Pain syndrome in gynecology. Pelvic pain in gynecology is a time bomb. Which doctor should i contact if there is gynecological pain

Gynecological pain can be of a different nature. First of all, gynecological pain can be acute or chronic.

For what diseases does gynecological pain occur?

Acute gynecological pain / i> is a sudden, severe pain that lasts for several hours or days. Acute pain can be accompanied by fever, nausea, vomiting, bowel problems, severe weakness and malaise. In cases of acute pain, especially in combination with the complaints described above, it is necessary to urgently consult a gynecologist. Almost any inflammatory diseases of the uterus and appendages, ectopic pregnancy, torsion or rupture of the ovarian cyst, as well as a number of other conditions that require immediate help, are manifested by acute pain.

A symptom of chronic gynecological pain is understood as periodically recurring or persistent pain in the lower abdomen for several months or even years. The causes of chronic gynecological pain differ significantly from the causes of acute pain, and therefore they were singled out as a separate concept. Chronic gynecological pains are extremely common - in every sixth woman. Pain is relatively rarely caused by any one cause, but more often by a combination of various factors. Therefore, diagnostic and therapeutic methods are very diverse. There are also frequent cases when the obvious causes of pain cannot be identified, but for such cases a certain treatment strategy has been developed, which requires mutual understanding and cooperation between the doctor and the patient.

The main causes of gynecological pain:
- Endometriosis.
- Features of the anatomical structure of the genitals, hormonal disorders.
- Vulvodynia (pain in the perineum and vaginal opening).
- Chronic inflammation of the genitals.
- Formations (benign and malignant) of the uterus and ovaries.
- Prolapse of the uterus and vaginal walls (pelvic organ prolapse).

Which doctor should i contact if there is gynecological pain

Gynecologist

For gynecological diseases, along with pain in the lower abdomen, lumbosacral pain is characteristic. This applies to pathologies such as displacement, prolapse and prolapse of the genital organs, inflammatory processes, tumors, especially those passing to the back wall of the pelvis or metastatic to the sacrum, menstrual disorders. Pain usually occurs due to increased blood flow to the pelvic organs and intoxication.

Sexual dissatisfaction in women it causes irritability, headaches, pain in the sacrum, a feeling of heaviness in the lower abdomen. Unresolved rush of blood to the genitals leads to stagnation in the small pelvis with subsequent morphological (swelling, enlargement of the uterus) and functional (increased secretion, menstrual irregularities) changes.

Incorrect position of the uterus. Normally, in women, the uterus is located in the center of the small pelvis at an equal distance from the pubis and sacrum, as well as from the side walls of the pelvis. The fundus of the uterus does not go beyond the plane of the entrance to the small pelvis. Quite often happens prolapse and prolapse of the uterus and vagina when the uterus and vaginal walls move downward. The main reasons for this are weakening of the muscles of the anterior abdominal wall, violation of the integrity of the pelvic floor muscles, often resulting from birth trauma (perineal rupture), age-related atrophy of the uterus, ligamentous apparatus and pelvic floor muscles. In nulliparous women, genital prolapse is extremely rare. With prolapse and prolapse of the uterus and vagina, women complain of a feeling of heaviness and pain in the lumbar region and sacrum, pulling pains in the lower abdomen, impaired urination (frequent, painful urination, urinary incontinence with stress, for example, when coughing, laughing), difficulty in the act of defecation ( constipation), a feeling of the presence of a foreign body in the genital fissure, difficulty walking.

The uterus is normally tilted slightly anteriorly, its bottom is directed to the anterior abdominal wall, that is, anteriorly and upward, which doctors call anteversio. An obtuse angle, open anteriorly, is formed between the body of the uterus and the cervix - anteflexio. Changes in the characteristics of the angle between the neck and the body are called position changes. This can happen when:

weakening of the ligamentous apparatus of the uterus (congenital feature or the result of multiple births);
tumors of the ovaries and fallopian tubes, uterine myoma;
inflammatory and adhesive processes in the small pelvis (with inflammation of the uterine appendages located on the side and somewhat posterior to the uterus, fusion of the uterus with the back wall of the pelvis is formed).

A sharper inclination of the body of the uterus anteriorly, at which the angle between the cervix and the body becomes acute, is called hyperantheflexia... Posterior tilt of the uterus is called retroversion, while the neck forms an angle with it, open posteriorly, - retroflection... In everyday life, this is often called the bend of the uterus. Women with a bend in the uterus may experience pain in the lumbosacral region and lower abdomen, pain during intercourse and during menstruation, increased frequency and pain of urination, and constipation. There may be problems with conceiving and carrying a pregnancy. Sometimes the listed abnormalities are asymptomatic.

Tumors of the uterus. Myoma of the uterus- a benign tumor arising from muscle tissue. It can be asymptomatic, and can cause pain, bleeding, dysfunctions of neighboring organs, infertility. Pain can be constant or during menstruation, can be localized in the lower abdomen, in the lower back, and in case of complications - throughout the abdomen.

Cancer of the body of the uterus usually develops in women over 50 years of age, nulliparous or low birth. It is manifested by uterine bleeding, blood-streaked or meat-like discharge, pain and a feeling of heaviness in the lower abdomen.

H. Romanovskaya

"Back pain and pain in gynecological diseases" and other articles from the section

Pains and their causes in alphabetical order:

gynecological pain

Gynecological pain can be of a different nature. First of all, gynecological pain can be acute or chronic.

For what diseases does gynecological pain occur:

Which doctor should i contact if there is gynecological pain

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Painful sensations in women in the lower abdomen is a rather nonspecific symptom that can be present in a wide variety of diseases of the pelvic organs.

Most often, women associate this with diseases of the female genital area and seek advice from.

As a rule, the occurrence of pain in the lower abdomen is associated with inflammatory and infectious processes occurring in the small pelvis.

Diseases can be different in severity and their manifestation, so it is very important not to delay the visit to the doctor.

Of course, these pains can be associated with surgical pathology, but it is important to diagnose and begin treatment in a timely manner.

In our clinic, we admit patients with acute pain without an appointment to provide emergency assistance, make a diagnosis, conduct laboratory and diagnostics, and if necessary, hospitalize or prescribe treatment. Also in our clinic we can carry out treatment in a day hospital.

Possible causes of lower abdominal pain associated with gynecological diseases

The factors provoking the appearance of pain can be conditionally divided into two groups:

organic - inflammatory diseases, neoplasms of the pelvic organs of benign and malignant nature, obstetric problems, etc.;
functional - various, painful.

Varieties of pain

The important characteristics of pain include its intensity, localization, concomitant clinical symptoms. First of all, it is worth determining what exactly the pain is associated with (with pregnancy, menstruation, etc.). Pain localized in the lower abdomen of a woman can be divided into several types:

sharp and sharp pain;
paroxysmal;
pulsating;
constant;
stupid.

Depending on the accompanying symptoms, one or another pathological condition can be suspected, in which the occurrence of pain is characteristic:

dull pain in the lower abdomen, combined with bleeding that has no connection with menstruation, most often occurs with inflammatory processes of the female reproductive system;
if the pain is accompanied by an increase in temperature - most likely, we are talking about infectious diseases of the small pelvis. The presence of infection is also indicated by pathological discharge from the genital tract;
the pathology of the urinary tract is indicated by pain in the lower abdomen along with urinary disorders;
the pathologies of the gastrointestinal tract are indicated by pain combined with nausea, vomiting, loss of appetite;
severe pain in the lower abdomen on the right, the intensity of which either subsides or increases, is a typical symptom of appendicitis.

The frequency and duration of pain episodes indicate the acute or chronic nature of the existing disease. So, the occurrence of bouts of acute pain, which lasts several hours, may indicate an exacerbation of a chronic disease.

Common diseases accompanied by pain in the lower abdomen

As already mentioned, in women, pain in the lower abdomen can appear for many reasons, but most often such a symptom indicates the presence of a gynecological or. The most common pathologies of the female genitourinary system include:

Inflammation of the uterus and appendages

It almost always begins acutely and is accompanied by an increase in body temperature, pain and signs of general intoxication of the body.

If there is adnexitis, then the pain is localized in the lower abdomen on the side.
When the pain is localized in the middle.
At chronic salpingo-oophoritis pains are constant, aching.

A benign disease characterized by the formation of a tumor, which, when it reaches a large size, can press on nearby organs, causing pain.

Complications of an ovarian cyst: if there is a cystic formation on the ovary, acute pain may indicate its rupture or torsion. In this case, emergency treatment is required.

Inflammation of the bladder, which causes cutting pain in the area above the pubis, making urination painful.

Ectopic pregnancy- Another pathological condition of a woman, in which paroxysmal pain occurs in the lower abdomen, which may be accompanied by bleeding. If the fallopian tube ruptures, the pain will become very sharp and sharp. This condition requires immediate surgical treatment.

Lower abdominal pain during pregnancy

During pregnancy, many women also experience pain in the lower abdomen. Mild, pulling pains are considered normal for any period of pregnancy. They should be reported to your doctor, but there are usually no serious reasons for concern. If the pain becomes severe, sharp or cramping, you should immediately seek medical help.

The most important ailments with which gynecological patients go to the doctor include lumbosacral pain; they can be a symptom of a wide variety of diseases. These pains are in some cases one-sided, in others - bilateral; they can come on suddenly, in other cases they develop gradually and imperceptibly. Sometimes patients note increased fatigue, aches, a feeling of painful tension, resp. pain. The strength and duration of pain varies widely - from short-term, easily tolerated, to long-term, constant and unbearably strong. As for the shades of pain, patients note a dull, aching, pressing, boring, tearing pain. It should be borne in mind that there is no definite parallelism between the intensity of pain and the severity of the underlying disease. With all the variety of pathological processes that cause lumbosacral pain, their mechanism is always reflex (MO Fridlyand).

These pains represent an unconditioned reflex of a protective nature, a "distress signal" that draws the attention of patients to the need to eliminate their cause. Along with this, the pain reflex is one of the important mechanisms that form the general reactivity of the body in relation to the pathological effect it experiences. It is important to keep in mind that the longer and stronger the pain, the more harmful it is, since the more the trophic functions of the body are disturbed.

Classification of lumbosacral pain

Lumbosacral pain can be caused by various lesions of the skeleton, muscles, nervous system and internal organs. Of the various classifications, the most complete and corresponding to modern requirements seems to us proposed by M.O. Fridlyand, which we present in an abbreviated form.

The following groups of diseases can cause lumbosacral pain:
T. Diseases of the skeleton (lumbar vertebrae, sacrum, pelvis):
A) Congenital anomalies: non-closure of the vertebral arch, spondylosis
spondylolisthesis, lumbarization, sacralization. B) Acquired diseases: 1) traumatic injuries; 2) inflammatory diseases (spondylitis, sacroiliitis, osteomyelitis; 3) degenerative lesions (spondylosis, spondyloarthrosis, thickening of the yellow ligaments); 4) static suffering; 5) paralytic curvature of the spine; 6) neoplasms.
II. Diseases of the muscles (lumbar and gluteal): 1) traumatic injuries; 2) inflammatory diseases.
III. Diseases of the nervous system of the lumbosacral region: 1) malformations of the nervous system; 2) inflammatory diseases (neuromyalgia, neuritis, plexitis, radiculitis, etc.); 3) metabolic disorders: a) general metabolic disorders of the body (diabetes, gout), b) local tissue nutritional disorders; 4) compression of nerve elements (nerve trunks, roots); 5) reflex diseases (radiculitis with a flat foot, "sympathetic suffering"); 6) functional diseases (neurasthenia, psychasthenia, hysteria).
IV. Diseases of the internal organs: 1) diseases of the abdominal organs (kidneys; intestines - colon, rectum, vermiform appendix); 2) organs of the pelvic region (uterus, its appendages, peritoneal peritoneum and tissue, bladder).

Of the skeletal diseases, lumbosacral deformities are important, in particular the latent splitting of various degrees of the spinous process of the vertebral arches, spondylolisthesis and, much less often, spondylolysis, sacralization and lumbarization.

Despite its congenital origin, hidden cleft vertebrae may first cause pain only in adolescence or even after the end of skeletal growth. The provocative moments are often minor injury or physical fatigue. With unilateral spondylolysis, pain is rare; they are mainly detected during bilateral spondylolysis.

In this disease, which is an underdevelopment of the arcuate part of the vertebra in its lateral section on the border with the vertebral body, the fibrous adhesion, replacing the normal bone fusion of the arch with the vertebra, may not be hardy enough for a large static-dynamic load of the lumbosacral spine. Due to this, the tension of the entire ligamentous apparatus increases, which leads to the reflex appearance of pain due to the abundance of receptors in this area, and to hypertension of the lumbar muscles. The pain is aggravated with an upright position and with physical exertion.

In people with a highly developed subcutaneous layer of fat on the abdomen and in pregnant women, the center of gravity of the body is shifted anteriorly, which leads to an involuntary backward reclining of the body with an increase in the physiological lordosis of the lumbosacral articulation. This circumstance contributes to the movement (sliding) of the lumbar vertebra. The clinical symptoms of the resulting spondylolisthesis are the stronger, the greater this slipping.

When examining the back, there is a deepening of the skin fold at the waist, an increase in lumbar lordosis with the movement of the most in-depth point, respectively, IV (and not III, as is normal) of the lumbar vertebra. Finger pressure on the spinous process of the IV or V vertebra causes a sharp increase in pain. An x-ray shows a characteristic elevation of the posterior end of the spinous process of the V lumbar vertebra.

Lumbosacral pains with lumbarization or sacralization are much less common and weaker. As facilitating moments, minor injuries, bruises of the lower back, significant physical efforts, and overwork are noted.

Under sacralization of the lumbar spine means the inclusion of the last lumbar vertebra in the composition of the sacral bone, and under sacral lumbarization, insufficient connection of the two upper sacral vertebrae. In the first case, shortening of the lumbar spine and lengthening of the sacral bone is obtained, with lumbarization, on the contrary, lengthening of the lumbar spine with simultaneous shortening of the sacral bone. In the latter case, there is an increase in the mobility of the spine, which leads to a decrease in the stability of the pelvis and faster fatigue. Sacralization is often incomplete, less often there is a varying degree of complete - the fusion of the lumbar vertebra with the sacrum bone.
The main complaint of patients is pain in the lumbar region and in one or both lower extremities. These pains relatively often occur suddenly due to hypothermia or injury; if acute pains in most cases pass quickly, the remaining aching pains last for a long time and are easily aggravated under the influence of various reasons.
Gynecologists need to know that sacroiliitis is relatively often the source of various combined lumbar, sacral and gluteal pains. It can be caused by a tuberculosis infection, sometimes a septic infection (infected abortion, postpartum illness).

As M. O, Fridland points out, sacroiliitis occurs in no less than one third of all patients with brucellosis. The pain in the articulation area increases with palpation and, especially, if the patient is placed on his stomach and in this position the leg is extended in the hip joint. Radiographically, it is often possible to establish changes in the form of widening of the gap, loosening of the edges of the joint, destructive changes, but with infectious-toxic sacroiliitis (for example, caused by influenza), radiological imputation is usually absent.

The source of sacro-pelvic and lumbosacral pain can be pelvic osteomyelitis. From degenerative lesions of the skeleton, as sources of beneficial pain, are important spondylosis and spondyloarthrosis that develop most often in the elderly as a result of physiological deterioration of the spine; however, they can also occur at a younger age as a consequence of chronic infectious processes (intoxication) and metabolic disorders. These pains are especially strong in the early stages of the disease before the formation of ankylosis of the vertebrae.

Lumbosacral pain sometimes they can also be caused by static changes on the basis of compensatory adaptations of the body to violations of the symmetry of the lower extremities or to deformities of their large joints. With the emerging scoliosis or pathological lordosis of the lower back, the pains that appear are due to the overstretching of the ligamentous apparatus of the spine. Similar phenomena can occur after difficult labor (for example, with a large fetus, or in multiparous with overstretching and relaxation of the sacroiliac ligaments and pubic ligaments
joints).

Finally, lumbosacral pain can be a consequence of the development of both primary and secondary neoplasms in the lumbar vertebrae (cancer, hypernephroma, etc.).

In addition to diseases of the skeletal system, muscular diseases (traumatic and inflammatory lesions of the lumbar and gluteal muscles) can also play a role in the origin of lumbosacral pain. Under the influence of forced muscle tension, their overstretching, tear, and sometimes a complete rupture, or hemorrhage in the muscle vagina can occur. In such cases, the patient's torso is usually tilted towards the injury and movement in the opposite healthy side is more painful, as well as palpation of the lateral abdomen along the lumbar-iliac muscle. Localization of damage on the right side may give rise to incorrect suspicion of appendicitis.
Severe lumbar pains of an infectious and infectious-toxic nature are well known. Infectious lordosis is mostly accompanied by high fever, pronounced leukocytosis with a shift of the hemogram to the left, an increased erythrocyte sedimentation rate. Pains have precise localization.

A more common cause of lumbar pain of muscle origin is myositis, a typical representative of which is lumbago ("lumbago"). It can develop in connection with the flu or other infectious diseases, as well as with metabolic disorders in the body.

Hypothermia (local or general) is a predisposing moment. Characterized by a sudden acute onset of pain, as it were, shooting in nature, especially when changing posture, when coughing, sneezing, etc. The slightest movement can cause severe pain. "Backache" is often one-sided, but sometimes bilateral. Feeling of the affected muscles is painful. Sometimes the process extends to the gluteal region (lumbar-gluteal myositis).

Lumbosacral pain can be caused by various toxic diseases of the nerve pathways, from the most peripheral parts to the spinal cord. As a provoking moment, for the most part, local cooling of tissues is important. In neuromyalgia or neuralgia, pain is the only symptom. With the simultaneous presence of symptoms from the motor and vegetative spheres, they speak of neuritis, etc.

Neuralgia of the sciatic nerve (sciatica) or its inflammation should not be confused with neuromyalgia of the lower back. Characteristic signs of sciatica are the presence of a painful point when pressing on the middle part of the femoral-gluteal fold (on the back of the thigh) at the exit of the nerve from the greater sciatic foramen, irradiation of pain along the lower limb, mainly along the outer surface, corresponding to the course of the peroneal nerve. In most cases, the process is one-way. The pain increases from the tension of the sciatic nerve (symptoms of Lasegue, Bekhterev, etc.).

One of the important causes of lumbar pain is inflammation of the nerve roots (sciatica). With lumbosacral radiculitis, sensory disorders prevail over motor disorders. The pain spreads to the nerves of the periosteum, due to which the pressure on the latter is painful. The pain intensifies when bending the head, when coughing, etc. Irradiation of pain in sciatica is even more pronounced than in sciatica.

In the pathogenesis of radiculitis, other changes in the vertebrae and soft tissues are also of great importance: arthrosis of the intervertebral joints, intracanal osteophytes, degenerative changes in discs without displacement, as well as hypertrophy of the ligamentum flavum and adhesion processes in the soft membranes.

The pathogenesis of lumbosacral radiculitis, which accounts for 12-20% of all diseases of the nervous system, is a complex chain of various links, in which it is very important to find the initial "trigger" link.

The clinic of lumbosacral radiculitis associated with discopathy, osteophytosis, lesion of the ligamentous apparatus has a number of features.

The cause of lumbar pain can sometimes be the displacement of the intervertebral disc and its hernia. Such hernias show their effect in combination with other factors or independently of them.

In the diagnosis of the final cause of the disease, X-ray of the spine is essential.

Pain in diseases of the abdominal organs

Finally, lumbosacral pain often occurs as a result of diseases of the internal organs (lesions of the urinary system, intestines, reproductive apparatus, etc.). It should be borne in mind that even with such frequent inguinal hernias, pulling pains are observed not in the lower abdomen, but in the lumbar region. Severe pain in the sacrum and lower back is often observed in advanced forms of rectal cancer.

From the pelvic organs, diseases of which can cause the appearance of lumbar and sacral pain, the uterus and its appendages should be put in the first place. With a disease, especially inflammation of the internal genital organs, patients note pains of varying intensity in the lower abdomen or in the lower back, radiating to the groin, sometimes to the anus, less often to the vagina, to the navel, under the spoon, to the thighs, etc.

Let us dwell on some of the often observed features of the localization of pain.

Subcostal pain

It occurs in a number of cases with inflammation of the uterine appendages, both in the acute, subacute, and in the chronic period; often there are stabbing or pulling pains in the back at the height of the XI-XII ribs; with a simultaneous increase in temperature, the thought of pleurisy naturally arises, however, in contrast to pleurisy, with deep breathing there is no stitching, and the pains not only do not intensify, but even, on the contrary, disappear. We find an explanation for this phenomenon in the fact that centripetal stimulation can be transmitted both along the animal (spinal) nerves and along the autonomic nervous system.

Scapular shoulder pain

Of the pains reflected in diseases of the pelvic organs, shoulder pain deserves special attention, the so-called phrenicus symptom.

This symptom is very often found in liver diseases, with its echinococcus, with subphrenic abscess, etc. However, it has been repeatedly observed with tubal miscarriage or, less often, with rupture of a pregnant tube. Characterized by the appearance of scapular-shoulder pain with a positive outcome of blowing the fallopian tubes. Gas (air) trapped in the abdominal cavity penetrates under the diaphragm, especially when the patient is sitting or standing, irritating the endings of the phrenic nerve. When a certain amount of blood is interrupted, poured into the peritoneal cavity, sometimes flowing during an acute attack along the sides of the ascending or descending colon into the subphrenic space, it can irritate the branches of the specified nerve.

Soaring pain

This is a kind of complex, described by Sellheim back in the thirties of the XX century. This pain is based on the failure of the pelvic floor and soft parts that cover the pelvic outlet, that is, there is a preparatory stage of "refusal" from the normal activity of the supporting apparatus of the uterus.

An important cause of abdominal pain can be the prolapse of one or another abdominal organ, that is, splanchnoptosis, a particular manifestation of which in women is such a frequent prolapse of the walls of the vagina and uterus. It should be remembered that various parts of the intestine can also exhibit certain degrees of prolapse, which is especially common for the sigmoid colon. In the clinical picture, flatulence, pain in the left iliac region, a feeling of heaviness and pressure, constipation, alternating with periodic diarrhea with the release of a large amount of mucus, and sometimes even blood are noted. The long sigmoid colon gives rise to its partial twisting, and sometimes to complete volvulus, which leads to intestinal obstruction.

In women who have given birth, it is relatively often possible to ascertain the presence of a mobile kidney, especially the right one. Excessive mobility of the kidneys can cause a variety of painful sensations, contribute to the development of constipation, the appearance of various reflex phenomena, and also again entail all kinds of inflammatory processes (pyelonephritis, etc.).

Kidney disease is a common source of sacral pain. The pains that arise are usually localized on the corresponding side; they may depend not only on real kidney lesions (inflammation, hydronephrosis, tumor), but also on its displacement with the formation of an inflection of the ureter with the development of urinary stagnation in the renal pelvis. When stones move along the ureters, renal pains are often observed, which have the character of severe attacks. A more or less similar picture with the addition of a febrile temperature is given by paranephritis.

It is quite clear that other (extragenital) diseases of the small pelvis (hemorrhoids, colitis, diseases of the retroperitoneal glands, bladder, enlarged rectal veins, malignant infiltration of pelvic tissue, etc.) can cause sacral and lumbar pain. It should be borne in mind that with inguinal hernias, pulling pains are often observed not in the lower abdomen, but in the lumbar region.

Thus, lumbosacral pain can be a manifestation of a variety of diseases that are studied in gynecology, urology, neuropathology, orthopedics, and therapy. In particular, one should remember the significance of gout, rheumatism, and acute tuberculosis. Unilateral pain in the sacrum speaks mainly against its genital origin.

The following painful points are of great practical importance, mainly with appendicitis:

Macbourney point, located at a distance of 5 cm from the anterior-superior pelvic spine along the line leading to the navel;
Lanz point (Lanz) on the border of the right and middle third of the line connecting both anteroposterior spines of the pelvis;
point Kummel (Kummel), located one or two transverse fingers below the navel, somewhat to the right;
point Morris (Morris) at a distance of 4 cm from the navel along the line connecting the upper-anterior spine and the navel.
An unrecognized hernia is a very common source of diagnostic errors. The groin and nick (sigmoid colon) are of the greatest practical importance;
spleen;
the abdomen (especially hernia). Vascular pain in this area is also possible.

The relationship between the sigmoid flexure and the genitals deserves special attention, since in diseases of the sigmoid (sigmoiditis, intestinal tumor, spasm, or, conversely, the colon and flexure), the symptoms that appear are easily worn due to the genital apparatus, since the intestine is ill in isolation much less often than the appendages ...
the nature of the pain is sometimes clarified due to their rapid elimination with aspirin, amidopyrine, etc.

Pain in the coccyx area - coccygodynia - depends either on damage to the coccyx itself, or has a reflected character. However, coccygodynia is often observed in the absence of pronounced changes in the coccyx, for example, in diseases of the uterus and appendages, especially in posterior and pelveoperitonitis, as well as in diseases of the rectum. Sometimes these pains are of a neuralgic nature, in particular with sciatica. Coccyx pain can also depend on common causes (flu, sometimes alcoholism).

General diagnosis of the causes of pain

The genitals, in terms of their sensitivity, are no exception compared to other organs of the abdominal cavity. Pressure on them from the outside does not cause pain, but compression of a healthy movable ovary is usually sensitive. In most nulliparous women, artificial expansion of the cervical canal of the uterus is very painful. Soreness of the uterus on palpation indicates its pathological condition (acute metritis, metroflebitis, fibromatous node infarction, myoma necrosis, etc.). Palpation of the pelvic organs is especially painful with concomitant inflammation of the peritoneum.

Although in most cases, patients are not able to indicate exactly what place they are in pain, noting often a rather extensive area of the lower abdomen, nevertheless, the topography of the pain is of great importance.

To clarify the localization of pain, it is customary to divide the abdominal cavity into several zones. The simplest division is a division into four quadrants: a median line from the xiphoid process to the pubic articulation and a transverse line drawn through the navel. In gynecological suffering, as a rule, only the lower two quadrants attract our attention (although reflected pains can occur far beyond these areas).

Pain in the lower abdomen in the midline in most cases, they depend on diseases of the uterus, bladder, rectum, and sometimes come from the appendages of the uterus displaced to the midline. However, even with hernia of the navel, the white line (especially after surgery), complaints of pain in the middle of the abdomen are often encountered. When localized from the side, it is necessary to distinguish between unilateral and bilateral pain. Right-sided pains most often depend on diseases of the genital area (mainly of the right appendages of the uterus and pelvic peritoneum), the appendage of the cecum, kidney, ureter, intestine, hernia, abdominal wall diseases. Pain below the line connecting the anterior-superior pelvic spine and the navel generally indicates damage to the internal genital organs, and above this line - diseases of the intestines, kidneys, etc. Inflammation of the cecum is accompanied by the greatest pain in the middle of the specified line.

Umbilical hernia, however, there are also epigastric hernias that are not associated with the navel. To identify them, it is necessary to examine the patient in an upright position, since otherwise the hernia can be easily viewed. However, it should be remembered that, even in the absence of a hernia, the inguinal ring is very sensitive under pressure, possibly due to the especially developed innervation of the round ligaments.

In case of pain in the left half of the abdomen, one should bear in mind the possible damage to the internal organs.

Acute pain associated with a congenital malformation of the sigmoid mesentery (megacolon - Hirschsprung's disease ), Due to the excessive length of the mesentery, twisting of the overflowing intestine is possible, which can simulate an interrupted ectopic pregnancy, a twisted ovarian cyst, etc.

VF Snegirev paid particular attention to the importance of the pelvic plethora. Sharp pain when touching the palnem to the highest point of the posterior fornix is a sure sign of determining the well-known zones of reflected pain (Zakharyin-Ged zone), an important objective sign is the phenomenon of a decrease in skin resistance to direct current in areas corresponding to motor or sensory disorders.

The decrease in the skin's resistance to galvanic current is explained by the fact that impulses emanating from the visceral organs and transmitted along the afferent nerve pathways to a certain segment of the spinal cord cause overstimulation there, which, in turn, radiates to the afferent sympathetic fibers passing along with the mixed spinal nerves to skin. This phenomenon is, according to Albrecht, E.T. Zalkindson (1930) and others, an objective method for studying the projection of pain descending from the internal organs onto the skin, and acquires an important meaning in the delimitation of neuroses and psychoneuroses from organic diseases - Although the method of galvanopalpation is an objective and almost self-sufficient way of finding projection pain points in skin segments with a disease of one or another abdominal organ; it should be used in combination with other clinical data.

A schematic representation of pain points found (according to A.P. Gubarev) when feeling the anterior and posterior surfaces of the pelvic region is shown in Figs. 61 and 62.

Rice. 61. Scheme of pain points when feeling the anterior surface of the pelvis (according to A.P. Gubarev). 1 - the place of passage of the anterior external cutaneous nerve of the thigh; 2 - the place of projection of pain in diseases of the ureter; 3 - the area of the external opening of the inguinal canal; 4 - painful point with a disease of the hip joint; 3 - sacroiliac joint; c - the location of the appendix.

Rice. 62. Scheme of pain points when feeling the posterior surface of the pelvis (according to A.P. Gubarev). 1 - the place of passage through the fascia of the saphenous branch of the io-, hypogastric nerve; 2 - the inner edge of the posterior-superior spine; 3 - articulation of the coccyx with the sacrum; 4 - the place of passage of the sciatic nerve; b - hip joint; c - a painful point with a disease of the hip joint; 7 - a painful point with damage to the sacroiliac joint.

With a careful systematic sequential internal (vaginal and rectal) examination, it is mostly possible to identify painful areas both in the pelvic organs and in the area of the joints of the pelvic bones, in the nerve plexuses, etc.