Pain in the perineum as a reason to visit a urologist

What is femoral nerve neuritis? How is the femoral nerve structured, what functions does it perform in the body? Why does the disease occur? Modern methods of treatment.

Our expert in this field:

Lashch Natalia Yurievna

Neurologist of the highest category, candidate of medical sciences, associate professor. Laureate of the Moscow City Prize in the field of medicine.

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The femoral nerve is a fairly large nerve of the leg. It is mixed in function, that is, it contains both motor and sensory nerve fibers. With the development of the inflammatory process - neuritis - their functions are disrupted.

The main causes of femoral neuritis:

• Poisoning with certain substances.
• Diabetes mellitus is a disease that leads to disruption of blood flow in small vessels, as a result of which the nutrition of the nerve is disrupted and an inflammatory process develops in it.
• Vasculitis is an inflammatory process in blood vessels.
• Violation of the ratio of various proteins in the blood serum (dysproteinemia).
• Impairment of blood flow to the nerve as a result of compression.
• Tunnel syndrome is a condition in which a nerve is compressed in a canal formed by bone and ligaments. There are characteristic places where compression of the femoral nerve can occur with subsequent development of neuritis, for example, under the inguinal ligament.

Neuropathy of the pudendal nerve

Definition:

Pudendal nerve neuropathy, also known as Pudendal neuralgia, Pudendal canal syndrome, Alcock canal syndrome, Pudendal nerve compression syndrome, Tunnel pudendopathy, is a fairly common but rarely diagnosed disease.

Symptoms : pain in the perineum, genitals, anus. Like all types of neuropathic pain, this pain is characterized by a burning sensation, tingling, or “pins and needles.” of a foreign body in the rectum , vagina and/or urethra is quite common In addition to these symptoms, there may be: urinary or fecal incontinence, with sexual dysfunction . The pain intensifies when sitting. In women, symptoms of pudendal neuralgia include pain (burning, itching, tingling) in the clitoris, pubis, vulva, lower 1/3 of the vagina and labia. The skin in these areas may be hypersensitive to touch and pressure (hyperesthesia and allodynia).

Possible symptoms also include burning, numbness, hypersensitivity, electrical or knife sensation, aching pain, sensation of a lump or foreign body in the vagina or rectum, a feeling of twisting or constriction, abnormal temperature sensations, a "hot poker" sensation, constipation, pain and difficulty defecating, difficulty or burning when urinating, pain during intercourse, and sexual dysfunction - loss of sensation in the clitoris and/or the anterior third of the vagina.

Diagnostic criteria for pudendal nerve neuropathy:

Main criteria -

• Pain (burning, itching) in the area of ​​three branches of the pudendal nerve (clitoris, anus, vestibule of the vagina)
• Neuropathic nature of pain (burning, itching, tingling, goosebumps, hypersensitivity or loss of sensitivity)
• Effect of pudendal nerve block (pain reduction for 12 - 36 hours)
• A decrease in blood flow velocity in the pudendal artery, which is determined during Doppler ultrasound scanning. Since the pudendal artery passes along with the pudendal nerve in Alcock's canal, processes leading to compression of the pudendal nerve also lead to compression of the pudendal artery.

Anatomy of the pudendal nerve ( nervus pudendus , pudendal nerve ):

The pudendal nerve leaves the spinal cord at the level of the 2nd, 3rd, and 4th sacral vertebrae (S2-S4), leaves the pelvic cavity through the greater sciatic foramen, and then returns to the small pelvis through the piriformis foramen, under the piriformis muscle. The piriformis muscle can cause compression (squeezing) of the pudendal nerve in myofascial syndrome (piriformis syndrome) .

In the pelvic cavity, the pudendal nerve passes through Alcock's canal, where it can also be compressed by the sacrospinal ligament.

Further, it is divided into three branches:

• Rectal nerve
• Perineal nerve
• Clitoral nerve

That is why symptoms of pudendal nerve neuropathy appear in the anus , perineum and external genitalia.

Interactive atlas of pelvic anatomy (link)

Causes of pudendal nerve neuropathy:

• Obstetric neuropathy - damage to the pudendal nerve during childbirth, sometimes the obturator nerve suffers along with it
• Myofascial syndromes - hypertonicity of the piriformis muscle can cause compression of the pudendal nerve in the foramen infrapiriformis. In addition, compression of the pudendal nerve may be caused by spasm of the obturator internus or levator ani muscles.
• Traumatic neuropathy – caused by chronic trauma (riding a bicycle or horse) or a fracture of the pelvic bones.
• Compression of the pudendal nerve in Alcock's canal

Diagnosis of pudendal nerve neuropathy:

The diagnosis is made based on the so-called diagnostic criteria (Aix-en-Provence diagnostic criteria):

• Localization of pain (one or more branches of the pudendal nerve - usually on one side)
• Nature of the pain (burning, goosebumps, tingling, sensation of electric shock)
• Increased pain when sitting
• Reducing pain in the lying position
• Unilateral nature of the pain
• Positive effects of cold
• Injecting an anesthetic into the area of ​​the pudendal nerve reduces pain for 12 hours or more
• Ultrasound examination of the Alcock canal with determination of the speed of blood flow in the pudendal artery allows us to suspect compression of the pudendal nerve when the speed of blood flow in the artery decreases - since they pass together in this canal.

Treatment:

Treatment must be comprehensive:

• Drugs affecting neuropathic and chronic pain (Lyrica, Tebantin)
• Physiotherapy
• Pudendal nerve blocks with anesthetics and glucocorticoids
• Surgery – decompression of the pudendal nerve
• Neuromodulation

Remember that the duration of treatment is at least 6 months.

In the field of diagnosis and treatment of pudendal neuralgia , we work closely with Prof. Eric Botrand , one of the world's leading specialists in the treatment of chronic pelvic pain, who regularly consults in our clinic. Professor Botran's next visit will take place in December 2014.

In our clinic we use all modern treatment methods.

• Pudendal nerve block
• Cryoanalgesia of the pudendal nerve using a modern cryosurgical device CRYO S Electric
• Osteopathic correction
• Decompression operations

We are the only clinic in Russia where operations on decompression of the pudendal nerve .

Contact us and we will do our best to help you!!!

Patients from other cities believe that treatment in our clinic is long and therefore difficult for them to come to us! Sometimes this is true, but in most cases one day is enough for diagnosis. The next day, an injection of botulinum toxin, cryoneurolysis of the pudendal nerve, decompression of the pudendal nerve, TVT surgery are performed - in general, the most effective manipulations for the treatment of chronic pelvic pain syndrome and urinary disorders. Patients can continue treatment at home - under our close supervision via Skype, email, etc. We provide all necessary medications and (if necessary) devices for home physiotherapy.

What is hip neuritis?

"Neuritis" is a term that refers exclusively to inflammation in the nerves and has nothing to do with the joints. The inflammatory process in the hip joint is called coxitis.

Usually, neuritis of the hip joint is mistakenly called the same femoral neuritis, or damage to another nerve - the obturator, which is responsible for adducting the hip inward. A characteristic sign of obturator neuritis is the inability to cross your legs.

Often a person comes to the conclusion that he has “neuritis of the hip joint” because he heard this term from someone before, and he began to be bothered by pain in the hip joint. The reasons may be different: damage to the joint, nerve, muscles, bones. You need to visit a doctor and get examined.

If you notice symptoms of neuritis - pain, numbness in the leg, muscle weakness, impaired movement - consult a doctor immediately. Early treatment may provide the best prognosis.

Enduring pain is dangerous!

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Causes of pinched sciatic nerve in pregnant women

Among the most common causes of pinched sciatic nerve during pregnancy are:

• Pressure on the sciatic nerve from the enlarged uterus. Accordingly, as the fetus grows in the uterus, this pressure increases.
• Displacement of intervertebral discs in the lumbar region. This, in turn, can occur due to excessive weight gain, multiple pregnancies, and polyhydramnios.
• Traumatic injuries of the spine in the lumbar region.

In cases where a woman previously had a history of sciatica, but after appropriate treatment its symptoms went away, a relapse may occur during pregnancy. In addition, pinching and inflammation of the sciatic nerve during pregnancy can be a consequence of intervertebral hernia, diabetes mellitus, malignant or benign tumor, osteochondrosis and other diseases. That is why, in order to be able to prevent the occurrence of sciatica or to be prepared for its manifestation, a woman needs to tell her doctor everything about her health.
, the woman will be observed
by a neurologist
together with a gynecologist .

Treatment of neuritis of the femoral nerve

For femoral neuritis, the following types of treatment are performed:

• B vitamins - to improve the functioning of nervous tissue.
• Drugs that improve blood flow - to improve nerve nutrition.
• Drugs that improve metabolic processes in the nervous system and the conduction of nerve impulses.
• Drugs from the group of non-steroidal anti-inflammatory drugs - they help cope with pain and inflammation.
• Your doctor may also prescribe diuretics to relieve swelling in the area of ​​the inflamed nerve.
• Physiotherapy procedures help: electrophoresis with novocaine, ultraphonophoresis with hydrocortisone, UHF therapy.
• They provide massage and physical therapy.

If femoral nerve neuritis is caused by an infection, the neurologist will prescribe antibiotics or antiviral drugs.

If, despite treatment, there is no improvement within 1-2 months, the question of surgical intervention arises. Usually, during the operation, the doctor frees the nerve from the tissues compressing it or restores its integrity and sews together the torn fibers.

Do not self-medicate. At the international neurology clinic Medica24, effective medical care is available at any time. Administrators are ready to take your call every day, including holidays and weekends. Contact us by phone +7 (495) 230-00-01.

Take care of yourself, book a consultation now

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What functions does the femoral nerve perform? What are the main symptoms of femoral neuritis? Manifestations of the inflammatory process in another nerve of the leg – the obturator nerve.

The femoral nerve can be compared to an electrical cable, with many individual “wires” running inside it. They perform different functions: some are responsible for movement, others for sensitivity. Such nerves carrying different types of nerve fibers are called mixed. So is the femoral nerve. Here are the main functions it performs:

• Skin sensitivity: on the front of the thigh, on the inner surface of the lower leg.
• Movements: hip flexion (the femoral nerve helps tuck the legs toward the abdomen), calf extension.

Accordingly, violations of these functions will act as the main symptoms of femoral neuritis.

Treatment of pudendal nerve neuropathies

Therapeutic and diagnostic blockades

Conservative treatment is aimed primarily at removing tension (decompression) of the nerve in “critical zones” and restoring normal trophism.
The first stage is recommended to carry out therapeutic and diagnostic blockades of these very problem areas, which we talked about at the very beginning (areas of ligaments and muscles).

The most common are blockades with local anesthetic (lidocaine, bupivacaine) and glucocorticoid (betamethasone).

Transvertebral magnetic neuromodulation

Within the walls of our center, a unique method of treating neuropathic pain has been developed and adapted. It is highly effective for true pudendal nerve neuropathy and is used in parallel with blockades. The deep impact of a directed magnetic pulse with a certain frequency on the area where the pudendal nerve exits the spine (level S2-S3) allows you to “reset” the innervation and break the vicious circle of pain. The course of treatment with magnetic neuromodulation ranges from 10 to 15 sessions, depending on the severity of the disease.

Botulinum therapy.

Indicated in the presence of muscular-tonic syndrome, when the muscle needs to be relaxed. Botulinum toxin type A is successfully used specifically to target this pathological component.

When used correctly (according to indications and with good navigation via ultrasound), the risks of complications are minimal.

Transcranial magnetic neuromodulation

The newest method of influencing brain structures.
In Russia, we are leaders in the use of neuromodulation of the central and peripheral nervous system for the treatment of pelvic floor dysfunction and chronic pelvic pain syndrome. This technique is aimed at eliminating central sensitization - a condition that develops during a long course of the disease, when the patient did not receive adequate treatment in time.

Remember, even with a prolonged course of the disease there is a way out!

Manual therapy.

The main goal of treatment by an osteopathic neurologist is to eliminate biomechanical disorders and pathological changes in soft tissue structures.

When a person has a sore muscle, he tries to reflexively “save” it by changing his position, sitting or walking. This leads to the fact that these structures, which bear an additional “volume of work,” begin to experience additional stress and get sick. And this only strengthens the vicious circle of disease development. With the help of manual techniques, it is possible to return to its place what has been displaced and is involved in the pathological process.

Pudendal nerve neuropathy: a patient’s history of recovery

Characteristic symptoms of neuritis of the femoral nerve

If the neuritis occurs in the upper part of the femoral nerve, before it exits the pelvis, the clinical picture of the disease will be most striking. All possible symptoms of femoral neuritis occur:

• Impaired hip flexion. This makes it difficult to lift the body from sitting and lying positions.
• Impaired leg extension. It becomes difficult to walk, run, or climb stairs. A person tries not to bend his leg at the knee again, because after that it is difficult to straighten it. The leg is constantly strongly extended, because of this the gait changes - the patient throws his straight leg forward and places the entire sole on the floor at once.
• Atrophy of the thigh muscles. The affected leg becomes thinner than the healthy leg, which may be noticeable externally.
• Impaired sensitivity. The person does not feel touch or pain on the front surface of the thigh or inner surface of the lower leg.
• Pain. They occur in the same places where sensory disturbances occur.

An experienced neurologist will be able to understand the symptoms that are bothering you and prescribe the correct treatment.

Methods for treating pinched and damaged femoral nerve

It is always necessary to begin treatment for a pinched femoral nerve by eliminating the cause of the development of this condition. If the factor that compresses the nerve fiber is not eliminated, then there is no point in carrying out therapy.

Therefore, during the initial diagnosis, the doctor must determine what is compressing the nerve and try to remove this influence using manual therapy. If these are tumor processes or hernias of the inguinal area, then an emergency consultation with a surgeon is indicated. You may need prompt assistance to remove these tumors. Unfortunately, without this it will not be possible to restore the functionality of the femoral nerve.

In the future, if the femoral nerve is damaged, restorative therapy is carried out. It includes:

• massage and osteopathy, which improve microcirculation of blood and lymphatic fluid, which has a positive effect on tissue trophism;
• traction traction of the spinal column is used if the cause of this disease is compression of a certain area of ​​the lumbosacral spine;
• reflexology or effects on biologically active points on the human body, allows you to trigger the mechanism of spontaneous restoration of the damaged area of ​​uneven fiber;
• laser exposure helps relieve swelling and inflammation;
• Therapeutic gymnastics and kinesiotherapy speed up the healing process, increase the overall tone of the body, and strengthen muscles.

The course of treatment is always developed individually. The doctor takes into account the patient’s age and the presence of concomitant health problems. Therefore, if you need medical help, we recommend that you attend a free consultation. neurologist in our manual therapy clinic.

How does obturator nerve neuritis manifest?

Not far from the femoral nerve there is another nerve - the obturator. If neuritis develops in it, the following symptoms occur:

• I can't cross my legs.
• Difficulties arise when trying to turn the leg outward.
• The sensitivity of the skin on the inner thigh is reduced.

In order to correctly understand the symptoms of the disease, you need to be examined by a neurologist. Contact a doctor at the Medical Center International Clinic Medica24 immediately after you notice the neurological disorders described on this page. Call at any time of the day.

The material was prepared by Natalya Yurievna, a neurologist at the international clinic Medica24, Candidate of Medical Sciences Lasch.

Groin area, regio inguinalis

The groin area has the shape of a right triangle (Fig. 1.9), the boundaries of which are:

above - a line connecting the anterior superior iliac spines,

below and laterally – projection of the inguinal ligament,

medially - projection of the lateral edge of the rectus abdominis muscle

Inguinal triangle

limited:

below – inguinal ligament,

medially - the outer edge of the rectus abdominis muscle,

from above - a horizontal line drawn from the border between the outer and middle thirds of the inguinal ligament to the intersection with the outer edge of the rectus abdominis muscle. In the area of ​​the inguinal triangle, the inguinal space and the inguinal canal are located.

Inguinal space

, being the weakest and most pliable place, is a defect in the muscles of the anterior abdominal wall, formed as a result of the detachment of muscle and tendon fibers of the internal oblique and transverse muscles, which go to the formation of the muscle that lifts the testicle and its fascia. This area of ​​the inguinal triangle lacks full muscle coverage and is therefore a “weak spot” of the anterior abdominal wall.

Boundaries of the inguinal space:

above – the lower edges of the internal oblique and transverse abdominal muscles,

below – inguinal ligament,

medially - the outer edge of the rectus abdominis muscle.

There are four shapes of the inguinal space: slit-like, round, oval and triangular. The largest dimensions of the inguinal gap are observed with a triangular shape, especially in men. With this form, inguinal hernias most often form, mostly straight.

Leather

thin, mobile, easily extensible, has hair, and is rich in sweat and sebaceous glands. Subcutaneous tissue is abundantly developed. The superficial fascia consists of two layers.

In the area of ​​the inguinal triangle, in the subcutaneous fatty tissue or under the superficial fascia, branches of the femoral artery pass: the superficial epigastric artery, medially from it lies the external genital artery, outwardly - the superficial artery that bends around the ilium. Veins of the same name pass along with the arteries. Lymphatic vessels drain into the superficial inguinal lymph nodes.

The cutaneous nerves of the inguinal region are branches: subcostal nerves (nn. subcostales), iliohypogastric and ilioinguinal nerves (nn. iliohypogastricus et ilioinguinalis). The iliohypogastric and ilioinguinal nerves (branches of the lumbar plexus), piercing the muscular layers of the anterolateral abdominal wall from the inside out, near the anterior superior iliac spine, are located between the internal oblique and transverse abdominal muscles. Then the iliohypogastric nerve pierces the aponeurosis of the external oblique abdominal muscle 2.5 cm above the superficial inguinal ring, penetrating the subcutaneous tissue. The ilioinguinal nerve, passing inside the inguinal canal along with the spermatic cord or round ligament, exits through the superficial inguinal ring of the inguinal canal and ends in the skin of the pubis.

Surgical anatomy of the inguinal canal.

Anatomically, the inguinal canal (canalis inguinalis) is a defect in the lower part of the anterior abdominal wall. It results from the descent of the testicle, which migrates from the retroperitoneum into the scrotum.

The inguinal canal occupies an oblique position parallel to the inguinal ligament, running from top to bottom, from back to front, from outside to inside. The length of the canal in men is 4-5 cm.

Its walls are: in front - the aponeurosis of the external oblique abdominal muscle, above - the overhanging edges of the internal oblique and transverse abdominal muscles, behind - the transverse fascia, below - the groove of the inguinal ligament.

In the upper abdomen, the transverse fascia is thin; below, especially closer to the inguinal ligament, it thickens, turning into a fibrous plate. This thickening is called the iliopubic tract, tractus iliopubicus (Fig. 1.10). It is attached, just like the inguinal ligament, lig. inguinale, to the pubic tubercle and the anterior superior iliac spine and runs parallel to the inguinal ligament posterior to it. They are separated only by a very narrow gap, therefore in surgery the complex of these two ligamentous formations is often called one term: the inguinal ligament.

There are two rings in the inguinal canal: superficial and deep.

The superficial inguinal ring (anulus inguinalis superficialis) is formed due to the splitting of the fibers of the aponeurosis of the external oblique abdominal muscle (Fig. 1.11, 1.11, 1.13). In this case, two legs are formed: the medial one (crus mediale), attached to the pubic symphysis, and the lateral one (crus laterale), attached to the pubic tubercle. Outside, that is, at the site of the splitting of the aponeurosis, the superficial inguinal ring is limited by interpeduncular fibers (fibrae intercrurales).

The inside of the ring is limited by a curved ligament (lig. reflexum) [located behind the spermatic cord. The spermatic cord and terminal branches of the ilioinguinal nerve emerge through the superficial ring of the inguinal canal in men, and the round ligament of the uterus in women. Normally, during examination, the superficial ring allows the tip of the index finger to pass through.

The deep inguinal ring, anulus inguinalis profundus, is a funnel-shaped depression in the transverse fascia (Fig. 1.10, 1.12, 1.13), that is, it is not a hole with smooth edges like a buttonhole, but a protrusion of the fascia into the inguinal canal in the form of a finger from a rubber glove. This is easier to imagine if you remember that the testicle, descending into the scrotum, protrudes in front of itself all the layers of the anterior abdominal wall, including the transverse fascia.

Rice. 1.11.Inguinal canal (according to Netter, with modifications).

1 - m. obliquus externus bdominis; 2 - aponeurosis of the t. obliquus externus abdominis; 3 - spina iliaca anterior superior; 4 - m. obliquus internus abdominis; 5 - m. transversus abdominis; 6 - anulus inguinalis profundus; 7 - a. et v. epigastrica inferior under the transverse fascia; 8 - funiculus spermaticus, covered with fascia spermatica interna and m. cremaster; 9 - lig. inguinal; 10 - crus laterale anulus inguinalis superficialis; 11 - lig. fundiforme penis; 12 - funiculus spermaticus, covered with fascia spermatica externa; 13 - anulus inguinalis superficialis; 14 - fibrae intercrarales; 15 - crus mediale anulus inguinalis superficialis 16 - lig. reflexum; 17 - falx inguinalis (tendo conjunctive); 18 - fascia transversalis (place of exit of direct hernias); 19 - linea alba.

In this regard, the protrusion, surrounding the vas deferens and other elements of the spermatic cord, is its shell, fascia spermatica interna. Along the cord, this fascia reaches the scrotum in men and along the round ligament of the uterus to the labia majora in women.

The deep inguinal ring on the side of the abdominal cavity corresponds to the lateral inguinal fossa.

Rice. 1.12. . Deep inguinal ring, Hesselbach's triangle (according to Netter, with modifications).

1 - linea arcuata; 2 - m. rectus abdominis; 3 - linea alba; 4 - trigonum Hesselbachii;

5 - falx inguinalis; 6 - symphysis pubica; 7 - lig. lacunare; 8 — anulus femoralis (dotted line); 9 - lig. pectineale; 10 - anastomosis between a. obturatoria and a. epigastrica inferior; 11 - a. obturatoria; 12 - ductus deferens; 13 - m. iliopsoas; 14 - a. epigastrica inferior; 15 - a., v. iliaca externa; 16 - a., v. testicularis; 17 - anulus inguinalis profundus;

18 - fascia transversalis (cut off); 19 - lig. inguinal; 20 - spina iliaca anterior superior.

On the inner surface of the anterior abdominal wall in its lower parts, the parietal peritoneum forms five folds (Fig. 1.14). In the midline, between the navel and the bladder, there is an unpaired median umbilical fold (plica umbilicalis mediana), it is formed above the obliterated urinary duct (urachus). From the lateral surfaces of the bladder to the navel there are two medial umbilical folds (plicae umbilicales mediales), above the obliterated umbilical arteries. Outward from the medial umbilical folds, respectively, above the lower epigastric vessels, folds of the peritoneum are visible, called lateral umbilical folds (plicae umbilicales laterales).

Fig. 1.13. Inguinal canal and spermatic cord (according to Netter, with modifications).

1 - ductus deferens (covered by the peritoneum); 2 - a., v. epigastrica inferior; 3 - plica umbilicalis medialis; 4 - plica umbilicalis mediana; 5 - m. rectus abdominis; 6 - m. pyramidalis;

7 - falx inguinalis; 8 - anulus inguinalis superficialis; 9 - fascia spermatica externa; 10 - tuberculum pubicum; 11 - lig. inguinal; 12 - a., v. femoralis; 13 - m. cremaster et fascia cremasterica; 14 - funiculus spcrmaticus; 15 - n. ilioinguinalis; 16 - fascia spermatica interna (protrusion of the transverse fascia); 17 - m. obliquus externus abdominis; 18 - m. obliquus internus abdominis; 19 – m. transversus abdominis; 20 - fascia transversalis; 21 - tela subserosa; 22 - peritoneum parietale; 23 - a., v. testicularis (covered by the peritoneum);

24 - a., v. iliaca externa (covered by the peritoneum).

Between these folds, on each side of the midline, there are three pits. Between the median and medial umbilical folds a supravesical fossa (fossa supravesicalis) is formed; between the medial and lateral umbilical folds - the medial inguinal fossa (fossa inguinalis medialis) and outward from the lateral umbilical folds - the lateral inguinal fossa (fossa inguinalis lateralis). The latter, as indicated, is the location of the deep inguinal ring. formed as a result of the descent of the testicle.

Fig.1.14. The anterior wall of the abdomen from the abdominal cavity

(according to Sinelnikov, with modifications).

1 - m. iliopsoas; 2 - fossa inguinalis lateralis; 3 - fossa inguinalis medialis;

4 - fossa supravesicalis; 5 - peritoneum parietale; 6 - m. obturatorius externus;

7 - m. obturatorius internus; 8 - m. levator ani; 9 - prostata; 10 - glandula seminalis; 11 - vesica urinaria; 12 - ureter; 13 - ductus deferens; 14 - lig. interfoveolare; 15 - v. iliaca externa; 16 - a. iliaca externa;17 - vasa testicularia; 18 - fascia iliaca; 19 - anulus inguinalis profundus; 20 - a. et v. epigastricae inferiores; 21 - lig. umbilicale laterale; 22 - vagina m. recti abdominis (lamina posterior); 23 - m. rectus abdominis; 24 - plica umbilicalis mediana; 25 - lig. umbilicale medium; 26 - peritoneum parietale; 27 - plica umbilicalis medialis; 28 - plica umbilicalis lateral.

The process of testicular descent occurs as follows. During the first 3 months of intrauterine life, the testicle is located in the lumbar region. The peritoneum covers it on three sides and fuses with the tunica albuginea of ​​the testicle. From the lower pole of the testicle behind the peritoneum there is a special connective tissue cord, the so-called testicular conductor - gubernaculum testis (Hunteri). It penetrates at the level of the future internal opening of the inguinal canal into the scrotum. The transverse fascia and the parietal layer of the peritoneum protrude there, and the latter, even before the descent of the testicle, forms the so-called vaginal process (processus vaginalis peritonei) (Fig. 1.15).

Rice. 1.15. Testicular descent (diagram).

I - 4th month of intrauterine development; II - 7th month; III - 8th month; IV - end of the 9th month.

1 - testis; 2 - peritoneum; 3 - fascia endoabdominalis; 4 - covers; 5—processus vaginalis;

6—gubernaculum testis; 7— os pubis; 8 - ductus deferens; 9 - obliterated processus

vaginalis; 10 - tunica vaginalistestis; 11 - fascia spermatica interna.

The testicle descends behind the peritoneum starting from the 4th month of intrauterine life. By the 7th month, the testicle reaches the level of the internal opening of the inguinal canal and begins to protrude the peritoneum in front of it. Then the testicle passes through the muscular aponeurotic layers of the anterior abdominal wall, forming the inguinal canal in them, and at the 9th month it enters the scrotum. The testicular conductor atrophies by this time.

In the scrotum, the testicle is covered with two layers of peritoneum, forming the tunica vaginalis (propria) testis. One of these layers - visceral - is fused with the tunica albuginea of ​​the testicle, the other - parietal - is part of the processus vaginalis of the peritoneum. Between the two layers of peritoneum covering the testicle, a small gap remains, and above the testicle, along the spermatic cord, the bulging part of the peritoneal sac (processus vaginalis peritonei) usually closes up by the time of birth. Sometimes this fusion does not occur, and then the peritoneal cavity directly communicates with the scrotal cavity.

The contents of the inguinal canal in men are the spermatic cord, funiculus spermaticus, the ilioinguinal nerve, n. ilioinguinalis, passing along the anterior surface of the cord, and the genital branch of the genital femoral nerve, ramus genitalis n. genito-femoralis. In women, the same two nerves and the round ligament of the uterus, lig, pass through the inguinal canal. teres uteri.

The round uterine ligament passing through the inguinal canal in women is surrounded by a fascial sheath due to the transverse fascia, similar to the internal spermatic fascia in men. Upon exiting the inguinal canal, the ligament ends with individual fibers in the tissue of the labia majora, and with others it is attached to the pubic bones. Next to the round ligament runs, just like in men, a closed vaginal process of the peritoneum, the peripheral end of which reaches the upper part of the labia majora. If the process is not fused, a canal (the so-called canalis Nuckii) is formed in its place, due to which cysts of the labia majora or congenital inguinal hernias can occur.

The spermatic cord, funiculus spermaticus, consists of membranes and elements of the spermatic cord. The membranes include: the external spermatic fascia (fascia spermatica externa), the fascia of the muscle that lifts the testicle (fascia cremasterica), the muscle that lifts the testicle (m. cremaster), and the internal spermatic fascia (fascia spermatica interna) - a derivative of the transverse fascia. The elements of the spermatic cord include the vas deferens (ductus deferens), vessels and nerves supplying the duct, the testicle, as well as traces of the vaginal process of the peritoneum (vestigium processus vaginalis). The vessels include: the testicular artery (a. testicularis), which arises from the abdominal aorta, the right testicular artery, which sometimes arises from the right renal artery; the artery of the vas deferens (a. ductus deferens), which departs from the inferior vesical artery, and the artery of the muscle that lifts the testis (a. cremasterica), which supplies the membranes of the spermatic cord, departs from the inferior epigastric artery.

The veins leaving the testicle form pampiniform plexuses (plexus pampiniformis), which then pass into the testicular vein (v. testicularis). The left testicular vein drains into the renal vein, and the right testicular vein drains directly into the inferior vena cava.

The innervation of the spermatic cord is carried out by the nerve plexuses surrounding the arteries and the vas deferens, the testicular plexus and the plexus of the vas deferens (plexus testicularis et plexus differentialis).