Pozavcherashny (cervical) endometriosis

Pozavcherashny, or cervical, endometriosis frequency ranks third (after the defeat of the uterus and ovaries). The pathogenesis is associated with the "flow" or perforation endometrioid ovarian cysts, retrograde throwing menstrual blood, the growth of endometriosis of the isthmus of the uterus, especially after repeated determinirovannykh manipulation. In addition, and with this in recent years, faced increasingly, is embryonic Genesis POSADSKOGO endometriosis. The latter is too early to show clinical activity and to grow into the rectum and posterior vaginal vault.
Complaints of patients due to the localization of heterotopia and the proximity of the rectum, Sacro-uterine ligaments, posterior fornix of the vagina and the pelvic plexus. There is no direct relation between the site of endometriosis and the severity of the pain. Rather inversely proportional dependence. Usually patients complain of a dull aching pain deep in the pelvis, lower abdomen and lumbar-sacral region. Before and during menstruation pain intensifies, can take paroxysmal throbbing, or pulled character and give rectum and vagina. Rarely is extending to the side wall of the pelvis and leg, there is a difficulty with walking. This may be one indication of the growth of endometriosis in the side of parametri and possible involvement of the lower section of the ureter. This is manifested clinically frequent urination during periods of exacerbation (i.e. during menstruation). Therefore, in the process of examination of patients need to find out the condition of the urinary system. With the development of the disease in intensity and duration of pain increased (from several hours to several days).
In addition, patients complain of constipation, also rising on the eve of the month. Gradually constipation worse, until the development of partial intestinal obstruction. In the future join increased craving for the bottom, there tenesmus, ribbon-like feces, mucus is secreted, and menstrual blood. Constipation may alternate with diarrhea and release mucus and blood from the rectum, which is the reason for hospitalization in the infectious diseases clinic in connection with a suspected case of dysentery. Moreover, in some patients during periods of exacerbation observed increase body temperature.

pozavcherashny endometriosis
Fig. 7. Adenomyosis (endometriosis) of the uterus and pozavcherashny endometriosis (scheme).

Ingrowth POSADSKOGO endometriosis (Fig. 7) in the posterior vaginal vault is accompanied by the formation of a bluish-purple cysts and "eyes" and ulceration of scar-modified uneven surface that bleeds easily in the study (especially noticeable on the eve of menstruation or sexual intercourse. In addition, the sexual activity is accompanied by pain before and after your period within 5-7 days. Over time, the number of days when the patient experiencing pain during coitus, is increased, and the increasing intensity of pain, and then due to pain sex life becomes impossible. Increased nervousness. For 7-10 days before and during menstruation is difficult to sit.
Abdominal pain and depth of the pelvis worse with the shock body (fast walking, lesson sports, the use of transport, and so on) and physical activity.
2/3 of our patients pozavcherashny endometriosis combined with adenomyosis of the uterus was observed severe dysmenorrhoea, which increased the suffering of the sick.
Among the observed us more than 450 patients with pozavcherashny endometriosis 35 % of the disease was severe (substantial or total loss of working capacity during 10-15 days of each month), in 55 % of patients - moderate and 10 % were moderate and mild severity.
Vaginal (better vaginal-pryamokishechnye) study allows to detect on the back side of the isthmus of the uterus tight painful education (site) with a rough surface the size of a pea (beans) and larger (up to 4-5 cm in diameter). The site is surrounded by dense, also painful in the study, infiltration, propagating in the front wall of the rectum and posterior vaginal vault. In addition, there may be dissemination of infiltration into the side parametrium.
Before and during menstruation is the size of the site (or conglomerate sites) several increase and the pain increases. This is the reason for gynecologists to diagnose acute back parametritis, and for surgeons - acute paraproctitis, despite normal or low-grade fever. At the end of the period of exacerbation painful rough education on the back side of the isthmus of the uterus probed more clearly, can be traced its relationship with the front wall of the rectum. Resizing hearth POSADSKOGO endometriosis and its echoes depending on the phase of the menstrual cycle can be observed by ultrasound. In case of emergence in the bowel lumen with consideration of complaints (the mucus and blood from the rectum, constipation, tenesmus, pain in the rectum) and probing tuberosity in the front wall of the colon at a depth of 9-12 cm occurs suspected carcinoma of the rectum, and virtually all patients diagnosed tumor of the rectum.
When rectoromanoscopy at a depth of 9-12 cm from the skin-anal folds in the thick swollen mucosa with severe vascular injection can be observed purple-bluish small cysts in the form of small slices of raspberries or blackberries, single or in groups. A number of patients detected polypoid overgrowth easily bleeding tissue. This picture pronounced before and during menstruation. After graduation edema and hyperemia pass, small cystic education pale, polypoid tissue growth also diminish and fade, becomes more clearly expressed cicatricial deformity of the mucosa of the colon. The procedure itself (introduction proctoscope, swelling of the bowel air) is accompanied by pain.


Fig. 8. Radiograph (barium enema) sick L. Sharp narrowing and deformation of the rectum above ampoule with its defeat endometriosis.

Fig. 9. Radiograph (barium enema) the patient Including the rectum Area above ampoules sharply narrowed due to the endometriosis lesions.

Thus, the clinical picture and objective data of the survey show a number of similarities to those of tumors of the rectum, moreover, that a number of patients due to stenosis of the bowel lumen a proctoscope cannot enter higher narrowing place. Barium enema (Fig. 8, 9) allows to reveal the same the deformation and the narrowing of the lumen of the intestine, which is characteristic of the tumor process. However, the way of distinguishing these diseases is quite possible, given the cyclical nature POSADSKOGO of endometriosis, the presence of other foci of endometriosis and the results of the histological examination byobserving material. The latter is not always possible to identify glands and stroma of the endometrium. However, the absence of tumor cells (defined only inflammatory infiltration with hemorrhages in the studied regions of the mucous membrane bowel) allows to exclude carcinoma. As for the size of the uterus, it is caused by the presence of adenomyosis or fibromyoma, usually related pozadina to endometriosis. The uterus is tilted back and mobility is limited. During the operation the uterus when pozavchera endometriosis bring in the operative wound is possible only after ligation and crossing Sacro-uterine ligaments.
In the cancer plan is extremely important submitted observations when palpation dense site of the alleged POSADSKOGO endometriosis with rectovaginal examination is not accompanied by pain. In such a situation it is necessary to carefully examine the gastrointestinal tract (particularly the stomach)to way of distinguishing cervical endometriosis from metastasis Shnitzler representing the metastasis of carcinoma of the stomach into the thickness of the front wall of the rectum and the peritoneum uterine-pryamokishechnye deepening. Patients are x-ray examination of the stomach and fibrogastroscopy.
The author of the monograph watched 7 women with metastasis of Shnitzler was mistaken for pozavcherashny endometriosis.
The survey clarified. One patient (patient is 47 years) metastasis of Shnitzler combined with endometriosis isthmus of the uterus.
Surveillance, P. Kharchenko (1959), J. Ruszkowski (1972) demonstrated the need for genital differentiation, including behind the cervical, endometriosis with tuberculosis. Until recently it was believed that genital tuberculosis is observed in younger women up to 30 years (at present and endometriosis to 30 years - a common phenomenon). History of such patients include instructions on tuberculosis of other organs (usually of the lungs), irregular and painful periods, estrogennaya insufficiency and primary infertility. Tuberculosis often affects the fallopian tubesthan the uterus and ovaries.
In genital endometriosis more often in women 35 years of age and older; in history many of them have childbirth and abortion, infertility often secondary and functional. Production of estrogen increased or normal on a background of deficiency of the hormone yellow body.
For differential diagnosis must be considered a tuberculin skin test, signs of tubercular intoxication , etc. should Not forget the fact that TB and endometriosis genitalia can be combined and mutually burden for diseases. Filed J. Ruszkowski (1972), of the 42 patients 15 TB of internal genital organs combined with endometriosis.
Certain clinical importance is the peritoneal endometriosis uterine-pryamokishechnye deepening propagating in the pararectal cellular tissue. When this localization patients often celebrate the laxative effect of the intestine or more frequent emptying his before and during menstruation. In intermenstrual period there is a tendency to constipation. The minority of patients with the intestinal function can not be violated. Pain during sexual intercourse are seen less and less pronounced than in women with pozavcherashny endometriosis. The progression of the process lead to ingrown of endometriosis in the muscular layer, and then in the rectum at the level of srednetemperaturnogo her Department.
Diagnosis of endometriosis this localization based on the above complaints, determine painful infiltration peritoneal uterine-pryamokishechnye deepening and pararectal cellular tissue when vaginal-pryamokishechnye study. Laparoscopy allows you to specify the diagnosis or to put it in low severity or absence of specific complaints. However, this method is informative only in the absence of the cicatricoadhesive changes, eliminating the possibility of inspection samotechny part of the small pelvis.
The presence of cystic degeneration of the ovary (s) or cystadenoma ovarian combined with infiltrative changes peritoneal uterine-pryamokishechnye deepening and pararectal cellular tissue is an indication for cytological study flushing, obtained by puncture of the posterior vaginal fornix or laparoscopy with the purpose of differentiation from the malignant cystadenoma ovary.