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Pains in the field of a basin at women

Table of contents
Pains in the field of a basin at women
Anamnesis
Physical inspection
Diagnostic testings
Diagnostic approach

Pains in the field of a basin can be defined as feeling of discomfort in the lower part of a stomach, more precisely in the field of lying below a navel, above and medialny inguinal sheaves and in the suprapubic area. At women differential diagnosis of pains in the field of a basin is at a loss the fact that in female generative organs diverse pathological processes can develop. Approximately the third part of the patients addressing for consultation the gynecologist complain of pains in the field of a basin, however and doctors of other specialties also quite often meet this symptom. Prevalence of cases of pains in the field of a basin does necessary an adequate assessment of a disease and its correct treatment. The exact differential diagnosis is absolutely necessary as often pains in the field of a basin are a signal of such life-threatening states as an extrauterine pregnancy, appendicitis and malignancies of ovaries. The greatest responsibility for the initial diagnosis and treatment lies on the doctor performing primary inspection of the patient. It is necessary to use all available methods of inspection and to appoint the correct treatment of the patient having pains in the field of a basin.

In this chapter methods of research of this category of patients are discussed and it is offered how we hope, the effective scheme of differential diagnosis facilitating work of the practical doctor.

Anatomic features of a basin

Effectively to treat a pain syndrome in the field of a basin, it is necessary to imagine well anatomic and physiological features of this zone. The feeling of pain is transferred to a cerebral cortex both on somatic, and on vegetative afferent fibers. These fibers get into a spinal cord through back horns and climb a lateral spinotalamichesky path. Afferent fibers, the innervating first floors of an abdominal wall, a crotch and internals of a basin, get into a spinal cord at the level of Tkh below. The abdominal wall below a navel is innervated by segments of Tkh — Ii while the bottom of a basin and a crotch are innervated by the Liv — Siv segments. Thus, the feeling of superficial pain arises at the expense of the various sensitive fibers coming to rather small site of a spinal cord.

The sensitive innervation of area of a basin can be divided into 2 parts: somatic which innervates all superficial and some internal structures, and vegetative which provides an innervation of all internals of a basin and the most part of its deep structures.
The vegetative system is provided by sympathetic and parasympathetic textures. Painful impulses from internals of a basin can pass in the ways provided to table. First, the numerous afferent fibers passing in Sii — Siv form a parasympathetic pelvic texture. This texture provides an afferent innervation of the lower uterine segment, a neck of uterus, cervical sheaves and an upper third of a vagina, and also a sensitive innervation of the lower part of ureters surrounding them connecting tissue, a zone of a triangle of a bladder, a back urethra and rectosigmoid department of a large intestine. Secondly, the sympathetic system provides the most part of the afferent fibers supplying an uterine fundus, an average third of uterine tubes, mezosalpinks and a wide ligament of a uterus. These fibers also innervate a bladder, a greater cul-de-sac, distal part of a small intestine, a caecum, a worm-shaped shoot and distal departments of a large intestine. These fibers pass to an abdominal brain, to the lower mesenteric texture and, at last, to back roots of a spinal cord through sympathetic a ganglion from there. Thirdly, ovaries, lateral two thirds of uterine tubes, part of a mezosalpinks and proximal part of pelvic department of an ureter give sensitive fibers to an upper mesenteric texture, and from there through sympathetic system to segments of Tkh — Txii of a spinal cord.

 

Vegetative innervation of bodies of a basin


Texture

Segment of back
brain

The innervated bodies

sexual

urinary

digestion

Pelvic

S2 — S4

Vagina  (upper third)
Neck of uterus

Bladder triangle, pelvic  department  of ureters,     surrounding  connecting fabric

Direct and sigmoid gut

Cervical sheaves

Main   ligaments of a uterus

Lower   segment of a uterus

Solar

(back roots)

Uterine fundus Uterine   tubes (average third) Mezosalyshnks   and wide    ligaments of a uterus
Connecting fabric and vessels around a uterus

Bladder bottom

Ileal, caecum and appendix Distal part of a colon

Aortal

T10 — T12

Uterine   tubes (lateral  two thirds) Ovaries
Part    of a mezosalpinks

Proximal part of pelvic department of an ureter and surrounding   connecting fabric

 

From this very superficial analysis of an innervation of pelvic bodies it is visible what large number of various afferent fibers comes to each of segments of a spinal cord. Bol from superficial structures is given on a somatic nervous system to the advanced centers of a cerebral cortex, however it does not belong to visceral pain. At the person pain is projected in bark through a vegetative nervous system. The diffusion and nonspecific innervation as it was already described, complicates localization of pelvic pain. However some generalizations can be made, based on the characteristic moments in pain of patients. Pain from a neck of uterus and from the lower uterine segment often irradiates on uterosacral sheaves in a lower back, in buttocks and in a back surface of hips. Pain from a middle part of uterine tubes, an uterine fundus and a bottom of a bladder can irradiate in the lower or middle part of an abdominal wall, to the area known as "a pipe and ovarian triangle". Pain from ovaries, lateral part of uterine tubes and a rectum often irradiates in front part of an abdominal wall, lateralny a navel or directly under it, at the same time, if the parietal peritoneum is mentioned, pain becomes more intensive and accurately localized. Unfortunately, pain in a navel can be caused by different processes at which the parietal peritoneum, including an acute appendicitis, a diverticulitis, and also thrombosis of a mesenteric artery is mentioned. Pain from an ileal gut, a caecum, an appendix and a sigmoid gut can irradiate in retrosternal, epigastriß and lower abdominal areas. The feeling of pain from a mesentery, connective tissue educations and vessels of a basin usually happens deep, stupid and is indistinctly localized on an abdominal wall.

The reasons of pains in the field of a basin

Contain almost as much types of pains in the field of a basin how many and their reasons. Pains in the field of a basin can be a genital, not genital and psychogenic origin. One of classifications which can be useful at statement of the differential diagnosis is given in table. In more detail about it read in the section "Diagnostic Approach".

Differential diagnosis of pains in the field of a basin

The pains connected with generative organs

Pathological

 

 

Complications of pregnancy or abortion
Extrauterine pregnancy
Endometritis Hysterorrhesis
Placental detachment
Septic abortion Spontaneous abortion
Infections
Inflammatory diseases of pelvic bodies
Pelvic abscess
Tumors
High-quality
Oothecoma (torsion, gap, bleeding)
Uterus leiomyoma (torsion, necrosis) Malignant
Germination of a tumor
Planting of a peritoneum tumor Not tumoral diseases
Endometriosis
Adenomyosis
Stagnation of blood in bodies of a basin
Torsion of a normal appendage
Commissures in a pelvic cavity
Others
Feeling of generative organs
Dispareuniya

Physiological

Mittelschmerz
Dysmenorrhea

The pains which are not connected with generative organs of the Urological origin
Intestinal  origin

Infection of urinary tract
Stones of urinary tract Divertuculosis
Appendicitis
Thrombosis of a mesenteric artery
Regional enteritis
Gut torsion
Intestinal impassability
Malignant tumor of intestines

Muscular origin
Psychogenic etiology

Hematoma of direct muscles of a stomach



 
"Pains in a face   Acute pain"