Injuries and diseases of the perineum

Damage crotch men most often observed at the drop of a solid object. Gunshot wounds of the perineum often combined with damage to the rectum and urethra. Wounds of the perineum can be easily infected, you may experience phlegmon with the transition to the pelvic tissue. Shows the initial surgical treatment of wounds, the introduction of antibiotics. In cases of injury crotch - conservative treatment (rest, ice, then thermal procedures); when closed the gap urethra, with extensive bruising crotch - surgery.
Damage crotch women are more likely to occur during childbirth, much less due to the injuries of the pelvis or when falling on acute solid object, rarely during sexual intercourse. Causes tearing of the perineum during childbirth: a decrease in elasticity in elderly nulliparous, scars after the previous gaps, high perineum; childbirth in the rear view occipital presentation, extensor presentation, the removal of the head of the fetus during labor in the pelvic presentation, childbirth large fruit; labor at observamanagement the pelvis (acute h angle); childbirth with the imposition of forceps delivery; improper management of labour (premature extension of the head of the fruit, extension head during attempts etc).
There are 3 degrees tearing of the perineum. The first degree of the violation of the integrity of the rear wall of the vagina, rear spikes and skin of the perineum; muscles remain intact. Second degree - along with breaks these tissues are damaged muscles of the perineum (except the external sphincter, rectum). At break of the third degree perineal broken and external sphincter, rectum, sometimes its wall.
Breaks crotch dangerous development of postpartum infection. Further unembroidered breaks predispose to the omission and the loss of sexual organs. During the break of the third degree perineal women often incontinent gas and feces. In this regard, every gap crotch should be carefully sewn. Stitching old gap crotch - colpoperineorrhaphy - produce at loss of the vagina; for plastics use the mucous membrane of the posterior wall of the vagina and the muscles of the pelvis.
Independent midwife has the right stitches only if perineal ruptures first and second degree; at break of the third degree it is obliged to call a doctor or to transport sick (after removal of the placenta) in the nearest maternity hospital.
Sew up the hole in the crotch with the observance of aseptic and antiseptic rules. For sutures prepare: vaginal speculum, lifts, korangi, tweezers, hemostatic clamps, scissors, needle holder, surgical needle, syringe with the needle for anesthesia, suture material (catgut, silk), sterile tampons and napkins. Usually sew up the hole in the crotch of first and second degree under local anesthesia.
When you break the crotch of the first degree in the beginning impose knotted kedgotoline seams on the wall of the vagina, and then silk - skin. Seams are imposed on distance of 1 sm from each other. At break of the second degree initially impose one or more ketotofin seams on the upper corner of the wound (the back wall of the vagina). Then impose several submersible ketotofin seams on the deep muscles of the perineum, then sew kedgotoline seams mucous membrane of the vagina. Connecting seams surface muscles of the perineum, then on the skin of the perineum impose knotted silk sutures. The line of stitches grease alcoholic iodine solution.
Prevention tearing of the perineum: proper management of labour and the implementation of the basic rules of protection of the perineum (see Childbirth). When threatened gap, and high-rigid crotch should cut it (perineostomy), as the surgical wound has more smooth edges and therefore better heals. Damage crotch women with injuries of the pelvis, at falling on a sharp object treated by the General rules of surgery.

The damage. Closed trauma to the perineum in men is essential, if accompanied by a rupture of the urethra, anus, rectum, and open - and also the penetration of the wound into the cavity of the abdomen (pelvis). Depending on these characteristics damage are held and therapeutic activities (see the Urethra, rectum). Non-penetrating, without wounds of hollow organs, wounds crotch subject surgical treatment according to General rules (see the Wounds, wounds); severe wounds with damage to the organs of the perineum can require the imposition of unnatural anus or suprapubic urinary fistula.
Damage crotch women. Most often damage the perineum in women occur in childbirth, especially in nulliparous.
It is customary to distinguish between three degrees tearing of the perineum. At break of I degree is broken back spike (tendon crotch seam). The gap II degree captures tendon center of the perineum (centrum tendineum) and m coming to him. constrictor cunni, m. transversus perinei superficialis, m. levator ani. The gap III - m. sphincter ani (with a wall or no wall of the rectum).
When the so-called Central breaks crotch spike the vagina remains a gap occurs in the area centrum tendineum. In the absence of obstetric care fetus may even be born through this gap, bypassing hiatus genitalis.
The perineal ruptures in childbirth rarely give significant bleeding. At the same time unembroidered breaks crotch may further lead to the omission and the loss of the uterus, vagina (see). Each of perineum must be sewn, and perineum should be restored. So in childbirth after the separation of the placenta should be inspected crotch, widely spreading the vulva. Breaks I and II degrees should sew up under local infiltration anaesthesia 0.25% solution novokaina; break I can sew one doctor, and in his absence - midwife.
At break of I degree impose several (2-3) silk sutures; vCal do from the edge of the gap, the needle are under the bottom and put on the opposite side of the divide.
Breaks II degree better to sew up with the assistant. The edges of the gap widely stretch. When damage to the walls of the vagina impose a number ketotofin seams, held under the bottom of the gap. On the first crotch impose several deep submersible ketotofin seams, having them pushed the leg muscles that raise the anus. After that, the skin and the fascia crotch impose separate silk sutures.
Breaks crotch III degree sew under General anesthesia. This operation is possible only qualified obstetrician-gynecologist, skilled vaginal operations. Widely stretching the wound edges, the surgeon sews the rectal wall. Impose seams round (intestinal) small needle, catgut; ukoly and vicoly - without perforation mucosa. After mending ulcer change tools and wash sublimate hands. After that impose two seams on dispersed beams external sphincter anal opening and closing operation as well as during the breaks of the II degree.
Postpartum women and adolescent girls torn perineum require special care. In the postpartum period should not be washed external genitals, crotch need to keep dry. At break of II degree on the 4th day prescribed a laxative, on 5-th shoot silk sutures with the perineum. At break of III degree should be assigned to this template shall not diet (soup, biscuits, jelly, juice); on the 6th day, give a laxative, on the 7th remove the stitches.
Healing the hole in the crotch is in the great majority of cases, primary intention. In some cases, differences wounds at break of II degree should be the imposition of secondary sutures. When the wound is released completely from purulent raids and covered with pink granulations, under local anesthesia refresh the wound edges, remove excess granulation and impose silk sutures, passing through all the layers under the bottom of the wound. The variance of perineum III degree better to sew up in 3-4 months after birth, as if that fails it can only lead to excessive development of scar tissue that makes it difficult conditions subsequent operation.
To prevent the impending gap crotch in childbirth, especially during the operational delivery, should be perineostomy (see).
The restoration of the pelvic floor is a required part of every surgical intervention on the occasion of prolapse of the vagina and uterus. Stitching old gap crotch (colpoperineorrhaphy) is done under local anesthesia. Cut out the triangular flap of the mucous membrane of the posterior wall of the vagina, spending cuts through the entire thickness of the mucous membrane, which facilitates its further separation. The edges of the mucous membrane over naked triangular flap connect continuous ketotofin seam. A good place to start is stitching up stitches on the muscles of the pelvic floor, as after suturing legs m. levator ani top corner of the wound becomes inaccessible. Then stitching mucosa temporarily interrupt and suture on the legs m. levator ani. Pre-open covering them fascia not necessarily; better wrapped in gauze finger of the left hand file a m beam. levator ani and grab it steeply curved needle with strong ketotofin seam; do the same thing on the opposite side. Then finish the stitching of the mucous membrane of continuous ketotofin seam. On the fascia crotch put a few ketotofin joints, skin - silk sutures or continuous subcutaneous kathoey seam.
Non-consolidation of perineum III degree leads to incontinence of gas and liquid stool. Under the old perineal ruptures III degree rarely observed vaginal prolapse, since these gaps are less damaged m. levator ani. When breaking exciting mucous membrane of the rectum, perhaps a slight roll of her mucosa. The sphincter damage can be easily confirmed by rectal examination; this shows how the anus is separated from the vagina to only cross-reaching scar. It is visible radiant retraction of the skin, appropriate dispersed beams external sphincter rectum.
Mending "old" divide III degree, has captured the mucous membrane of the rectum (postoperative), should be made after careful preparation of the patient within 4 days, which is to assign Bashlakov diet (curdled milk, butter, eggs, soup), a sick for 3 days gets a laxative, and then siphon enema (per day and the day before surgery).

Priceprinivil performed under spinal anesthesia, or under endotracheal anesthesia. On the sides premonicion-vaginal scar impose locking clips and produce H-shaped incision; widely usepreview mucous membrane of the vagina from the rectum. After a full mobilization of the intestine start stitching its walls. Impose seams hub, kedgotoline, not touching mucous membrane of the rectum. Being sutured intestine, change tools and wash their hands. Impose two seams on the outside of the sphincter, rectum, cut off the excess mucous membrane vagina, and sew the crotch by the method of closing the gap crotch II degree. In the postoperative period for 6 days appoint template shall not diet; on the sixth day the patient receives a laxative, and on the seventh remove the stitches.
When old unembroidered breaks crotch II and even the III degree sometimes may come next pregnancy. Under these circumstances, given the difficulty of hospitalization and surgery in the lactation period, it is possible to make colpoperineorrhaphy and even priceprinivil in the first hours after birth. Postpartum period is held under customary for these operations rules.
When not fully fused breaks crotch III degree can be premonicion-perineal fistula. Most often they are small in size and are located at the upper end of the gap in the vagina. Typical complaints on incontinence gases and hit pieces of feces into the vagina. After appropriate preoperative preparation (as when stitching old breaks III degree) to perform surgery wide splitting (as in fistulography gallbladder-vaginal fistula). When low location fistula cut through the skin bridge crotch and produce the stitching of the formed gap crotch III degree.
Hematoma perineum are rare, more often after spontaneous labor. I believe that their existence is connected with pathological changes in the vascular system of the pelvis.
Hematoma crotch formed when outwardly entire crotch. A few hours after childbirth for postpartum women and adolescent girls the feeling of pressure, pain in the perineum. When viewed find posinenie skin and dense infiltrate. Hematoma is usually on the side of the middle line, usually the left. Hematomas can climb high up on the wall of the vagina (adfestivalua hematoma). Infection haematomas is rare.
Recognition of hematomas crotch is not difficult and is based on the emergence of a dense infiltrate without clear boundaries. In the first hours at a closer location bruising the skin may remain unchanged, but in the next few days you receive the typical colour of a bruise.
Treatment of hematomas crotch in most cases, conservative. To crotch put a rubber bag with ice wrapped sterile lining; on the third day pass to heat (warmer).
In some cases, when a very large haematomas, portable hard pains, with the possible necrosis of the skin at the top of hematoma produce emptying. Discover and to sheathe the bleeding vessel in imperialino blood tissue rare; by this time has already come for his thrombosis. Therefore bed loose plugging and the wound is sutured.
Diseases crotch - various purulent processes (paraproktit, osteomyelitis of the sacrum or coccyx, suppuration of a dermoid cyst), skin tuberculosis, syphilis, occasionally - hernia. The treatment, depending on the nature of the disease.