Female genital organs: blood supply, innervation, topography, structure. Blood supply and innervation of the internal genital organs in women

Blood supply to the internal genital organs It is carried out mainly from the aorta (the system of the common and internal iliac arteries). Main uterine blood supply ensured uterine artery (a uterina), which departs from the internal iliac (hypogastric) artery (a iliaca interna). In about half of the cases, the uterine artery independently departs from the internal iliac artery, but it can also originate from the umbilical, internal pudendal and superficial cystic arteries.

Uterine artery goes down to the lateral pelvic wall, then passes forward and medially, located above the ureter, to which it can give an independent branch. At the base of the broad uterine ligament, it turns medially towards the cervix. In the parametrium, the artery connects with the accompanying veins, nerves, ureter, and cardinal ligament. The uterine artery approaches the cervix and supplies it with the help of several tortuous penetrating branches. The uterine artery then divides into one large, very tortuous ascending branch and one or more small descending branches, supplying the upper part of the vagina and adjacent part of the bladder. The main ascending branch goes up along the lateral edge of the uterus, sending arcuate branches to her body. These arcuate arteries surround the uterus under the serosa. At certain intervals, radial branches depart from them, which penetrate into the intertwining muscle fibers of the myometrium. After childbirth, the muscle fibers contract and, acting like ligatures, compress the radial branches. The arcuate arteries rapidly decrease in size towards the midline, so there is less bleeding with median incisions of the uterus than with lateral ones. The ascending branch of the uterine artery approaches the fallopian tube, turning laterally in its upper part, and divides into tubal and ovarian branches. The tubal branch runs laterally in the mesentery of the fallopian tube (mesosalpinx). The ovarian branch goes to the mesentery of the ovary (mesovarium), where it anastomoses with the ovarian artery, which originates directly from the aorta.

The ovaries are supplied with blood from ovarian artery (a.ovarica) extending from the abdominal aorta on the left, sometimes from the renal artery (a.renalis). Going down along with the ureter, the ovarian artery passes along the ligament that suspends the ovary to the upper section of the wide uterine ligament, gives off a branch for the ovary and tube; the terminal section of the ovarian artery anastomoses with the terminal section of the uterine artery.

AT blood supply to the vagina, in addition to the uterine and genital arteries, the branches of the inferior vesical and middle rectal arteries are also involved. The arteries of the genital organs are accompanied by corresponding veins. The venous system of the genital organs is highly developed; the total length of the venous vessels significantly exceeds the length of the arteries due to the presence of venous plexuses, widely anastomosing with each other. The venous plexuses are located in the clitoris, at the edges of the bulbs of the vestibule, around the bladder, between the uterus and ovaries. AT innervation of the genital organs of a woman the sympathetic and parasympathetic parts of the autonomic nervous system, as well as the spinal nerves, are involved.

The fibers of the sympathetic part of the autonomic nervous system, which innervate the genital organs, originate from the aortic and celiac ("solar") plexuses, go down and form at the level of the fifth lumbar vertebra superior hypogastric plexus. It gives off fibers that form right and left lower hypogastric plexuses (plexus hypogastrics sinister et dexter inferior). Nerve fibers from these plexuses go to a powerful uterovaginal, or pelvic, plexus (plexus uterovaginal, s.pelvicus).

Uterovaginal plexus are located in the parametric fiber on the side and behind the uterus at the level of the internal os and cervical canal. Branches approach this plexus pelvic nerve (n.pelvicus) related to the parasympathetic part of the autonomic nervous system. Sympathetic and parasympathetic fibers extending from the uterovaginal plexus innervate the vagina, uterus, internal sections of the fallopian tubes, and the bladder. The ovaries are innervated sympathetic and parasympathetic nerves from the ovarian plexus (plexus ovaricus).

Efferent parasympathetic fibers start from the lateral horns of the S II -S IV segments of the spinal cord (erection center), repeat the ways of regulating urination (the second neuron is located in the prostate plexus) - pelvic splanchnic nerves (nn. splanchnici pelvini), or excitatory nerves (nn. erigentis) cause vasodilatation of the cavernous bodies of the penis, pudendal nerves (nn. pudendi) innervate the sphincter of the urethra, as well as the sciatic-cavernous and bulbous-spongy muscles (mm. ishiocavernosi, mm. bulbospongiosi)(Fig. 12.13).

Efferent sympathetic fibers begin in the lateral horns L I -L II (ejaculation center) of the segments of the spinal cord and through the anterior roots, the nodes of the sympathetic trunk, interrupted in the hypogastric plexus, reach the seminal ducts, seminal vesicles and the prostate gland along the paravascular branches of the hypogastric plexus.

The reproductive centers are partly under neurogenic influence, realized through the reticulospinal fibers, partly under the humoral influence from the higher hypothalamic centers (Fig. 12.13).

According to Krucke (1948), the posterior longitudinal fasciculus (fasciculus longitudinalis dorsalis), or the bundle of Schutz, has a continuation in the form of an unmyelinated parepindemic bundle (fasciculus parependimalis), descending on both sides of the central canal to the sacral spinal cord. It is believed that this path connects the diencephalic genital centers, located in the region of the gray tubercle, with the sexual center of the lumbosacral localization.

Bilateral damage to the sacral parasympathetic center leads to impotence. Bilateral damage to the lumbar sympathetic center is manifested by a violation of ejaculation (retrograde ejaculation), testicular atrophy is observed. With a transverse injury of the spinal cord at the level of the thoracic region, impotence occurs, which can be combined with reflex priapism and involuntary ejaculation. Focal lesions of the hypothalamus lead to a decrease in sexual desire, weakening of erection, delayed ejaculation. The pathology of the hippocampus and limbic gyrus is manifested by a weakening of all phases of the sexual cycle or complete impotence. During right hemispheric processes, sexual stimuli fade, unconditional reflex reactions weaken, the emotional sexual attitude is lost, and libido weakens. With the left hemispheric processes, the conditioned reflex component of the libido and the erectile phase are weakened.

Violations of sexual function and its components can be induced by a wide range of diseases, but in most cases (up to 90%) are associated with psychological causes.

Peripheral autonomic syndromes

Syndrome of peripheral autonomic failure occurs when postganglionic vegetative fibers are damaged in patients with polyneuropathies of various etiologies. In the pathogenesis of the syndrome, a decisive role is played by a violation of the release of norepinephrine by sympathetic fibers and acetylcholine by parasympathetic fibers. Symptoms are manifested by a picture of loss of function of sympathetic or parasympathetic fibers, or a combination of them. The leading signs are orthostatic hypotension, resting tachycardia, fixed pulse, arterial hypertension in the supine position, hypo- or anhidrosis, impotence, gastrointestinal motility disorders (constipation or diarrhea), urinary retention or incontinence, decreased twilight vision, sleep apnea. Distinguish between primary peripheral autonomic failure associated with a primary lesion of the ANS (Bradbury-Eggleston, Riley-Day syndromes) and secondary, caused by diseases of the spinal cord and damage to the peripheral nervous system. The latter is due to systemic, autoimmune and infectious diseases, exo- and endotoxic factors.

Bradbury–Eggleston syndrome (pure autonomic dysfunction, idiopathic orthostatic hypotension) is a degenerative disease of the ANS in which both the sympathetic and parasympathetic divisions of the autonomic nervous system are affected, but the structures and functions of the CNS, as a rule, remain intact. Clinically, the disease is manifested by peripheral autonomic failure. In the blood, there is a significant decrease in the content of norepinephrine (up to 10% of the norm and below).

Riley-Day syndrome due to a congenital disorder mainly in the peripheral parts of the ANS and is manifested by reduced lacrimation, impaired thermoregulation, orthostatic hypotension, episodes of severe vomiting. The disease has an autosomal recessive mode of inheritance.

Shaye-Dreijer syndrome (multiple system atrophy). Severe autonomic failure is combined with cerebellar, extrapyramidal and pyramidal insufficiency. The nature of clinical manifestations depends on the degree of involvement of these systems in the pathological process. The syndrome is manifested by orthostatic hypotension, parkinsonism, impotence, impaired pupillary reactions, urinary incontinence. The autonomic system remains almost intact, but the nature of the CNS lesion is such that it causes disturbances in the regulatory functions of the autonomic nervous system.

Winterbauer syndrome It usually manifests itself in women over 20 years of age with telangiectasias, skin calcification, acrocyanosis, increased sensitivity to cold, sclerodactyly, recurrent ulcerations, degeneration of the terminal phalanges, leading to deformities of the hands and feet.

Causalgic syndrome (Pirogov-Mitchell disease).

Characterized by intense pain due to irritation of the autonomic structures of peripheral nerves. It is more common in traumatic lesions of the median, sciatic and tibial nerves, which contain a large number of sympathetic fibers. Characterized by a sharp, burning, difficult to localize, widely radiating pain, the intensity of which is somewhat relieved by wetting the skin with cold water or wrapping the limb with a cloth soaked in cold water. Vegetative pain in this case can be provoked by external influences (touch, sharp sound stimuli, etc.). In the zone of innervation of the affected nerve, permanent hyperpathy, vascular, and often trophic disorders are detected.

Charcot-Grasset syndrome. Characterized by vegetative-vascular and trophic disorders in the legs, mainly in the distal sections, manifested by cyanosis, edema, sympathalgia.

12.2.3. Metasympathetic division of the autonomic nervous system

A complex of microganglionic formations located in the walls of internal organs that have motor activity (heart, intestines, ureter, etc.) and ensure their autonomy. The function of the nerve nodes is, on the one hand, in the transmission of central (sympathetic, parasympathetic) influences to the tissues, and on the other hand, in ensuring the integration of information coming through local reflex arcs. They are independent entities capable of functioning with full decentralization. Several (5–7) nearby nodes are combined into a single functional module, the main units of which are oscillator cells that ensure the autonomy of the system, interneurons, motor neurons, and sensory cells. Separate functional modules make up a plexus, thanks to which, for example, in the intestine, a peristaltic wave is organized.

The activity of the metasympathetic division of the ANS does not depend on the activity of the sympathetic or parasympathetic nervous system, but can change under their influence. So, for example, activation of parasympathetic influence enhances intestinal motility, and sympathetic influence weakens it.

Generalized data on the innervation of the genital organs are as follows.

Figure: Nerves of the uterus.

1 - gangl. coeliacum; 2 - gangl. renale; 3 - gangl. ovaricum; 4 - gangl. mesentericum infer.; 5 - plexus uterinus magnus; 6 - plexus hypogastricus; 7 - nn. sacrales I–IV; 8 - gangl. cervicale; 9 - rectum; 10 - plex. ovaricus; 11 - uterus.

Most of the nerves going to the uterus are of sympathetic origin; along the way, spinal fibers from n join them. vagi, phrenici, splanchnici, nn. communicantes et plexus sacralis. In particular, the sympathetic fibers of the plexus hypogastricus take a great part in the innervation of the uterus, the plexus of which originates from the plexus aorticus, which lies on the large abdominal vessels. Aortic plexus, attaching branches from gangl. renale n. solare below the aortic bifurcation, runs along the anterior surface of the V lumbar vertebra in the form of a flat cord (plex. hypogastricus super.). At level I of the sacral vertebra plex. hypogastr super, is divided into two branches, forming a plexus - plex. hypogastr. inferior, or ganglion hypogastricum. They are located in the sacral cavity, close to the isthmus uteri. These ganglia represent the termination of the paravertebral sympathetic system in the pelvis. Plex. hypogastr. superior, or presacral nerve, is well accessible at the level of the cape. Plex. hypogastr. inferior, in addition to the uterus, innervates the rectum, bladder, ureters and vagina. This plexus is paired, located on the sides of the cervix, some authors classify it as a ganglion, while most consider it a typical plexus, and G.F. Pisemsky called it the “basic plexus of the pelvis” (plexus fundamentalis pelvis).

The uterus is innervated by that part of the plex. hypogastr. inferior, which forms the so-called plexus of the Rhine (anterior part of the lower edge of the plex. hypogastr. infer.). The Rhine plexus is referred to by some authors as plex. uterovaginalis, s. uterine magnus. The Rhine plexus receives branches: 1) from the anterior roots II, III and IV of the sacral nerves, due to the fibers extending from the last 4-6 nn. erigentes (nn. erigentes are also called nn. pelvici). The latter are connected along the way with branches from the sacral ganglia of the sympathetic border trunk; 2) from the sacral and coccygeal division of the border sympathetic trunk; 3) via plex. hypogastr. infer, from the lumbar sympathetic trunks, as well as from the X, XI, XII thoracic nerves; 4) from plex. haemorrhoid. infer., departing from the plex mesenter infer., which establishes a functional relationship between the genital apparatus and the rectum. The pelvic plexus, according to S. D. Astrinsky, containing mainly sympathetic fibers, also contains nn fibers. pelvici and is therefore a mixed plexus.

Thus, the uterus is innervated mainly by sympathetic nerves from the border sympathetic trunk of the lower hypogastric plexus, as well as by the parasympathetic system (pelvic nerves).

Previously, it was believed that the motor nerves for the uterus are the branches of the lower hypogastric plexus, acting through the plexus of the Rhine, and the pelvic nerves are motor for the cervix. However, even in previous works (Dembo) there were indications that stimulation of the pelvic nerves by electric current causes the same contraction of the uterus as stimulation of the hypogastric nerves. At the end of the last century, the opinion prevailed that in both systems - sympathetic and parasympathetic - there are both motor and sensory nerves, namely: centrifugal motor and centripetal sensory. Studying the bioelectrical phenomena in the uterus, some authors found that irritation of the hypogastric nerve by a faradic current causes either an inhibitory or an intensifying effect, depending on whether the uterus is pregnant or not; stimulation of the pelvic nerves had the same effect on the pregnant and non-pregnant uterus in the form of an acceleration of the rhythm and an increase in the amplitude of contractions.

The view of the sympathetic innervation of the uterus (from the system of the hypogastric nerve) as exclusively motor has been shaken in recent decades. Experimental work has shown that some sympathetic nerves leading to the uterus, not only preganglionic, but also postganglionic, directly innervating the uterus, are cholinergic. Irritation of the hypogastric nerve led to the release of acetylcholine, and uterine contractions occurred; injections of physostigmine (the paralyzing effect of cholinesterase that destroys acetylcholine) increased uterine contractions. These facts indicate the exceptional role of acetylcholine in the emergence and development of the contractile activity of the uterus, which was especially emphasized by A.P. Nikolaev (1945). Based on the data of the school of I.P. Pavlov, who established that only the tonotropic effect belongs to the sympathetic system, and the tonomotor effect is carried out due to nerves that have vasodilating fibers (i.e., parasympathetic, cholinergic), A.P. Nikolaev considers acetylcholine a substance that has main importance in the development of neurohumoral influences on the muscles and, in particular, on the uterus and its motor function. Thus, the tonomotor function, according to modern views, does not belong to the sympathetic system as a whole, but to the vagus system and cholinergic areas of the sympathetic nervous system, as well as their mediator, acetylcholine.

The extensive innervation of the cervical region and the lower segment of the uterus consists of an external extramural plexus, rich in ganglia, and a juxtamural plexus located under the peritoneum directly at the myometrium and the muscular layer of the vagina, especially on the back side. The juxtamural plexus consists of macro- and microganglia, anastomosing with each other, the upper border of this plexus is the level of the internal os. The extra- and juxtamural plexuses are most developed on the sides of the uterus, braiding the cervix from here. The juxtamural plexus lies on the myometrium and is introduced into the superficial layers of the muscles, the ganglia of this plexus are located exclusively in the neck.

Neurohistological studies of the body of the uterus showed that the uterus is not devoid of ganglion cells. It comes across ganglia located at irregular intervals from the side of attachment of the broad ligaments. So, Sofoterov, examining the extirpated uterus, found its ganglion cells in the myometrium. According to D. Sinitsin, nerve fibers of ganglion formations are distributed between muscle layers in the form of plexuses and give nerve endings to individual muscle cells, as well as to the integumentary and glandular epithelium of the uterine mucosa

Nerve fibers braid the glands and end on glandular cells in the form of buttons, lumps or clusters.

Functionally, these nerve endings are receptors. “The uterus is a huge receptive field with which the maternal organism is turned to the fetus (N. L. Garmasheva). T.P. Bakkal discovered morphological receptors in the wall of the uterus at the border with the mucous membrane, in addition, she found them in the uterine veins and veins of the ovaries.

Modern studies, based on the teachings of IP Pavlov, believe that the uterus, due to its abundant innervation, receives numerous activating and inhibitory impulses from the central nervous system - the cerebral cortex. The reflex activity of the uterus is extremely varied and rich. The most complex and diverse are rhythmic, progressive contractions of the uterus in labor. Impulses to the uterus can sometimes come from distant parts of the body. Stimulation of the activity of the mammary glands, especially at the end of pregnancy, causes uterine contractions, sometimes very intense and painful. Of even greater importance are psychogenic influences that can slow down the contractile activity of the uterus to a pathological degree.

The fallopian tubes receive their nerve fibers partly from the ovarian plexus, partly from the Rhine plexus. After the nerve fibers form superficial subserous plexuses, they penetrate deeper - between smooth muscle fibers, longitudinal and circular, and form a second, intramuscular plexus, from which the nerve branches go to the mucous membrane. Along with this sympathetic innervation of the tube, there is an additional innervation from the ganglionic centers, which have not yet been sufficiently studied.

The ovaries are innervated by fibers n. spermatid, which originate from the paravertebral ganglia, lateral to a. mesenterica inf. The distribution of these fibers is limited, however, to the blood vessels and ovarian stroma. The innervation of the ovary has been studied in recent years by A. 3. Kocherginsky on human embryos; this author described a very long neural pathway from the spinal cord to the ovary.

According to B.P. Khvatov, the nerve trunks penetrate the hilum of the ovary along with the blood vessels in the early stages of the development of the organ. However, nerve fibers are found in the cortex much later, when the development of vesicular follicles occurs. By the period of puberty, new nerve trunks enter the cortex, innervating the follicles.

It should not be forgotten that the bladder and rectum share innervation with the uterus; the practical significance of this circumstance lies in the fact that the overflow of these reservoirs can reflexively cause a weakening of the labor activity of the uterus.

The vagina is supplied with branches from the plexus of the Rhine; these branches are located mainly in the upper two-thirds of the vagina and form a plexus, equipped with small ganglia.

The external genital organs and the perineum are innervated mainly by n. pudendi and its twigs. Partial participation in the innervation of the external genitalia is taken by n. ilioinguinalis, n. perineus, branches n. cutanei femoris poster, etc.

Barrel n. pudendi enters the cavum ischiorectale at the medial part of the ascending branch of the ischium.

Physiological data on the reception of the uterus were obtained mainly by domestic authors; understanding them is very important for many issues in obstetrics.

For obstetrics, it is especially important to know those reflex reactions of the maternal organism that occur in response to physiological changes in the state of the fetus associated with its development and growth.

The experimental data of the laboratory led by N. L. Garmasheva give reason to believe that the maternal organism is able to analyze various changes in the state of the fetus and, adapting to these changes, satisfy its needs.

The first link, with the excitation of which the analyzer and adaptive reaction of the maternal organism begins during pregnancy, is the sensitive nervous apparatus of the uterus, its receptors. Violation of this reaction can cause pathology of pregnancy or childbirth.

The reflex reactions that occur when the uterine receptors are excited follow the same physiological patterns as the reflexes of other interoreceptors. They can be suppressed by deep anesthesia, perverted if they are accompanied by a pain reaction. One of the features of the reception of the uterus is its great dependence on the amount and ratio of ovarian, pituitary, and other hormones in the body (N. L. Garmasheva et al.).

The innervation of the internal genital organs is carried out by the autonomic nervous system. Autonomic nerves contain sympathetic and parasympathetic fibers, as well as efferent and afferent. One of the largest efferent autonomic plexuses is the abdominal aortic plexus, which is located along the course of the abdominal aorta. A branch of the abdominal aortic plexus is the ovarian plexus, which innervates the ovary, part of the fallopian tube and the broad ligament of the uterus.

Another branch is the lower hypogastric plexus, which forms organ autonomic plexuses, including the uterovaginal plexus. The uterovaginal plexus of Frankenheiser is located along the uterine vessels as part of the cardinal and sacro-uterine ligaments. This plexus also contains afferent fibers (roots Th1O - L1).

FIXING DEVICE OF THE INTERNAL GENITAL ORGANS OF A WOMAN

The fixing apparatus of the internal genital organs of a woman consists of a suspension, fixing and supporting apparatus, which ensures the physiological position of the uterus, tubes and ovaries (Fig. 61).

Suspension apparatus

It unites a complex of ligaments connecting the uterus, tubes and ovaries with the walls of the pelvis and among themselves. This group includes round, wide ligaments of the uterus, as well as suspensory and own ligaments of the ovary.

Round ligaments of the uterus (lig. teres uteri, dextrum et sinistrum) are a paired cord 10-15 cm long, 3-5 mm thick, consisting of connective tissue and smooth muscle fibers. Starting from the lateral edges of the uterus somewhat lower and anterior to the beginning of the fallopian tubes on each side, the round ligaments pass between the sheets of the wide uterine ligament (intraperitoneally) and go to the side wall of the pelvis, retroperitoneally.

Then they enter the internal opening of the inguinal canal. The distal third of them is located in the canal, then the ligaments exit through the external opening of the inguinal canal and branch out in the subcutaneous tissue of the labia.

Broad ligaments of the uterus (lig. latum uteri, dextrum et sinistrum) are frontally located duplications of the peritoneum, which are a continuation of the serous cover of the anterior and posterior surfaces of the uterus away from its “ribs” and split into sheets of the parietal peritoneum of the side walls of the small pelvis - outside. At the top, the wide ligament of the uterus closes the fallopian tube, located between its two leaves; below, the ligament splits, passing into the parietal peritoneum of the pelvic floor. Between the leaves of the broad ligament (mainly at their base) lies fiber (parametrium), in the lower part of which the uterine artery passes from one side to the other.

The broad ligaments of the uterus lie freely (without tension), follow the movement of the uterus and cannot, of course, play a significant role in keeping the uterus in a physiological position. Speaking of the broad ligament of the uterus, it is impossible not to mention that with intraligamentary tumors of the ovaries located between the sheets of the broad ligament, the usual topography of the pelvic organs is violated to one degree or another.

Suspension ligaments of the testicles ica(lig. suspensorium ovarii, dextrum et. sinistrum) go from the upper (tubular) end of the ovary and fallopian tube to the peritoneum of the side wall of the pelvis. These relatively strong, thanks to the vessels passing through them (a. et v. ovagisae) and nerves, the ligaments keep the ovaries in limbo.

Own ligaments of the ovary a(1ig. Ovarii proprimu, dextrum et. sinistrum) are a very strong short fibrous-glucomuscular cord connecting the lower (uterine) end of the ovary with the uterus, and pass through the thickness of the broad ligament of the uterus.

Fixing, or actually fixing, apparatus (retinaculum uteri) is a "densification zone" consisting of powerful connective tissue strands, elastic and smooth muscle fibers.

In the fixing apparatus, the following parts are distinguished:

The anterior part (pars anterior retinaculi), which includes the pubovesical or pubic-vesical ligaments (ligg. pubovesicalia), continuing further in the form of vesicouterine (vesico-cervical) ligaments (ligg. Vesicouterina s. vesicocervicalia);

The middle part (pars media retinaculi), which is the most powerful in the system of the fixing apparatus; it mainly includes the system of cardinal ligaments (1igg. cardinalia);

The back part (pars posterior retinaculi), which is represented by sacro-uterine ligaments (1igg. sacrouterina).

Some of these links should be considered in more detail.

1. Vesicouterine, or vesicocervical, ligaments are fibromuscular plates that cover the bladder on both sides, fixing it in a certain position, and keeping the cervix from moving backwards.

2. The main, or main (cardinal), ligaments of the uterus are a cluster of intertwined dense fascial and smooth muscle fibers with a large number of vessels and nerves of the uterus, located at the base of the wide uterine ligaments in the frontal plane.

3. The sacro-uterine ligaments consist of muscle bundles and depart from the posterior surface of the cervix, arcuately covering the rectum from the sides (weaving into its side wall), and are fixed to the parietal sheet of the pelvic fascia on the anterior surface of the sacrum. Raising the upper peritoneum, the sacro-uterine ligaments form the recto-uterine folds.

Supporting (supporting) apparatus united by a group of muscles and fascia, forming the bottom of the pelvis, over which the internal genital organs are located.

The following methods are used:

1. Common in medical practice: examination, palpation, percussion, auscultation, etc.;

2. Special research methods: examination of the cervix using mirrors, vaginal and bimanual examination, probing, separate diagnostic curettage, etc.;

3. Laboratory research methods.

General inspection.

With a general objective study, an assessment is made of the type of constitution, the condition of the skin, general hair growth, a study of the organs and systems of the abdomen, and the characteristics of the mammary glands.

Along with the normal physique, there are the following body types of women: 1) infantile (hypoplastic); 2) hypersthenic (picnic); 3) intersex; 4) asthenic

Infantile type It is characterized by small (or medium, less often high) growth, generally evenly narrowed pelvis, underdevelopment of the mammary glands, external and internal genital organs, late onset of menarche, and menstruation is irregular and painful.

Hypersthenic type characterized by low (medium) growth, with a well-developed subcutaneous fat layer, insignificant leg length compared to the length of the body, mild back kyphosis, high-lying lordosis and relatively narrow shoulder girdle. In most women, specific functions are not impaired.

intersex type characterized by insufficiently complete differentiation of sexual characteristics, which is reflected in the appearance of a woman and the functions of the genital organs. These women have physical and mental signs inherent in the male body: they are rather tall, have a massive skeleton, a wide shoulder girdle, a pelvis that is close in shape to a man's, non-closing legs. Hair on the genitals is excessive and developed according to the male type. There is a lot of hair on the legs and around the anus. These women often have genital hypoplasia, menstrual dysfunction, sexual indifference and infertility.

Asthenic type the predominance of longitudinal dimensions, a decrease in the tone of the entire muscular and connective tissue systems are characteristic. Such women often have excessive uterine mobility and posterior kinks, pain in the sacrum, heaviness in the lower abdomen, painful menstruation, constipation, and decreased ability to work. After childbirth, due to the weakness of the ligamentous apparatus and muscles of the pelvic floor, prolapse of the walls of the vagina and uterus easily occurs.

Of great importance for the diagnosis of endocrine disorders is the knowledge height and weight indicators, since, for example, with a deficiency or excess of body weight, violations of the MC can be observed. Body type is assessed using anthropometric curves (morphograms) according to Decourt and Doumic, who proposed to determine five sizes using a centimeter tape, stadiometer and pelvis. Assessment of body type with the help of morphograms allows, first of all, to establish the possibility of a retrospective assessment of the features of the ratios of the levels of hormonal influences during puberty, which determine the size of individual parts of the body during the formation of the bone skeleton.

Body mass index (BMI):

BMI of a woman of reproductive age is 20-26;

· BMI above 30 - the average risk of developing metabolic disorders;

· BMI above 40 - a highly developed degree of risk of metabolic disorders;

According to the degree of development and distribution fatty tissue can be judged on the function of the endocrine glands. With the pathology of the hypothalamic region, the deposition of fatty tissue in the form of an apron is observed. Cushing's syndrome is characterized by the deposition of fat on the face, trunk, back, and abdomen. For the climacteric type of obesity, which is due to a sharp decrease in the functional activity of the ovaries, the deposition of fat on the shoulders, in the region of the VII cervical, I and II thoracic vertebrae, on the chest, abdomen and hips is characteristic.

Evaluation of the severity and features of the distribution of hairline allow us to judge the hormonal activity of the ovaries, adrenal glands and the sensitivity of hair follicles to the action of androgens. To assess the hairline, Ferriman and Galway proposed a special method for assessing the degree of hairline in different parts of the body, according to which, depending on the severity of hairiness, this indicator is estimated in points.

The final assessment of the severity of the development of the hairline is the hirsute number, which is the sum of the indicators for the areas of the body (table No. 1)

Table #1

For rate sexual development it is necessary to take into account the degree of development of the mammary glands, hair growth on the pubis and armpits and the characteristics of menstrual function.

The degree of development of the mammary glands:

Ma0 - the mammary gland is not enlarged, the nipple is small, non-pigmented.

Ma1 - swelling of the areola, an increase in its diameter, pigmentation of the nipple is not expressed.

Ma2 - the mammary gland is conical in shape, the areola is not pigmented, the nipple does not rise.

Ma3 - youthful breasts are rounded, the areola is pigmented, the nipple rises.

Ma4 - a mature chest of a rounded shape.

Hair stages:

POAx0 - no pubic and axillary hair.

PlAx1 - single straight hair.

P2Ax2 - hair is thicker and longer, located in the central part of these areas.

RZAx3 - hair on the entire triangle of the pubis and labia is thick, curly; the armpit is covered with curly hair.

The severity of the menstrual function:

Me0 - absence of menstruation.

Me1 - menarche during the examination period.

Me2 - irregular menstruation.

Me3 - regular menstruation.

After a visual assessment of these signs, the sex formula is calculated.

To calculate the sex formula, each trait must be multiplied by its coefficient for measurement in points, and then everything is added up, where P is 0.3; Ah-0.4; Me- 2.1; Ma-1,2.

At examination of the abdomen, it is necessary to pay attention to its size, configuration, swelling, symmetry, participation in the act of breathing. A change in the abdomen and its shape is observed with large tumors (myoma, cystoma), ascites, effusion peritonitis. In the presence of an ovarian cystoma, the abdomen acquires a domed shape, and with ascites, a flattened shape (“frog” abdomen).

At palpation determine the tone of the muscles of the abdominal wall, the presence of muscle protection, diastasis of the rectus abdominis muscles, pain. Feeling the abdomen allows you to determine the size, shape, consistency, boundaries, mobility and soreness of tumors, as well as infiltrates. Muscular protection is detected in acute inflammation of the uterine appendages and pelvic peritoneum (pelvioperitonitis).

At percussion clarify the boundaries of tumors, infiltrates, determine the presence of free fluid in the abdominal cavity. Percussion of the abdomen can be used for the differential diagnosis of parametritis and pelvioperitonitis. With parametrization, the borders of the infiltrate determined by percussion and palpation coincide, and with pelvioperitonitis, the percussion border of the infiltrate seems smaller due to gluing of intestinal loops over its surface.

Auscultation of the abdomen allows you to determine the presence of intestinal motility and its nature. The weakening of intestinal noises can be observed after complex gynecological operations, as this reduces intestinal motility. Violent peristalsis is noted with intestinal obstruction. The absence of peristalsis usually indicates intestinal paresis observed in peritonitis. Auscultation allows a differential diagnosis between large tumors of the internal genital organs and pregnancy.

Examination of the mammary glands is of great importance, since a significant part of gynecological diseases is accompanied by pathology of the mammary glands.

It is necessary to pay attention to the degree of development of the mammary glands, the shape of the nipple. Thus, infantilism is characterized by underdevelopment of the mammary glands. On palpation, attention should be paid to their consistency, the presence of seals, soreness, and the presence of discharge from the nipple. Detection of dense formations requires additional examination methods (ultrasound, mammography, etc.) to exclude a malignant neoplasm. These methods include: examination of the external genital organs; examination of the cervix using mirrors; vaginal, bimanual examination.

Lymphatic vessels, diverting lymph from the external genital organs and the lower third of the vagina, go to the inguinal lymph nodes. The lymphatic pathways extending from the middle upper third of the vagina and cervix go to the lymph nodes located along the course of the celiac and iliac blood vessels.

intramural plexus carry lymph from the endometrium and myometrium to the subserous plexus, from which the lymph flows through the efferent vessels.

Lymph from the lower part of the uterus enters mainly the sacral, external iliac and common iliac lymph nodes; some lymph also enters the lower lumbar nodes along the abdominal aorta and the superficial inguinal nodes. Most of the lymph from the upper uterus drains laterally into the broad ligament of the uterus, where it joins the lymph collected from the fallopian tube and ovary. Further, through the ligament that suspends the ovary, along the course of the ovarian vessels, the lymph enters the lymph nodes along the lower abdominal aorta. From the ovaries, lymph is drained through the vessels located along the ovarian artery, and goes to the lymph nodes lying on the aorta and inferior vena cava. There are connections between the indicated lymphatic plexuses - lymphatic anastomoses.

AT innervation of the genital organs of a woman the sympathetic and parasympathetic parts of the autonomic nervous system, as well as the spinal nerves, are involved.

The fibers of the sympathetic part of the autonomic nervous system, which innervate the genital organs, originate from the aortic and celiac ("solar") plexuses, go down and form at the level of the fifth lumbar vertebra superior hypogastric plexus. It gives off fibers that form right and left lower hypogastric plexuses (plexus hypogastrics sinister et dexter inferior). Nerve fibers from these plexuses go to a powerful uterovaginal, or pelvic, plexus (plexus uterovaginal, s.pelvicus).

Uterovaginal plexus are located in the parametric fiber on the side and behind the uterus at the level of the internal os and cervical canal. Branches approach this plexus pelvic nerve (n.pelvicus) related to the parasympathetic part of the autonomic nervous system. Sympathetic and parasympathetic fibers extending from the uterovaginal plexus innervate the vagina, uterus, internal sections of the fallopian tubes, and the bladder.

The ovaries are innervated sympathetic and parasympathetic nerves from the ovarian plexus (plexus ovaricus).

External genitalia and pelvic floor mainly innervated by the pudendal nerve (n.pudendus).

Pelvic tissue. Blood vessels, nerves and lymphatic tracts of the pelvic organs pass through the tissue, which is located between the peritoneum and the fasciae of the pelvic floor. Fiber surrounds all the organs of the small pelvis; in some areas it is loose, in others in the form of fibrous strands. The following spaces of fiber are distinguished: periuterine, pre- and paravesical, periintestinal, vaginal. The pelvic tissue serves as a support for the internal genital organs, and all its departments are interconnected.