RU2475187C1 - Clinical diagnostic technique for sphincter contractility of lower one-third of vagina - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely diagnostic methods to study and may be used for diagnosing of the insufficiency of pelvic floor muscles. That is ensured by the visual examination of vulva either relaxed, or with all the muscles of perineum maximally contracted on underbelly and with all the muscles of perineum maximally contracted. The visible vulva is localised, and a degree of closing and opening shows four degrees of the sphincter insufficiency of a lower one-third of the vagina, as well as a criterion of inertia and normal function of such muscle.

EFFECT: normal diagnosing of the insufficiency of the pelvic floor muscles.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to diagnostic methods of research, and is intended to determine the parameters of the strength of the tonic, static, dynamic contractions of the obturator muscle of the lower third of the vagina and can be used to diagnose anatomical or functional insufficiency of the pelvic floor muscles with the aim of early diagnosis of disorders of the pelvic function organs.

Despite the fact that the vulva consists of the lower third of the vagina, the clitoris, the labia minora, the labia majora and the pubis, only the pubis and labia majora are normally the visible parts of the external female genital organs and only with the fingers extending the labia majora can the labia minora , the clitoris and the external opening of the urethra with the entrance of the vagina [Linda Heffener. The reproductive system is normal and pathological: Per. from English - M .: GEOTAR-MED, 2003 - 128 pp.], But in a certain number of women with an initial position lying on their backs, legs bent at the knees and hips (feet at the level of the buttocks) when gaping to the sides, there is a gaping vulva, during which the clitoris, labia minora, vestibule of the vagina, the anterior or posterior walls of the vagina are exposed [Errol R. Norwich, John O. Shorge. Visual obstetrics and gynecology: Per. from English - M.: GEOTAR-MED, 2003. - 144 p.].

Today, all etiological factors contributing to the development of genital prolapse are divided into congenital and acquired, which separately or in combination can lead to anatomical or functional failure of the pelvic floor muscles [V.I. Krasnopolsky, V.E. Radzinsky, S.N. Buyanova et al. Pathology of the vagina and cervix. - M .: Medicine, 1999 - 272 p.]. But due to the prolonged and asymptomatic prolapse, the early stages of the development of insufficiency of the obturator muscle of the lower third of the vagina due to the lack of adequate diagnostic methods [M.Yu. Korshunov et al. Prolapse of the pelvic organs. Manual for doctors. - SPb .: Ed. N-L, 2003 - 16 p.] Remain undiagnosed.

A known method of digitally determining the strength of muscle contraction of levators according to A.E. Mandelstam [Semiotics and diagnosis of female diseases. - M .: Medicine, 1976 - 412 pp.], Including finger stretching of the muscles of the vaginal entrance, during which the force of contractions is visually determined, but the parameters of contractions are not evaluated. This method does not allow you to quickly, easily and objectively evaluate the contractility of the obstructive muscles of the vagina.

A known method for the functional diagnosis of contractility of the muscles of the pelvis, characterized in that the device is inserted into the vagina for determining the contractility of the muscles of the pelvis, containing a handle, a body in the form of a cylinder 233 mm long, 25 mm in diameter and two parallel measuring bars adjacent to it, which fixed in the grooves of the body and fixed with a cap. Inside the housing there are two strain gauge sensors having a measuring range from 0.5 kPa to 30 kPa. The patient is asked to tighten the muscles of the sphincter of the anus, vagina and group of muscles involved in interrupted urination, and hold for 1-2 minutes. Signals are recorded and recorded using an obstetric computer monitor [patent RU 2364336, 2009]. The method allows to increase the sensitivity of the measurement, reduce the study time, and also provides a separate and total determination of the force of contraction, but the high cost, limited availability in medical institutions limit widespread use.

As a prototype, the method of finger stretching of the muscles of the entrance of the vagina according to McKenzie L.J., Carson S.A. 2003, which consists in the fact that during the maximum compression of the muscles of the perineum (as with interrupted urination) with the fingers of a doctor-researcher, the strength and duration of contractions of the muscles - levators closing the entrance to the vagina are determined on a scale [N.M. Podzolkova, O.L. Glazkova . Symptom Syndrome Diagnosis: differential diagnosis in gynecology. - Moscow: GEOTAR-Media, 2005 - 474 p.]. However, when this method is carried out, finger stretching of the levator muscles is carried out to determine muscle strength, which does not allow us to assess the strength and tone of the vulva muscles at rest and during stretching, since the strength of the fingers of the researchers is different.

The objective of the invention is to develop an effective and easy to use method for assessing the contractility of the obturator muscle of the lower third of the vagina according to the parameters of strength and degree of insufficiency.

The technical result when using the invention is to increase the accuracy of the assessment by obtaining objective parameters of the strength and degree of insufficiency of the contractility of the obstructive muscle of the lower third of the vagina.

The proposed method for assessing the contractility of the obturator muscle of the lower third of the vagina is as follows. First, a visual examination of the vulva in a relaxed (normal) state is carried out in the initial position of the patient lying on her back (gynecological chair or couch), the legs are bent at the knee and hip joints, divorced (feet at the level of the buttocks), the yaw of the vulva is determined, that is, the visible parts vulva (technique No. 1): - with a normal tone (ton) of the obturator muscle of the lower third of the vagina, a closed condition of the vaginal entrance is observed, the pubis and large labia are visible; then they take technique No. 2 - a visual examination of the vulva in the same starting position with the maximum contraction of all the muscles of the perineum to the lower abdomen (as with constipation), this technique allows you to identify the strength of the dynamic (din - action potential) contraction and depending on the degree of insufficiency the obturator muscle yawning of the vulva is observed: the clitoris, labia minora, the external opening of the urethra become visible; then they take technique No. 3 - visual inspection of the vulva in the same starting position with maximum compression of all the muscles of the perineum (as with interrupted urination), performing this technique reveals the strength of the static (stat - resting potential) muscle contraction in which the vulva closes, behind which the large and small labia, the clitoris, the external opening of the urethra, the entrance to the vagina with the anterior or posterior wall are closed. Carrying out these techniques allows you to identify the strength of the contractile ability of the obstructive muscle of the lower third of the vagina according to the degree of closure and gaping of the vulva. The contraction force of the obturator muscle of the lower third of the vagina is evaluated on a five-point Harrison scale recommended by the British Medical Research Council to determine the strength of muscle contractions:

- 5 points - when performing methods 1-3, a completely closed (closed) state of the vulva is observed, the pubis and labia majora are visually visible, the contractile ability of the obturator muscle of the lower third of the vagina is assessed as normal;

- 4 points - when performing reception No. 1, there is a slight gaping of the vulva, visible labia minora, when performing reception No. 2 - incomplete gaping of the vulva, visible are the labia minora and clitoris, when performing reception No. 3 - complete closure of the genital gap; the contractility of the obturator muscle of the vagina is assessed as the I-st degree of insufficiency;

- 3 points - when performing reception No. 1, the incomplete gaping of the vulva is observed, the labia minora is visible, the clitoris, when performing reception No. 2 - the full gaping of the vulva is visible, the labia minora, the clitoris and the external opening of the urethra are visible, while performing reception No. 3 - incomplete closure of the vaginal entrance; the contractility of the obturator muscle of the vagina is assessed as II degree of failure;

- 2 points - when performing admission No. 1, the full vulvar gap is observed, the labia minora, the clitoris, the external opening of the urethra are visible; when performing admission No. 2, the vulva is large gaping, the labia minora, the clitoris, the external opening of the urethra are visible, the front or rear walls of the vagina, when performing reception No. 3 - there is a slight contraction of the muscles during compression, leading to a slight closure of the vulva; the contractile ability of the obstructive muscles of the vagina is assessed as III degree of failure;

- 1 point - when performing reception No. 1, the complete vulvar gap is observed, the labia minora, the clitoris, the external opening of the urethra, the front or rear walls of the vagina are visible, when performing method No. 2, the vulva is fully gaped, the labia minora are visible, the clitoris, the external opening of the urethra, the anterior or posterior walls of the vagina significantly bulge out of the vulva, while taking method No. 3 - a visually barely noticeable muscle contraction that does not lead to closure of the vulva, which is completely yawns, the labia minora, the clitoris, the external opening of the urethra, the front or back walls of the vagina are visible; the contractility of the vaginal obstructive muscle is assessed as the IV degree of insufficiency;

- 0 points - when performing reception No. 1, there is a complete significant gaping of the vulva, visible are the labia minora, clitoris, the external opening of the urethra, the front or back walls of the vagina, which significantly bulge out of the vulva, and when taking reception No. 2, significant gaping and bulging all formations of the vulva for the vulvar ring, when performing technique No. 3 - a gaping vulva with all anatomical formations, the labia minora and labia minora, clitoris, and the external opening of the urethra are visible , The front and rear wall of the vagina due to lack of muscle contraction; the contractility of the vaginal obstructive muscle is assessed as absent (prolapse of the vaginal obstructive muscle).

Thus, the addition of a visual examination of the external genitalia with tests for maximum tension and compression of the perineum to the lower abdomen reveals a lack of contractility of the obstructive muscle of the lower third of the vagina according to the degree of closure and gaping of the vulva. The proposed method allows you to objectively at the initial stage to identify on a five-point Harrison scale the degree of insufficiency of the contractility of the obstructive muscle of the lower third of the vagina:

- 5 points - normal muscle contractility;

- 4 points - I degree of failure;

- 3 points - II degree of insufficiency;

- 2 points - III degree of insufficiency;

- 1 point - IV degree of failure;

- 0 points - lack of contractility.

The proposed method allows to detect functional and anatomical disorders of the contractility of the obstructive muscles of the vagina associated with insufficient strength of contractions of the muscles of the vagina.

The application of this method allows the patient (independently) and the doctor to objectively, non-invasively evaluate the contractility of the obturator muscle of the lower third of the vagina with various anomalies of the development of the external genital organs (asthenia, hypoplasia, etc.), the strength of contractions.

The invention is illustrated by the following figures.

Figure 1 shows a General view of the patient when performing reception No. 1 - visually observed closed condition of the vulva, which indicates anatomically and functionally intact obturator muscle of the lower third of the vagina, corresponds to normal contractile ability of the muscle.

In figure 2, when taking reception No. 2, the patient has a slight gaping of the vaginal entrance, revealed the I-th degree of insufficiency of contraction of the obturator muscle of the vagina.

In figure 3, when performing reception No. 3 in a woman who underwent normal childbirth through the natural birth canal, complete closure of the vulva is observed, which indicates the normal contractility of the obstructive muscle of the lower third of the vagina.

In figure 4, when performing reception No. 3, a complete significant gaping of the vaginal entrance is observed, indicating the absence (insolvency) of the contractile ability of the obstructive muscles of the vagina after traumatic birth through the natural birth canal.

INDICATIONS FOR USE

The use of this method is indicated for women:

- reproductive age after childbirth through the natural birth canal;

- to evaluate the results of conservative treatment;

- to assess the results of surgical treatment in women who underwent surgery on the external genitalia.

RESTRICTIONS AND CONTRAINDICATIONS FOR USING THE METHOD

An absolute contraindication to the use of this method is bleeding from the genital tract.

RESULTS OF CLINICAL STUDIES

In this way, we diagnosed the force of contractions of the obturator muscle of the lower third of the vagina in 68 patients of reproductive age, aged 23 to 42 years, the average age of the examined women was 23.4 ± 4.5 years. By the age of the onset of menarche, the time of the establishment of the menstrual cycle, no significant fluctuations were observed. A history of gynecological diseases was noted by 12 (17.6%) women, mainly inflammatory diseases of the internal genital organs. Reproductive function: in all, 42 women (61.7%) were observed undergoing childbirth through the natural birth canal, of which 8 (19%), only 34 births (81%) underwent births. Children with body weight from 2800 to 2999 g were born in 8 (19%), from 3000 to 3499 g in 18 (42.8%), from 3500 to 3999 g in 10 (23.8%) and from 4000 to 4200 g in 6 (14.2%) women. A significant number of women noted after the first birth restoration of soft tissue injuries of the perineum - 33 (78.5%), among which suturing of shallow vaginal ruptures was performed in every second, perineal dissection was performed in 26 (61.9%), perineal tears of the first degree in 16 (38%), perineal tears of the II and III degree in the study was not.

We obtained the results of a clinical study on a five-point Harrison scale: when taking reception No. 1 revealed: 5 points in 20 (29.4%), 4 points - 31 (45.5%), 3 points - 10 (14.7%), 2 points - 6 (8.8%), 1 point - 1 (1.4%), 0 points were not observed. Admission No. 2 revealed - 5 points in 13 (19.1%), 4 points in 33 (48.5%), 3 points in 13 (19.1%), 2 points in 7 (10.2%), 1 score in 2 (2.9%), 0 points were not observed. During reception No. 3 the following was observed: 5 points in 24 (35.2%), 4 points - 26 (38.2%), 3 points - 16 (23.5%), 2 points - 15 (22%), 1 point - 3 (4.4%), 0 points were not observed.

An example of clinical use of the proposed method.

Patient B., 25 years old, was admitted for delivery with a diagnosis of Pregnancy 40 weeks. Head presentation. Mature cervix. Primipara. OAA (1 honey / abortion). History: 2 years ago, she had one medical abortion for a period of 7-8 weeks, without pathology. Upon admission, the patient underwent a visual examination of the structure of the external genital organs, there were no visible congenital malformations and traumatic injuries of the perineal tissue, the study was supplemented with diagnostic methods.

Reception No. 1 - a closed condition of the vulva is observed, muscle tone is high, the anatomy and function of the obturator muscle of the lower third of the vagina is not disturbed, the pubis and labia majora are visually visible.

Reception No. 2 - the reception did not reveal any muscle function disorders, the high muscle tone kept the vaginal entrance closed, the pubis and large labia remained visible.

Reception No. 3 - during the reception, a pronounced closure of the vaginal entrance occurred, which indicated a high contractility of the obturator muscle.

The strength of contractions of the obturator vaginal muscle in the patient according to the Harrison scale corresponded to 5 points - normal.

After 6 days, spontaneous labor began, which ended in childbirth through the natural birth canal. In the second stage of childbirth, the woman performed a right-sided episiotomy for a menacing crotch tissue rupture.

An examination of the force of contractions of the obturator vaginal muscle after a month in dynamics revealed:

Reception No. 1 - when performing the reception, the incomplete gaping of the vulva is observed, the labia minora, the clitoris are visible, which corresponds to 4 points.

Reception No. 2 - when performing, a slight gaping of the vulva is observed, the labia minora, the clitoris, the external opening of the urethra are visible, corresponds to - 4 points (I-stage degree of insufficiency).

Reception No. 3 - the administration led to the complete closure of the vulva sexual fissure, which indicates the normal contractility of this muscle after childbirth.

Conclusion, the force of contractions of the obturator vaginal muscle in a patient who underwent childbirth through the natural birth canal with a right-sided episiotomy after a month on the Harrison scale was 4 points (grade I failure).

Thus, the use of this method (clinical diagnosis of insufficiency of the force of the obturator muscle of the lower third of the vagina) allows you to:

- painlessly, atraumatic, non-invasively diagnose insufficiency of contractility of the obturator muscle of the lower third of the vagina;

- visually assess the state of closure of the vulva, the degree of development of obstruction of the obturator muscle before and after childbirth through the natural birth canal, surgical interventions on the external genitalia;

- provides an opportunity for a woman to independently, repeatedly evaluate the results of conservative, surgical, rehabilitation treatment and rehabilitation after childbirth.

Claims (1)

A method for assessing the contractile ability of the obturator muscle of the lower third of the vagina, including examining the muscle with maximum compression of the perineum muscles (as with interrupted urination) while lying on the back, legs bent at the knee and hip joints, divorced, characterized in that the visual examination is performed as a study vulva with the definition of its visible parts, which is carried out sequentially: reception No. 1 - in a relaxed (normal) state, then reception No. 2 - with a maximum reduction of all muscles between lower abdomen (as with constipation), after which reception No. 3 - with maximum compression of all muscles of the perineum, evaluate the force of contraction of the obturator muscle of the lower third of the vagina according to a five-point Harrison scale of the British Council for Medical Research to determine the strength of muscle contractions, namely: if the implementation of methods 1-3, a completely closed (closed) state of the vulva is observed, the pubis and labia majora are visually visible, then the contractile ability of the obturator muscle is assessed as normal - 5 points; if during the implementation of reception No. 1, a slight gaping of the vulva is observed, the labia minora is visible, during the implementation of reception No. 2, the incomplete gaping of the vulva is visible, the labia minora and the clitoris are visible, during the implementation of reception No. 3 — complete closure of the genital gap; then the contractility of the obturator muscle of the vagina is assessed as the I-st degree of insufficiency - 4 points; if during the implementation of reception No. 1, the incomplete gaping of the vulva is observed, the labia minora is visible, the clitoris, when the reception of No. 2 is the complete gaping of the vulva, the labia minora, the clitoris and the external opening of the urethra are visible, when the reception of No. 3 is the incomplete closure vaginal entry; then the contractility of the obstructive muscles of the vagina is estimated as II degree of insufficiency - 3 points; if during the implementation of reception No. 1 there is a complete gaping of the vulva, the labia minora, the clitoris, the external opening of the urethra are visible, during the implementation of reception No. 2, the large vulva is visible, the labia minora, the clitoris, the external opening of the urethra are visible, the anterior or posterior the walls of the vagina, when taking method No. 3 - a weak contraction of the muscles during compression, leading to a slight closure of the vulva; then the contractility of the obstructive muscles of the vagina is assessed as III degree of failure - 2 points; if during the implementation of reception No. 1 there is a complete gaping of the vulva, the labia minora, the clitoris, the external opening of the urethra, the anterior or posterior walls of the vagina are visible, during the implementation of reception No. 2, the complete large gaping of the vulva is visible, the labia minora, the clitoris are visible the opening of the urethra, the anterior or posterior walls of the vagina significantly bulge out of the vulva, while taking method No. 3 - a visually barely noticeable muscle contraction that does not lead to closure of the vulva, which is completely is, visible are the labia minora, the clitoris, the external opening of the urethra, anterior or posterior vaginal wall; then the contractility of the obturator muscle of the vagina is assessed as the IV-th degree of insufficiency - 1 point; if during the implementation of reception No. 1 there is a complete significant gaping of the vulva, the labia minora, clitoris, the external opening of the urethra, the anterior or posterior walls of the vagina, which significantly bulge from the vulva, are visible, when performing reception No. 2, there is a significant gaping and bulging of all vulvar formations for the vulvar ring, when taking technique No. 3 - a gaping vulva with all anatomical formations, the labia minora and labia minora, the clitoris, the external opening of the urethra, are visible dnyaya and posterior vaginal wall due to lack of muscle contraction; then the contractility of the vaginal obstructive muscle is assessed as absent (prolapse of the obstructive muscle of the lower third of the vagina) - 0 points.

Images