Introduction
Today, gynecological pathology, which actively influences the level of women's reproductive health, is one of the leading problems for many women around the world [1]. These include various types of incorrect positions of the uterus. This pathology leads to various types of ovarian-menstrual cycle disorders (hypomenorrhea, algomenorrhea), often leads to female infertility, being its etiological uterine factor [2, 3]. It should be noted that abnormal positions of the uterus as such do not always require treatment. If they do not cause subjective complaints and functional disorders, then the abnormal position of the uterus alone is not an indication for treatment. The question of treatment may arise in the presence of symptoms such as pain, frequent and painful urination, urinary incontinence, and menstrual irregularities. Methods of treating abnormal positions of the uterus can be conservative and surgical. The relevance of the issues discussed in this article is due to the fact that today, among the variety of gynecological problems, many women of reproductive age have a special place for abnormal positions of the uterus, especially those formed relative to the horizontal plane [2].
For a better understanding of the essence of the issue studied by the author of this study, I would like to briefly present the main theoretical points of the initial problem that a number of gynecological patients have. The issues of restorative treatment and physical rehabilitation of uterine position disorders along their horizontal axis are the least studied and, in our opinion, are undeservedly little used today both in obstetrics and gynecology, and in medical rehabilitation.
In the physiological and anatomical norm, the fundus of the uterus does not extend beyond the plane of the entrance to the small pelvis and an obtuse angle, open forward, is formed between the body and the cervix. The uterus is tilted slightly forward, due to which its fundus is directed toward the anterior abdominal wall and has a bend between the cervix and the body, forming an obtuse angle open forward. This tilt of the uterus is called versio; under normal conditions, the uterus is tilted forward – anteversio [3]. Thus, the normal position of the uterus in the pelvic cavity corresponds to anteflexio-anteversio. However, with pathological bending, this angle can be acute, open forward (hyperanteflexio) or backward (retroflexio). Of all the types of incorrect positions of the uterus, the most important clinical significance are retrodeviation (posterior displacement, mainly retroflexion) and pathological anteflexion (hyperanteflexion) [3]. There are the following types of displacement of the uterus in the horizontal plane: displacement of the entire uterus (body and cervix) – antepositio, retropositio, dextropositio and sinistropositio, abnormal inclinations of the uterus – retroversio, dextroversio, sinistroversio and pathological bending of the uterus. Displacement of the entire uterus can be in four forms – antepositio, retropositio, dextropositio and sinistropositio [3].
Aim of study
The purpose of this article is to present and analyze the research conducted by the author concerning the practical application of the proposed method of non-drug differentiated restorative treatment for the purpose of rehabilitation of gynecological patients At the beginning of this study, its author had a working hypothesis, the essence of which was as follows: practical application of the methods of therapeutic gymnastics and special gynecological massage, carried out according to the methods proposed by I.I. Benediktov, taking into account the practical recommendations proposed by M.G. Schneiderman, and a set of classes of therapeutic gymnastics/therapeutic physical education, according to the method of D.N. Atabekov, modified by F.A. Yunusov (1985), can be effective in a certain number of gynecological patients as a means of their rehabilitation.
Material and methods
In conducting this study, its author used such research methods as literary and critical analysis of both domestic and foreign, scientific and scientific-methodological literature on the issue under study. Also, in practice, in the studied groups of gynecological patients, with incorrect positions of the uterus, the methods of therapeutic gymnastics and special gynecological massage, carried out according to the methods proposed by I.I. Benediktov, taking into account the practical recommendations proposed by M.G. Schneiderman, and a set of classes of therapeutic gymnastics/therapeutic physical education, according to the method of D.N. Atabekov, modified by F.A. Yunusov (1985), as well as the method of mathematical Statistics. Also, all available medical documentation of the patient, the results of laboratory diagnostics, gynecological examination and ultrasound examination were carefully selected and studied. All patients who took an active part in the study conducted by the author. gave their voluntary, both verbal and written consent to participate in it. All references in the text of this research article are indicated, with a mandatory, strict, place of their borrowing, in order to avoid cases of plagiarism.
Results and discussion
The study on the use of an approximate set of methods for correcting a number of abnormal positions of the uterus was carried out on the basis of and with the assistance of the gynecological department and the women's consultation of the municipal institution "Central City Hospital" in Nova Kakhovka, Kherson region, Ukraine in the period preceding the start of the war in Ukraine, from the beginning of 2022. In the conditions of the antenatal clinic, all patients who took part in the study, after preliminary familiarization with their medical documentation, underwent a general clinical examination, a gynecological examination, and an ultrasound examination. After studying the obtained materials, 3 groups were formed (n=37). All of them were selected after their voluntary consent and explanation of the purpose and methods of the study to the patients.
When conducting courses of gynecological massage, we adhered to the mandatory requirements for its implementation, proposed by I. I. Benediktov [4], taking into account the practical recommendations proposed by Schneiderman M. G. [5]. Also, in the process of correcting incorrect positions of the uterus, taking into account the identified additional pathology, we used exercise therapy complexes, the action of which was aimed not only at correcting the existing pathology, but also at strengthening the muscles of the pelvic floor, perineum, anterior abdominal wall, as well as a set of exercises in isotonic and isometric mode according to the method of Epifanov V. A. (1989) and a set of special exercises for the abdominal muscles and pelvic floor, according to the method of Vasilyeva V. E. (1970), as well as special exercises according to the Kegel method, to strengthen the muscles of the pelvic floor [2, 4, 6, 7].
At the time of the complex of corrective and rehabilitation measures, using gynecological massage, a specially selected type of therapeutic physical culture/gymnastics, all patients had a stable remission of existing chronic inflammatory processes, confirmed by clinical, laboratory and instrumental examination methods. It was taken into account that exercise therapy is indicated in the case of mobile acquired deviations of the uterus, as well as positional anomalies complicated by mild inflammatory adhesions of the genitals with surrounding tissues [8]. During this study, we identified the following types of uterine malpositions:
• The first group (n=12) – retroflexion and retrodeviation of the uterus – in 9 or 75% of gynecological patients; deviation of the uterus to the left or right – in 3 patients - 25%.
• The second group (n=11) – retroflexion and retrodeviation of the uterus – in 7 patients, or 69.60% of gynecological patients; deviation of the uterus to the left or right – in 4 patients, or 38.40%;
• The third group (n=14) – deviation of the uterus to the left or right – in 11 gynecological patients, or 78.57%; retroflexion and retrodeviation of the uterus – in 3 patients – or 38.40%.
Patients in all three groups underwent 20 sessions of gynecological massage, conducted every other day [4]. The cycle of sessions was conducted after the end of menstrual bleeding (in the intermenstrual period). The first session was usually conducted as an introductory diagnostic session and lasted from 5-7 to 10-15 minutes.
In the first group (n=12), there were patients from 22 to 32 years old, the average age was 27.6±1.5 years. Treatment for the existing pathology was 6.4±1.3 years. Retroflexion and retrodeviation of the uterus (retroversion et retrodeviatio submobilis et fixate) were diagnosed in 9 patients (75.00%), deviations of the uterine body to the right or left side (dextra et sinistra lateroversio et flexio) were diagnosed in 3 patients (25.00%). From the anamnesis it was established that this pathology in patients of the first group is associated with the presence in the anamnesis of inflammatory processes of both specific and nonspecific etiology (adnexitis, metritis, metroendometritis), spontaneous and artificial abortions in the early stages of pregnancy.
Also, the patients of this group underwent a course of therapeutic physical training, in the form of a special set of exercises in isotonic and isometric mode according to the method of Epifanov V.A. (1989) [7]. To consolidate the obtained result, the patients were recommended to use a set of therapeutic physical training exercises and special Kegel exercises to strengthen the muscles of the anterior abdominal wall and the muscles of the pelvic floor in the conditions of the therapeutic gymnastics room of the antenatal clinic and/or in the conditions of spa treatment [6, 8]. In the second group (n=11), there were patients from 26 to 33 years old, the average age was 29.3±1.3 years. Treatment for the existing pathology was 4.2±1.2 years. In 8 patients (72.73%), grade I vaginal prolapse was diagnosed - prolapse of the anterior vaginal wall, posterior wall or both at once; in all cases, the walls do not extend beyond the area of the entrance to the vagina. Three patients (27.27%) were diagnosed with stage I uterine prolapse, in which they had a downward displacement of the body of the uterus, but the cervix was in the vagina.
Also, 7 (63.64%) were diagnosed with retroflexion and retrodeviation of the uterus (retroversion et retrodeviatio submobilis et fixate), and 4 (36.36%) patients in this group had an incorrect position of the uterus in the form of its lateral deviations (dextra et sinistra lateroversio et flexio) in relation to the horizontal plane. Exercise therapy was added to the therapy, in the form of a set of special exercises for the abdominal muscles and pelvic floor, according to the method of V. E. Vasilyeva (1970), as well as special exercises according to the Kegel method, to strengthen the pelvic floor muscles [2, 7]. In the third group (n = 14), there were patients from 23 to 32 years old, the average age was 28.2 ± 1.3 years. Treatment for the existing pathology was 5.4 ± 1.6 years. In 11 patients (78.57%), tuboperitoneal infertility was diagnosed against the background of chronic inflammatory processes of the pelvic organs, of specific and non-specific etiology, with the development of an intensive adhesive process, aggravated by the incorrect position of the body of the uterus in the form of its deviations to the side (dextra et sinistra lateroversio et flexio), in 3 (21.43%) patients, the presence of retroflexion and retrodeviation of the uterus (retroversion et retrodeviatio submobilis et fixate) was diagnosed [1, 3, 4].
Gynecological massage sessions in this group were the most intensive (up to 25-30 minutes), which was determined by the presence of numerous adhesions, weakness of the ligamentous apparatus of the uterus and pelvic floor muscles. In this group, additionally, for more intensive development (stretching of adhesions), the initial positions of the patient in the knee-elbow, and especially in the knee-wrist positions were used [5, 8]. Patients in this group were prescribed a course of therapeutic physical training according to the method of D. N. Atabekov, as modified by F. A. Yunusov (1985) [5, 8]. A control gynecological examination and ultrasound examination showed obvious changes in the topography of the uterus and appendages, a decrease in the number of adhesions and adhesions, and strengthening of the pelvic floor muscles was noted. Patients were offered further rehabilitation measures in the conditions of the therapeutic physical training room of the women's consultation and at the sanatorium-resort stage of rehabilitation.
This concludes another original research article, thematically dedicated to non-drug, differentiated, restorative treatment and rehabilitation of gynecological patients, in particular – with different variants of incorrect positions of the uterus.
Conclusions
1. Despite all the apparent benefits of gynecological massage as a means of treatment and rehabilitation in gynecological practice, it must be used in a complex of physical rehabilitation and physiotherapy methods.
2. The approximate complex of methods for correcting incorrect positions of the uterus in the horizontal plane that we have proposed can be offered for practical use at the outpatient and polyclinic and sanatorium-resort stages of rehabilitation in patients of reproductive age with manifestations of vaginal wall prolapse.
3. The methods of non-drug, restorative treatment and rehabilitation proposed by the author of this study can be actively used both at the outpatient and sanatorium stages of rehabilitation in patients with uncomplicated variants of abnormal positions of the uterus.
