changes in the vaginal wall, the rectum in the form of "thorns", and also in the fiber of the rectovaginal septum are determined.

Rice. 5-7. Rectovaginal examination.

Rectal examination. Examine the anus and the surrounding skin, perineum, sacrococcygeal region. Pay attention to the presence of traces of scratching on the perineum and in the perianal region, anal fissures, chronic paraproctitis, external hemorrhoids. The tone of the sphincters of the anus and the state of the muscles of the pelvic floor are determined, volumetric formations, internal hemorrhoids, and tumors are excluded. Pain or space-occupying formations of the recto-uterine cavity are also determined. In virgins, all internal genital organs are palpated through the anterior wall of the rectum. After removing the finger, the presence of blood, pus or mucus on the glove is noted.

In cases where it is necessary to determine the relationship of the tumor of the abdominal cavity with the genital organs, along with a bimanual study, a study using bullet forceps is indicated. The necessary tools are spoon-shaped mirrors, a lifter and bullet tongs. The cervix is exposed with mirrors, treated with alcohol, bullet forceps are applied to the front lip (you can put the second bullet forceps on the back lip). Mirrors are removed. After that, the index and middle fingers (or only one index) are inserted into the vagina or rectum, and the lower pole of the tumor is pushed upward through the abdominal wall with the fingers of the left hand through the abdominal wall. At the same time, the assistant pulls on the bullet forceps, displacing the uterus downwards. In this case, the leg of the tumor, emanating from the genital organs, is strongly stretched and becomes more accessible for palpation. You can apply another approach. The handles of the bullet forceps are left in a calm state, and with external methods the tumor is displaced up, to the right, to the left. If the tumor originates from the genital organs, then the handles of the forceps are drawn into the vagina when the tumor is moved, and with tumors of the uterus (MM with a subserous location of the node), the movement of the forceps is more pronounced than with tumors of the uterine appendages. If the tumor comes from other organs of the abdominal cavity (kidney, intestines), the forceps do not change their position.

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Palpation (palpation) of the abdomen

At the end of the examination, they begin to Feel the abdomen, for which both hands are placed with the palmar surfaces of the fingers on symmetrical places (Fig. 13) and with slow, smooth movements they feel the abdominal integument, their thickness, tension, sensitivity, consistency and divergence of the rectus abdominis muscles, constantly comparing between are symmetrical places. Palpation can be performed with one hand (Fig. 14). Hands must be necessarily warm, otherwise it is unpleasantly sick, and besides, reflex muscle contraction is easily caused, which makes it difficult to study. With deeper palpation, with pliable abdominal walls, one can determine the pulsating aorta lying on the spine, the sacral cape, and the intestines (the degree of its filling). In the groin, enlarged inguinal lymph nodes, hernial protrusions, round ligament tumors, and varicose veins can be found. In the upper abdomen, in the hypochondrium, the edge of the liver is found on the right, and the edge of the spleen on the left, provided they are enlarged. Palpation of the kidneys and deep-lying tumors is performed with the help of a hand brought under the lower back (Fig. 15). Unchanged internal genital organs are not palpable through the abdominal walls.

In the presence of a tumor in the abdominal wall, its upper and lateral borders, the borders towards the iliac pits and towards the pelvic cavity, the mobility of the abdominal integuments above the tumor and the mobility of the tumor under the abdominal integuments are determined.

Sometimes, when the abdomen is felt, especially after abdominal cuts, crepitus is felt, which depends on the ingress of air into the subcutaneous fat (subcutaneous emphysema). Subcutaneous emphysema is sometimes observed after improperly performed subcutaneous injections, when air is injected into the subcutaneous tissue along with the infused fluid.

The presence of fluid in the abdomen is determined as follows: one hand is fixed flat on one of the lateral surfaces of the abdomen, with the other hand, on the opposite side, a jerky movement is made towards the hand fixed on the abdomen - a feeling of fluctuation is obtained. It must be remembered that with severe obesity of the abdominal wall, a sensation of false fluctuation (fluctuation of the fatty wall) can be obtained.

When feeling the patient's abdomen, it is necessary to pay attention to the sensitivity to pressure in various parts of the abdomen. Soreness when feeling the abdomen is observed in inflammatory diseases of the internal genital organs and especially where the peritoneum is involved in the process; it turns out a "protective" contraction of the muscles of the abdominal wall at every touch.

Feeling the abdomen also determines the pain points characteristic of the inflammatory processes of certain organs of the abdominal cavity (for example, the gallbladder, appendix). As you know, in diseases of the appendix, one of the characteristic signs is soreness at the McBurney point, which lies in the middle of the line connecting the anterior superior spine of the right iliac bone with the navel. Being able to find this daughter is important for recognizing appendicitis. It is also necessary to know the location of the point on the abdominal wall corresponding to the location of the ovary. This point lies on the border between the middle and lower third of the line connecting the umbilicus with the middle of the pupart ligament.

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Examination of the internal genital organs

After examining the external genital organs, a study is carried out using mirrors, since a preliminary digital examination can change the nature of vaginal discharge and injure the mucous membrane of the cervix and vagina, which makes the examination results unreliable and makes it impossible to obtain correct diagnostic data when using endoscopic research methods (colposcopy, cervicoscopy, microcolposcopy, etc.).

Inspection of the vagina and cervix is carried out using vaginal mirrors (cylindrical, folded, spoon-shaped, etc.). The condition of the vaginal walls is determined (the nature of folding and the color of the mucous membrane, the presence of ulcerations, growths, tumors, etc.), the arch and cervix (size, shape - cylindrical, conical; in nulliparous, the external opening of the cervical canal is round, in those who have given birth - in the form transverse fissure; various pathological conditions - ruptures, erosion, epithelial dysplasia, submucosal endometriosis, mucosal eversion, tumors, etc.), as well as the nature of vaginal discharge.

For diagnostic purposes, as well as for various manipulations on the cervix, the latter is fixed with bullet forceps, which have one sharp tooth on each branch, or with Musot forceps, which have two teeth on each branch, and is brought closer to the entrance to the vagina.

Vaginal examination should be combined (bimanual). Spreading the labia with the thumb and forefinger of the left hand, the doctor inserts the index (and then the middle) finger into the vagina, paying attention to the sensitivity, the width of the entrance to the vagina, the elasticity of its walls. With the other hand, he fixes the organ under study (uterus, appendages) through the abdominal wall or tries to probe one or another area of the small pelvis. The study is carried out with one index finger or two fingers - index and middle.

It must be borne in mind that the most sensitive places are the clitoris and the anterior wall of the vagina in the urethra, so you should not put pressure on this area; fingers should slide along the back wall of the vagina. If the insertion of fingers into the vagina is difficult, it is necessary to take the perineum down, pre-lubricate the fingers with indifferent fat (Vaseline).

Inserting fingers deep into the vagina, determine the condition of the vaginal mucosa (degree of moisture, the presence of growths, roughness, scarring, displacement), the presence of tumors, septa (double vagina); exclude bartholinitis. Through the anterior wall of the vagina, the urethra can be felt for a considerable length during its infiltration.

Then the vaginal part of the cervix is found with a finger and its shape (conical, cylindrical), size, shape of the external uterine os, its opening (with isthmic-cervical insufficiency), the presence of ruptures and scars after childbirth, tumors on the cervix are determined. With cervical dysplasia, its surface sometimes seems velvety; ovula Nabothi are palpable in the form of small tubercles. By the location of the cervix, it is sometimes possible to judge the displacement of the uterus.

In the future, they proceed to a bimanual (combined) vaginal-abdominal examination, which is the main type of gynecological examination, as it allows you to establish the position, size, shape of the uterus, determine the condition of the appendages, pelvic peritoneum and fiber.

The bimanual examination is a continuation of the vaginal examination. In this case, one hand (inner) is in the vagina, and the other (outer) is above the pubis. In a bimanual examination, it is necessary to feel the organs and tissues not with the fingertips, but, if possible, with their entire surface.

First, the uterus is examined. To determine its position, shape, size and consistency, the vaginal part of the uterus is fixed with fingers inserted into the vagina, lifting it slightly upward and anteriorly and thereby bringing the bottom of the uterus closer to the anterior abdominal wall. Normally, the uterus is located in the small pelvis along the midline, at the same distance from the pubic joint and the sacrum, as well as from the side walls of the pelvis. In the vertical position of a woman, the bottom of the uterus is turned upwards and anteriorly and does not go beyond the plane of the entrance to the small pelvis, and the cervix is turned downwards and backwards. Between the cervix and the body of the uterus there is an angle open anteriorly. However, there are a number of deviations from this normal (typical) position of the uterus in the form of various kinks and displacements in one direction or another, which makes it necessary to change the research methodology.

Normally, the uterus of an adult woman has the shape of a pear, flattened from front to back; its surface is flat. When palpated, the uterus is painless and moves in all directions. Physiological reduction of the uterus is observed in menopause. Pathological conditions accompanied by a decrease in the uterus include infantilism and atrophy of the uterus (with prolonged breastfeeding, after surgical removal of the ovaries).

The consistency of the uterus is normally tight elastic, during pregnancy the uterine wall is softened, with myoma it is compacted. In some cases, the uterus may fluctuate. This is typical for hematometers and pyometra.

After examining the uterus, they begin to palpate the appendages (ovaries and fallopian tubes). Unchanged fallopian tubes are thin and soft, usually they are not palpable. Ligaments, fiber and uterine appendages are normally so soft and pliable that they cannot be palpated.

The sactosalpinx is palpated in the form of an oblong movable formation expanding towards the funnel of the fallopian tube. The pyosalpinx is often less mobile or fixed in adhesions.

Often, during pathological processes, the position of the fallopian tubes changes, they can be soldered with adhesions in front or behind the uterus, sometimes even on the opposite side.

The ovaries are well palpable in malnourished women in the form of an almond-shaped body 3x4 cm in size; they are quite mobile and sensitive. The ovaries usually enlarge before ovulation and during pregnancy. The right ovary is more accessible to palpation than the left.

The parauterine tissue (parametrium) and the serous membrane of the uterus (perimetry) are palpable only if they have an infiltrate (cancerous or inflammatory), adhesions or exudate.

When examination through the vagina is not possible (in virgins, with vaginal atresia), as well as in tumor formations, a rectal combined examination is indicated.

The study is carried out on a gynecological chair in a rubber glove or fingertip lubricated with petroleum jelly. You must first prescribe a cleansing enema.

A combined rectovaginal-abdominal examination is indicated for suspected pathological processes in the vaginal wall, rectum, or rectovaginal septum.

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2018 Women's Health Blog.