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},
"code": "N80.1",
"name": "Эндометриоз яичников",
"icd_name": "Эндометриоз яичников",
"gender": 0,
"age_min": 1,
"age_max": 100,
"cause": [],
"periodicity": 1,
"slug": "n80.1_endometrioz_yaichnikov",
"lead": "заболевание, при котором слизистая оболочка матки (эндометрий) разрастается в других отделах организма, где его в норме не бывает",
"description": "",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Разрастанию эндометриоидных очагов в овариальной ткани предшествует занос клеток эндометрия в малый таз. Хотя окончательно этиопатогенез заболевания не установлен, выявлен ряд факторов, повышающих вероятность развития эндометриоза. Основными из них являются:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Воспаление и неоплазии половых органов. При цервиците, эндометрите, сальпингите, аднексите, объемных новообразованиях тела и шейки матки может нарушаться выведение менструальной крови во влагалище и происходить ее ретроградный заброс.</span></li>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Иммунные нарушения. В норме клетки эндометрия, попавшие в полость таза, уничтожаются макрофагами. К снижению такого иммунного ответа приводят генетическая предрасположенность, аутоиммунные заболевания, ослабление защитных сил при хронических заболеваниях и приеме иммуносупрессивных препаратов.</span></li>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Инвазивные вмешательства. Клетки эндометрия могут попасть в тазовую полость во время аборта, гинекологических операций, диагностического выскабливания, гистеросальпингографии, других лечебных и диагностических процедур, при использовании ВМС на протяжении 5 лет и более.</span></li>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Эндокринные нарушения. Дисгормональные расстройства при заболеваниях яичников, щитовидной железы, коры надпочечников, сбои на гипоталамо-гипофизарном уровне влияют на сократительную активность фаллопиевых труб. В результате повышается риск ретроградного заброса менструальной крови.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">В группу риска также входят женщины, которые ведут малоподвижный образ жизни, страдают ожирением, нерационально питаются, часто испытывают стрессы. Заболевание чаще диагностируют у пациенток с нарушениями овариально-менструального цикла в подростковом возрасте, нереализованной детородной функцией или поздней первой беременностью. Развитию воспалительных процессов, на фоне которых возникает эндометриоз, способствует неразборчивость в выборе половых партнеров и секс без барьерных контрацептивов.</span></p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Если клетки эндометрия, которые попали в таз с ретроградным забросом менструальной крови не были уничтожены макрофагами, появляется возможность их внедрения в ткань яичников. Сначала эндометриодные очаги имеют небольшие размеры и располагаются поверхностно. В последующем эндометриоз поражает все большую площадь яичника и распространяется вглубь тканей. Клетки эндометриоидных разрастаний подвержены тем же циклическим изменениям, что и слизистая матки. Последовательно происходящие пролиферация, секреция и отторжение формируют характерные анатомические изменения и клиническую картину болезни.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">В яичниках образуются множественные кисты, размеры которых увеличиваются с каждым менструальным циклом. Из-за неполной резорбции в них накапливается свернувшаяся кровь, которая имеет характерный «шоколадный» цвет. Распространение процесса на фолликулярную ткань приводит к нарушению эндокринной функции. Регулярное поступление крови в полость малого таза становится причиной образования спаек между яичниками и расположенными рядом органами.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">На первичном приеме доктор выслушивает жалобы больной и собирает анамнез заболевания: уточняет время появления симптомов, их особенности и продолжительность, спрашивает о перенесенных болезнях, наличии хронических патологий, узнает, нет ли эндометриоза у мамы или бабушки. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">После беседы проводят гинекологический осмотр в кресле. Определить наличие кист на яичниках можно при помощи пальпации. Пораженные железы увеличиваются в размере, становятся плотными, болезненными на ощупь.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Для объективной диагностики назначают:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Анализ крови на онкомаркер СА-125 – при эндометриозе его уровень увеличивается в 1,5 раза.</span></li>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">УЗИ органов малого таза (чаще трансвагинальным методом) – скрининг показывает неровные контуры яичника, наличие поверхностных полых очагов. Ультразвук выявляет спаечные образования, жидкость в полости таза.</span></li>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">МРТ назначают при недостаточной информативности сонографии, для определения степени запущенности процесса.</span></li>\r\n<li><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Лапароскопия диагностическая – эндоскопическое оборудование позволяет увидеть кисты, точно определить их расположение, характер поражения, сопутствующие патологические процессы.</span></li>\r\n</ul>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Консервативная терапия</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выбор схемы лечения зависит от возраста женщины, ее репродуктивных планов, выраженности клинических проявлений и степени распространения процесса. Если заболевание протекает бессимптомно и выявлено случайно, рекомендуется динамическое наблюдение с осмотром гинеколога и проведением УЗИ 2 раза в год. Пациенткам с эндометриомами диаметром до 40 мм показана медикаментозная терапия:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Гормональные препараты. Женщинам, которые планируют беременность, назначают прогестины и комбинированные оральные контрацептивы. В период перименопаузы также могут применяться агонисты гонадолиберинов, андрогены, ингибиторы ароматаз.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Анальгетики. Выраженный эндометриоз-ассоциированный болевой синдром является показанием для назначения нестероидных противовоспалительных и других обезболивающих препаратов.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Седативные средства. При наличии сопутствующих эмоциональных расстройств эффективны успокоительные растительные экстракты, препараты магния и др.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Сочетание фармакологической и физиотерапии уменьшает интенсивность боли, улучшает результаты медикаментозного лечения, снижает риск образования спаек. При эндометриозе показаны электрофорез магния, витаминов В1 и Е, чрескожная электростимуляция нервов, магнитотерапия и импульсное лечение.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Хирургическое лечение</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При наличии эндометриоидных кист диаметром 40 мм и больше, неэффективности медикаментозных средств, стойком и выраженном болевом синдроме, бесплодии рекомендовано оперативное лечение. В зависимости от размеров эндометриом показаны следующие вмешательства:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Энуклеация кист. Выполняется через лапароскопический доступ для удаления небольших по размеру образований. С помощью специального зонда оболочка кисты расслаивается, после чего эндометриома вылущивается.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Лапароскопическая лазерная и электрокоагуляция. Эндометриоидные разрастания на яичниках могут прижигаться, что приводит к деструкции и остановке роста гетеротопий.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Резекция или удаление яичников. При значительном поражении овариальной ткани орган удаляется частично или полностью. С учётом объема вмешательства выбирается лапароскопический или лапаротомический доступ.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">После операции рекомендовано назначение курса гормональной терапии.</span></p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"prevention": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Для профилактики эндометриоза рекомендовано воздерживаться от тяжелых физических нагрузок во время менструации, использовать барьерные методы контрацепции, планировать наступление беременности, регулярно посещать гинеколога (особенно при наличии предрасполагающих факторов)</span></p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">На начальном этапе эндометриоидные образования на яичнике никак себя не обнаруживают. Первые 5-7 лет заболевание имеет латентное течение, без симптомов. По мере прогрессирования патологии появляются клинические проявления: боль, нарушение месячных и репродуктивной функции. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Болевой синдром локализуется в нижней части живота, распространяется на паховую область, поясницу, отдает в крестец, прямую кишку. Болезненность появляется при дефекации, мочеиспускании, усиливается во время полового акта. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В межменструальный период болевые ощущения носят тянущий, ноющий характер. По мере приближения месячных боли становятся режущими и более сильными. При длительном течении эндометриоза яичников болезненность присутствует постоянно, становится хронической. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Большие кисты давят на соседние органы малого таза, благодаря чему клиническую картину дополняют: </span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">вздутие живота на фоне усиленного газообразования;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">нарушение работы кишечника – запоры;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">частые позывы к мочеиспусканию;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">болевые ощущения в нижних конечностях;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">при сдавливании нервных стволов появляются симптомы поясничного радикулита: люмбаго (приступы сильной боли в поясничном отделе позвоночника), прострелы в бедро.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выраженные изменения на железах приводят к изменениям менструальной функции. Продолжительность месячных увеличивается, они становятся обильными и болезненными. За несколько дней появляются мажущие выделения. Некоторые больные во время менструации жалуются:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">на слабость, головокружение;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">тошноту, рвоту;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">небольшое повышение температуры тела, озноб.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Гормональные сбои делают женщину подавленной, раздражительной, плаксивой. Она не может спокойно спать, страдает от бессонницы. Эндокринные нарушения ухудшают состояние кожи. Дряблость, сухость кожного покрова, появление угрей – одни из симптомов эндометриоза яичников.</span></p>\r\n<p> </p>",
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"name": "Эндометриоз кишечника",
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"description": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Эндометриоз кишечника — это заболевание, при котором в кишечнике разрастаются ткани внутренней слизистой оболочки матки.</span></p>",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Точная причина эндометриоза неизвестна, болезнь возникает при одновременном воздействии нескольких факторов. В последние годы обсуждается возможная роль в развитии эндометриоза генетических мутаций, стволовых клеток, факторов внешней среды и гормональных расстройств, например избытка эстрогена и дефицита прогестерона.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">К факторам риска относятся:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">раннее начало менструаций (в 11 лет и ранее);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">непродолжительный менструальный цикл (менее 26–27 дней);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">низкий вес при рождении;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">ожирение;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">гормональные нарушения;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">случаи эндометриоза в семье, например, у мамы или сестры;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">хронические заболевания органов малого таза: эндометрит, сальпингит и сальпингоофорит </span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Существуют несколько теорий возникновения эндометриоза:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Имплантационная теория — при менструации часть клеток эндометрия не выходит из полости матки, а попадает через маточные трубы в брюшную полость. Если они не погибают, то остаются на поверхности внутренних органов, в том числе и кишечника.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Превращение нормальных клеток брюшной полости в эндометрий — клетки в очагах эндометриоза появляются не из полости матки, а превращаются из нормальных клеток брюшины, так как они имеют общую клетку-предшественника.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Эмбриональная теория — клетки в очагах эндометриоза являются остатками зародышевых тканей, которые в норме полностью исчезают при внутриутробном развитии. При эндометриозе эти клетки по неизвестным причинам сохраняются и начинают расти под действием стимулирующих факторов, например высокого уровня эстрогенов в определённые дни цикла.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При обследовании учитывается цикличность клинических проявлений, а также наличие эндометриоза в анамнезе. Для диагностики существует целый ряд обследований. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Во время гинекологического осмотра возможно обнаружение эндометриоидных очагов, в ходе бимануального влагалищного обследования можно выявить наличие спаек и деформаций матки. </span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Важное значение имеют эндоскопические методики: колоноскопия и ректороманоскопия, а также МРТ-обследование. Для уточнения распространенности процесса назначается УЗИ, томография.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Одним из эффективных методов диагностики является лапароскопия, в ходе которой можно взять биоптат для гистологического исследования — одной из самых точных диагностических методик и сразу удалить эндометриодный очаг.</span></p>\r\n<p><span id=\"docs-internal-guid-ffd94c24-7fff-1afe-08b9-44762bbe06da\"> </span></p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">На ранних стадиях заболевание лечится консервативными методами с подбором индивидуальной схемы лечения, где учитывается сопутствующая патология, стадия эндометриоза, возраст больного и его состояние. Пациентке следует быть готовой к тому, что лечение будет продолжаться длительное время. В схемах лечения обязательно используют:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #4d5d65; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">гормональные, противовирусные препараты и антибиотики;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #4d5d65; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">иммуностимуляторы и иммуномодуляторы;</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 6.5pt; font-family: Verdana; color: #4d5d65; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">физиотерапевтические процедуры.</span></p>\r\n</li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Если использование данных препаратов в течение 6 месяцев не дает результатов и улучшения состояния, а эндометриоз прогрессирует, то специалисты рекомендуют хирургические методы лечения.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Если эндометриоидным процессом задета вся стенка кишки, то хирургическому удалению подлежит матка с придатками, а также другие органы с эндометриозом, в том числе и кишечник. Оперативная тактика по его удалению зависит от протяженности поражения и варьирует от частичной резекции стенки до полного удаления всего отдела кишечника, пораженного эндометриозом.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Удаление эндометриоидных очагов производится различными способами. При поверхностных очагах используется лазерная абляция (разрушение), электро- и термокоагуляция, при более глубоких поражениях — механическое вырезание (эксцизия — полное удаление, резекция — неполное удаление) и комбинация перечисленных методов. Наиболее эффективной считается эксцизия (вырезание) пораженных участков до границы со здоровой тканью. Этот метод позволяет производить также гистологическое исследование удаленной ткани для подтверждения диагноза. Но такой подход трудно использовать во всех случаях из-за риска кровотечения и угрозы ранения жизненно важных органов.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Наиболее часто для удаления эндометриоидных очагов используется электрокоагуляция и электроэксцизия, при которых ткани плавятся и режутся электрическими инструментами. При необходимости удаления больших узлов, фрагментов тканей и отдаленном расположении пораженных участков от жизненно важных органов используется монополярная электрохирургия. В случаях близкого расположения кишечника, мочевого пузыря, мочеточников, прямой кишки биполярная электрохирургия является более безопасной. При этом методе риск поражения окружающих тканей практически отсутствует. Поверхностные небольшие очаги также удобнее удалять биполярными электроинструментами.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">После хирургического лечения больной в течение полугода необходимо принимать противорецидивную терапию.</span></p>",
"prevention": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Специфическая профилактика эндометриоза не разработана.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">К факторам, которые предположительно снижают риск развития эндометриоза, относятся:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">приём комбинированных оральных контрацептивов (длительность зависит от репродуктивных планов пациентки);</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">наличие беременностей и родов;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">приём НПВС и анальгетиков при болях во время менструации;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">длительное грудное вскармливание.</span></li>\r\n</ul>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Эндометриоз кишечника практически всегда сочетается с другими формами эндометриоза, поэтому их симптомы схожи.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Заподозрить заболевание можно при следующих признаках:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">обильные и болезненные менструации — боль не исчезает или почти не уменьшается при приёме комбинированных оральных контрацептивов (КОК) и нестероидных противовоспалительных препаратов (НПВП);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">нерегулярные менструации и скудные кровянистые выделения до и после менструации (более двух дней);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">боль при половом акте и кровотечение после него;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">бесплодие;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">диарея, запор, тошнота, боли при дефекации, спазмы в кишечнике, вздутие живота;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">раннее насыщение — чувство, что желудок переполняется сразу после начала приёма пищи;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">частые мочеиспускания с болью или без неё, особенно в период менструации;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">эндометриоидные кисты в малом тазу</span></li>\r\n</ul>\r\n<p> </p>\r\n<p><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\"> </span></p>",
"image": null,
"image_alt": null,
"standard_type": 0,
"danger": 1,
"published": 1,
"parent": 6928,
"block_rubric": 156,
"standards": []
},
{
"id": 13061,
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"lead": "дивертикулоподобное выпячивание стенки прямой кишки в сторону влагалища (переднее ректоцеле) и/или по задней полуокружности кишки (заднее ректоцеле)",
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"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Основной фактор, который способствует появлению переднего ректоцеле, это ослабленная ректовагинальная перегородка и мышцы тазового дна.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Выделяют и другие причины, среди которых:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">слабые мышцы тазового дна, ректовагинальной перегородки, которые являются истонченным внутриутробно;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">разрывы или разрезы промежности при родовой деятельности, роды большого плода;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">хронически повышенное внутрибрюшное давление из-за нарушенной работы желудочно-кишечного тракта или чрезмерных физических нагрузок;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">функциональные нарушения анальных сфинктеров;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">возрастные дистрофические изменения сфинктеров, мышц тазового дна и ректовагинальной перегородки;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">острые и хронические формы заболевания половых органов у женщин;</span></li>\r\n<li><span style=\"font-size: 7pt; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">последствия гистероктомии или удаления матки.</span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">У молодых девушек ректоцеле диагностируют после родовой деятельности, после аборта или выкидыша. Причиной развития становится и врожденная слабость ректовагинальной перегородки и тазовых мышц.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">У женщин после климакса ректоцеле развивается после многочисленных родов, возрастных изменений, проблем с кишечником.</span></p>",
"pathogenesis": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Ректоцеле представляет собой состояние, при котором часть прямой кишки выпячивается в сторону влагалища и постепенно пролабирует его стенку, образуя мешкообразный карман, в котором задерживаются фекальные массы. Выпячивание прямой кишки является причиной расстройства акта дефекации и развития тяжелых запоров. Пациентке с ректоцеле приходится сильнее тужиться, чтобы опорожнить кишечник. Давление в кишке во время дефекации все больше возрастает, это влечет за собой увеличение выпячивания и дальнейшее прогрессирование патологии.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В конечном итоге ректоцеле достигает степени, при которой эффективность консервативных мероприятий все больше снижается, единственным способом восстановить нормальные анатомические взаимоотношения между органами малого таза и наладить акт дефекации становится оперативное вмешательство.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Диагноз ректоцеле выставляют с учетом характерной симптоматики, данных осмотра промежности и перианальной области, гинекологического исследования, ректального исследования, эндоскопии и радиологических диагностических методик. При осмотре области ануса у больных ректоцеле могут выявляться анальные трещины и увеличенные геморроидальные узлы. При недержании кала в области анального отверстия видны следы фекальных масс и участки раздражения. При проведении гинекологического и ректального исследования пациентку с ректоцеле просят натужиться. При натуживании стенка кишки выпячивается во влагалище. Врач определяет размер и расположение выпячивания (высокое, среднее, низкое), отмечает наличие либо отсутствие содержимого ректоцеле (кал, каловые камни) оценивает толщину влагалищной перегородки и состояние мышц тазового дна.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В процессе ректороманоскопии у больных ректоцеле обнаруживается характерный карман в области передней стенки прямой кишки. Для более точной оценки выраженности расстройства акта дефекации и степени ректоцеле назначают дефекографию (эвакуаторную проктографию). Густую бариевую взвесь вводят в кишку, а потом выполняют серию снимков во время акта дефекации. Иногда радиологическое исследование заменяют магнитно-резонансной дефекографией. </span></p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Лечение заболевания 1 степени консервативное. При 2 и 3 степени патологии используются комбинированные методики, включающие в себя хирургическое вмешательство, пред- и послеоперационные консервативные мероприятия, направленные на устранение запоров, восстановление кишечной перистальтики и улучшения эвакуации содержимого из прямой кишки. Обязательной частью лечения ректоцеле является диета, предусматривающая увеличение количества грубой растительной клетчатки (для стимуляции моторной функции кишечника) и достаточное количество воды (для обеспечения мягкости фекальных масс).</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Для восстановления регулярности акта дефекации больным ректоцеле назначают мягкие слабительные средства осмотического действия. Для коррекции состава кишечной микрофлоры применяют комбинированные пробиотики. Для нормализации моторной функции кишечника используют прокинетики (домперидон и его аналоги). Медикаментозную терапию ректоцеле дополняют физиопроцедурами и специальными комплексами ЛФК, направленными на укрепление мышц тазового дна.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Консервативная терапия позволяет замедлить развитие болезни, но не может обеспечить полное выздоровление. Единственным радикальным способом лечения ректоцеле является операция. Все хирургические вмешательства при данной патологии можно разделить на две группы: направленные на устранение кармана, образованного прямой кишкой, и имеющие целью укрепление перегородки между влагалищем и прямой кишкой. Для коррекции ректоцеле используется доступ через влагалище, прямую кишку, промежность либо переднюю брюшную стенку.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В процессе операции врач ушивает и фиксирует переднюю стенку кишки, осуществляет укрепление ректовагинальной перегородки и проводит мероприятия по восстановлению сфинктера. При комбинированной патологии, наряду с ректоцеле включающей в себя геморрой, трещину заднего прохода, цистоцеле либо полипы прямой кишки, выполняют комбинированное хирургическое вмешательство, направленное на устранение всех имеющихся нарушений. Операции могут проводиться как традиционным способом, так и с использованием эндоскопического оборудования.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">В ходе лечебной эндоскопии больной ректоцеле устанавливают сетчатый имплантат, укрепляющий ректовагинальную перегородку и препятствующий выпячиванию прямой кишки во влагалище. В пред- и послеоперационном периоде назначают ЛФК, физиотерапию, пробиотики и прокинетики. При наличии противопоказаний к оперативному вмешательству пациенткам с 2 и 3 степенями ректоцеле рекомендуют использовать пессарий – специальное приспособление, которое вводят во влагалище для поддержания правильного положения органов малого таза.</span></p>",
"prevention": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Чтобы предупредить развитие болезни и избежать осложнений, следует соблюдать профилактические меры:</span></p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">избегайте расстройств желудочно-кишечного тракта, ходите в туалет при появлении позывов, не тужьтесь при испражнении;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">следите за своим весом — стремительное ожирение либо потеря веса способствует появлению пролапса;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">следите за рационом и употребляйте продукты с высоким содержанием клетчатки;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">не занимайтесь самолечением и вовремя диагностируйте воспалительные и инфекционные заболевания желудочно-кишечного тракта;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">исключите подъем тяжестей;</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">укрепляйте мышцы тазового дна и промежности.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Женщинам следует каждых полгода посещать гинеколога даже при отсутствии жалоб. При беременности, после абортов и после родовой деятельности советуют посещать профилактический осмотр чаще.</span></p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Проблемы и степень дискомфорта изменяются в зависимости от стадии заболевания:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">На первой стадии больные жалуются на затрудненную дефекацию, которая возникает периодически. Появляется оно из-за того, что каловый комок попадает в выпячивание и остается в нем, несмотря на усиленные потуги. Справиться с проблемой помогает очистительная клизма и прием слабительных препаратов, однако проблема не исчезает, а болезнь прогрессирует.</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">На второй стадии у больных появляется ощущение неполного опорожнения кишечника из-за того, что каловые массы задерживаются в выпячивании прямой кишки в больших объемах. Для полного опорожнения прямой кишки необходимо двухэтапная дефекация, а иногда и дополнительные манипуляции — нажатие на промежность или выталкивание калового кома рукой через заднюю стенку влагалища. Периодически могут беспокоить распирающие боли в прямой кишке, внизу живота или промежности, так как застой кала провоцирует воспалительные процессы в дистальном отделе толстой кишки. Из-за необходимости долго и сильно тужиться возникают сопутствующие проблемы — геморрой, анальные трещины, криптит. При ректоцеле 2 степени сложно обойтись без слабительных препаратов.</span></li>\r\n<li><span style=\"font-size: 7pt; color: #000000; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">При ректоцеле 3 степени описанные ранее симптомы дополняются выпадением части прямой кишки во влагалище и из половой щели. Больные жалуются на ощущение инородного предмета в половых путях, многочисленные ложные позывы к опорожнению прямой кишки. У них регулярно возникают инфекции половых путей, развивается опущение матки, недержание мочи. На этом этапе слабительные средства не помогают облегчить дефекацию, женщине приходится помогать процессу выхода калового кома надавливаниями на выпячивание.</span></li>\r\n</ul>",
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},
"code": "N82.0",
"name": "Пузырно-влагалищный свищ",
"icd_name": "Пузырно-влагалищный свищ",
"gender": 0,
"age_min": 25,
"age_max": 100,
"cause": [
"0"
],
"periodicity": 1,
"slug": "n82.0_puzyrno-vlagalischnyy_svisch",
"lead": "патология, характеризующаяся образованием аномального сообщения между влагалищем и мочевым пузырем",
"description": "",
"etiology": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Сообщение между мочевым пузырем и влагалищем возникает вследствие разрушения стенок органов при травмах и патологических процессах в полости малого таза. Специалисты в сфере гинекологии и урологии выделяют несколько групп травматических, воспалительных и деструктивных причин, приводящих к формированию мочепузырно-влагалищных свищей. Основными из них являются:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Гинекологические оперативные вмешательства. До 70% пузырно-вагинальных фистул становятся следствием гистерэктомии при доброкачественных фибромиомах матки. К их формированию также приводят непредумышленные повреждения при кесаревом сечении, хирургическом лечении эндометриоза, рака матки, других заболеваний тазовых органов.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Патологические роды. Длительное сдавливание мягких тканей родовых путей при затяжных родах, вторичной слабости родовых сил, прохождении крупного плода, узком тазе матери вызывает ишемический некроз с последующим образованием свищевого хода. Травматические повреждения возникают при неправильном наложении щипцов и разрывах тканей.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Случайные травмы. В небольшом количестве случаев пузырно-генитальные свищи формируются после травматических разрывов тканей из-за ДТП, несчастных случаев на производстве и быту, изнасилований. Возможна перфорация стенок влагалища, мочевого пузыря во время мастурбации с введением в вагину или уретральный канал острых предметов.</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Онкологические заболевания репродуктивных органов. Стенки вагины, мочевого пузыря могут разрушаться из-за прорастания опухолью при раке шейки матки, влагалища, других злокачественных новообразованиях. Одними из наиболее сложных для лечения считаются фистульные ходы, образовавшиеся после лучевой терапии онкологической патологии.</span></li>\r\n<li><span id=\"docs-internal-guid-07c1b21f-7fff-2001-b262-2caf1f916bdc\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">Воспалительные процессы. Во влагалище, мочевой пузырь могут прорываться абсцессы малого таза с образованием свищей. Свищевые ходы между этими органами появляются вследствие повреждения их стенок при некоторых инфекционных болезнях — венерической лимфогранулеме, шистоматозе, актиномикозе, туберкулезе мочевыделительных органов.</span></span></li>\r\n</ul>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>",
"pathogenesis": "<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Начальным этапом образования пузырно-вагинальных свищей становится перфорация тканей, которые разделяют влагалище и мочевой пузырь. Если такое повреждение не было вовремя замечено и ушито, существующая разница давлений между органами и постоянное подтекание мочи не позволяют отверстию зарубцеваться. В результате за 7-14 дней возникает фистульный ход, выстланный эпителиальной тканью. Ситуация усугубляется при наличии воспалительных или деструктивных процессов в области свищевого канала. В 65-66% случаев мочепузырно-влагалищные фистулы проявляются в первые 10 дней после травмы, а окончательно формируются за 3-5 месяцев.</span></p>",
"diagnostics": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Диагностику мочеполовой фистулы осуществляет акушер-гинеколог или уролог. Пациентке назначают ряд исследований, который включает:</span></p>\r\n<ul>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">общий анализ крови;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">общий анализ мочи;</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">цистоскопию (эндоскопический осмотр мочевого пузыря);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">кольпоскопию (инструментальный гинекологический осмотр);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">экскреторную (внутривенную) урографию (рентген мочевыделительной системы с контрастом);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">ретроградную цистографию (рентген мочевого пузыря с контрастом);</span></li>\r\n<li><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">КТ и МРТ органов малого таза и др.</span></li>\r\n</ul>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Для дифференцирования диагноза и выявления сопутствующих патологий также могут назначаться дополнительные исследования (УЗИ органов малого таза и почек, вагинография (рентген влагалища) с контрастом и др.), консультации нефролога и онколога.</span></p>",
"treatment": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Медикаментозных методов терапии расстройства не предложено. Самопроизвольное заживление фистулы, соединяющей вагину с мочевым пузырем, наблюдается у 2-3% больных женщин при небольшом размере свищевого отверстия. Ускорению процессов регенерации в подобных случаях способствует отвод мочи с помощью постоянного уретрального катетера. У некоторых пациенток эффективной оказывается коагуляции краев свища электротоком или препаратами серебра со стороны влагалища или мочевого пузыря. В остальных случаях рекомендовано одно из хирургических вмешательств по восстановлению поврежденной стенки влагалища.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">П</span><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-style: normal; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">о мнению большинства урогинекологов, наиболее оправдана отсроченная фистулопластика, которая выполняется спустя 4-6 месяцев после образования свища. За это время максимально стихают воспалительные процессы, вызванные травмирующим воздействием, может быть проведена качественная предоперационная подготовка — удалены лигатурные камни, санированы мочевой пузырь и влагалище, восстановлено кровоснабжение тканей. При выборе конкретной техники учитывают размеры и место расположения свища, наличие рубцовых изменений, удаленность от устьев мочеточников, эластичность влагалищных стенок. Наиболее распространены:</span></p>\r\n<p> </p>\r\n<ul style=\"margin-top: 0; margin-bottom: 0; padding-inline-start: 48px;\">\r\n<li style=\"list-style-type: disc; font-size: 8pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Влагалищное иссечение свища. Операция отличается физиологичностью, малой травматичностью, сохранением целостности мочевого пузыря, более простым способом ушивания фистульного хода, сравнительно быстрым выздоровлением и отсутствием тяжелых осложнений. Метод показан для иссечения небольших неосложненных свищей при хорошей подвижности и растяжимости тканей влагалища. Ограничениями для проведения таких операций служат грубые рубцовые изменения вагины и глубокое залегание фистульного канала, при устранении которого может повредиться интравезикальный участок с устьями мочеточников.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 8pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Трансабдоминальное иссечение свища. Закрытие дефекта через разрез передней брюшной стенки и мочевого пузыря показано при наличии больших по размеру фистул, вовлечении мочеточников, обнаружении комбинированных свищей, сопутствующей кишечной патологии. При более высокой травматичности преимуществами способа считаются хороший доступ и достаточный обзор для эффективного удаления измененных тканей, сохранение нормальной уродинамики после операции, возможность ликвидации даже сравнительно больших и сложных дефектов с качественным ушиванием вовлеченных органов.</span></p>\r\n</li>\r\n<li style=\"list-style-type: disc; font-size: 8pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre;\" dir=\"ltr\">\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Реконструктивная пластика. Наиболее сложными являются операции по восстановлению целостности пузырно-влагалищной перегородки после радиотерапии. У таких пациенток ткани, окружающие свищ, фибротизированы, неэластичны, имеет ограниченную васкуляризацию и плохо заживают. Дефект закрывают методом тканевой интерпозиции трансплантатом — фрагментом тонкой или малой мышцы бедра, фиброзно-жировым лоскутом из большой половой губы, брюшиной, серозно-мышечным кишечным лоскутом, сегментом сальника или желудочной стенки. Операция требует тщательной подготовки во избежание рецидива.</span></p>\r\n</li>\r\n</ul>",
"prevention": "<p><span id=\"docs-internal-guid-48aeccb6-7fff-f246-0e45-787b44a4ec6a\"><span style=\"font-size: 7pt; font-family: Verdana; background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;\">В целях профилактики расстройства рекомендованы регулярные осмотры у гинеколога для раннего выявления заболеваний, требующих хирургического лечения, своевременная постановка на учет для снижения риска осложнений в родах, бережное ведение родов, технически точное выполнение гинекологических, урологических операций.</span></span></p>",
"clinical_picture": "<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Заболевание характеризуется постоянным непроизвольным выделением мочи из влагалища. При этом самостоятельное мочеиспускание отсутствует полностью, а при небольшом размере свища сохраняется незначительно. Количество непроизвольно подтекаемой жидкости может быть различным: от нескольких капель с сохранением самостоятельного мочеиспускания до тотального выделения мочи только через влагалище. Характер мочеиспускания зависит, в первую очередь, от размера и локализации свища.</span></p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">Пациентки могут замечать непроизвольное выделение мочи сразу после операции или в течение ближайших месяцев. Иногда перед появлением подтекания мочи возникает боль внизу живота, гематурия, повышается температура тела, мочеиспускание становится частым и болезненным. После формирования свища эти симптомы проходят.</span></p>\r\n<p> </p>\r\n<p style=\"line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;\" dir=\"ltr\"><span style=\"font-size: 6.999999999999999pt; font-family: Verdana; color: #000000; background-color: transparent; font-weight: 400; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;\">При длительном истечении мочи кожа наружных половых органов и внутренней поверхности бёдер пропитывается жидкостью и набухает. Также пациентки отмечают неприятный запах и боли в области мочевого пузыря, а при появлении язв и очагов некроза — болезненность и невозможность половых контактов.</span></p>",
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