Tsistotsele — omission of a bladder in a vagina owing to insolvency of a pelvic diaphragm. It is shown by feeling of a foreign matter in a vagina, urination delays, an urine incontience, a dispareuniya, pains in the bottom of a stomach and in a waist. It is diagnosed by means of vaginal survey, ultrasonography of an urethra and a bladder, complex urodinamichesky, videourodinamichesky researches. Conservative treatment to a tsistotsela the pessariya includes a training of pelvic muscles, replaceable hormonal therapy, installation vaginal. During surgical correction carry out a forward kolporafiya, a vaginopeksiya with installation or without installation of a synthetic artificial limb, slang operations.
Tsistotsele (protrusion, omission, loss of a bladder) — the most frequent type of a genital prolapse which is coming to light at 34% of women with a syndrome of a pelvic distsention. Practically it is always combined with the ureterotsel. The term "tsistotsele" for the description of hernia of a forward wall of a vagina was for the first time used in the 1600th years. Incidence increases with age, reaching 55-60% in a postmenopause. Despite achievements of preventive medicine, continuous reduction of patrimonial traumatism, reduction of employment of women on heavy productions, frequency remains to a tsistotsela in population high and continues to increase that is connected with increase in average life expectancy. Relevance of timely diagnostics and adequate treatment of loss of a bladder is caused by considerable deterioration of life, and in hard cases and an invalidization of patients.
Reasons for a tsistotsela
The prolapse of a bladder is one of manifestations of a syndrome of insolvency of a pelvic bottom and loss of other bodies develops under the influence of the same factors, as (a rectum, a uterus, a vagina). Easing and formation of gryzhepodobny defects musculo copular the device supporting a bladder, first of all – a lonno-cervical puzyrny fastion becomes an immediate cause to a tsistotsela. Experts in the sphere of urology and an uroginekologiya allocate a number of the contributing factors increasing risk of a pelvic distsention:
- Frequent childbirth. The probability of emergence to a tsistotsela increases after each subsequent natural rodorazresheniye. By results of observations, at the women who were giving birth 4 times and more the risk of a mochepuzyrny prolapse is 3,3 times more, than at single childbirth. Patients who took out a large fruit enter into group of the increased risk, transferred rapid childbirth, ruptures of a vagina and crotch, obstetrical obstetric operations.
- Disgormonalny states. Easing musculo structures is promoted by estrogenic insufficiency what increase of cases to a tsistotsela in the period of a perimenopauza and after an ooforektomiya is connected with. The probability of a prolapse of a bladder increases from 6,6% at 20-29-year-old women to 55,6% at 50-59-year-old. Dependence between prevalence of pathology and level of estrogen is confirmed by decrease in incidence at purpose of replaceable hormonal therapy.
- Hereditary dysplasia of connecting fabric. Frequency of a family form to a tsistotsela reaches 30%. Weakening of a pelvic diaphragm is promoted as genetic anomalies (Marfan's syndrome, Elersa-Danlos's disease), and undifferentiated forms of kollagenopatiya which are shown hernias of other localization, juvenile osteochondrosis of a backbone, varicose veins, hemorrhoids, a miopiya, flat-footedness and other frustration.
- Increase in intra belly pressure. Hernial protrusion of a bladder in a cavity of a vagina is promoted by heavy physical activities and diseases at which pressure in an abdominal cavity increases. Tsistotsele arises at the women suffering from resistant locks, bronchial asthma more often. The risk of an urovezikalny protrusion increases in the presence of ascites, obesity, volume new growths of an abdominal cavity (subserous myomas, cysts of ovaries).
Basis of emergence and progressing to a tsistotsela is discrepancy of durability of a pelvic diaphragm to pressure under which it is. After long ischemia of a forward vaginal wall at the time of delivery, at gaps musculo and copular structures, hereditary weakness of soyedinitelnotkanny fibers, hypoestrogenic decrease in the general tone of muscles of a crotch and relaxation of sheaves the functional solvency of the copular device holding urinogenital bodies worsens. As a result at increase in intra belly pressure the bladder is squeezed out through defect of a pelvic bottom in a vagina, at the same time the forward vaginal wall falls. Violation of outflow of urine leads to increase in its residual quantity and growth of vnutripuzyrny pressure. The vicious circle supporting further increase in volume of hernial protrusion is as a result formed.
Systematization of clinical forms to a tsistotsela is based on extent of omission of body. Today two options of classification of weight of a mochepuzyrny protrusion are offered. The international gynecologic and uroginekologichesky associations recommended the standardized systematization of a prolapse of genitals of POP-Q according to which length of a vagina and an anatomic position of a marker point Ba on its forward wall in relation to the plane of a gimen is estimated. Domestic urologists and gynecologists use the simplified clinical option of definition of forms to a tsistotsela allowing to pick up optimum tactics of treatment more often:
- Protrusion of the I degree. At an easy prolapse the bladder falls to a middle part of a vagina and decides at gynecologic survey on a natuzhivaniye. In most cases for correction of violation it is enough to use conservative non-drug and medicamentous methods.
- Protrusion of the II degree. With moderate loss of a bladder hernial protrusion is found in patients in the lower half of a vagina and can reach its entrance. Comes to light at gynecologic survey without natuzhivaniye. Surgical treatment is more effective though also conservative approach is admissible.
- Protrusion of the III degree. The bladder goes beyond a sexual crack. The prolapse remains at physical rest. Against the background of the tsistotsel complications often develop from urinogenital bodies. Conservative elimination of defect of a pelvic bottom is impossible, reconstructive plasticity is recommended.
Symptoms to a tsistotsela
At a small prolapse the clinical symptomatology is absent. In process of increase in hernial protrusion the mochepuzyrny protrusion begins to be shown by feelings of pressure, presence at a vagina of a foreign matter which amplify during an urination, defecation, at a tussiculation, a raising of weights. In process of progressing of a disease the stream of urine is weakened up to a sharp delay, because of increase in volume of residual urine there is a feeling of the crowded bladder, imperative desires to an urination. The feeling of a large alien subject in a genital tract remains constantly. At 30% of patients because of morbidity during sexual intercourse sexual function is broken. At the heavy tsistotsel the urine incontience in stressful situations is observed. Weight, feeling of squeezing, the dull aching aches in the lower part of a stomach, a waist which can irradiate to the inguinal area is noted.
Increase in amount of residual urine promotes development or an exacerbation of cystitis, formation of stones in a bladder cavity. Long obstructive violation of natural urination increases risk of formation of infectious pyelonephritis, a gidroureteronefroz, an urolithic disease which in the subsequent can be aggravated with a chronic renal failure. Because of essential deterioration of life women with the tsistotsel have subdepressions and asteno-neurotic frustration (isolation, tearfulness, irritability, bystry fatigue) more often.
At diagnosis to a tsistotsela use the data of fizikalny survey and tool researches allowing to verify a prolapse in a bladder vagina. For the choice of an optimum way of treatment it is recommended to estimate integrity of a pubic and cervical fastion. The most informative in the diagnostic plan are:
- Survey on a chair. The vaginal research is recommended to be conducted in litotomichesky situation with introduction on a back vaginal wall of a single-door mirror. The Prolabirovanny bladder usually is found on a forward wall in the form of soft reducible opukholevidny education which increases in volume and is condensed at the patient's natuzhivaniye.
- Ultrasonography of a bladder. Sonografichesky signs to a tsistotsela are the shift of a back mochepuzyrny wall lower than the level of a pubis at rest and at a natuzhivaniye (tussiculation), its deformation in the form of an acute triangle. The hyper mobility and dislocation of an urethra defined at ultrasonography of an urethra testifies to the central defect of a cervical and pubic fastion.
- Complex urodinamichesky research (KUDI). Carrying out an urofloumetriya, tsistometriya of filling, a tsistometriya of tension allows to reveal violation of switching function of an uretrovezikalny sphincter and decrease in sokratitelny ability of a detruzor. Addition of KUDI with a videourodinamichesky research gives the chance to refine data on results of removal of contrast.
Tsistografiya at diagnostics to a tsistotsela is used mainly as an auxiliary method. Performance of a tsistoskopiya is, as a rule, complicated. At an endoscopic research usually it is possible to visualize only prisheechny sites of a bladder and the longitudinal skladchatost going down on its back wall. Survey of mouths of mochetochnik becomes possible after intravaginalny introduction of wadded or gauze tampons, at the same time the bottom in the form of the hill presses in a bubble cavity. Tsistotsele is differentiated with other types of a genital prolapse (omission of a uterus and vagina, the rektotsel, the enterotsel), an urethra diverticulum, a paraurethral cyst, skineity, bartolinity, a uterus eversion, loss of miomatozny knot, uterus neck cancer. To destination the urologist, the gynecologist or an uroginekolog the patient are advised by the proctologist, the gastroenterologist, the surgeon, the oncologist.
Treatment to a tsistotsela
At the initial stages of formation of a prolapse the main therapeutic objective is correction of a mochepuzyrny protrusion. At the expressed omission for normalization of function of a bladder, adjacent bodies it is required to restore anatomic integrity of a diaphragm of a basin. The tsistotsel are recommended to patients with easy and average degrees correction of a way of life with an exception of heavy physical activities, treatment of the accompanying pathology promoting formation of genital hernias, etiopatogenetichesky and symptomatic conservative therapy of an uretrovezikalny prolapse:
- Strengthening of muscles of a pelvic bottom. At decrease in a muscular tone after the delivery, against the background of an involute or postoperative gipoestrogeniya performance of exercises of Kegel or the LFK complex across Atabekov is effective. Trainings are less productive with anatomic defects of fabrics, though in this case it is possible to reduce expressiveness of a protrusion and violations of an urination.
- Replaceable hormonal therapy. Purpose of estrogensoderzhashchy or phytoestrogenic medicines is recommended to women with the symptoms to a tsistotsela which arose against the background of a climax or a postkastratsionny syndrome. Hormonal therapy allows to raise a tone of pelvic muscles and to strengthen sheaves, having reduced a prolapse and the related frustration.
- Installation pessariya. Introduction to a vagina of the special supporting device prevents further omission of walls and provides mechanical fixing of the dropped-out bladder. The method is considered palliative and is recommended to women who refuse surgical treatment or cannot be operated for health reasons.
In complex conservative treatment to a tsistotsela also apply physiotherapeutic techniques (laser therapy, an elektromiostimulyation). At inefficiency of therapeutic approaches with heavy or complicated to a tsistotsela performance of reconstructive operations is shown to patients. The choice of a type of surgical intervention depends on a state cervical fastion. In the absence of anatomic defect in fastsialny fabric the best results are observed after carrying out a vaginopeksiya, a forward kolporafiya. If integrity of the fastion connecting a bladder to a lonny joint is broken synthetic mesh artificial limbs are established. For elimination of an incontience of urine plasticity is supplemented with low-invasive slang (loopback) interventions — TVT, TVT-O.
Forecast and prevention
Application of conservative methods of therapy in the absence of rough anatomic defects of a pelvic bottom allows to improve significantly quality of life of the patient, to postpone carrying out operation. Efficiency of surgical treatment at a forward kolporafiya makes from 45 to 91%, positive results at a vaginopeksiya are observed at 95-97% of the operated women. For prevention in the postnatal and perimenopauzalny period it is recommended to tsistotsela to strengthen muscles of a pelvic bottom by means of Kegel's exercises, physiotherapeutic procedures, to keep to a diet for prevention of locks, to limit heavy lifting to freights no more than 3 kg. In the presence of the ekstragenitalny pathology capable to provoke a mochepuzyrny prolapse, timely adequate therapy of the main disease is required. An important role in the prevention to a tsistotsela is played by decrease in obstetric traumatism due to careful conducting childbirth, anatomic restoration of integrity of patrimonial ways after gaps, nitevy lifting of a vagina when weakening a pelvic diaphragm.