pelvic floor peritoneal hernia
Introduction
Introduction to pelvic floor peritoneal hernia The pelvic peritoneum and abdominal organs or tissues, protruding into the rectal genital depression (between the rectum and the vagina, or between the rectum and the prostate), called the pelvic floor peritoneocelehernia, also known as Douglas depression, or pelvic floor Peritoneal bulging. The contents of the sputum are mostly small intestine, sigmoid colon, sometimes uterus or even omentum, which can oppress the rectum and cause emptying disorders, which is one of the important reasons for obstructive chronic constipation at the functional exit. Women with this disease are more common than men, and more With perineal decline, rectal mucosal intussusception, rectal prolapse and so on. basic knowledge The proportion of sickness: 0.01% Susceptible people: no special people Mode of infection: non-infectious Complications: toxic shock syndrome, nausea and vomiting
Cause
Pelvic floor peritoneal hernia
(1) Causes of the disease
The pelvic floor peritoneal hernia is due to the weakness of the pelvic floor muscles, the pelvic floor peritoneum is excessively loose, and the fascia supporting structure of the posterior vaginal wall is damaged. Under the effect of long-term intra-abdominal pressure, the Douglas sag gradually deepens and the pelvic floor peritoneal cavity expands. It is formed between the rectum and the vagina that protrudes from the normal peritoneum.
1. Degeneration and relaxation of pelvic floor muscles, resulting in pelvic floor prolapse more common in elderly muscle and fibrous connective tissue degeneration and obesity.
2. Vaginal fascia support structure degeneration, relaxation, weak vaginal upper fascia support structure including uterine ligament ligament, main ligament, rectal vaginal septum, etc., women in the process of repeated pregnancy, childbirth, etc. easily lead to uterine ligament, main ligament , rectal vaginal septum and other repeated traction, expansion damage, can lead to vaginal fascia support structure damage, degeneration, relaxation, weakness.
3. Intra-abdominal pressure increases certain chronic diseases, such as habitual constipation, chronic bronchitis, emphysema, etc., which can maintain the intra-abdominal pressure at a high level for a long time.
(two) pathogenesis
The sac of the peritoneal sac of the pelvic floor is formed by the peritoneal sac of the pelvic floor and the anterior rectal area of the normal peritoneum. The contents of the sputum are mostly the small intestine, the sigmoid colon, the uterus and the greater omentum can also enter.
1. Pathophysiology is different from other abdominal hernias. The periorbital fistula of the pelvic floor is very large, rarely causing complete intestinal obstruction, but leads to obstructive constipation at the functional exit. The mechanism is:
(1) The contents directly compress the rectum, the anal canal, and close the upper mouth of the anal canal, hindering the discharge of the feces, and the more forceful defecation, the greater the pressure of the contents on the anterior wall of the rectum, the more difficult it is to discharge the feces.
(2) The contents of the sputum squeeze the rectum to the surface of the tibia, so that the stool stagnates the rectum, above the junction of the sigmoid colon, can not enter the rectum and induce defecation reflex, resulting in water absorption, dry stool and difficult to discharge.
(3) When the content of the sputum is sigmoid colon, it is more common in patients with long mesangial or sigmoid colon. When it is between the rectum and the vagina, the sigmoid colon can be twisted into an angle, hindering the passage of feces.
According to reports in the literature, the disease is often accompanied by rectocele, rectal prolapse, bladder bulging, uterine or vaginal prolapse, perineal descent syndrome and other diseases, in the patients with difficulty in defecation, about 18% from the small intestine into the rectum Between the vaginal and the vagina, 1/3 of them had rectal (internal) prolapse, Fenner reported that 9 of 234 defecations were sigmoid colons; Jorge reported that 24 of 463 defecations were sigmoid sputum .
2. Pathological typing
(1) According to the pelvic floor peritoneal intrusion position classification: Bremmer divides the pelvic floor peritoneal sputum into three types based on defecating angiography and pelvic floor peritoneal angiography:
1 Rectal pelvic floor peritoneal sputum: refers to a kind of sputum in the rectal wall of the rectum, which is the same as the rectal sinus of the rectum and the rectal wall of the rectum.
2 septal pelvic floor peritoneal sputum: refers to the pelvic floor peritoneum (sac sac) protruding into the rectal vaginal septum, and pressure blocking the vagina and rectum, up to the level of perineum.
3Vaginal pelvic floor peritoneal sputum: refers to a kind of sputum that protrudes into the vagina. At rest, there is no sputum content in the sac. When the intra-abdominal pressure increases (such as forced defecation), the small intestine, sigmoid colon The omentum or uterus will enter the hernia sac under the pressure of the intra-abdominal pressure; some scholars will regard it as the result of the development of the pelvic floor peritoneal hernia.
(2) According to the content classification:
1 Hernia of sigmoid: refers to the pelvic floor of the small intestine, the pelvic floor of the small intestine, the contents of the sputum can oppress the vaginal and rectum, which is caused by long-term forced defecation, neurological damage of the pelvic floor striated muscle caused by childbirth, etc. The pelvic floor muscle defect caused by the factors, but not caused by the deepening of the Douglas sag, to some extent, after the hysterectomy, the genital warts are part of the intestinal fistula, so it is often confused, in fact, both are in the etiology, pathology and treatment. different.
2 Sigmoicele: refers to the pelvic floor peritoneal hernia of the sigmoid colon. The sigmoid colon as a sputum content can be twisted into an angle and compress the rectal anal canal. Jorge divides it into 3 degrees:
I degree: refers to the sigmoid colon fistula that is invaded into the depression above the pubic line.
II degree: refers to the sigmoid colon intestines between the person's pubic line and the ischial tail line.
III degree: refers to the sigmoid colon intestines into the sciatic tailline below.
3 uterine hernia (uterine hernia): refers to the contents of the uterus pelvic floor peritoneal hernia, the more common pelvic floor hernia is intrauterine prolapse, after the intrusion, oppression of the rectum above the humerus, resulting in obstructive constipation symptoms.
Prevention
Pelvic floor peritoneal hernia prevention
Should actively correct the imbalance of water and electrolyte acid-base balance, to prevent intestinal necrosis, such as strangulation should be removed necrotic intestine segment, end-to-end anastomosis, repair the cryptic peritoneal fissure pores to avoid recurrence. Symptomatic treatment is mainly used to alleviate and/or eliminate the symptoms of chronic constipation. The measures include:
(1) Eat more dietary fiber and drink more water.
(2) Develop good timing and regular bowel habits.
(3) levator ani exercise.
(4) If necessary, supplemented with oral fruit guide and laxative laxative Chinese medicine, but it should be used with caution and less irritant laxatives containing terpenoids. If necessary, it can be applied intermittently, otherwise it will damage the enteric nervous system. It causes the colon to be weak and can induce "colon blackening".
Complication
Pelvic floor peritoneal hernia complications Complications toxic shock syndrome nausea and vomiting
One of the important causes of chronic acid constipation of functional obstruction is the occurrence of imbalance of water-electrolyte acid-base balance, toxic shock and intestinal necrosis of the intestine. Women with this disease are more common than men and are often accompanied by complications such as perineal decline, rectal mucosal intussusception, and pre-rectal bulging. Some patients can combine mood irritability, abdominal distension, abdominal pain, nausea, loss of appetite, waist, appendix pain and so on.
Symptom
Symptoms of pelvic floor peritoneal palsy Common symptoms Constipation, urgency, bloating, loss of appetite, abdominal distension, abdominal pain, nausea
Symptom
(1) constipation: manifested as reduced number of bowel movements or difficulty in excretion of feces, a small number of patients have both, according to statistics, about 83% of patients with pelvic floor peritoneal hernia have obvious symptoms of rectal emptying constipation, such as difficulty in defecation Excessive exertion, excessive feeling, anorectal sensation, repeated bowel movements, etc., when the bowel movement is severe, you need to help with bowel movements. If some patients feel vaginal during the bowel movement, the perineal bulge, often need to massage around the anus Or some of the feces can be removed from the posterior wall of the vagina.
(2) Other symptoms: such as irritability, abdominal distension, abdominal pain, nausea, loss of appetite, waist, appendix pain and so on.
2. Physical examination
When the paralyzed patient performs simulated defecation movement, the anterior wall of the rectum has a full feeling, and a bulging bulge appears in the posterior vaginal region of the vagina. The rectum, vaginal double-conspiratory diagnosis and the presence of intestinal fistula and other sputum contents exist between the two.
Examine
Examination of pelvic floor peritoneal hernia
The general physical examination is of little significance for diagnosis. The diagnosis is mainly based on sputum angiography, synchronous sputum pelvic angiography, when there is content in the pelvic floor peritoneal sac, according to the vaginal and rectal spacing or sigmoid colon, small intestine according to defec The lower edge is below the shame line to presume that the intestine enters the peritoneal sac of the pelvic floor. For the pelvic floor peritoneal hernia without content, a pelvic floor peritoneal angiography is needed. The angiography can clearly show the size and shape of the pelvic floor peritoneal hernia sac. , level, etc., is a more reliable method.
Defecation angiography
2 to 3 hours before the faecal angiography examination, the oral contrast agent is used first. When the force is used for defecation, the small intestine containing the contrast agent and/or the sigmoid colon are invaded between the rectum and the vagina, and the anterior wall of the rectum and the upper anal canal are compressed, resulting in a contrast agent in the rectum. Excreted, Mellgren detected a pelvic floor peritoneal sputum rate of 19.0% in 2816 cases of faecal angiography. Lu Renhua et al reported that the detection rate was 13.02%, but oral tincture developed small intestine for the diagnosis of intestinal fistula, but also increased The weight of the small intestine makes it easier to enter the pelvic cavity, which increases the possibility of false positive rate.
2. Synchronized defecation pelvic angiography
Some scholars have found that although there is a contrast agent before oral administration of faecal angiography, there are still some difficulties in the diagnosis of pelvic floor peritoneal hernia. Fenner reported that 5 cases of patients with clinical diagnosis of sigmoid fistula were not confirmed by defecation angiography, and 9 Only 7 patients with sigmoid colon fistula diagnosed with sputum sputum were clinically diagnosed, and Bremmer et al. had significant defecation dysfunction in 22 patients. Patients with gastrointestinal tract stenosis were found to have a wide rectal vaginal interval. Except for 2 cases without peritoneal hernia, the other 20 cases had different degrees of peritoneal hernia, and 9 cases had intestinal tract into the hernia sac. Domestic scholar Zhang Shengben reported the use of synchronous phlebography for pelvic floor angiography. Mucosal phase examination showed obvious hernia sac, the contents of the hernia sac (small intestine or sigmoid colon) and the lower edge of the inguinal hernia reached below the shame line. Rectal pelvic floor peritoneal hernia was accompanied by rectal prolapse or complete rectum. Prolapse, in addition to the pathological Douglas fossa deepening, the prolapsed anterior parietal serosa layer with the prolapse of the full layer of the rectum to form a hernia, in the resting state, the hernia sac can not appear, but forced defecation and defecation Rear The sac is obviously enlarged and deepened, resulting in interruption of defecation. Combined with pelvic floor peritoneal angiography, the mucosal phase can clearly show the hernia sac in the rectal wall. This is a reliable method for diagnosis. Vaginal pelvic floor peritoneal pelvic floor Peritoneal angiography shows that the contrast agent fills the rectal vaginal space, and when the force is discharged, it can reach the perineal body and break into the posterior wall of the vagina.
Diagnosis
Diagnosis and differentiation of pelvic floor peritoneal hernia
diagnosis
There is no typical basis for the diagnosis of this disease. The diagnosis mainly depends on symptoms, double or triple diagnosis, phlebography and synchronous phlebostomy.
Differential diagnosis
Clinical attention should be paid to the identification of cold abscess, hematoma, lipoma, cyst and vaginal and rectal prolapse.
