Topographic anatomy of the female pelvis as a whole. Topography of the pelvis Topographic anatomy of the pelvic organs in women

The pelvis is a part of the human body that is limited by the pelvic bones: ilium, pubis and ischium, sacrum, coccyx,

BORDERS AND STORES OF THE SMALL PELVI The border line (linea terminalis) divides the pelvis into large and small

BORDERS AND STORES OF THE SMALL PELVIS

The pelvic cavity is divided into three floors: - peritoneal - subperitoneal - subcutaneous

The subperitoneal floor of the pelvis (cavum pelvis subperitoneale) is a section of the pelvic cavity enclosed between the parietal peritoneum of the pelvis

The main cellular spaces of the pelvis

Subcutaneous floor of the pelvis (cavum pelvis subcutaneum) - the lower part of the pelvis between the pelvic diaphragm and the integument related to the area

TOPOGRAPHY OF THE MALE PELVIC ORGANS

TOPOGRAPHY OF FEMALE PELVIC ORGANS

BLADDER OPERATIONS

Suprapubic capillary puncture of the bladder (from: Lopatkin N.A., Shvetsov I.P., editors, 1986): a - puncture technique; b - diagram

Diagram of the stages of trocar epicystostomy (from: Lopatkin N.A., Shvetsov I.P., editors, 1986): a - position of the trocar after the injection; b -

Cystotomy is an operation of opening the bladder cavity (Fig. 16.7). High cystotomy (syn.: epicystotomy, high section

Stages of cystostomy. (from: Matyushin I.F., 1979): a - line of skin incision; b - fatty tissue along with the transitional fold

OPERATIONS ON THE UTERUS AND APPENDIXES

Puncture of the rectouterine cavity of the peritoneal cavity through the posterior vaginal fornix (from: Savelyeva G.M., Breusenko V.G.,

RECTAL OPERATIONS

Topographic anatomy of the perineum

Operative surgery of the perineum

Labiaplasty

Reducing the vaginal opening

Entrance to the vagina

The essence of the operation

When is additional anterior plastic surgery necessary?

"Net"

Typical mistakes and complications of vaginoplasty

Modern technologies

Thank you for your attention.

Ultrasonography ( ) pelvic organs is one of the main methods for diagnosing the causes. Its undeniable advantages are low cost, absence of side effects and obvious contraindications, as well as fairly high information content. It should be borne in mind that ultrasound is not the only diagnostic method, and to confirm the causes of infertility it is necessary to undergo a number of additional laboratory tests.

Therefore, doctors may combine sulforaphane with chemotherapy to reduce side effects and improve treatment outcomes, especially in patients with chemotherapy-resistant cancers. Colon cancer is the fourth most commonly diagnosed malignancy among men and the third among women. The discovery and implementation of effective treatments is a very important goal in the treatment of colon cancer. Resistance to standard chemotherapy is also a problem.

Therefore, scientists around the world are actively working to find new, more specific drugs to combat this disease. One of these products is sulforaphane brocholy, which acts as an antiviral agent at high concentrations. Preparation of the dissertation "biological and environmental factors interacting with intellectual disabilities and cognitive functions and personality traits" make a complex for people with intellectual disabilities research - environmental, genetic or multiple factors, biopsychosocial interacting phenomena in the context of the model.

Ultrasound examination is a method, the results of which largely depend on the experience and skills of the diagnostician, since the diagnosis and, accordingly, subsequent treatment tactics depend on the correct interpretation of the symptoms and signs visible on the monitor. When conducting research, it is important to talk with a doctor, since finding out some vital details allows you to exclude or, conversely, assume certain pathological abnormalities.

The document summarizes the morbidity structure of persons with intellectual disabilities, the degree of mental disability with factors of the social environment. To substantiate the systematic relationship between inheritance, intelligence, and personality traits, twins who were identified as having zygosity using molecular markers were studied. This is the first large-scale twin study of this kind in Lithuania. Research may benefit health care professionals by deepening the concept of biopsychosocial phenomena.

Infertility is a pathological situation in which a couple who does not use any method of contraception fails for 12 months. This pathology is quite common and occurs with a frequency of 10 to 15% among couples of reproductive age. According to statistics, the cause of infertility can be equally likely in both men and women. Ultrasound examination is a fairly informative method for diagnosing most causes of female infertility. However, it should be understood that ultrasound is only effective in identifying existing structural anomalies, the scale of which corresponds to the resolution of the device. Hormonal disorders, functional changes in the genital organs, disruption of the hormonal-nervous system responsible for cyclical changes and maintenance, the presence of antibodies to the partner’s sperm, as well as a number of other pathologies cannot be detected using echography ( Ultrasound). These diseases, as well as male infertility, require detailed laboratory research, which is more informative in such situations.

The dissertation confirms data on aspects of cognitive processes and personal inheritance phenomena. It took almost two years to live and work in Germany, working with patients with urinary incontinence and pelvic floors. We have collaborated to identify and refine our existing efforts, and we are working to implement improved treatments for urinary and pelvic incontinence in clinical practice. The dissertation topic is practical and easily adaptable to hospitals in Lithuania. Obviously, this is not just a problem for older women.

What female organs are located in the pelvis?

The female genital organs can be divided into internal and external. The external genitalia are in direct contact with the external environment, while the internal genitalia are protected from this. In addition, all internal genital organs are located in the pelvic cavity.

Almost a third of women experience involuntary urination. Urinary incontinence is an involuntary flow of urine of varying degrees. It hurts twice as often as men. However, those who laugh until they cry or sometimes have to get wet on the spot when exercising, do not be upset - this problem has been solved. Modern technologies make it possible to treat urinary incontinence using a non-invasive laser method. We are talking about gynecologist Inese Zeima.

What causes urinary incontinence in women? Urinary incontinence is several times more common in women than in men. The most common causes are pregnancy and childbirth. Postpartum pelvic changes in relative position, so the more births, the greater the likelihood of encountering the problem of urinary incontinence. It also depends on obesity, various diseases, natural aging and genetics.

The external female genitalia include:

• Crotch. The perineal region, which in some cases can be considered outside the genital complex, is nevertheless an extremely important structure. This is due to the fact that in this region there is a layer of muscles that form the pelvic floor, and the role of which is extremely high during pregnancy and. In addition, the normal functioning of the urinary and digestive systems depends on the strength of contraction of these muscles, or rather, on their tone, since excessive contraction can impede the passage of urine and feces, and excessive relaxation can lead to incontinence.
• Pubis. The pubis is a slightly rounded area located superior to the labia majora and slightly anterior to the pubic bone of the pelvis. During puberty, pubic hair develops.
• Labia majora. The labia majora are represented by two voluminous longitudinal folds, which consist of fatty and connective tissue covered with skin. Their size and shape may vary slightly among different women depending on their constitution, as well as the thickness of the subcutaneous fatty tissue. The skin of the labia contains hair follicles, which form hair during puberty.
• Labia minora. The labia minora are two small longitudinal folds of skin that are located between the labia majora and the opening of the vagina. In front, the labia minora unite to form the frenulum of the clitoris ( thin folds of skin extending from the clitoris).
• Hymen. The hymen is a thin connective tissue membrane that is located at the entrance to the vagina. At the stage before puberty, this membrane performs a protective function, protecting the internal genital organs from penetration. However, in most cases, this membrane is not completely impermeable and is able to pass through menstrual blood that forms after puberty. Usually the hymen is torn during sexual intercourse, but in some cases it can be damaged under other conditions ( intense sports, cycling, injuries, masturbation using dildos or other objects).
• Clitoris. The clitoris is a formation similar in structure to the head of the male penis. It is located anterior to the labia minora, close to their junction. The size of the clitoris in an adult woman ranges from one to two centimeters. This organ is formed by two legs that are attached to the periosteum of the pelvic bones. The clitoris is an extremely sensitive organ, capable of erection - a slight increase in size during sexual arousal due to a rush of venous blood.
• The vestibule of the vagina and the external opening of the urethra. Between the clitoris and the vaginal opening is a triangular area known as the vaginal vestibule, which extends all the way to the posterior junction of the labia minora. In this area is the external opening of the urethra, which is located approximately one centimeter anterior to the entrance to the vagina. In the same place, the ducts of the skin glands open on both sides.
• Skene's and Bartholin's glands. The Skene and Bartholin glands, located at the opening of the urethra and at the back of the vaginal opening, are small organs that produce a substance that lubricates the vagina.

• vagina;

Vagina

Uterus

Anatomically, the following sections are distinguished in the uterus:

What age is the most common problem for younger women? The first signs may appear during the first pregnancy or immediately after birth. But when he is born at an earlier age, the recovery is less complete.

What problems does this disorder cause? What are the possible complications without treatment? This causes women to feel self-esteem and inferiority. And this affects family relationships, sex life and female libido. If the problem gets worse, and with age, when the connective tissues weaken, this is the case, and the problems deepen. Therefore, this problem needs to be addressed as soon as you begin to notice the first symptoms. This can help prevent many health problems in the future, such as pelvic flooring, decreased sexual satisfaction, urinary incontinence, physical activity, etc.

• Cervix. The cervix is ​​the lower part of this organ, which is the anatomical boundary between the vagina and the body of the uterus. The cervix is ​​a cylindrical muscular structure through the center of which runs the cervical canal, which passes menstrual blood from the uterine cavity into the external environment, as well as sperm from the vagina into the uterine cavity. This canal is filled with special mucus, which has some bactericidal properties, which protects the overlying genital structures from infections that often affect the vagina and external genitalia. The cervix is ​​influenced by hormones during pregnancy ( or rather, hormones at the end of pregnancy) softens significantly, which leads to the expansion of the canal, making vaginal birth possible. The average length of the cervix is ​​three to five centimeters.
• Body of the uterus. The body of the uterus is a small, round and dense muscular organ with relatively thick walls. In most cases, the body of the uterus is tilted slightly anteriorly, but some anatomical differences may be observed. It should be noted that a posterior bend of the uterus or excessive anterior bending relative to the axis of the vagina can cause problems with conceiving a child. The average weight of the uterus in a non-pregnant and nulliparous woman is about 40 - 50 grams, while in women who have given birth its weight is slightly larger - about 100 - 110 grams. During pregnancy, the uterus undergoes significant structural changes and increases in size in order to accommodate the fetus with amniotic membranes. Muscular contractions of the uterus that occur during childbirth ( so-called contractions), promote labor. If uterine contractions occur before the due date, either premature birth or spontaneous abortion may occur. Excessive activity of the uterus during pregnancy in the absence of sufficient dilatation of the cervix can lead to hypoxia ( oxygen starvation) of the fetus, as well as to rupture of the uterus itself.
• Isthmus. The isthmus is the narrow part of the uterus located between the body and the cervix.

It should be noted that dysfunction of the endometrium, be it hormonal changes that disrupt the menstrual cycle, or structural damage with the inability to proliferate and restore the mucous layer ( consequences of infectious processes, certain diseases or aggressive medical procedures), is one of the common causes of female infertility.

Is it true that Pegel exercises can help? Do you really need surgery? Pegel exercises are certainly worthwhile for every woman. However, recent studies have shown that even when working out with a trainer, not all women tighten the muscles they need - that is, the pelvic floor. Regularity is also important. If you do the exercises occasionally, there will be no effect. Due to the busy pace of life, women forget, do not study, and do not perform exercises properly.

However, even with ideal exercise, some women will experience urinary incontinence and some will not. This is due to the inherent inadequacy of connective tissue inherent in the development of urinary incontinence. You should then seek medical attention for laser or surgical treatment. However, surgical intervention is not always necessary - in cases of mild or moderate urinary incontinence, it is enough to “give” a restorative laser procedure.

The fallopian tubes

The length of the fallopian tubes is approximately 10 centimeters, and the diameter is about ten millimeters. The end of the tube, located near the ovary, has specific outgrowths ( fringes), which are located around the ovary and serve to capture and transport the egg.

Which laser treatment for urinary incontinence is superior to others? Laser incontinence is painless, the results are quickly noticed, it does not cause discomfort, straight from the office you can return to your daily work, and after a few weeks to have sex. However, if you develop urinary incontinence, you will need surgery. Laser action is a tissue release that results in a reduction in symptoms of complete recovery or severe urinary incontinence.

In laser-treated tissue, connective tissue molecules are reduced, resulting in a lifting, contracting effect. The structures are shortened and their attachment points are not bones. By contracting and tightening, the connective tissue lifts the bladder above it. Activated cells that synthesize collagen are also activated and the formation of new blood vessels is stimulated, thereby strengthening connective tissue. This treatment is very effective when applied on time without causing illness.

The structure of the fallopian tubes includes the following segments:

• Isthmus. The isthmus is the part of the tube that is located in close proximity to the body of the uterus.
• Ampoule. The ampulla is the expanding part of the tube, which is the site of normal physiological fertilization ( penetration into the egg).
• Funnel. The funnel is the outermost part of the fallopian tube, on which the fimbria described above are located.

The patency of the fallopian tubes depends on the following parameters:

Are all surgeries suitable for all women? Laser treatment for urinary incontinence is not suitable for all women. Unfortunately, it is not suitable for high fat obesity with diabetes, many smokers, pregnant women. It also cannot be used until acute inflammation and cancer have healed. All other women, regardless of age, can be successfully used.

Are these procedures painful? Sexual relations are possible after several weeks. At the same time, it is not allowed to swim in a bathtub, swimming pool, lakes or other body of water, it is recommended that you do not carry more than 5 kg of weight for about 1 month after the procedure, avoid constipation for a couple of weeks and do not use smears for a month.

• Internal lumen of the fallopian tubes. If the internal lumen of the fallopian tubes decreases for any reason, this creates significant obstacles to the path of both sperm and eggs. The most common causes of narrowing of the fallopian tubes are infectious processes ( ), which can be caused by both nonspecific infectious agents and pathogens of sexually transmitted infections ( more often). In addition, narrowing of the fallopian tube can be congenital. It should be noted that sometimes the fallopian tubes are tied and cut by women at their own request, as one of the radical methods of contraception ( which, however, does not provide a 100% guarantee).
• The mucous membrane of the fallopian tubes. Normally, the inside of the fallopian tubes is lined with cells that have cilia on the surface. The movements of these microscopic cilia create a wave that helps propel the egg and sperm along the tube. A change in the cellular composition of the mucous layer or atrophy of these cilia can occur as a result of a local infectious process, as well as certain hormonal imbalances.
• Contraction of the muscle fibers of the fallopian tubes. The fallopian tubes are formed by muscle fibers that contract and create a peristaltic wave that stimulates the advancement of the egg or fertilized egg. This process is disrupted when the fallopian tubes are infected.

Main causes of female infertility

Depending on the location, the following causes of infertility are distinguished:

• cervical infertility;
• ovarian infertility;
• tubal infertility.

Cervical infertility

In addition, it should be noted that the cervical canal is filled with special mucus, which significantly affects the movement of sperm. A change in the properties of this mucus can cause female infertility. These changes cannot be detected by ultrasound, but they are determined during a gynecological examination by examining the viscosity of the cervical mucus. It should be borne in mind that the properties of mucus change depending on the level of sex hormones, which fluctuate during the menstrual cycle.

Uterine infertility

The following congenital pathologies can cause uterine infertility:

• congenital underdevelopment or absence of internal female genital organs;
• the presence of a septum inside the vaginal cavity or uterus;
• change in the shape or size of the internal cavity of the uterus;
• blind growths in the walls of the uterine body.

• Endometritis. is a disease of inflammatory nature that affects the inner mucous membrane of the uterus. It can develop as a result of the penetration of infectious agents, most often pathogens, as well as as a consequence of trauma during childbirth, diagnostic or therapeutic, placement of intrauterine devices and other procedures. Inflammatory reaction, characteristic of endometritis, can cause the formation of intracavitary ( fibrous cords stretched between the inner walls of the uterus), which significantly reduce the uterine cavity, limit its functionality, and also interfere with the normal process of implantation. It should be noted that in some cases, endometritis can provoke complete atrophy of the uterine mucosa, thereby disrupting menstrual and reproductive functions.
• Placental polyps. Placental are benign formations that develop on the basis of the remains of the placenta, fragments of which may have remained after a previous pregnancy. These growths change the configuration of the uterus, limit its internal cavity, and disrupt the menstrual cycle. It should be noted that this pathology is quite rare and cannot be the cause of primary infertility ( since the presence of fragments of the placenta is assumed, which can form only after the development of pregnancy).
• Intracavitary and subserous fibroids. is a benign tumor that disrupts the normal functioning of the uterus and can cause not only infertility, but also a number of other unpleasant symptoms such as bleeding and pain. This pathology occurs quite often, but it is much more common among women during their period, which is associated with hormonal changes in the body. Among young women of reproductive age, this pathology is somewhat less common.
• Endometriosis. is a disease affecting women of reproductive age in which endometrial cells migrate into the pelvic cavity, attaching to the peritoneum, fallopian tubes, ovaries, or into the deeper layers of the uterus. At the same time, these cells continue to change cyclically during the menstrual cycle, thereby provoking pain, menstrual irregularities, and infertility.
• Erosion, ulceration of the mucous membrane. and ulcers on the surface of the uterine mucosa can occur as a result of an infectious lesion, an inflammatory process, direct trauma, and also as a result of insufficient intake of essential nutrients and minerals into the body.

Ovarian infertility

The formation of cells that are subsequently transformed into eggs begins in the early embryonic period - in the first trimester of a girl. In this case, about seven million oocytes are laid ( eggs), which freeze at the first stage of division. Subsequently, their number decreases and by birth it is about two million. By puberty, only half a million oocytes are retained. It is from them that, during reproductive age, adult eggs are formed, ready to merge with sperm.

The maturation of eggs occurs under the influence of hormones of the hypothalamic-pituitary-ovarian system. Every month, from several developing oocytes, one egg and several follicular cells are formed, which surround the egg and perform the function of producing a number of sex hormones.

Disruption of the process of formation and maturation of the egg can occur with pathologies of the menstrual cycle, when hormonal disorders do not occur ( maturation and release of the egg).

Ovulation can be disrupted with the following pathologies:

• Chromosomal abnormalities. The process of egg maturation is associated with cell division, which is disrupted when the number of chromosomes changes. The fact is that during normal division of germ cells, ( structures that store genetic information) are distributed to daughter cells, but a change in their number can cause disruption of this process. In addition, the presence of extra chromosomes, as well as their absence, is one of the reasons for changes in many internal organs, including the hormonal system. All this leads to the impossibility of developing a normal, fertile egg.
• Impaired functioning of the hypothalamus. The hypothalamus is a brain structure that exercises the function of controlling internal organs through regulation through the autonomic nervous system, as well as through the production of a number of specific hormones ( liberins and statins). These hormones can stimulate or block the production of other hormones, including sex hormones. As a result of dysfunction of the hypothalamus, a lack of sex hormones that regulate the menstrual cycle and the process of egg maturation develops, and infertility occurs.
• Hormonal imbalances. Changes in the level of sex hormones, as mentioned above, can cause menstrual and reproductive dysfunction. However, it should be noted that in the process of onset and maintenance of pregnancy, an important role also belongs to hormones of the pituitary gland. A change in the concentration of the substances they produce can lead to both disruption of the processes of egg maturation and the impossibility of normal maintenance of pregnancy with the development of the usual ones.
• Structural changes in the ovaries. Changes in the structure of the ovaries ( tumors, ovarian underdevelopment) leads to the impossibility of normal development and maturation of the egg.

Tubal infertility

Other reasons

Infertility often occurs as a result of the development of an immune reaction to the partner’s sperm. This happens when the body becomes sensitized and begins to attack foreign cellular elements – sperm. As a result, the process of conception becomes impossible, as the number of sperm reaching the egg decreases. And, contrary to popular belief, one male reproductive cell is not enough for conception, since the special one contained in the sperm is needed to dissolve the protective shell of the egg.

Indications for ultrasound of the pelvic organs for infertility

In most cases, an ultrasound examination is prescribed by a gynecologist. However, this can also be done by another specialist who treats infertility of a couple. In some cities there are even separate fertility centers or family centers, in which the efforts of medical personnel are aimed at solving the problem of infertility and providing maximum assistance in conceiving a healthy child.

It should be understood that ultrasound can only detect macroscopic structural changes. For this reason, it is not prescribed for suspected functional disorders. However, it should be noted that changes in the endometrium visible on ultrasound are a direct indication of a disorder of menstrual function, which can occur against the background of both structural and functional disorders.

Ultrasound examination of the pelvic organs allows us to identify the following indicators:

• size and shape of the uterus;
• structure of the muscular layer of the uterus;
• cervical length;
• condition of the cervical canal;
• condition of the vaginal part of the cervix;
• structure and growth of the endometrium throughout the menstrual cycle;
• endometrial thickness;
• position of the ovaries;
• ovarian size;
• ovarian structure;
• structure of the fallopian tubes.

• fibroleiomyoma of the uterine body or cervix ( benign tumor);
• endometriosis;
• , polyps or inflammation of the endometrium ( uterine lining);
• erosions, ulcers, cysts of the uterus and cervix;
• and ovarian tumors;
• inflammation of the fallopian tubes;
• accumulation of fluid in the lumen of the fallopian tubes ( hydrosalpinx);
• adhesions in the pelvic cavity;
• scars of the body of the uterus.

Research methodology

When conducting an ultrasound examination, a special sensor is used, which is also an emitter of sound waves. The phenomenon of sound generation is based on the piezoelectric effect, that is, on the phenomenon of vibrations occurring in special crystals when an electric current of a certain frequency is passed through them. These waves propagate deep into the tissue, and then the sensor records their reflection.

When studying the female reproductive system, several types of sensors can be used, which differ in the type of sound beam they generate. It should also be noted that there are two main research methods - transabdominal and transvaginal. Transvaginal examination involves inserting a probe through the vagina, which allows a better study of the internal structure of the genital organs. Transabdominal testing involves applying a probe to the skin in the abdominal area. This method is used much more often, but it depends on the condition of the organs adjacent to the uterus and ovaries - the bladder and intestines.

Thus, when examining the female internal genital organs, bowel and bladder preparation is necessary. For this purpose, before the study, carminatives are usually prescribed, that is, drugs that reduce gas formation in the gastrointestinal tract. To do this, two to three days before the study, capsules of simethicone, plantex or herbal preparations of sage, mint, oregano are prescribed. In addition, it is recommended to exclude products that increase gas formation ( fresh vegetables, fruits, cabbage, beans, carbonated drinks, kvass, beer). Because a full bladder improves the conduction of sound waves into the pelvic cavity and optimizes the examination of the ovaries and uterus, it is recommended to drink plenty of fluids immediately before the examination.

Ultrasound of the uterus

It is necessary to understand that many parameters when examining the uterus depend on the phase of the menstrual cycle, body type, number of pregnancies and births. In addition, some individual characteristics may be observed in the structure of the internal female genital organs. For this reason, interpretation of study results based solely on ultrasound readings is incorrect, since a full diagnosis requires a history of previous diseases, obstetric and gynecological history, as well as an assessment of the general condition of the body.

Basic parameters when examining the uterus

The most common causes of infertility detected by ultrasound are the following uterine pathologies:

• Endometrial polyps. Endometrial polyps develop as multiple benign pedunculated tumors, which consist of overgrown endometrium. In most cases, they are asymptomatic or accompanied by uterine bleeding, infection, pain and infertility. On ultrasound they are best visible in the first half of the menstrual cycle or in the second half after preliminary administration of a contrast agent into the uterine cavity. Revealed as hyperechoic ( light) structures in the uterine cavity.
• Intrauterine adhesions. Adhesions in the uterine cavity develop as a result of damage to the basal layer of the endometrium and are dense fibrous cords that limit the uterine cavity. Characterized by the absence of the menstrual cycle or scanty menstrual flow. Best visualized during menstruation ( if there are any), when the exfoliating endometrium envelops them and, thus, seems to contrast. Ultrasound reveals hyperechoic bridges between the walls of the uterus.
• Endometriosis. Endometriosis, as described above, is a pathological situation in which areas of the endometrium appear outside the internal cavity of the uterus. Most often, the endometrium grows into the muscular layer of the uterus. The disease manifests itself as pelvic pain, disrupted menstrual cycle and heavy discharge during menstruation. An ultrasound examination reveals an enlarged uterus, which, however, may be of normal size. The muscular layer of the uterus takes on a "Swiss cheese" aspect with multiple hypoechoic ( dark) zones, as well as with traces of bleeding and. Sometimes the entire uterine wall becomes less dense with occasional large cysts.
• Endometrial hyperplasia. Hyperplasia ( proliferation) of the uterine mucosa can occur as a result of excessive stimulation by the female sex hormone estrogen. In this case, an increase in the thickness of the endometrium is observed.
• Malignant tumor of the endometrium. Malignant tumor of the endometrium ( endometrial carcinoma) is a severe oncological pathology that occurs mainly in the postmenopausal period, but can also develop during reproductive age. Ultrasound reveals hyperechoic masses in the uterine cavity, thickening of the endometrium, free fluid in the uterine cavity and pelvis, and sometimes destruction of the mucous and submucosal layer.
• Leiomyoma ( uterine fibroids). Leiomyoma is the most common benign tumor of the uterus, occurring in almost a quarter of women of childbearing age. It is an overgrown smooth muscle tissue that can grow into the uterine cavity, into the wall of the uterus, or into the pelvic cavity. An ultrasound examination reveals an increase in the size of the uterus and a change in the contour of the uterus. A formation can be identified, the acoustic density of which depends on the content of muscle and connective tissue fibers.
• Anomalies of the structure and shape of the uterus. With some congenital pathologies, additional cavities, septa and other abnormal formations may be detected in the uterus. Sometimes the uterus may be completely absent or underdeveloped. All this is quite easily detected by ultrasound.

Ultrasound of the fallopian tubes

Basic parameters when examining the fallopian tubes

It should be noted that the optimal period for performing an ultrasound of the fallopian tubes is the period immediately after ovulation, since the fluid secreted by the follicle facilitates their visualization.

Most often, in case of infertility, the following pathologies of the fallopian tubes are detected:

• Salpingitis. Salpingitis is an inflammatory process involving the fallopian tubes on one or both sides. In the initial stages, an ultrasound examination may not reveal any pathological abnormalities, but later a thinning of the wall of the fallopian tubes is revealed, a change in their contour, which becomes less clear and smooth. Sometimes echogenic formations are detected in the lumen of the dilated tubes, which in most cases indicates pyosalpinx - a purulent-infectious process.
• Benign tumor. Benign tumors ( leiomyomas) fallopian tubes are quite rare, despite the same embryonic origin of the tissues of the uterus and tubes. Overgrown muscle fibers can cause narrowing or closing of the lumen of the tube, thereby causing infertility. An ultrasound examination reveals a dense formation in the area of ​​the fallopian tube, the acoustic density of which, as in the case of uterine fibroids, depends on its tissue composition. Quite often these tumors have a heterogeneous structure.
• Malignant tumor. Malignant tumor of the fallopian tubes is the rarest type of cancer in gynecological practice. This pathology manifests itself through pain, bleeding and the discharge of whitish contents from the genital tract. Ultrasound reveals a heterogeneous spindle-shaped mass located in the area of ​​the uterine appendages.
• Narrowing of the lumen of the fallopian tube. To examine the lumen of the fallopian tubes, a special contrast agent is used, which is injected under sterile conditions through a special catheter into the uterine cavity and rises through the fallopian tubes. This method allows you to better visualize the internal lumen of the pipe, its contours and, most importantly, patency.

Ultrasound of the ovaries

The features of these two methods are:

• With transabdominal access It is advisable that the bladder be full at the time of the study. This will make it easier for sound waves to pass through tissue and make the examination more accurate. The recommended wave frequency is 3.5 – 3.75 MHz.
• Transvaginal examination does not require filling of the bladder. The sensor is brought closer to the ovaries than with the transabdominal approach. The recommended wave frequency is from 5 to 10 MHz. This version of the procedure is more reliable and informative. It requires a higher qualification of the doctor who conducts the study. The fact is that many anatomical structures turn out to be “inverted” in the resulting image. Because of this, an inexperienced specialist may experience some difficulties.

Basic parameters when examining the ovaries

Reasons for poor visualization of the ovaries may include:

• insufficient filling of the bladder ( optimal filling – when in the picture the edge of the bladder overlaps the fundus of the uterus);
• abnormal position of the ovaries ( their insufficient descent into the abdominal cavity, location behind the uterus or in the inguinal canal);
• pathological underdevelopment of the ovaries ( Turner syndrome, some pituitary diseases);
• excessive accumulation of gas or contents in intestinal loops;
• the presence of scars after operations in the pelvic area.

Most often, in women with infertility, the following abnormalities can be detected on ultrasound:

• Pathological ovarian cysts. If an ovarian cyst on ultrasound reaches more than 5 cm in diameter, we can talk about pathology. In addition, hemorrhage may occur into the cavity of the Graafian vesicle. Then its contents become more echogenic. A cyst forms.
• Thecal lutein cyst. Such formations reach 8–10 cm in diameter and are most often caused by simultaneous pathological processes in other organs ( for choriocarcinoma, hydatidiform mole, etc.). These cysts can be bilateral. An ultrasound often reveals several chambers in their cavity.
• Ovarian tumor. As a rule, ultrasound cannot accurately determine the nature of the tumor or even tell whether it is benign or malignant.
• Ovarian torsion. Ultrasound usually reveals an enlarged ovary ( up to 5 – 7 cm), free fluid may be found in the abdominal cavity due to the inflammatory process.
• Oophoritis. In acute inflammation, the ovary is significantly enlarged in size, its contours are clearly visible, but its echogenicity is reduced. When areas of necrosis and pus form, pinpoint formations with increased echogenicity are visible. In chronic cases, the structure of the organ may be heterogeneous. The dimensions are usually within normal limits.
• Ovarian apoplexy. The echogram clearly shows the location of the rupture. There, the contour of the enlarged ovary is abruptly interrupted. It is difficult to confirm an accurate diagnosis using ultrasound alone.
• Ovarian endometriosis. The contour of the organ is unclear, echogenicity varies in different areas. Multiple small cysts are found that change the shape of the organ; the surface may be bumpy. In this case, endometriosis is difficult to distinguish from polycystic ovary syndrome.
• Polycystic ovary syndrome. The process is usually two-way. Organs enlarge 3 to 5 times compared to normal. The outline of the ovary is easy to distinguish. Multiple formations with a diameter of 1.5–2 cm are found inside.

The pelvic organs are located in the anatomical space limited by the pelvic bones. What organs are located here? First of all, it depends on whether the body is a woman or a man. Let's take a closer look at what organs are located in the female and male body, as well as what organs are present in both organisms.

Internal organs of the pelvis of a woman and a man

Rectum

Both female and male pelvic organs include this part of the colon. It accumulates and then removes digestive waste from the human body. The length of the rectum in an adult is 15 cm, and its diameter is 2-8 cm. Behind it are the coccyx and the sacrum.

Bladder

It is located behind the pubic symphysis and is separated from it by loose tissue, which is located in the space behind the pubis. The apex of the bladder, when it is filled, comes into contact with the abdominal anterior wall and begins to protrude above the symphysis. It should be noted that the close location of the pelvic organs has a certain impact on their functions. So, if one of the organs becomes ill, the disease can affect the condition of neighboring organs.

Female pelvic organs

Ovary

This organ is paired. In the ovaries, eggs mature and then develop. In addition, female sex hormones are formed here, which subsequently enter the blood and lymph. The ovary has a slightly pinkish color, and its surface merges into a convex posterior margin and into the mesenteric margin anteriorly. Examining the structure of a woman’s pelvic organs, one can notice rudimentary formations located near each ovary. The epididymis is located among the layers of the mesentery of the fallopian tube. It consists of transverse grooves and a longitudinal duct of the appendage. Near the tubal end of the ovary, in the mesentery of the fallopian tube, lies the periovarian - a small formation consisting of several blind tubules separated from each other.

Uterus

The female pelvic organs include an unpaired, pear-shaped muscular organ. It is located in the middle part of the pelvic cavity, behind the bladder and in front of the rectum. The fundus of the uterus protrudes slightly above the line of confluence of the fallopian tubes. It has a convex shape. The body of the uterus is the middle part of the organ and has a cone shape. In the lower part it narrows and smoothly passes into the cervix, the lower part of which protrudes into the vaginal cavity.

Vagina

This is a complete unpaired organ located in the space from the uterus to the genital slit. It has a tubular shape, slightly curved at the back. Its upper end originates from the cervix, then goes down, where its lower end opens with the opening of the vagina, after which it passes through the urogenital diaphragm. It should be noted that the length of the vagina is about 10 cm, and the thickness of its walls is 3 cm.

Male pelvic organs

Seminal vesicle

It is a paired organ located on the side and behind the bladder, as well as on top of the prostate gland. The seminal vesicle is a secretory organ. Its length is about 5 cm, width is about 2 cm, thickness is 1 cm. In cross-section, this organ looks like vesicles communicating with each other. Here the vas deferens connects with the excretory duct, where they form the ejaculatory duct. Its length is about 2 cm, and the width of the lumen at the beginning is 1 mm; at the urethra - only 0.3 mm.

Prostate

The male pelvic organs also include such a muscular-glandular unpaired organ as the prostate gland. She secretes a secretion that is part of sperm. The prostate gland is located under the bladder, in the lower anterior part of the pelvis. The beginning of the urethra and both ejaculatory ducts pass through this organ. The longitudinal size of the prostate gland is 3 cm, the transverse size is 4 cm, and its thickness is 3 cm.

Also in the pelvis there are many connective tissues that hold organs in place. The health of all these organs is very important for the body, since they are all located very close and can have a negative impact on each other if one of them becomes ill. Now you yourself know very well which organs are located in the pelvic area. This information can help you protect your health!

Topographic anatomy of the pelvis allows you to study the physiological characteristics of the pelvic region layer by layer. These layers are conditional and are used by scientists for convenience in detailed research. What features does the topography of the pelvis have?

Bone component

If we consider topographically the bone structure of the pelvic region, then in adulthood it consists of several bones and bone elements. In childhood, the skeletal system consists of a larger number of structures, which then grow together.

The pelvis consists of bones connected horizontally into a ring:

• sacrum;
• fifth vertebra;
• coccyx;
• a pair of unnamed bones.

The innominate bones are the fused pubis, ilium and ischium. By the age of 25, they become monolithic, representing a single structure. The sacrum forms a fixed connection with the iliac crest of the innominate bone, while the pubic elements of the pelvis are connected by cartilage. The pelvis is connected to the lower extremities by means of the hip joints, formed from the articular surface of the femoral head and the acetabulum of the innominate bones.

The bone structure is the support for the body, muscles and ligaments are attached to the bones, and the pelvic cavity itself serves as a container for internal organs.

Multi-storey pelvic cavity

The pelvis is an area that is topographically defined by the boundaries of the bones. Tissues that are located outside this boundary are not included in this area as a topographic unit. That is, anatomically, the pelvis is a cavity limited by the innominate bones, coccyx and sacrum; in this area, the lower parts of the rectum, urinary canaliculi and genital organs are considered. The upper border is the peritoneal tissue, the lower border is the perineum.

The pelvic region is also divided conventionally into a small and large pelvis. The large one is limited by the sacrum, the iliac wings, covered by the iliopsoas muscle, and includes the peritoneum (up to the iliac fossae). The topography of the small pelvis has several floors (sections):

• peritoneal;
• subperitoneal;
• perineal.

Each section contains certain internal organs.

Peritoneal section

From above, the upper floor is formed by the area of ​​the peritoneum, which passes to the bladder, on both sides of it there are peritoneal peri-vesical fossae, and in the area of ​​the symphysis pubis there is a transverse fold.

This same floor includes the upper zones of the vas deferens in men; in women, this includes most of the uterus along with the appendages. There are no other gender differences in the structure of the peritoneal pelvis.

Subperitoneal section

The second floor begins immediately above the peritoneum and is limited below by the pelvic fascia. In men, the abdominal area includes the following elements:

• lower bladder;
• distal part of the rectum;
• prostate;
• ureters.

In women, instead of the prostate gland, the department contains the cervix and vagina.

Cellular space

The cellular space begins in the abdominal region, which acts as a kind of organ separator. It delimits the elements of the genitourinary and digestive systems from the side walls of the pelvis.

The cellular space that surrounds the walls of the pelvis is called parietal, the one that surrounds the internal organs is called visceral. Fiber is examined on a sagittal (vertical) section.

The wall spaces include the following areas:

1. Retropubic. The area between the symphysis pubis, the transversalis fascia and the fascia of the bladder. It is divided into the prevesical and preperitoneal space.
2. Lateral. Left and right cellular spaces separated by a conventional sagittal plane. Passes between the piriformis and obturator muscles and the pubic ligaments.
3. Posterior rectal. Its area begins behind the rectum and borders the sacrum.

This classification is suitable for describing the cellular spaces of the female pelvis. In the male body, another region is distinguished - the retrovesical, which runs along the posterior wall of the peritoneum and borders the visceral space of the prostate.

Fact! All types of fiber that communicate with each other have a circulatory system and nerve fibers.

If we talk about the visceral cellular space, this includes the following types:

1. Paravesical. It surrounds the bladder, while its layers in the upper region of the organ are thinner. In the back, in women it is combined with the periuterine space, in men – with the periprostatic space.
2. Circumferential. Divided into pericervical, perilateral and retrocervical. The thickness is most pronounced in the cervical area.
3. Peri-vaginal. They are divided according to the vessels of the rectum into the posterior vaginal and anterior vaginal areas.
4. Periprostatic. Surrounds the prostate gland and is aligned with the perineum.
5. Pararectal. It is divided along the passing fascia into posterior, lateral and anterior sections.

Visceral types of space communicate with each other and with the anterior wall tissue.

Perineal department

The perineal section, completing the three-story structure, is limited from above by the surface of the pelvic diaphragm. It includes the entire lower part of the internal organs (bladder and rectum) and the ischiorectal fossa.

Circulatory system

The internal iliac artery is the main blood vessel of the pelvic region. It runs along the anterior wall of the rectum to the sciatic foramen, where it is divided into two trunks - anterior and posterior. The first feeds the visceral arteries:

• middle rectum;
• parental;
• obturator;
• umbilical

The posterior trunk has a more powerful structure and includes several gluteal, rectal, and parietal arteries. Nutrition of internal organs is carried out with the help of small capillaries extending from the main vessels.

If we talk about the outflow of blood, the venous bloodstream, then it originates in the internal organs and passes through the internal iliac vein, intertwining with other smaller vessels.

For reference! In the pelvic cavity, lymph flows through the anterior wall and visceral lymph nodes.

Nerves

A group of nerve fibers, the sacral plexus, departs from the piriformis muscle. Short bundles of nerves depart from it and pass to the gluteal region. In the infrapiriform foramen, nerve fibers meet the sciatic and pudendal nerves. The latter, making a loop around the pear-shaped opening, returns to the pelvic cavity. Several more branches depart from it, which go to the sphincter area, the perineum.

Topographic anatomy helps to gain a whole range of important knowledge about the structure of the body. It is knowledge of physiological characteristics that allows us to understand how and why a particular disease develops.

16.1. BORDERS AND STORES OF THE SMALL PELVIS

The pelvis is a part of the human body that is limited by the pelvic bones (iliac, pubic and ischial), sacrum, coccyx, and ligaments. The pubic bones are connected to each other using the pubic fusion. The iliac bones and the sacrum form low-moving semi-joints. The sacrum is connected to the coccyx through the sacrococcygeal fusion. Two ligaments begin from the sacrum on each side: the sacrospinous ligament (lig. Sacrospinale; attached to the ischial spine) and the sacrotuberous ligament (lig. sacrotuberale; attached to the ischial tuberosity). They transform the greater and lesser sciatic notches into the greater and lesser sciatic foramina.

The border line (linea terminalis) divides the pelvis into large and small.

Big pelvisformed by the spine and wings of the ilium. It contains the abdominal organs: the cecum with the appendix, the sigmoid colon, and loops of the small intestine.

Small pelvisIt is a cylindrical cavity and has upper and lower openings. The superior aperture of the pelvis is represented by the boundary line. The lower aperture of the pelvis is limited behind by the coccyx, on the sides by the ischial tuberosities, and in front by the pubic fusion and the lower branches of the pubic bones. The inner surface of the pelvis is lined with parietal muscles: iliopsoas (m. iliopsoas), piriformis (m. piriformis), obturator internus (m. obturatorius internus). The piriformis muscle performs the greater sciatic foramen. Above and below the muscle there are slit-like spaces - supra- and infrapiriform openings (foramina supra - et infrapiriformes), through which blood vessels and nerves emerge: the superior gluteal artery, accompanied by veins and the nerve of the same name through the suprapiriform opening; the inferior gluteal vessels, inferior gluteal, sciatic nerves, posterior cutaneous nerve of the thigh, internal genital vessels and the pudendal nerve - through the infrapiriform foramen.

The pelvic floor is formed by the muscles of the perineum. They make up the pelvic diaphragm (diaphragma pelvis) and the urogenital diaphragm (diaphragma urogenitale). The pelvic diaphragm is represented by the levator ani muscle, the coccygeus muscle and the superior and inferior fascia of the pelvic diaphragm covering them. The urogenital diaphragm is located between the lower branches of the pubic and ischial bones and is formed by the deep transverse perineal muscle and the urethral sphincter with the upper and lower layers of the fascia of the genitourinary diaphragm covering them.

The pelvic cavity is divided into three floors: peritoneal, subperitoneal and subcutaneous (Fig. 16.1).

Peritoneal floorpelvis (cavum pelvis peritoneale) - the upper section of the pelvic cavity, enclosed between the parietal peritoneum of the small pelvis; is the lower part of the abdominal cavity. Here

Rice. 16.1.Floors of the pelvic cavity

(from: Ostroverkhov G.E., Bomash Yu.M., Lubotsky D.N., 2005):

1 - peritoneal floor, 2 - subperitoneal floor, 3 - subcutaneous floor

contains organs or parts of the pelvic organs covered with peritoneum. In men, part of the rectum and part of the bladder are located in the peritoneal floor of the pelvis. In women, this floor of the pelvis contains the same parts of the bladder and rectum as in men, most of the uterus, fallopian tubes, ovaries, broad ligaments of the uterus, and the upper part of the vagina. The peritoneum covers the bladder from above, partly from the sides and from the front. At the transition from the anterior abdominal wall to the bladder, the peritoneum forms a transverse vesical fold (plica vesicalis transversa). Behind the bladder in men, the peritoneum covers the inner edges of the ampoules of the vas deferens, the tops of the seminal vesicles and passes to the rectum, forming a rectovesical cavity (excavatio rectovesicalis), limited on the sides by rectovesical folds of the peritoneum (plicae rectovesicales). In women, during the transition from the bladder to the uterus and from the uterus to the rectum, the peritoneum forms the anterior - vesico-uterine recess (excavatio vesicouterina) and the posterior - rectouterine recess, or pouch of Douglas (excavatio rectouterina), which is the lowest place abdominal cavity. It is bounded laterally by rectal-uterine folds (plicae rectouterinae), running from the uterus to the rectum and sacrum. Inflammatory exudates, blood (in case of injuries to the abdominal and pelvic organs, tube ruptures during ectopic pregnancy), gastric contents (perforation of a stomach ulcer), urine (injuries to the bladder) can accumulate in the recesses of the pelvis. The accumulated contents of the recess of Douglas can be identified and removed by puncture of the posterior vaginal fornix.

Subperitoneal floor pelvis (cavum pelvis subperitoneale) - a section of the pelvic cavity, enclosed between the parietal peritoneum of the pelvis and a layer of pelvic fascia covering the levator ani muscle on top. In the subperitoneal floor of the small pelvis in men there are extraperitoneal sections of the bladder and rectum, prostate gland, seminal vesicles, pelvic sections of the vas deferens with their ampoules, pelvic sections of the ureters, and in women - the same sections of the ureters, bladder and rectum , as well as the cervix and the initial part of the vagina. The pelvic organs occupy a mid-position and do not come into direct contact with the walls of the pelvis, from which they are separated by fiber. In addition to organs, this part of the pelvis contains blood vessels, nerves and lymph nodes of the pelvis: internal iliac arteries

with parietal and visceral branches, parietal veins and venous plexuses of the pelvic organs (plexus venosus rectalis, plexus venosus vesicalis, plexus venosus prostaticus, plexus venosus uterinus, plexus venosus vaginalis), sacral nerve plexus with nerves arising from it, sacral section of the sympathetic trunk, lymphatic nodes lying along the iliac arteries and on the anterior concave surface of the sacrum.

The fascia of the pelvis, covering its walls and insides, is a continuation of the intra-abdominal fascia and is divided into parietal and visceral layers (Fig. 16.2). The parietal layer of the pelvic fascia (fascia pelvis parietalis) covers the parietal muscles of the pelvic cavity and the muscles that form the pelvic floor. The visceral layer of the pelvic fascia (fascia pelvis visceralis) covers the organs located in the middle floor of the small pelvis. This leaf forms fascial capsules for the pelvic organs (for example,

Rice. 16.2.Fascia and cellular spaces of the pelvis:

1 - peri-rectal cellular space, 2 - peri-uterine cellular space, 3 - prevesical cellular space, 4 - lateral cellular space, 5 - parietal layer of the intrapelvic fascia, 6 - visceral layer of the intrapelvic fascia, 7 - abdominoperineal aponeurosis

Pirogov-Retsia for the prostate gland and Amousse for the rectum), separated from the organs by a layer of loose fiber in which blood and lymphatic vessels and nerves of the pelvic organs are located. The capsules are separated by a septum located in the frontal plane (Denonvillier-Salischev aponeurosis; septum rectovesicale in men and septum rectovaginale in women), which is a duplicate of the primary peritoneum. Anterior to the septum are the bladder, prostate gland, seminal vesicles and parts of the vas deferens in men, and the bladder and uterus in women. Posterior to the septum is the rectum.

Cellular spaces, secreted in the pelvic cavity include both fiber located between the pelvic organs and its walls, and fiber located between the organs and the fascial sheaths surrounding them. The main cellular spaces of the pelvis, located in its middle floor, are the prevesical, paravesical, periuterine (in women), perirectal, retrorectal, right and left lateral spaces.

The prevesical cellular space (spatium prevesicale; space of Retius) is a cellular space bounded in front by the pubic symphysis and branches of the pubic bones, and behind by the visceral layer of the pelvic fascia covering the bladder. In the prevesical space, with fractures of the pelvic bones, hematomas develop, and with injuries to the bladder, urinary infiltration. From the sides, the prevesical space passes into the paravesical space (spatium paravesicale) - the cellular space of the small pelvis around the bladder, limited in front by the prevesical fascia and behind by the retrovesical fascia. The peri-uterine space (parametrium) is the cellular space of the small pelvis, located around the cervix and between the leaves of its wide ligaments. The uterine arteries and the ureters that cross them, the ovarian vessels, the uterine venous and nerve plexuses pass through the periuterine space. Abscesses formed in the periuterine space along the round ligament of the uterus spread in the direction of the inguinal canal and the anterior abdominal wall, as well as towards the iliac fossa and into the retroperitoneal tissue; in addition, an abscess may break through into the adjacent cellular spaces of the pelvis, pelvic organ cavities, gluteal region, on the thigh. Pararectal space (spatium pararectale) - cellular space limited by the fascial sheath of the rectum

intestines. The posterior rectal space (spatium retrorectale) is a cellular space located between the rectum, surrounded by visceral fascia, and the anterior surface of the sacrum, covered by the pelvic fascia. In the tissue of the retrorectal space there are the median and lateral sacral arteries with their accompanying veins, sacral lymph nodes, pelvic sections of the sympathetic trunk, and the sacral nerve plexus. The spread of purulent leaks from the retrorectal space is possible into the retroperitoneal cellular space, the lateral spaces of the pelvis, and the peri-rectal space. Lateral space (spatium laterale) is a paired cellular space of the small pelvis, located between the parietal layer of the pelvic fascia, covering the side wall of the pelvis, and the visceral layer, covering the pelvic organs. The tissue of the lateral spaces contains the ureters, vas deferens (in men), internal iliac arteries and veins with their branches and tributaries, nerves of the sacral plexus, and inferior hypogastric nerve plexus. The spread of purulent leaks from the lateral cellular spaces is possible into the retroperitoneal space, into the gluteal region, into the retrorectal and prevesical and other cellular spaces of the pelvis, the bed of the adductor muscles of the thigh.

Subcutaneous floorpelvis (cavum pelvis subcutaneum) - the lower part of the pelvis between the pelvic diaphragm and the integument related to the perineal area. This section of the pelvis contains parts of the organs of the genitourinary system and the final section of the intestinal tube. The ischiorectal fossa (fossa ischiorectalis) is also located here - a paired depression in the perineal area, filled with fatty tissue, limited medially by the pelvic diaphragm, laterally by the obturator internus muscle with its covering fascia. The fiber of the ischiorectal fossa can communicate with the fiber of the middle floor of the pelvis.

16.2. TOPOGRAPHY OF THE MALE PELVIC ORGANS

Rectum- the final section of the colon, starting at the level of the third sacral vertebra. The rectum ends with the anal opening in the anal area of ​​the perineum. Anterior to the rectum are the bladder and prostate gland, ampullae of the vas deferens, seminal vesicles

Rice. 16.3. Topography of the male pelvic organs (from: Kovanov V.V., ed., 1987): 1 - inferior vena cava; 2 - abdominal aorta; 3 - left common iliac artery; 4 - cape; 5 - rectum; 6 - left ureter; 7 - rectovesical fold; 8 - rectovesical recess; 9 - seminal vesicle; 10 - prostate gland; 11 - muscle that lifts the ani; 12 - external anal sphincter; 13 - testicle; 14 - scrotum; 15 - tunica vaginalis of the testicle; 16 - epididymis; 17 - foreskin; 18 - head of the penis; 19 - vas deferens; 20 - internal spermatic fascia; 21 - cavernous bodies of the penis; 22 - spongy substance of the penis; 2 - spermatic cord; 24 - bulb of the penis; 25 - ischiocavernosus muscle; 26 - urethra; 27 - suspensory ligament of the penis; 28 - pubic bone; 29 - bladder; 30 - left common iliac vein; 31 - right common iliac artery

and the terminal sections of the ureters. At the back, the rectum adjoins the sacrum and coccyx. The prostate gland is palpated through the anterior wall of the rectum, the rectovesical recess is punctured, and pelvic abscesses are opened. There are two sections in the rectum: pelvic and perineal. The boundary between them is the pelvic diaphragm. In the pelvic region, the supramullary part and the ampulla of the rectum, which is its widest part, are distinguished. The suprampullary part is covered with peritoneum on all sides. At the level of the ampulla, the rectum is covered with peritoneum, first in front and on the sides, below only in the front. The lower part of the rectal ampulla is no longer covered by peritoneum. The perineal section is called the anal canal. On the sides of it is located the tissue of the ischiorectal fossa. The rectum is supplied with blood by the unpaired superior rectal artery and the paired middle and inferior rectal arteries. The veins of the rectum form the subcutaneous, submucosal (in the lower sections represented by glomeruli of veins of the hemorrhoidal zone) and subfascial venous plexuses. Venous outflow from the rectum is carried out through the superior rectal vein into the portal vein system, and through the middle and lower rectal veins into the inferior vena cava system. Thus, there is a portacaval anastomosis in the rectal wall. Lymphatic drainage from the supramullary part and upper parts of the ampulla is carried out into the lymph nodes located near the inferior mesenteric artery; from the rest of the ampulla, lymph flows into the internal iliac and sacral lymph nodes; from the perineal section, lymphatic drainage is carried out into the inguinal nodes. The rectum is innervated from the inferior mesenteric, aortic, hypogastric nerve plexuses, as well as the pudendal nerve.

Bladderlocated in the anterior part of the small pelvis behind the pubic symphysis. The anterior surface of the bladder is also adjacent to the branches of the pubic bones and the anterior abdominal wall, separated from them by prevesical tissue. Behind the bladder lie the ampoules of the vas deferens, seminal vesicles, and rectum. The vas deferens are located on the sides. The ureters come into contact with the bladder at the border between the posterior and lateral walls. The loops of the small intestine are located on top of the bladder. Below the bladder is the prostate gland. When full, the bladder extends beyond the pelvic cavity, rising above the symphysis pubis, displacing

peritoneum upward, and is located in the preperitoneal tissue. These topographic features can be used for extraperitoneal access to the bladder. The bladder has the following parts: bottom, body, neck. The bladder is supplied with blood by the superior and inferior cystic arteries from the internal iliac artery system. The outflow of blood from the venous plexus of the bladder through the cystic veins is carried out into the internal iliac vein system. Lymph flows into the lymph nodes located along the internal and external iliac vessels, and the sacral lymph nodes. The bladder is innervated from the hypogastric plexus.

The beginning of the pelvic ureter on each side corresponds to the boundary line of the pelvis. At this level, the left ureter crosses the common iliac artery, and the right ureter crosses the external iliac artery. In the small pelvis, the ureters are adjacent to the lateral wall of the pelvis. They are located next to the internal iliac arteries. Heading downwards, the ureters cross the obturator neurovascular bundles on the corresponding sides. Inward from them is the rectum. Next, the ureters bend anteriorly and medially, are adjacent to the posterolateral wall of the bladder and rectum, cross the vas deferens, come into contact with the seminal vesicles and flow into the bladder at the bottom.

Prostate adheres to the bottom and neck of the bladder. Also adjacent to the base of the prostate gland are the seminal vesicles and ampoules of the vas deferens. The apex of the gland is directed downward and lies on the urogenital diaphragm. Anterior to the prostate gland is the pubic symphysis, on the sides of it are the muscles that lift the ani. Behind the prostate gland is the rectum, and through it the gland can easily be palpated. The prostate gland has two lobes connected by an isthmus and is covered by a capsule (visceral layer of the pelvic fascia). The prostate gland is supplied with blood from the inferior vesical and middle rectal arteries. Venous blood flows from the venous plexus of the prostate into the internal iliac vein system. Lymphatic drainage occurs in the lymph nodes lying along the internal and external iliac arteries, as well as in the lymph nodes located on the anterior surface of the sacrum.

Vas deferens in the small pelvis they are adjacent to the side wall of the pelvis and to the bladder (to its side and rear walls). In this case, the vas deferens and ureters intersect on the posterolateral wall of the bladder. The vas deferens medially from the seminal vesicles form ampoules. The ducts of the ampullae, merging with the ducts of the seminal vesicles, enter the prostate gland.

Seminal vesicles in the small pelvis are located between the posterior wall of the bladder and the ureters in front and the rectum in the back. The seminal vesicles are covered on top by peritoneum, through which loops of the small intestine can come into contact with them. From below, the seminal vesicles are adjacent to the prostate gland. Internally from the seminal vesicles lie the ampoules of the vas deferens.

16.3. TOPOGRAPHY OF FEMALE PELVIC ORGANS

In the female pelvis, the blood supply, innervation and peritoneal coverage of the rectum are the same as in the male pelvis. Anterior to the rectum are the uterus and vagina. Posterior to the rectum lies the sacrum. The lymphatic vessels of the rectum are connected to the lymphatic system of the uterus and vagina (in the hypogastric and sacral lymph nodes) (Fig. 16.4).

Bladderin women, as in men, it lies behind the pubic symphysis. Behind the bladder are the uterus and vagina. The loops of the small intestine are adjacent to the upper part of the bladder, covered with peritoneum. On the sides of the bladder are the levator ani muscles. The bottom of the bladder lies on the urogenital diaphragm. The blood supply and innervation of the bladder in women occurs in the same way as in men. The lymphatic vessels of the bladder in women, like the lymphatic vessels of the rectum, form connections with the lymphatic vessels of the uterus and vagina in the lymph nodes of the broad ligament of the uterus and the iliac lymph nodes.

As in the male pelvis, the right and left ureters at the level of the boundary line cross the external iliac and common iliac arteries, respectively. They are adjacent to the lateral walls of the pelvis. At the point where the uterine arteries depart from the internal iliac arteries, the ureters intersect with the latter. Lower in the cervix, they once again intersect with the uterine arteries, and then adhere to the vaginal wall, after which they empty into the bladder.

Rice. 16.4.Topography of the female pelvic organs (from: Kovanov V.V., ed., 1987):

I - fallopian tube; 2 - ovary; 3 - uterus; 4 - rectum; 5 - posterior vaginal fornix; 6 - anterior vaginal vault; 7 - entrance to the vagina; 8 - urethra; 9 - clitoris; 10 - pubic joint;

II - bladder

Uterusin the pelvis of women, it occupies a position between the bladder and the rectum and is tilted forward (anteversio), while the body and cervix, separated by the isthmus, form an angle open anteriorly (anteflexio). The loops of the small intestine are adjacent to the fundus of the uterus. The uterus has two sections: the body and the cervix. The part of the body located above the confluence of the fallopian tubes into the uterus is called the fundus. The peritoneum, covering the uterus in front and behind, converges on the sides of the uterus, forming the broad ligaments of the uterus. The uterine arteries are located at the base of the broad ligament of the uterus. Next to them lie the main ligaments of the uterus. The fallopian tubes lie in the free edge of the broad ligaments of the uterus. The ovaries are also attached to the broad ligaments of the uterus. On the sides, the broad ligaments pass into the peritoneum, covering the walls of the pelvis. There are also round ligaments of the uterus, running from the angle of the uterus to the internal opening of the inguinal canal. The uterus is supplied with blood by two uterine arteries from the system of internal iliac arteries, as well as ovarian arteries - branches of the abdominal aorta. Venous drainage occurs through the uterine veins into the internal iliac veins. The uterus is innervated from the hypogastric plexus. Lymph flows from the cervix to the lymph nodes located along the iliac arteries and sacral lymph nodes, from the body of the uterus to the peri-aortic lymph nodes.

The uterine appendages include the ovaries and fallopian tubes.

The fallopian tubeslie between the leaves of the broad ligaments of the uterus along their upper edge. In the fallopian tube, there is an interstitial part located in the thickness of the uterine wall, an isthmus (narrowed part of the tube), which passes into an expanded section - the ampulla. At the free end, the fallopian tube has a funnel with fimbriae, which is adjacent to the ovary.

Ovarieswith the help of the mesentery they are connected to the posterior leaves of the broad ligament of the uterus. The ovaries have uterine and tubal ends. The uterine end is connected to the uterus by its own ovarian ligament. The tubal end is attached to the lateral wall of the pelvis by the suspensory ligament of the ovary. In this case, the ovaries themselves are located in the ovarian fossae - depressions in the side wall of the pelvis. These depressions are located in the area where the common iliac arteries divide into internal and external. The uterine arteries and ureters lie nearby, which should be taken into account when performing operations on the uterine appendages.

Vaginalocated in the female pelvis between the bladder and rectum. At the top, the vagina passes into the cervix, and at the bottom

opens with an opening between the labia minora. The anterior wall of the vagina is closely connected to the posterior wall of the bladder and the urethra. Therefore, when the vagina ruptures, vesicovaginal fistulas can form. The posterior wall of the vagina is in contact with the rectum. At the vagina, there are fornices - indentations between the cervix and the walls of the vagina. In this case, the posterior fornix borders on the pouch of Douglas, which allows access to the rectouterine cavity through the posterior vaginal fornix.

16.4. BLADDER OPERATIONS

Suprapubic puncture (syn.: bladder puncture, bladder puncture) - percutaneous puncture of the bladder along the midline of the abdomen. The intervention is performed either in the form of a suprapubic capillary puncture or in the form of a trocar epicystostomy.

Suprapubic capillary puncture (Fig. 16.5). Indications: evacuation of urine from the bladder if catheterization is impossible or there are contraindications, in case of urethral trauma, burn of the external genitalia. Contraindications: low capacity

Rice. 16.5.Suprapubic capillary puncture of the bladder (from: Lopatkin N.A., Shvetsov I.P., editors, 1986): a - puncture technique; b - puncture diagram

bladder, acute cystitis or paracystitis, tamponade of the bladder with blood clots, the presence of bladder tumors, large scars and inguinal hernias that change the topography of the anterior abdominal wall. Anesthesia: local infiltration anesthesia with 0.25-0.5% novocaine solution. Patient position: on the back with a raised pelvis. Puncture technique. A needle with a length of 15-20 cm and a diameter of about 1 mm is used. The bladder is punctured with a needle at a distance of 2-3 cm above the pubic fusion. After urine is removed, the puncture site is treated and a sterile sticker is applied.

Trocar epicystostomy (Fig. 16.6). Indications: acute and chronic urinary retention. Contraindications, patient position, pain relief the same as for capillary puncture of the bladder. Operation technique. The skin at the operation site is dissected over 1-1.5 cm, then the tissue is punctured using a trocar, the stylet is removed, a drainage tube is inserted into the bladder through the lumen of the trocar tube, the tube is removed, the tube is fixed with a silk suture to the skin.

Rice. 16.6.Scheme of the stages of trocar epicystostomy (from: Lopatkin N.A., Shvetsov I.P., ed., 1986):

a - position of the trocar after injection; b - removal of mandrin; c - insertion of a drainage tube and removal of the trocar tube; d - the tube is installed and fixed to the skin

Cystotomy -operation of opening the bladder cavity (Fig. 16.7).

High cystotomy (syn.: epicystotomy, high section of the bladder, section alta) is performed in the area of ​​the apex of the bladder extraperitoneally through an incision in the anterior abdominal wall.

Rice. 16.7.Stages of cystostomy. (from: Matyushin I.F., 1979): a - line of skin incision; b - fatty tissue, together with the transitional fold of the peritoneum, is peeled upward; c - opening of the bladder; d - a training tube is inserted into the bladder, the bladder wound is sutured around the drainage; d - final stage of the operation

Anesthesia:local infiltration anesthesia with 0.25-0.5% novocaine solution or epidural anesthesia. Access - inferomedian, transverse or arcuate extraperitoneal. In the first case, after dissection of the skin, subcutaneous fatty tissue, linea alba, the rectus and pyramidal muscles are pulled apart, the transversalis fascia is dissected in the transverse direction, and the prevesical tissue is peeled off along with the transitional fold of the peritoneum upward, exposing the anterior wall of the bladder. When performing a transverse or arcuate approach, after an incision of the skin and subcutaneous fatty tissue, the anterior walls of the sheaths of the rectus abdominis muscles are dissected in the transverse direction, and the muscles are pulled apart (or crossed). The opening of the bladder must be done as high as possible between two ligatures, having previously emptied the bladder through the catheter. Bladder wounds are sutured with a two-row suture: the first row - through all layers of the wall with absorbable suture material, the second row - without suturing the mucous membrane. The anterior abdominal wall is sutured in layers, and the prevesical space is drained.

16.5. OPERATIONS ON THE UTERUS AND APPENDIXES

Operative access to the female genital organs in the pelvic cavity:

Abdominal-wall:

Lower median laparotomy;

Suprapubic transverse laparotomy (Pfannenstiel);

Vaginal:

Anterior colpotomy;

Posterior colpotomy.

Colpotomy is a surgical access to the female pelvic organs by dissecting the anterior or posterior wall of the vagina.

Puncture of the posterior vaginal fornix - diagnostic puncture of the abdominal cavity, performed with a needle on a syringe by inserting it through a puncture of the wall of the posterior vaginal fornix into the rectal-uterine cavity of the pelvic peritoneum (Fig. 16.8). Patient position: on the back with the legs pulled to the stomach and bent at the knee joints. Anesthesia: short-term anesthesia or local infiltration anesthesia. Intervention technique. The vagina is opened wide with speculums and bullet forceps

Rice. 16.8.Puncture of the rectouterine cavity of the peritoneal cavity through the posterior vaginal fornix (from: Savelyeva G.M., Breusenko V.G., ed., 2006)

The posterior lip of the cervix is ​​grasped and directed to the pubic fusion. The posterior vaginal vault is treated with alcohol and iodine tincture. Using a long Kocher clamp, grasp the mucous membrane of the posterior vaginal fornix 1-1.5 cm below the cervix and slightly pull it forward. The fornix is ​​punctured with a sufficiently long needle (at least 10 cm) with a wide lumen, the needle is directed parallel to the wire axis of the pelvis (to avoid damage to the rectal wall) to a depth of 2-3 cm.

Uterine amputation(subtotal, supravaginal supravaginal amputation of the uterus without appendages) - surgery to remove the body of the uterus: with preservation of the cervix (high amputation), with preservation of the body and supravaginal part of the cervix (supravaginal amputation).

Extended extirpation of the uterus with appendages (syn.: Wertheim operation, total hysterectomy) - an operation of complete removal of the uterus with appendages, the upper third of the vagina, periuterine tissue with regional lymph nodes (indicated for cervical cancer).

Cystectomy- removal of a pedunculated ovarian tumor or cyst.

Tubectomy- surgery to remove the fallopian tube, most often in the presence of a tubal pregnancy.

16.6. RECTAL OPERATIONS

Rectal amputation - an operation to remove the distal part of the rectum with the reduction of its central stump to the level of the perineal-sacral wound.

Unnatural anus (syn.: anus praeternaturalis) - an artificially created anus, in which the contents of the colon are completely released out.

Rectal resection - an operation to remove part of the rectum with or without restoring its continuity, as well as the entire rectum while preserving the anus and sphincter.

Resection of the rectum according to the Hartmann method - intraperitoneal resection of the rectum and sigmoid colon with the application of a single-barrel artificial anus.

Extirpation of the rectum - an operation to remove the rectum without restoring continuity, with removal of the closure apparatus and suturing of the central end into the abdominal wall.

Extirpation of the rectum using the Quenu-Miles method - one-stage abdominoperineal extirpation of the rectum, in which the entire rectum with the anus and anal sphincter, surrounding tissue and lymph nodes is removed, and a permanent single-barrel artificial anus is formed from the central segment of the sigmoid colon.

16.7. TEST TASKS

16.1. The main cellular spaces of the pelvic cavity are located within:

1. Peritoneal floor of the pelvis.

2. Subperitoneal floor of the pelvis.

3. Subcutaneous floor of the pelvis.

16.2. The urogenital diaphragm is formed by two of the following muscles:

2. Coccygeal muscle.

16.3. The pelvic diaphragm is formed by two of the following muscles:

1. Deep transverse muscle of the perineum.

2. Coccygeal muscle.

3. The levator ani muscle.

4. Ischio-cavernous muscle.

5. Sphincter of the urethra.

16.4. The prostate gland is located in relation to the bladder:

1. Front.

2. From below.

3. Behind.

16.5. A digital rectal examination in men is carried out to determine the condition primarily:

1. Bladder.

2. Ureters.

3. Prostate gland.

4. Anterior sacral lymph nodes.

16.6. The fallopian tube is located:

1. Along the upper edge of the broad ligament of the uterus.

2. Along the lateral edge of the uterine body.

3. In the middle section of the broad ligament of the uterus.

4. At the base of the broad ligament of the uterus.

16.7. The supramullary part of the rectum is covered with peritoneum:

1. From all sides.

2. On three sides.

3. Front only.

16.8. The rectal ampulla is covered for the most part by the peritoneum:

1. From all sides.

Small pelvis It is a cylindrical cavity and has upper and lower openings. The superior aperture of the pelvis is represented by the boundary line. The lower aperture of the pelvis is limited behind by the coccyx, on the sides by the ischial tuberosities, and in front by the pubic fusion and the lower branches of the pubic bones. The inner surface of the pelvis is lined with parietal muscles: iliopsoas (m. iliopsoas), piriformis (m. piriformis), obturator internus (m. obturatorius internus). The piriformis muscle performs the greater sciatic foramen. Above and below the muscle there are slit-like spaces - supra- and infrapiriform openings (foramina supra - et infrapiriformes), through which blood vessels and nerves emerge: the superior gluteal artery, accompanied by veins and the nerve of the same name through the suprapiriform opening; inferior gluteal vessels, inferior gluteal, sciatic nerves, posterior cutaneous nerve of the thigh, internal genital vessels.

Anterior to the rectum are the uterus and vagina. Posterior to the rectum lies the sacrum. The lymphatic vessels of the rectum are connected to the lymphatic system of the uterus and vagina (in the hypogastric and sacral lymph nodes)

Bladder in women, as in men, it lies behind the pubic symphysis. Behind the bladder are the uterus and vagina. The loops of the small intestine are adjacent to the upper part of the bladder, covered with peritoneum. On the sides of the bladder are the levator ani muscles. The bottom of the bladder lies on the urogenital diaphragm

Uterus in the pelvis of women, it occupies a position between the bladder and the rectum and is tilted forward (anteversio), while the body and cervix, separated by the isthmus, form an angle open anteriorly (anteflexio). The loops of the small intestine are adjacent to the fundus of the uterus. The peritoneum, covering the uterus in front and behind, converges on the sides of the uterus, forming the broad ligaments of the uterus. The uterine arteries are located at the base of the broad ligament of the uterus. Next to them lie the main ligaments of the uterus. The fallopian tubes lie in the free edge of the broad ligaments of the uterus. The ovaries are also attached to the broad ligaments of the uterus. On the sides, the broad ligaments pass into the peritoneum, covering the walls of the pelvis. There are also round ligaments of the uterus, running from the angle of the uterus to the internal opening of the inguinal canal. The uterus is supplied with blood by two uterine arteries from the system of internal iliac arteries, as well as ovarian arteries - branches of the abdominal aorta.

The fallopian tubes lie between the leaves of the broad ligaments of the uterus along their upper edge. In the fallopian tube, there is an interstitial part located in the thickness of the uterine wall, an isthmus (narrowed part of the tube), which passes into an expanded section - the ampulla. At the free end, the fallopian tube has a funnel with fimbriae, which is adjacent to the ovary.

Ovaries with the help of the mesentery they are connected to the posterior leaves of the broad ligament of the uterus. The ovaries have uterine and tubal ends. The uterine end is connected to the uterus by its own ovarian ligament. The tubal end is attached to the lateral wall of the pelvis by the suspensory ligament of the ovary. In this case, the ovaries themselves are located in the ovarian fossae - depressions in the side wall of the pelvis. These depressions are located in the area where the common iliac arteries divide into internal and external. The uterine arteries and ureters lie nearby, which should be taken into account when performing operations on the uterine appendages.

Vagina located in the female pelvis between the bladder and rectum. At the top, the vagina passes into the cervix, and at the bottom it opens with an opening between the labia minora. The anterior wall of the vagina is closely connected to the posterior wall of the bladder and the urethra. Therefore, when the vagina ruptures, vesicovaginal fistulas can form. The posterior wall of the vagina is in contact with the rectum. At the vagina, there are fornices - indentations between the cervix and the walls of the vagina. In this case, the posterior fornix borders on the pouch of Douglas, which allows access to the rectouterine cavity through the posterior vaginal fornix.