Vol 23, No 6 (2021)

This review is addressed to the specialists who treat and correct pathologies of the perianal area and pelvic floor. The pelvic floor area is a space in which the organs of different systems have a common origin and a common framework, therefore they are located in close contact with each other. In view of these features, all specialists working with pelvic floor dysfunction should be aware of the possible combination with disorders from neighboring organs and systems. The article discusses the most urgent and common proctological and urological problems of pregnant women and maternity women, including perineal damage during vaginal childbirth with the development of anal incontinence and urinary incontinence, rectocele, prolapse and prolapse of pelvic organs. The paper presents a detailed description of all anatomical structures involved in the pathological process, as well as their gradual embryonic development. The article presented in details the disorders, which are lying in the base of pelvic organ dysfunctions, from the point of view of modern anatomical data, and discussed different diagnostic protocols and tactical approaches to the choice of treatment. Special attention is paid to the points of interaction of related specialists (urologists and proctologists) and the need for their joint participation in the medical and diagnostic process. Colorectal surgeons should be aware of the frequently associated gynecological pathologies described in this article. The cooperation of related specialists in the field of working with pelvic floor pathology is necessary to exchange experience and improve the quality of care for this category of patients. The article is illustrated with original drawings and clinical examples “before and after”.

The review presents a critical analysis of data on the role of immune factors in the pathogenesis of endometriosis. The research results accumulated by now convincingly demonstrate that an abnormal subclinical inflammatory response and disorders in the immune control system play a significant role in the onset, progression and persistence of endometriosis. In spite of the fact that many studies are concentrates on particular components of immune disorders in the pathogenesis of endometriosis, there is still no overall picture summarizing these data. Further research is needed to find immunological parameters that can be used as markers for clinical use in non-invasive diagnosis of this disease. The search for specific immune markers that could be used for target immunotherapy of endometriosis also remains relevant.

Aim. To compare the vaginal and endometrial microbiome in patients with cesarean scar niche (both in the presence of specific complaints of secondary infertility in combination with a niche with stagnant contents, and in the absence of such).

Materials and methods. The prospective study included 67 female patients of reproductive age who had a uterine scar after caesarean section that met the inclusion criteria. Depending on the presence or absence of clinical complaints of secondary infertility, ultrasound and/or magnetic resonance imaging of the pelvic organs to visualize stagnant content in the projection of the niche, the patients were divided into two groups: group 1 (n=40) – patients with secondary infertility in combination with stagnant contents in the projection of a niche (main group), group 2 (n=27) – patients without clinical complaints, with a formed scar on the uterus, without signs of a niche (control group). All patients underwent a comparative study of the vaginal samples and the endometrial samples. The species and quantitative composition of the microbiome was analyzed using real-time polymerase chain reaction. Statistical research was carried out using the IBM SPSS Statistica v22 software (IBM Corp., USA).

Results. Various microbiological communities were found in the analysis of samples of the vagina and endometrium in patients with stagnant content in the projection of the niche (group 1, main) and without it (group 2, control). Lactobacillus spp. was found most often in vaginal discharge samples (more than 50% of cases) both in group 1 and in group 2, however, their level was statistically significantly higher in group 2 (57.5 and 88.9%, respectively), p=0.005. When comparing endometrial samples from patients of groups 1 and 2, it was revealed that in group 1, in the presence of liquid content in the projection of a niche, opportunistic microorganisms were most often detected (more than 50% of cases): Enterobacteriaceae (65%) p<0.0001, Streptococcus spp. (60%) p<0.0001, Staphylococcus spp. (52.5%) p<0.0001, and Gardnerella spp. (22.5%) p=0.0342 and there was a deficiency of Lactobacillus spp. (25%), on the contrary, in group 2, Lactobacillus spp. prevailed (66.7%) p=0.008. Comparative analysis of vaginal samples and endometrial samples of the niche projection in group 1 revealed the predominance (more than 50% of cases) of Lactobacillus spp. in the vagina (57.5%) p=0.003, on the contrary, in the uterine cavity there is a predominance of opportunistic microbiota, p<0.001. Comparative analysis of vaginal samples and endometrial samples of the uterine cavity in group 2 revealed a statistically significant predominance of Lactobacillus spp. both in the vagina (88.9%) and in the uterine cavity (66.7%), p=0.0497. In patients with secondary infertility associated with the presence of stagnant content in the projection of the niche, compared with the control group, there was a higher alpha-diversity both in the samples of vaginal discharge (Shannon's index 2.017±0.093 vs 1.060±0.044; p=0.0120), and in endometrial samples (Shannon's index 3.448±0.267 vs 1.020±0.040, р=0.00008; Simpson's index 1.109 vs 0.003; p=0.00006). When analyzing beta-diversity, there were no statistically significant differences between groups.

Conclusion. In the structure of the microbiome of the vagina and uterine cavity in women without scar defect on the uterus Lactobacillus spp. predominate. The presence of stagnant content in the projection of a niche is associated with an increase in the frequency and quantitative content of opportunistic microbiota of the uterine cavity, especially Enterobacteriaceae, Streptococcus spp., Staphylococcus spp., Gardnerella spp. Also, in patients with stagnant contents in the projection of the niche, a higher biodiversity was revealed both in the vaginal discharge samples and in the endometrial samples. These results highlight the importance of assessing the endometrial microbiome in women with cesarean section scar, especially those faced with the problem of secondary infertility.

Aim. To determine the role of chronic cervicitis and violations of local immunity of the cervix in the etiology of miscarriage of the first trimester, as well as to justify the necessary scope of examination for timely therapeutic and preventive measures.

Materials and methods. The results of a prospective and retrospective study of 225 women with undeveloped pregnancy who were admitted to a gynecological hospital are presented. All women received microscopic, cultural, and molecular genetic (PCR), studies of vaginal and cervical canal discharge, cytological studies of scrapings from the cervical canal and cervix, studies of the structure of cervical mucus and its immunoglobulin A, and pathomorphological studies of the fetal egg. According to the results of the pathomorphological examination of the abortion material in combination with the clinical data, the examined patients were divided into 2 groups. Group 1 included 95 women with bacterial infection of the fetal egg, group 2 – 90 women with viral infection of the fetal egg. As a control group, 40 women with normal progressive pregnancy were taken, who were admitted for its artificial termination.

Results. Inflammatory diseases of the lower genital organs in the group of women with bacterial infection of the fetal egg are significantly more common than in the group of viral infection of the fetal egg and the control group, and correlate with the results of pathomorphological studies in more than 86.7% of cases. In the group of women with bacterial infection, according to the results of the study of the structure of cervical mucus and the level of secretory IgA, a decrease in local immunity of the cervix was revealed.

Conclusion. The analysis of the research results allows us to confirm the concept of ascending infection of the fetal egg in the bacterial etiology of undeveloped pregnancy, which deserves the practical attention of obstetricians and gynecologists and further study for the timely treatment of at hospital phase dysbiotic and inflammatory diseases of the lower parts of the female genital organs during pregravidar preparation.

Aim. Retrospective assessment of the efficiency and safety of the anti-rhesus Rh (D) immunoglobulin Rhesogam® N in preventing isoimmunization in Rh-negative women during pregnancy.

Materials and methods. An analysis of medical records of 196 Rh-negative patients who received anti-Rh immunoglobulin Rhesogam® N in the period 2019–2021 was performed. The indications for the drug were the aspiration of chorionic villi, amniocentesis and prenatal prophylaxis in women with negative level of anti-Rh antibodies and in the case of Rh-positive husbands.

Results. In total, 227 doses of the anti-rhesus immunoglobulin Rhesogam® N were administered, including those women who underwent invasive procedures (aspiration of chorionic villi, amniocentesis). There were no adverse events, including anaphylaxis or drug-related events. 172 rhesus-positive babies were born. No cases of hemolityc disease of the newborns were reported. Anti-Rh antibodies were not found in their mothers after childbirth.

Conclusion. The study confirmed the efficacy and safety of the antiresus Rh (D) immunoglobulin Rhesogam® N for the prevention of Rh isoimmunization.

Aim. Evaluate the effectiveness of combined treatment and establish the frequency of recurrence of the ovarian endometrioma.

Materials and methods. The prospective observational study evaluating the effectiveness of combined treatment of endometriomas, established the frequency of relapse after treatment. 186 patients with an established diagnosis of endometriosis of the ovaries were monitored, who underwent operative treatment in the volume of laparoscopic cystectomy. 95.0% of patients received anti-relapse hormonal treatment.

Results. Against the background of treatment, positive dynamics were noted: dyspareunia, hyperspolymenorrhea and pre- and postmenstrual bloody discharge were stopped in 98.7% of cases, dysmenorrhea – in 97.4% of cases, chronic pelvic pain – in 94.8% cases. Pregnancy occurred in 11.7% of cases (1.3% of which when using assisted reproduction). The recurrence rate of endometriomas after 2 years was 1.4%, after 3 years – 3.7%.

Conclusion. Combination treatment was effective in reducing the severity or completely cured the symptoms of endometrioid ovarian cysts in 95% of women. The recurrence rate of endometriomas after 2 years was 1.4%, after 3 years – 3.7%.

Aim. To study the effect of deep infiltrative endometriosis on the state of the ovarian reserve in patients of reproductive age, as well as to evaluate the spectrum of mutations in the PIK3CA gene among patients with infiltrative form of external genital endometriosis.

Materials and methods. The main group of the study included 50 patients of reproductive age with deep infiltrative endometriosis, in 18 of whom deep infiltrative endometriosis was combined with ovarian endometriomas. The comparison group included 25 patients of reproductive age who underwent laparoscopic metroplasty of an inconsistent uterine scar from a cesarean section. All patients underwent determination of the level of anti-Müllerian hormone, follicle-stimulating hormone and estradiol in the blood by enzyme immunoassay, as well as counting the number of antral follicles in the ovaries during transvaginal ultrasound examination. The search for activating mutations of the PIK3CA gene was carried out by sequencing a new generation of DNA in tissue samples of ovarian endometriomas in patients with a combination of infiltrative endometriosis and endometrioid ovarian cysts (n=18), as well as in biopsies of healthy ovarian tissue in all patients of the main group (n=50) and comparison groups (n=25).

Results. When assessing the state of the ovarian reserve in the patients of the two groups, it was found that the anti-Müllerian hormone level in the patient with the infiltration form of external genital endometriosis was 2.6±2.2 ng/ml, while in the comparison group it was 3.6±3.5 ng/ml, however, the difference did not reach statistical significance, p>0.05. The number of antral follicles according to transvaginal ultrasound was significantly lower in the main group (8.5±4.5) than in the comparison group (12.2±4.1), p=0.001. This difference was statistically significant both for patients with ovarian endometriomas (6.0±4.2, p<0.001) and for patients without ovarian endometriomas (9.8±4.2, p=0.04). Our study did not reveal PIK3CA gene mutations in any of the ovarian endometrioma tissue samples from patients with a combination of infiltrative endometriosis and endometrioid ovarian cysts, as well as in none of the healthy ovarian tissue biopsies from patients of the main group and the comparison group using the new generation DNA sequencing method.

Conclusion. The presence of deep infiltrative endometriosis is associated with a decrease in ovarian reserve in patients of reproductive age, regardless of the presence of endometrioid ovarian lesions. Population studies are needed to identify mutations of this gene in endometriosis, as well as to study mutations of other genes encoding proteins regulating the antiapoptotic signaling pathway PI3K/AKT/mTOR, to identify the mechanism of ovarian reserve depletion in infiltrative form of external genital endometriosis.

Background. Currently the problem of immunological conflict, due to incompatibility in the ABO system and the development of hemolytic disease (HD) of the newborn, does not lose its relevance. Unlike Rh isoimmunization, with ABO incompatibility, the development of HD of the fetus/newborn is possible during the first pregnancy and there is no specific prophylaxis.

Aim. To establish prognostically unfavorable obstetric predictors in mothers whose newborns had HD according to the ABO system.

Materials and methods. A retrospective cross-sectional study included 40 newborn-mother pairs. The main group consisted of 17 newborns with a confirmed diagnosis of HD according to the ABO system and their mother, the control group included 23 newborns without HD of the fetus according to the ABO system and their mothers. The medical documentation was studied, which made it possible to evaluate the anamnestic, clinical data and contained a full range of general clinical, laboratory, functional research methods.

Results. When assessing the state of the newborns of the main group, it was revealed that mild HD was detected in 58.8±4.2% of cases (icteric form), in 41.2±5.2% – moderate severity (anemic form – 11.8%, icteric form – 29.4%). Reproductive losses in women of the main group were revealed 1.8 times more often than in the control group (38.6 and 20.9%, respectively; p=0.003). In the main group, 75.5% of patients had one or another acute infectious process during pregnancy. Mothers who gave birth to children with hypertension had high titers of antibodies (anti-A) in the blood and there was no correlation with the severity of HD of the newborn.

Conclusion. According to the existing regulatory documents, it is not recommended to routinely examine all pregnant women with blood group 0(I) for the determination of immune antibodies. It is necessary to identify patients at high risk for the development of HD according to the ABO system and send them to the determination of immune anti-A and anti-B antibodies at 36 weeks.

Background. Modern gynecology uses all the latest achievements of other medical, basic natural sciences and medical technologies. However, sexopathology in women with gynecological diseases, due to the complexity of etiopathogenesis, remains poorly understood.

Aim. Development of a diagnostic algorithm and identification of the structure of sexual disorders (SD) in chronic salpingo-oophoritis (CSO).

Materials and methods. We examined 100 gynecological patients aged 18–38 (on average 27.3±1.2) years with a diagnosis of CSO (N70.1 according to ICD-10), 67% of whom had sexual dysfunctions. Research methods: clinical-psychopathological, psychometric, experimental-psychological, sexological, gynecological, statistical.

Results. SD which are present in 67% of women with CSO, are more often (40.3%) of a mixed nature. Neurotic disorders are represented by somatoform (F45) – 29.9%; anxiety-phobic (F40) – 22.4%; conversion (F44) – 14.9% disorders and neurasthenia (F48.0) – 7.5%.

Conclusion. The severity of the course of CSO does not always correspond to the level of manifestations of sexual dysfunction; the predominant sexual dysfunction is dyspareunia (54%). Somatogenic asthenia, which according to ICD-10 refers to mental disorders, is reduced by purely somatic (gynecological) therapy. The tactics of gynecologists to identify sexual dysfunctions in women with gynecological diseases have been determined. An in-depth analysis of SD in CSO has been carried out in two main directions (“sexo” ↔ “gyneco”) in the domain of science (“logy”) as a variant of the modern biopsychosocial model proposed in ICD-11.

Uterine leiomyoma, along with endometriosis, occupies a leading position in the structure of gynecological diseases associated with hyperproliferation. The disease can negatively affect the reproductive potential, gynecological health, somatic status and quality of life of women. The only radical "cure" for the disease is hysterectomy. Therefore, clinical research and assessment of the effectiveness of drug therapy for uterine leiomyoma is one of the most important tasks of modern gynecology, primarily for the health improvement of young women striving to preserve reproductive function. From the point of view of world demography (declining birth rates in the world and depopulation in European countries), the search for new pharmacological agents for the treatment of fibroids is not only a medical problem, but also a global socio-economic problem

The authors have described a clinical case of a spontaneous pregnancy in a patient with decreased ovarian reserve, secondary infertility and a history of an in vitro fertilization failure. Based on literature data and their own experience, the authors believe that intraovarian administration of platelet-rich plasma can increase the ovarian reserve and improve reproductive potential.

To carry out a systematic analysis of the data available in the modern literature on the pathogenesis of the formation of vaginal prolapse with the formation of rectocele rectum. The failure of the pelvic floor, namely its posterior compartment with the formation of a rectocele against the background of the lowering of the posterior vaginal wall, continues to be one of the most common gynecological diseases. This article presents an analysis of current literature data on the pathogenesis of pelvic organ prolapse with the formation of rectocele. Analyzing the above-mentioned data, it can be noted that the research data of recent years have significantly expanded the understanding of the etiology and pathogenesis of pelvic organ prolapse in its posterior compartment. However, the issues of etiology and pathogenesis of genital prolapse in patients of reproductive age, the role of individual risk factors and their combinations, pathogenetic mechanisms of development are still far from being resolved. Unfortunately, none of the above theories fully explains all the reasons for the formation of pelvic organ prolapse in its posterior compartment.