CROTCH [perineum (PNA, JNA, VNA)] — area between a pubic symphysis in front, a top of a tailbone behind, sciatic hillocks and sacral bugrovymi sheaves from sides. Is the lower wall of a trunk closing a small pelvis from below, through to-ruyu there pass the urethra, a rectum, and also a vagina (at women). The item prevents loss of pelvic bodies, creates a possibility of keeping of their contents (kcal, urine) both control of an urination and defecation.
Isolation of intra germinal primary gut, formation of a foul place happen on 3 — 4th week of embryonic development (fig. 1). On the front and back ends of primary gut the blind pockets covered by an entoderm are formed. The hip-pocket at this stage of development extends, connects to channels of an allantois and an average kidney (a mezonefrichesky channel) and turns into a foul place (cloaca). On an exterior surface of a body according to an arrangement of a foul place deepening — an outside cloacal pole (fovea externa cloacalis) is formed, edges for the 4th week gradually goes deep towards a foul place. The bottom of the specified proctal deepening (proctodaeum) separates from a foul place a cloacal membrane (membrana cloacalis). At the same time from the tail of a tselom the pair epithelial folds containing a mesenchyma and forming a mochepryamokishechny partition grow into a foul place, edges grows towards a proctodeum and divides a foul place into two departments — the proctal channel (canalis analis) and an urinogenital sine (sinus urogenitalis). Upon termination of division of a foul place to 6 — 7th week of development the cloacal membrane is broken off, forming two openings: proctal (anus) and urinogenital (ostium urogenitale). The bottom of a mochepryamokishechny partition containing a mesenchyma creates in the subsequent a perineal body (corpus perineale), upper is exposed to a reduction, remaining with adults in the form of a bryushinnopromezhnostny fascia (fascia peritoneoperinealis). Extent of development of a mochepryamokishechny partition defines external shape of P.: at its considerable development by P. convex, at poor development she is concave. P.'s deformations meet at a concave form more often.
The muscles of a crotch developing after muscles of an abdominal wall are differentiated from various sources (fig. 2): the cloacal sphincter (sphincter cloacalis) which is divided later (according to division of a foul place) on laying of sphincters of a rectum and urinogenital bodies is formed of a dorsal mesoderm on the 4th week; from a ventral mesoderm muscles of a bladder and an urethra are differentiated; from sacral myotomes the pelvic phrenic plate (lamina diaphragmatica pelvica), originative to the muscle lifting an anus and a coccygeal muscle forms.
The item at the taken-away and bent legs in a form it is similar to a rhombus (fig. 3). Tops of corners of a rhombus are in front the pubic symphysis, behind a top of a tailbone, from sides sciatic hillocks. The parties of a rhombus form in front of a branch pubic and ischiums, behind sacral and awned sheaves which are covered with bottom edges of big gluteuses. In the middle P. passes a median tendinous seam (raphe) passing at men in front into a seam of a scrotum in the sagittal direction.
Part P. located between back commissure of big vulvar lips and an anal orifice is called an obstetric crotch since matters in obstetric practice. To it there corresponds the tendinous center P. — the place of fixing of the majority of muscles of this area.
The horizontal line drawn through both sciatic hillocks (linia biiachiadica), P. is divided into two areas: anal (regio analis) and urinogenital (regio urogenitalis).
Anal area makes back department of P. through which passes rectum (see). Skin of this department of P. thick, grows together with a mucous membrane anus (see) and muscle bundles of an outside sphincter of an anus, forming radiant folds here; contains a lot of grease and sweat glands. Hypodermic cellulose and a superficial fascia are well-marked. In this layer skin branches of an internal sexual (pudental) artery, hypodermic limf are located. vessels, perineal nerves (branch of a sexual nerve), perineal branches of a back cutaneous nerve of a hip.
More deeply own fascia of P. (fascia perinei propria) lies, after a section the cut opens an ischiorectal pole (fossa ischiorectalis) filled with friable connecting and fatty tissue — an adipose body (corpus adiposum). An outside wall of a pole is the internal locking muscle and its fascia, internal — a lower surface of the muscle lifting an anus, the lower fascia of a diaphragm of a basin covering it and an outside sphincter of an anus (fig. 4, 5, 6). Front border of a pole consider a superficial cross muscle of P. though the pole presses in the form of a narrow pocket and in the urinogenital area. In cellulose of a pole the lower pryamokishechny vessels and the nerves of the same name are located; on a lateral wall in splitting of a fascia (the pudendalny channel, sapa-lis pudendalis, Olkok's channel) there pass internal sexual vessels and a sexual nerve (tsvetn. fig. 1, 2).
In anal area P. the following muscles are located. Outside sphincter of an anus (m. sphincter ani ext.) begins from a top and side departments of a tailbone, zadneprokhodno-coccygeal sheaf (lig. anococcygeum) and adjacent sites of skin. Bunches of a sphincter bypass an anus on the right and at the left and connect ahead of it; they are supported with muscle bundles of a longitudinal layer of a rectum, bunches of the muscle lifting an anus and a zadneprokhodno-coccygeal muscle (m. anococcygeus). Depth of coverage of the proctal channel a sphincter makes 3 — 5 cm, thickness of a sphincter to 8 mm. In a sphincter allocate three parts: hypodermic (pars subcutanea), superficial (pars superficialis) and deep (pars profunda). The muscle lifting an anus (m. levator ani), a steam room together with a coccygeal muscle makes a diaphragm of a basin (diaphragma pelvis). Depending on the place of the beginning of its separate portions it is divided into two muscles: pubic and coccygeal (m. pubococcygeus) and iliococcygeal (m. iliococcygeus). The pubic and coccygeal muscle begins from a back surface of pubic bones and from the forefront of a tendinous arch of the muscle lifting an anus (arcus tendineus m. levatoris ani), formed by a locking fascia. Bunches of a muscle extend kzad, cover a rectum, and they intertwine with bunches of the muscle of the same name of other party and with longitudinal muscle bundles of a gut and are attached to a zadneprokhodno-coccygeal sheaf, a tailbone and a ventral sacrococcygeal sheaf. At men front edges of a pubic and coccygeal muscle are closely spliced with the capsule of a prostate; this part of muscle bundles is allocated as the muscle raising a prostate gland (m. levator prostatae). At women such bunches adjoin a wall of a vagina and are designated as a pubic and vulval muscle (m. pubovaginalis). The Podvzdoshnokopchikovy muscle originates from a tendinous arch of the muscle lifting an anus and a sciatic awn. Bunches of a muscle go from top to bottom, kzad and medially and are attached to a tailbone and a ventral sacrococcygeal sheaf. Bunches of this muscle intertwine at a rectum with bunches of a pubic and coccygeal muscle and form loop-shaped coverage around a gut. The coccygeal muscle (m. coccygeus) originates from a sciatic awn and is attached to a side surface of the lower sacral vertebrae and a tailbone. Allocate still pubic pryamokishechnuyu a muscle (m. puborectalis), edges begins from pubic bones, goes to a rectum, lying more superficially, than the pubic and coccygeal muscle, connects to an outside sphincter of an anus. The listed muscles are covered with the lower fascia of a diaphragm of a basin.
Blood supply anal area it is carried out through an internal sexual artery (and. pudenda int.) and the arteries which are its branches: lower pryamokishechny (and. rectalis inf.), going to the anal channel and an anus, and perineal (and. perinealis) — to P.'s muscles; venous outflow is made through the veins of the same name.
It is innervated anal area sexual nerve (n. pudendus) and its branches: lower pryamokishechny nerves (nn. rectales inferiores), the innervating an outside sphincter of an anus, perineal nerves (n. perinealis) giving muscular branches and also zadneprokhodno-coccygeal nerves (nn. anococcygei), the being branches of a coccygeal nerve.
Lymph drainage passes through okolovlagalishchny (nodi lymphatici paravaginales), perirectal (nodi lymphatici pararectales), lower buttock (nodi lymphatici gluteales inf.), sacral (nodi lymphatici sacrales) and inguinal (nodi lymphatici inguinales) limf. nodes.
The urinogenital area
at men is In urinogenital area scrotum (see) and root penis (see), women have external genitals (see. Vulva ). Skin has a pilar cover and is plentifully supplied grease and sweat glands. Hypodermic cellulose and a superficial fascia are expressed. Own fascia is a part of own fascia
of P. Glubzhelezhashchiye of education create two spaces of urinogenital area: superficial and deep. In superficial space (spatium perinei superficiale) 3 muscles lie: superficial cross muscle of P., sciatic and cavernous and bulbous and spongy. The superficial cross muscle of P. (m. transversus perinei superficialis) pair, narrow, goes from a sciatic hillock to the tendinous center P. Sciatic and cavernous muscle (t. ischiocavernosus) a steam room, originates from a sciatic hillock and is attached to a white of a cavernous body; under muscles legs of a root of a penis at men and a leg of a clitoris — at women lie. The bulbous and spongy muscle (m. bulbospongiosus) pair, begins from the tendinous center P., at men covers an inferiolateral surface of a bulb of a penis and in the middle grows together with the same muscle of other party; at women it surrounds vaginal opening.
In deep space (spatium perinei profundum) the urinogenital diaphragm (diaphragma urogenitale) differently called by an urinogenital triangle (trigonum urogenitale), formed by a deep cross muscle of P. and the fastion covering it from above and from below — a top and bottom fascia of an urinogenital diaphragm is located (fasciae diaphragmatis urogenitalis sup. et inf.). Deep cross muscle of P. (t. transversus perinei profundus) begins from sciatic hillocks and branches of sciatic and pubic bones. Its bunches go cross in the medial direction to the centerline where with a muscle of the opposite side form a tendinous median seam of the Item. At men passes through a muscle urethra (see), women have an urethra and vagina (see). The part of a muscle surrounding an urethra is called a sphincter of an urethra (m. sphincter urethrae). The first line of a deep cross muscle does not reach a symphysis, and this interval is filled with P. which grew together a top and bottom fastsiyama of an urinogenital diaphragm, forming here a cross sheaf — lig. transversum perinei (old name: a cross pubic sheaf — lig. transversum pubis). A part of this union, adjacent to a symphysis, is called the arc-shaped pubic sheaf (lig. arcuatum pubis). At men between an urethra and an anal part of a rectum below a rectovesical partition under skin the perineal body (corpus perineale) is located. At women this body is between a front wall of an anus and a back wall of a vagina below a rectovaginal partition. The perineal body is densely attached behind to the forefront of an outside sphincter of an anus, and in front — to a prostate and a webby part of an urethra (at men) and to a vagina (at women). The perineal body represents fibromuscular weight 1,5 — 2 cm wide (the sizes of its 1 — 1,5 cm in perednezadny and 2 — 2,5 cm in vertical the directions).
Blood supply formations of urinogenital area carry out branches of an internal sexual artery: men have scrotal arteries (rr. scrotales posteriores), urethral artery (. urethralis), artery of a bulb of a penis (. bulbi penis), artery of a penis (aa. profunda et dorsalis penis); women have back lip arteries (rr. labiales posteriores), urethral artery (and. urethralis), artery of an entrance of the vagina (. vestibuli vaginae), artery of a clitoris (aa. profunda et dorsalis clitoridis). Outflow of a venous blood goes through the veins of the same name bringing blood to an internal ileal vein (v. iliaca int.).
Innervate this area of a branch of perineal nerves: back scrotal (lip) — nn. scrotales (labiales) posteriores, a dorsal nerve of a penis (clitoris) — n. dorsalis penis (clitoridis).
Lymph drainage passes through the same limf, nodes, as from anal area P.
Malformations. Inborn crevices of P. arise in late stages of development of an embryo as a result of nonunion of genital folds. At boys the crevice is located on the course of a median seam of P. and represents narrow rectilinear defect of fabric, walls to-rogo are covered with the mucous membrane producing slime. At girls the crevice merges with a sexual crack and is covered with the mucous membrane going from an entrance of the vagina; back commissure of vulvar lips is absent.
Wedge. manifestations of a crevice of P. at boys consist in irritation of skin of a crotch and a cash of a chiya of an itch. At girls of the complaint are absent.
At boys the crevice independently does not grow therefore operational treatment is shown, a cut consists in excision of the mucous membrane covering a crevice together with skin edges and sewing up of a wound tightly. At girls of a crevice usually heal independently.
Teratoid educations of P. are a consequence of disturbance of embryonic development. Occur as at children (is more often at girls), and at adults (is more often at men). At children teratoid educations are characterized by rapid growth and considerable danger of a malignancy, edge, according to different data, is observed at 10 — 25% of patients and is connected with a low differentiation of cells of education. Meet more often teratomas (see), is much more rare — dermoid cysts (see. Dermoid ) and epidermoid cysts (see). At adults epidermoid and dermoid cysts prevail, teratomas meet seldom. The malignancy is observed approximately at 2% of patients.
The teratoma usually is located under skin of a crotch between a top of a tailbone and an anus, often hangs down between legs of the child. Because of rapid growth it can displace an anus of a kpereda or in lateral face. At the same time the rectum and an urethra are quite often squeezed that leads to a delay of a chair and an urination. Dermoid and epidermoid cysts have an appearance of the tumorous educations located in hypodermic cellulose of a crotch (fig. 7). Cysts have a tugoelastichesky consistence, sometimes it is possible to feel fluctuation. Quite often teratoid educations suppurate and are spontaneously opened with the subsequent education is long not healing single or multiple fistulas.
Epidermoid and dermoid cysts are diagnosed on a wedge. to signs. One of characteristic signs of a teratoma is alternation in it dense sites of fabric with cystous educations. The survey X-ray analysis allows to find bone structures and calcific inclusions. In certain cases teratoid educations differentiate with spinal hernia (see. Spina bifida ), and in the presence of fistulas — with fistulas rectum (see). In these cases it is most effective fistulografiya (see) and puncture tsistografiya (see): in the presence of teratoid educations on roentgenograms cystous formations of rounded shape decide on smooth accurate internal contours. In doubtful cases it is necessary biopsy (see).
Treatment of teratoid educations operational. At children in connection with a frequent malignancy of teratomas operation is performed urgently. Make a cross arc-shaped section of skin on a crotch, the ends to-rogo reach sciatic hillocks, and the middle will be spaced on 5 cm of a kzada from an anal orifice. Tumorous education is separated in front from a wall of a rectum. For removal of the part it located in a basin sometimes resect a tailbone. Delete a teratoma with the uniform block without opening of cystous cavities. After excision of the formed surplus of skin the wound is sewn up tightly with leaving of rubber drainages.
Dermoid and epidermoid cysts at adults delete with the uniform block, applying the bordering section of skin and avoiding opening of a gleam of a cyst. In the presence of the draining fistulas the last exsect within healthy fabrics. The wound is taken in with leaving of rubber drainages. In the presence of purulent fistulas the wound is not taken in tightly, and only narrow it seams.
The forecast during operational removal of high-quality teratoid educations favorable. At malignizirovanny and primary malignancies the forecast adverse.
Damages crotches can be closed (bruises, hypodermic gaps, hematomas, etc.) and opened (cut and chipped wounds, gunshot wounds, etc.). In those and other cases of damage of P. can be combined with damage of extra peritoneal department of a rectum, bladder, urethra and pelvic bones, as defines a wedge. picture. P.'s damages at women connected with childbirth (see below) have certain specifics.
The sharp pains which sometimes are followed by an unconscious state, fervescence are characteristic of all injuries of P. Due to hemorrhage (see) or education hematomas (see) it is noted chuv a stvo of a raspiraniye in P., eminates edges, skin gets it cyanotic coloring. The closed P.'s injuries with injury of a rectum, bladder or urethra are observed usually in the presence of changes of pelvic bones. In these cases urine and kcal can get to surrounding fabrics. At the combined wounds of P. and a rectum right after wound desires to defecation appear insistent (sometimes false). From wound openings the kcal and gases are allocated for P., in excrements impurity of blood is found; function of an outside sphincter of an anus is often broken. The combined wounds of P. and a bladder or urethra are followed by release of urine from P.'s wound, uric infiltration of cellulose P. with formation of uric zatek (see. Uric became numb ).
Wounds of soft tissues near an anal orifice are exposed at defecation to pollution and are infected. And if superficial wounds heal often without essential complications, then at deep and extensive wounds the phlegmons extending to pelvic cellulose quite often develop. At the same time accession is possible mephitic gangrene (see).
Diagnosis of damages of P. is based on characteristic a wedge. symptoms and data of sounding of a wound, manual research of a rectum, anoskopiya, rektoskopiya and rentgenol. researches.
Treatment of damages of P. depends on their character. At P.'s bruises without injury of a rectum or a bladder (urethra) apply conservative treatment — rest, in the first days cold on P., then thermal procedures (see. Hurt ). The hematomas which do not have tendency to increase treat also conservatively; at spread of a hematoma make operation with the purpose of a hemostasis (see. Hematoma ). Superficial wounds of P., considering the raised their infitsiruyemost, widely cut, excise impractical fabrics and well drain (see. Drainage ).
At P.'s wound with injury of a rectum cut a wound on P., excise the necrotic and contaminated by a stake fabrics, process a wound antiseptic agents and antibiotics and drain it tampons with ointment. The wound in a wall of a gut depending on the size of defect and prescription of wound is sewn up or drained after imposing of a kolostoma (see. Colostomy ). The damaged fibers of an outside sphincter of an anus are sewed.
At the combined wounds of a crotch, rectum and bladder (urethra) complicated by pelvic phlegmon widely cut and drain P.'s wound, open purulent flow, impose an unnatural anus (see. Anus praeternaturalis ) and high vesical fistula.
Diseases. Purulent processes in P. can arise at microtraumas and P.'s wound, damage and inflammatory processes in a rectum, wound of an urethra, a purulent inflammation of a prostate and seed bubbles, osteomyelitis of a sacrum and tailbone, suppuration of teratoid educations; also transmission of infection from the remote centers on limf is possible. and to venous ways.
Furuncles, hypodermic abscesses and phlegmons P. Klien are more often observed. the picture of a furuncle of P. a little in what differs from furuncles of other localizations (see. Furuncle ).
At hypodermic abscess (see. Abscess ) P.'s skin early reddens, there is a fluctuation, process is localized at distance of 3 — 4 cm from an anus, but not in close proximity to it, as at perianal abscess. At a manual research of a rectum painful soft infiltrate and protrusion of a sidewall of a gut comes to light. The abscess can spontaneously be opened through skin of anal area P., a buttock or in a rectum.
At adverse development of process pus can break through the muscle lifting an anus and to cause phlegmon of pelvic cellulose, causing a picture paraproctitis (see). In this case the painful complicated urinations are often noted; at a manual research of a rectum solid, tenacious, deep infiltrate is defined. The general symptoms of inflammatory process (fervescence, tachycardia, changes from blood and other phenomena of intoxication) at phlegmon are expressed sharply (see. Phlegmon ). The infection can get into venous network of a basin and cause thrombophlebitis (see) with development of a venous staz in the lower extremities, thromboembolisms (see) etc. In a case hron. courses of abscess of P. the local inflammatory phenomena are expressed poorly. Dyushenn's symptom is characteristic of this form of a disease: in a standing position of the patient instinctively lowers a shoulder on the party of defeat, goes slowly with brought (on the party of defeat) a leg, without unbending it in a hip joint.
Treatment of a furuncle of P. is carried out by the general rules; at the same time rest, careful processing of skin in a circle of the center, protection it from infection, physiotherapeutic procedures is important. In complex treatment of an asbtsess and P.'s phlegmon the principal value has early broad operational opening of a suppurative focus with excision of necrotic fabrics and its drainage. Hypodermic abscesses open semicircular (in relation to an anal orifice) with cuts in the field of the closest accumulation of pus to skin. For opening of phlegmon of pelvic cellulose use various options of cuts depending on localization and depth of the center. Apply the semicircular cuts added if necessary with radial more often.
P.'s actinomycosis is observed extremely seldom. Is caused by different types of a radiant fungus (see. Actinomycetes ). The disease develops slowly: on a crotch, is more often at an anus, there is a dense, gradually increasing, a little painful infiltrate which is softened later; in its center the zybleniye appears. At independent break or operational opening of infiltrate the insignificant amount of dense pus is distinguished. In it can be found ochroleucous color of a grain which at microscopic examination are druses of a fungus. After opening of infiltrate the last does not resolve, and slowly extends, occupying big sites of a crotch. At the same time the multiple fistulas penetrating infiltrate are formed. A current of an actinomycosis of a crotch chronic, progressing. At treatment actinomycosis (see) apply an immunotherapy aktinolizaty, radical excision of the center of defeat, antibiotic treatment, a roentgenotherapy.
Sharp-pointed condylomas of P. — - the high-quality damage of skin caused by the Tumefaciens verrucarum virus. Arise in the form of the smallest papules of pink color which then expand and after merge remind a cauliflower. Education has a soft consistence and the narrow basis in the form of a leg.
Treatment — operational removal within healthy fabrics; greasing of 20% spirit solution of Podophyllinum.
The tuberculosis cutis of P. is observed at patients with hard proceeding forms of tuberculosis of internals. Penetration into P. of the tubercular mycobacteria which are allocated with urine and a stake is promoted by grazes and erosion of skin of the Item. On site implementations of causative agents of tuberculosis are shown the small yellowish-red small knots turning into sores which, merging, form large sharply erethistic ulcers with the bottom covered with grayish pus. Ulcers have the cut or subdug edges; current their sluggish.
Treatment shall be directed first of all to elimination of the main center of tuberculosis (see. Tuberculosis extra pulmonary ).
P.'s syphilis is shown in the form of primary syphilomas of the size of lentil which have regular shape, a dense consistence, reddish color. Then there is an erosion or an ulcer. Secondary syphilis in the form of a papular syphilide is often localized on a crotch. Sometimes papules increase in sizes, their basis becomes covered by growths, extends (flat condylomas). Syphilomas (tertiary syphilis) of a crotch happen from 1 to 3 cm in the diameter, are located in hypodermic cellulose. They are spontaneously opened and form ulcers with the subdug edges and scanty separated. Treatment specific — see. Syphilis ].
Perineal hernias meet seldom. Are observed at the people doing hard manual work, especially having a weak diaphragm of a basin or who had P. Razlichayut's injury front and back perineal hernias (see). Clinically they are shown in the form of the tumorous education arising at an exercise stress, walking, cough. Are easily set. At a palpation defect in muscles of the Item is found. Treatment — operational closing of hernial gate in a diaphragm of a basin for what use perineal access more often.
The lipoma — the tumor developing from fatty tissue is covered with the capsule; has the roundish, sometimes spread form, is located under skin of the Item. The sizes widely vary it. At a palpation a tumor of a soft consistence, mobile, painless. Grows slowly. Treatment operational.
P.'s (fig. 8) mesenchymoma meets less than a lipoma; represents a tumor of complex structure from derivatives of a mesenchyma. The tumor of a soft consistence, moderately mobile and low-painful, is covered with the capsule; on a section fabric it differs in big diversity.
Along with a knotty tyazhistoy fabric the cystous cavities with a diameter of 5 — 20 cm filled with viscous or liquid contents can meet. Microscopically the tumor represents the multicomponent education consisting of fatty, vascular and fibrous tissue in various combinations.
Often the mesenchymoma of a crotch is connected with a wall of a rectum. The mesenchymas of a tumor constructed of mature components proceed is good-quality.
For diagnosis use a puncture biopsy and rentgenol. methods of a research (survey X-ray analysis, proktografiya, pariyetografiya). In some cases there is a need to differentiate a mesenchymoma with perineal hernia and teratoid educations.
Treatment operational. Operational access — perineal. The postoperative wound is taken in with leaving of rubber drainages.
The injuries of a crotch at women connected with childbirth, have certain specifics. Most often gaps and hematomas of the Item meet.
Ruptures of a crotch are observed more often at pathological childbirth (extensive insertions, pelvic presentations) and at operational delivery (nippers, extraction of a fruit for the pelvic end, vacuum extraction).
Distinguish three degrees of break-up of P.: at a rupture of the I degree back commissure of big vulvar lips and P.'s skin without injury of muscles is damaged, (fig. 9, a); at a rupture of the II degree in addition to back commissure and skin of a crotch the tendinous center P. and the bulbous and cavernous muscles going to it, a superficial cross muscle of P., the muscle lifting an anus is broken off (fig. 9, b); at a rupture of the III degree disturbance of an integrity of an outside sphincter of an anus (fig. 9, c) with damage (a complete separation of the III degree) or without damage (an incomplete rupture of the III degree) of a wall of a rectum joins. Extremely seldom the so-called central rupture of P. meets, at Krom back commissure of big vulvar lips and upper part P. remain whole, the gap occurs in the field of the tendinous center P. (fig. 9, d); the fruit at the same time can be born through an opening between back commissure of big vulvar lips and an outside sphincter of a rectum, passing vaginal opening.
Diagnosis of gaps and a damage rate of P. is made at survey of a vulva after end afterbirth period (see).
Treatment of gaps operational. P.'s rupture of any degree shall be taken in that protects the woman in childbirth from penetration into a wound of an infection and prevents development in the future of insufficiency of muscles of a pelvic bottom with omission of walls of a vagina and uterus and a relaxation of a vagina; not taken in rupture of the III degree which is followed by not deduction of gases and fecal masses results in disability. For elimination of these phenomena in the subsequent resort to various options of a perineoplasty for the purpose of recovery of muscular and fascial structure of P. and a pelvic bottom (see. Prolapse of the uterus, vaginas ; Colpoperineoplasty ).
Sewing up of a rupture of the I degree it is possible to produce under a local infiltration anesthesia 0,25% solution of novocaine. The rupture of the II degree is recommended to be taken in under conduction anesthesia (see. Anesthesia local ), for what enter into each ischiorectal pole on 50 — 80 ml 0,25% of solution of novocaine; the infiltration anesthesia at a rupture of the II degree can complicate orientation in fabrics and their comparison with each other. The rupture of the III degree is taken in under anesthesia (see). Women in childbirth with toxicosis have pregnancies in order to avoid provocation of an attack eclampsias (see) all ruptures of P. are recommended to be taken in under anesthetic.
At a rupture of a crotch of the I degree on edges of a wound impose 2 — 3 silk seams which carry out under a bottom of a wound. At a rupture of the II degree at first put catgut stitches on the broken-off muscle lifting an anus, a fascia and a superficial cross muscle of P. and only after it impose silk seams on skin and back commissure of big vulvar lips. At a rupture of a crotch of the III degree at first sew up a rupture of a rectum, carry out seams (a catgut or thin lavsan) through muscles of a gut without piercing of a mucous membrane, two catgut seams sew an outside sphincter of an anus, and then work, as at a rupture of the Item II of degree. At the central gaps cut the remained back commissure of big vulvar lips, and then sew a gap the same as a rupture of the II degree.
After mending of ruptures of I and II degrees for the 4th day give laxative, for the 5th day remove seams. At a rupture of the III degree laxative is appointed to the 5th day, seams are removed for the 6th day.
Postoperative complications — suppuration, discrepancy of seams — are observed seldom, at the vast majority of women in childbirth of a wound begin to live first intention. In case of discrepancy of seams at ruptures of I and II degrees within 2 — 3 days apply the means clearing a wound of necrotic and purulent plaques and then through all layers of a wound impose secondary (silk) seams which remove on 7 — the 8th day. At a rupture of the III degree repeated intervention is possible in 3 — 4 months after the delivery when the inflammatory phenomena in the field of damage disappear.
Prevention of ruptures of P. consists in the correct maintaining childbirth (see), careful operational deliveries and also timely carried out P.'s section at threat of its gap. The last arises at P.'s restretching, a cut is characterized at first by cyanosis of skin (difficulty of venous outflow), then its blanching (reduction of arterial inflow) of the item at last, emergence of small cracks of epidermis on the lustrous surface of skin. At this moment at high II. it is recommended to make a median perineotomy, at low — a side perineotomy or an epiziotomiya (see. Perineotomy ).
P.'s hematomas are formed at externally unimpaired P., meet seldom, are more often combined with hematomas of a vagina and vulva. At the same time later a nek-swarm time after the delivery the woman in childbirth complains of feeling of a raspiraniye to crotches and pressure upon a rectum. At survey find P.'s protrusion, posineny skin. Borders of spread of a hematoma establish by means of mirrors, and also at a vaginal and rectal examonation. If the hematoma does not increase, then are limited to conservative treatment; in the first days — cold on a crotch, in the subsequent — heat, ultrasound, etc. Within 5 — 7 days apply antibiotics to prevention of infection. At increase of a hematoma it is necessary to open it and to tie up the bleeding vessel; in case of impossibility to find a vessel in imbibirovanny blood fabrics them stitch a thin catgut and tampon a wound. The infected hematoma is opened, tamponed and treat by rules of purulent surgery.
See also Childbirth , patrimonial traumatism.
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V. D. Fedorov; C.H. Davydov (gin.), S. S. Mikhaylov (An.).