Pelvic inflammatory disease: causes of the problem. Inflammation of the pelvic organs in women: treatment, symptoms and causes
Diseases of the pelvic organs include pathology reproductive organs, bladder and rectum. With health problems related to this area, people turn to a gynecologist, urologist, nephrologist or proctologist (depending on the disease).
Today, the incidence of inflammatory diseases of the pelvic organs in women (uterus and appendages) is very high. Apparently, this is due to the increasing prevalence of sexually transmitted diseases (such as gonorrhea, chlamydia, syphilis, gardnerellosis, etc.). This pathology, if not consulted in a timely manner and without treatment, can lead to adnexitis, endometritis (inflammation of the inner mucous membrane of the uterus), the formation of intrauterine synechiae and adhesions between the pelvic organs, obstruction fallopian tubes, and ultimately - to infertility.
Another common pathology of the female sphere is endometriosis. With this disease, foci of proliferating tissue appear outside the uterine cavity, histologically identical to endometrial tissue. In this case, pain occurs in the pelvic area, and problems with pregnancy are also possible.
Polycystic ovary syndrome is often diagnosed, in which infertility occurs due to lack of ovulation (the release of an egg). With age, the likelihood of fibroids increases ( benign tumor, affecting the uterus), more often myomatous nodes are not single, but multiple. Last but not least is oncological pathology, the risk of which also increases with age, so women at any age need to make regular preventive visits to the gynecologist. Other diseases in this area include congenital anomalies (for example, vaginal duplication), various cysts (including cyst torsion, classified as acute surgical pathology), hematosalpinx, etc.
With regard to pathology of the bladder, the first thing to be mentioned is cystitis - inflammation of the mucous membrane lining the cavity of the bladder. Characteristic symptoms - frequent urge to urination, pain at the end of urination. If you don't start on time competent treatment cystitis, an ascending infection occurs, leading to pyelonephritis and other kidney damage. In addition, urolithiasis is also recorded, in which calculi (stones) form not only in the kidneys, but also in bladder, as well as various cancers affecting the bladder.
People most often turn to a proctologist about hemorrhoids - a pathology of the veins of the rectum, in which they expand and form hemorrhoids, capable of becoming inflamed or pinched. Tumor diseases of the rectum also play an important role.
And, of course, they happen traumatic lesions pelvic organs, regardless of their belonging to one or another system (whether it is an organ classified as the genitourinary or gastrointestinal system).
Diagnosis of diseases of the pelvic organs is carried out using various methods. The general rule: always first ask about the patient’s complaints, conduct a direct medical examination (for example, a gynecologist conducts a manual intravaginal examination, a proctologist conducts a digital rectal examination), and prescribe a general blood and urine test. Further, depending on the area of interest, special imaging examination methods are prescribed if necessary. This may be an ultrasound examination, radiography, computed tomography. If there is insufficient data, magnetic resonance imaging (MRI) is prescribed. This method is completely safe for the reproductive organs, since it does not use x-rays. Moreover, it gives comprehensive information about the condition of the pelvic organs.
Pain in the lower abdomen will be the leading symptom of pelvic inflammation.The main cause of inflammatory processes in the pelvis is sexually transmitted infections, sexually transmitted diseases or sexually transmitted diseases (STDs). The most common pathogens are gonorrhea, trichomoniasis and chlamydia; there are combinations of them and combinations with common coccal and any other flora. Inflammation and sometimes suppuration can lead to damage to the fallopian tubes and tissue of the uterus, ovaries and surrounding organs. The inflammation can lead to serious complications, including infertility, ectopic pregnancy (pregnancy in the fallopian tube or elsewhere outside the uterus), abscess formation, and chronic pelvic pain.
Frequency and routes of spread of infection.
Every year, approximately every 300 women experience inflammatory diseases pelvic organs. Up to 10-15% of these women may become infertile. Most ectopic pregnancies and the need for surgery occur due to the consequences of a pelvic infection. The infection comes from external environment into the reproductive system, moves through the vagina into the uterus, fallopian tubes and into the abdominal cavity. Any pathological or conditionally pathological bacterium, when the woman’s body’s defenses are weakened, becomes more active and causes inflammation. But the most common cause of inflammation is gonorrhea and chlamydia. Each episode of inflammation leads to the formation of adhesions and scars in the pelvis and increases the risk of recurrent infections. Sexually active women of childbearing age are at greatest risk, especially those under 25 years of age. This is due to the fact that susceptibility to STDs in at a young age higher, immunity is not yet complete, partners change more often. The more sexual partners a woman has, the greater the risk of developing inflammation pelvic organs. In addition, a woman whose partner has more than one sexual partner also has a higher risk of developing inflammation, due to the possible greater number of infectious agents received. Among the additional risks of infection, the upward spread of germs during douching has been proven. Intrauterine device may contribute to the development of infection, so it is important when choosing this method of contraception to be tested for STDs.
Signs and symptoms of pelvic inflammatory disease
Symptoms can range from mild to severe. With chlamydial infection, symptoms may not be observed at all or may be minimal, but changes in the genital organs may be significant. However, it is also possible to simply be a carrier of chlamydia. Chlamydia is characterized by a combination with other microbes or protozoa.
Women with pelvic inflammation complain of pain of varying intensity and duration in the lower abdomen, sometimes in the upper, in the pit of the stomach (in the epigastric region) - a sign of general discomfort in the abdomen. Pelvic pain, as a rule, radiates to the perineum, to the anus, sometimes this is the only sign. There may be general manifestations characteristic of infectious process- fever, weakness, fatigue, aches in muscles and joints, dry mouth, headache. Vaginal discharge may change color, smell, and volume. Pain during sexual intercourse, pain and pain during urination may occur. Changes in menstruation are observed.
Complications of pelvic inflammation. Ectopic pregnancy.
Prompt and appropriate treatment can help prevent complications. The main complications - infertility and ectopic pregnancy occur due to impaired patency, elasticity of the fallopian tubes and mucous membrane by a scar process. Scar tissue either interrupts the normal movement of the egg into the uterus, or prevents the sperm from moving towards the egg, or the already fertilized egg cannot descend into the uterus and the pregnancy develops in the tube. Each subsequent episode of inflammation increases the risk of infertility.
An ectopic pregnancy, in turn, is dangerous due to the rupture of the walls of the fallopian tube by the growing embryo. The rupture is accompanied by severe pain, internal bleeding, and even death from blood loss or peritonitis. A less serious, but rather unpleasant complication would be the development of chronic pelvic pain syndrome (pain that lasts for several months or even years).
Diagnosis of pelvic inflammation.
The diagnosis is sometimes quite difficult to make. Until a clear clinical picture develops, many episodes of inflammation remain unnoticed and symptoms are scant. Women rarely seek help, and research does not provide alarming information, and medicine remains indifferent. Diagnosis is based on clinical data. If symptoms such as lower abdominal pain are present, a healthcare professional should perform a physical examination to determine the nature and location of the pain, check the patient for changes in vaginal flora, and changes in the condition of the genital tract mucosa. Conduct an analysis for the most common sexually transmitted infection - smears with microscopy, PCR. Perform an ultrasound examination. Ultrasound can detect altered fallopian tubes, the presence of ulcers, and determine the condition of the uterus and endometrium. In some cases, laparoscopy will be required. Laparoscopy is a surgical procedure in which a thin, rigid tube with a video camera (laparoscope) is inserted into the abdominal cavity through a small incision. This procedure allows the doctor to see internal organs, take material for laboratory research, and, if necessary, proceed to surgery.
Treatment of pelvic inflammation.
Women's acute inflammatory pelvic problems respond well to conservative antibacterial treatment, which should be selected taking into account the identified pathogen. Antibiotics help reduce inflammation and remove the pathogen. Those scar-adhesive changes that have already occurred cannot be cured with antibiotics. A long-term inflammatory process - chronic inflammation - does not always allow you to completely get rid of the pathogen, so early seeking medical help and starting treatment is extremely important. Prescribing two or more antibiotics that are effective against a wide range of infectious agents will improve the outcome. Symptoms may go away before the infection is treated. Even if the symptoms disappear, the woman should complete the course of prescribed medications. Treatment should be carried out under the supervision of a doctor, firstly, the effectiveness is assessed, and secondly, side effects are excluded. In addition, the sexual partner should also be treated. Hospitalization is required in severe cases (for example, nausea, vomiting and high fever), if the woman is pregnant, if it is not possible to take tablets and require parenteral administration, if there are signs of abscesses (ulcers) fallopian tubes and ovaries (tubo-ovarian abscess), in the presence of signs of ectopic pregnancy, with an unclear diagnosis and a threat to life. Chronic pelvic pain syndrome can be treated conservatively, but surgery is often required.
Prevention of inflammation and pain in the pelvis
Pelvic inflammation can be avoided by preventing STDs and early onset treatment if infection does occur. The surest way to avoid transmitting STDs is to abstain from sex, or to be in a long-term, mutually monogamous relationship with a partner who has been tested and is not infected.
Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of chlamydia and gonorrhea. Annual testing for chlamydia is recommended for all sexually active women under 25 years of age, over 25 years of age if there are risk factors (new sexual partner or multiple sexual partners), and all pregnant women. Symptoms such as pain, abnormal discharge, burning when urinating, or bleeding between menstrual cycles may indicate an infection, which requires stopping sexual relations and contacting a doctor. Treatment of sexually transmitted diseases early stage may prevent pelvic inflammation. Treatment should be carried out for all sexual partners, and relationships should not be resumed until the infection is completely cured.
Pelvic inflammatory diseases (PID) include inflammation of the uterus, its tubes, ovaries, parametrium and pelvic peritoneum. Isolated inflammation of these formations is extremely rare in clinical practice due to their anatomical proximity and functional unity.
SYNONYMS
In the English literature, these diseases are referred to as pelvic inflammatory disease. In the domestic literature, the most used term in relation to PID is “salpingitis” or “salpingoophoritis”.
ICD-10 CODE
N70 Salpingitis and oophoritis (including abscess of the fallopian tube, tubo-ovarian, ovarian, pyosalpinx, salpingoophoritis, tubo-ovarian inflammatory disease).
N71 Inflammatory diseases uterus, except the cervix (including uterine abscess, metritis, myometritis, pyometra, endo(myo-)metritis).
N72 Inflammatory diseases of the cervix (erosion and ectropion of the cervix without cervicitis are excluded).
N73 Other inflammatory diseases of the female pelvic organs.
N74 Inflammatory diseases of the female pelvic organs in diseases classified in other headings.
EPIDEMIOLOGY
Inflammatory diseases are the most common pathology of the internal genitalia in childhood. They make up from 1 to 5% of all acute surgical diseases abdominal organs in children, ranking third in frequency after acute appendicitis and intestinal obstruction. There are several age peaks in the incidence of PID:
at 3–5, 11–13 and 18–20 years old. The first two coincide with the age maximums of the disease of appendicitis, the last - with the debut of sexual activity. Due to the frequent combination of inflammation of the appendix and OVID, appendicular-genital syndrome is distinguished.
According to domestic and foreign scientists, girls aged 15–19 years are most at risk of inflammation. At this age, the immature multilayered epithelium of the cervix is more susceptible to the action of infectious, cocarcinogenic and carcinogenic agents. The current situation is due to freedom of sexual behavior, frequent changes sexual partners, ignorance or unwillingness to use barrier contraception, drug addiction.
Every year, 4% of women aged 15 to 44 undergo a medical abortion worldwide. 12.25–56% of patients develop endometritis after artificial termination of pregnancy.
In Russia in 2002, 1,782 million abortions were registered. Of these, 10.3% were teenagers and girls aged 15–19 years.
SCREENING
Conducted when visiting gynecologists and pediatricians, during preventive examinations.
CLASSIFICATION
Based on the topography of the damage to the macroorganism, inflammatory diseases of the lower part of the urogenital tract and ascending infection can be distinguished. Lesions of the lower part of the urogenital tract include urethritis, paraurethritis, bartholinitis, colpitis and endocervicitis.
Inflammatory processes are divided by duration into acute and chronic. Inflammatory processes lasting up to 4–6 weeks are considered acute; in most cases, acute inflammation ends within 1.5–2 weeks. In clinical practice, it is customary to distinguish between acute, subacute and chronic PID. By acute inflammation we mean a disease that has arisen for the first time and has a clear clinical picture.
Currently, according to the proposal of G. Monif (1983), four stages of acute inflammatory process:
- Stage I - acute endometritis and salpingitis without signs of inflammation of the pelvic peritoneum;
- Stage II - acute endometritis and salpingitis with signs of peritoneal irritation;
- Stage III - acute salpingoophoritis with occlusion of the fallopian tubes and the development of tubo-ovarian formation;
- Stage IV - rupture of the tubo-ovarian formation.
IN AND. Krasnopolsky (2002) identifies the following forms of PID:
- uncomplicated forms (salpingitis, oophoritis, salpingoophoritis);
- complicated forms (pyosalpinx, ovarian abscess (pyovar), purulent tubo-ovarian formation);
- severe purulent-septic diseases (panmetritis, parametritis, interintestinal, subphrenic abscesses,
genital fistulas, purulent-infiltrative omentitis, diffuse peritonitis, sepsis).
ETIOLOGY
As a rule, PID is characterized by polymicrobial etiology. Almost all microorganisms present in the vagina (with the exception of lactobacteria and bifidobacteria) can take part in the inflammatory process. However, the leading role belongs to the most virulent microorganisms: representatives of the Enterobacteriaceae family (primarily Escherichia coli) and staphylococcus. The role of anaerobes as copathogens is generally recognized, but it should not be overestimated.
In PID, staphylococci, streptococci, enterococci, anaerobes, chlamydia, mycoplasma, and ureaplasma are most often found. In recent years, great importance has been attached to opportunistic infection, which refers primarily to endogenous microorganisms that exhibit pathogenic properties mainly against the background of a violation of the body's anti-infective defense mechanisms. The development of opportunistic infections is facilitated by: irrational use of broad-spectrum antibiotics and hormonal drugs; surgical interventions; various invasive medical procedures; violation of the integrity of tissues and local immunity of the vagina as a result of primary infection, etc.
PATHOGENESIS
Infection of the internal genital organs can occur:
- lymphogenous with appendicitis, cholecystitis, perihepatitis, pleurisy, with the development of pelvioperitonitis and further lymphogenous spread to the peritoneum of the subdiaphragmatic region (abdominal Fitz-Hugh-Curtis syndrome);
- hematogenous, as evidenced by extragenital complications (for example, damage to the joint capsules due to chlamydia);
- canalicularly (through the cervical canal, uterine cavity, fallopian tubes to the peritoneum and abdominal organs).
CLINICAL PICTURE
Clinical manifestations acute inflammation of the internal genital organs: high body temperature, pain in the lower abdomen, there may be nausea, vomiting, disturbance general condition, severe intoxication, changes in the blood (leukocytosis, increased ESR, appearance of Reactive protein).
Subacute inflammation is a process that occurs for the first time with less severe symptoms than with acute inflammation internal genital organs: subfebrile body temperature, absence severe intoxication, slight pain reaction, low leukocytosis and moderately elevated ESR in the blood. This process is characterized by a protracted course. Obviously, this division is arbitrary, since the assessment of the manifestations of the inflammatory process is very subjective.
Chronic PID can be a consequence of acute inflammation that is not completely cured, and also have a primarily chronic nature. Chronic PID often occurs in waves with alternating periods of exacerbation and remission.
It is customary to distinguish between chronic salpingoophoritis in the acute stage, primary chronic salpingoophoritis and residual effects (cicatricial adhesions) of chronic salpingoophoritis.
The infection can spread upward or downward. It is necessary to distinguish between primary and secondary salpingitis. In primary salpingitis, the infection rises from the lower genital tract by spreading cervical or perianal flora on the fallopian tubes (diagnostic and therapeutic procedures). With secondary salpingitis, inflammation develops due to the penetration of the pathogen from nearby organs, in particular from the affected appendix.
DIAGNOSTICS
ANAMNESIS
When studying the anamnesis, it is necessary to pay attention to the presence of extragenital diseases (appendicitis, cholecystitis, perihepatitis, tonsillitis, etc.) and genital (vulvitis) foci of chronic infection.
PHYSICAL EXAMINATION
During bimanual rectoabdominal examination in the area of the location of the uterine appendages, soreness, slight increase. During the formation of a tubo-ovarian tumor of inflammatory origin formation is determined in the area of the uterine appendages, which can reach large sizes. If there is a pelvic ganglioneuritis, pain in the area of exit of the pelvic nerves and the absence of anatomical changes are noted internal genital organs.
LABORATORY RESEARCH
If PID is suspected, clinical trial blood (pay attention to leukocytosis, change leukocyte formula, increase in ESR, appearance of Reactive protein in the blood), microscopic and microbiological examination discharged contents from the genital tract, urethra. Also conducting research using the PCR method for the presence of chlamydial and gonococcal infections.
When viewing the results of an ultrasound of the pelvic organs, in some cases free fluid is found in the pelvic cavity pelvis The sensitivity of this method is 32–42%, specificity is 58–97%, which allows it to be classified as auxiliary diagnostic methods for PID. Ultrasound should be performed if there is suspicion of tubo-ovarian formations. In the same situation, it is advisable to perform an MRI of the pelvic organs.
DIFFERENTIAL DIAGNOSTICS
Inflammatory diseases of the internal genitalia often occur under the guise of ARVI, acute abdominal pathology (most often acute appendicitis), which often requires diagnostic laparoscopy to clarify condition of the appendix and uterine appendages. PID must be differentiated from uterine and ectopic pregnancy in sexually active adolescents or suspected sexual abuse. In this case, carry out Ultrasound determines the level of hCGβ in the blood serum. In addition, PID has a similar clinical and laboratory picture. ovulatory syndrome, ovarian apoplexy and uterine torsion.
In case of PID in children, it is necessary to consult with specialists in a therapeutic profile if there is a suspicion of infection or inflammatory diseases of the urinary tract, by a surgeon - to exclude acute surgical pathology of the abdominal organs, a phthisiatrician - to exclude the inflammatory process of tuberculosis etiology.
EXAMPLE OF FORMULATION OF DIAGNOSIS
Acute right-sided salpingoophoritis.
TREATMENT OF INFLAMMATION OF THE PELVIC ORGANS IN GIRLS
TREATMENT GOALS
Prevention of further development of the inflammatory process, prevention of reproductive disorders.
INDICATIONS FOR HOSPITALIZATION.
1. Body temperature is above 38 °C.
2. Severe intoxication.
3. Complicated forms of PID (presence of an inflammatory conglomerate - tubo-ovarian formation).
4. Pregnancy.
5. Availability of an IUD.
6. Unidentified or questionable diagnosis, presence of symptoms of peritoneal irritation.
7. Intolerance to oral medications.
8. No improvement during therapy after 48 hours.
NON-DRUG TREATMENT
In case of acute salpingo-oophoritis, physiotherapy is carried out only in combination with adequate antibacterial, detoxification and other drug therapy. Treatment can begin immediately after diagnosis.
Contraindications for use physical factors consist of general ones for physiotherapy and special ones for pathology genitals. In case of acute salpingitis, oophoritis, low-frequency magnetic therapy is indicated, therapy with constant magnetic field; in case of subacute inflammation of the appendages, microwave therapy with decimeter waves is performed, magnetic laser therapy, laser therapy, electrophoresis of drugs with pulsed currents.
During the period of stable remission, it is possible to use preformed physical factors: FNC and ultrasound therapy, low-frequency electrostatic field therapy, electropulse therapy using hardware and software complex "AndroGyn", laser therapy, nonspecific electrothermotherapy, interference therapy, electrophoresis of drugs pulse currents. The optimal time to start physiotherapy is the 5th–7th day of the menstrual cycle.
In case of chronic inflammatory process in the uterine appendages, especially in combination with chronic extragenital inflammatory diseases, plasmapheresis is pathogenetically justified, because During the procedure, not only elimination of toxic substances, Ag, AT, immune complexes, immunocompetent cells, but also deblocking own detoxification systems, immune system. The maximum efficiency of plasmapheresis can be achieved when carrying it out in the first phase of the menstrual cycle (immediately after the cessation of menstrual bleeding).
DRUG TREATMENT
TREATMENT OF ACUTE PIDID
The dosage of drugs is selected taking into account the age, body weight of the child and the severity of the clinical picture. diseases.
Antibacterial drugs or their combination are selected taking into account the pathogen and its sensitivity to antimicrobial drugs.
For mild forms of the disease, basic therapy consists of antibacterial drugs, derivatives nitroimidazole, antifungal and antihistamines. Additionally, NSAIDs are used immunomodulators.
For chlamydial and mycoplasma etiologies of PID, it is preferable to use antibiotics capable of accumulation in affected cells and blocking intracellular protein synthesis. Such drugs include tetracyclines (doxycycline, tetracycline), macrolides (azithromycin, josamycin, clarithromycin, midecamycin, oleandomycin, roxithromycin, spiramycin, erythromycin) and fluoroquinolones (lomefloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin, sparfloxacin).
In modern treatment of acute uncomplicated chlamydial or mycoplasma salpingo-oophoritis, the following antibiotics:
- azithromycin;
- doxycycline.
For salpingoophoritis caused by gonococci, “protected” penicillins are used - a combination of an antibiotic with substances that destroy β-lactamase, considering that 80% of gonococcal strains due to the production of β-lactamase resistant to penicillin drugs. No less effective are drugs from the cephalosporin group, especially III–IV generation (ceftriaxone, cefotaxime, etc.), and fluoroquinolones.
In modern treatment of acute uncomplicated gonococcal salpingoophoritis, the following antibiotics are used:
- ceftriaxone;
- amoxicillin + clavulanic acid;
- cefotaxime;
- fluoroquinolones (lomefloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin, sparfloxacin);
- Spectinomycin.
In the acute stage of the inflammatory process, in the absence of technical or clinical possibility of collecting material and to determine the type of pathogen ex juvantibus, a combination of several antibacterial agents is used broad-spectrum drugs for 7–10 days.
Schemes of possible combinations of antimicrobial drugs:
- amoxicillin + clavulanic acid and doxycycline;
- doxycycline and metronidazole;
- fluoroquinolone and lincosamide;
- fluoroquinolone and metronidazole;
- macrolide and metronidazole.
In severe cases, the presence of pelvioperitonitis and septic condition, purulent formations in girls The following modes are recommended antibacterial therapy:
- III–IV generation cephalosporin + doxycycline;
- ticarcillin + clavulanic acid (or piperacillin + tazobactam) and doxycycline (or macrolide);
- fluoroquinolone and metronidazole (or lincosamide);
- carbapenem and doxycycline (or macrolide);
- gentamicin and lincosamide.
If therapeutic and diagnostic laparoscopy is necessary, antibiotic therapy can be started 30 minutes before or during during induction of anesthesia or immediately after surgical treatment. In severe cases of the disease it is preferable parenteral route of drug administration.
It is mandatory to include synthetic (azoles) or natural (polyenes) antifungal drugs in treatment regimens for systemic and, if necessary, local use. Of the systemic azoles, fluconazole and Itraconazole and ketoconazole are practically not used due to their high toxicity. Antifungal agents should be taken with Use with caution in patients with severe liver dysfunction. No usage observations itraconazole in children under 14 years of age. Prophylactic use polyene antimycotics nystatin and levorin ineffective, currently natamycin is most often used among polyene drugs. For candidiasis salpingo-oophoritis use the same antifungal drugs, combining local and general therapy.
Of the antimycotics, fluconazole is most often used (for children under 12 years of age and weighing less than 50 kg, the dose of the drug is is 3–12 mg/kg body weight, for children over 12 years old and weighing more than 50 kg - 150 mg once in the 2nd and last day of taking antibacterial drugs); itraconazole (for children over 14 years old, 100 mg or 5 mg/kg body weight (with weight less than 50 kg) 2 times a day for 3 days 5 days before the end of antibiotic use) or natamycin (according to 100 mg 2–4 times a day while taking antibiotics).
Antibacterial therapy can be carried out in combination with plasmapheresis with a small volume of plasma exfusion. It is also possible to conduct a course of plasmapheresis sequentially after the end of antibacterial therapy. For extracorporeal detoxification, in addition to plasmapheresis, autologous blood is also irradiated with ultraviolet light, laser, ozone therapy.
The use of PG synthesis blockers - nimesulide is indicated (for children over 12 years of age, a single dose of 1.5 mg/kg is prescribed body weight, but not more than 100 mg, 2 times a day, maximum daily dose 5 mg/kg) or diclofenac (for children 6–15 years old use only enteric-coated tablets at a dose of 0.5–2 mg/kg body weight, divided by 2–3 reception; Adolescents over 16 years of age can be prescribed 50 mg 2 times a day orally or rectally in suppositories for 7 days).
Other NSAIDs may also be used. Diclofenac should be used orally with caution in patients with diseases of the liver, kidneys and gastrointestinal tract, and indomethacin - for patients with diseases of the liver, kidneys and erosive ulcers gastrointestinal lesions.
Among antihistamines, it is preferable to prescribe clemastine, quifenadine, mebhydrolin, chloropyramine, loratadine, ketotifen.
It is advisable to include IFN drugs, IFN inducers, as well as immunoactivators in the therapeutic complex. Viferon © prescribed rectally (for children under 7 years old, Viferon1 suppositories are used ©, over 7 years old and adults - Viferon2© - 2 times a day for 10 days), cycloferon © orally or intramuscularly (0.25 g each on the 1st, 2nd, 4th, 6th, 11th, 14th, 17th, 20th, 23rd, 26th th, 29th day of treatment). It is possible to use Kipferon© rectally, 1 suppository 2–3 times a day for 5–7 days.
To normalize the intestinal microflora (especially after treatment with antibiotics), the following can be used: drugs like bactisubtil © (children over 3 years old, 3–6 capsules per day for 7–10 days, over 3 years old, including adults, 4–8 capsules per day orally, an hour before meals), Hilak Forte © (infants: 15–30 drops 3 times a day day, older children age group 20–40 drops 3 times a day orally in a small amount of liquid).
Along with this, it is advisable to use antioxidants, vitamin preparations, adaptogens (saparal©, extract eleutherococcus, aralia tincture, pantocrine©, lemongrass tincture, ginseng tincture, etc.) and eubiotics. From eubiotics pre-pubertal girls should be prescribed bifid drugs (bifidumbacterin©, bifiform ©, etc.). For girls older adults are prescribed biological products containing both bifidobacteria and lactobacilli.
Alternative method
Antihomotoxic therapy drugs are used as complementary therapy. To prevent side effects effects of antibiotics, as well as to achieve anti-inflammatory, desensitizing, immunocorrective effect while taking antibacterial drugs, the following may be recommended drug complex:
- traumeel C © 1 tablet 3 times a day or 10 drops 3 times a day or 2.2 ml 3 times a day IM;
- hepel
- lymphomyosot © 20 drops 3 times a day;
- gynecohel
The use of the complex is discontinued along with the use of antibacterial drugs.
Then take gynecohel for 20 days © 10 drops 2 times a day (preferably at 8 and 16 hours), mucosa compositum © 2.2 ml 1 time every 5 days IM - 5 injections per course, hepel © 1 tablet 3 times a day except days taking mucosa compositum ©. To prevent the development of adhesions and exacerbations of the inflammatory process It is recommended to carry out a course of antihomotoxic therapy for 3 months:
- gynecohel © 10 drops 3 times a day;
- traumeel C © 1 tablet 3 times a day or 10 drops 3 times a day;
- galiumkhel © 10 drops 3 times a day.
TREATMENT OF CHRONIC PIDID
During chronic salpingoophoritis, phases of exacerbation and remission are distinguished. The disease in the acute stage may proceed in two different ways: in one case, a true exacerbation of inflammation develops, i.e. ESR increases, pain in the appendage area, leukocytosis, hyperthermia, and exudative process in the uterine appendages predominate.
In another, more common variant, acute phase changes in the clinical picture and blood count are not expressed, there is a deterioration in health, unstable mood is observed, neurotic reactions, note symptoms neuralgia of the pelvic nerves.
Treatment of exacerbation occurring according to the first option is carried out similarly to the treatment of acute salpingoophoritis (classes and dosages medicines see section “Treatment of acute PID”).
Enzyme preparations (Wobenzym©, phlogenzyme ©, trypsin ©, chymotrypsin ©, etc.) play an important role in pathogenetic therapy for PID. Wobenzym © prescribe 3 tablets 3 times a day for children under 12 years of age and 5 tablets 3 times a day for children over 12 years old orally 40 minutes before meals with plenty of liquid (250 ml). Use this drug with caution prescribed to patients with a high risk of bleeding and severe renal impairment and liver.
In case of exacerbation of salpingoophoritis, proceeding according to the second option, antibacterial drugs rarely used only when signs of the inflammatory process intensify. In complex therapy, physical factors are used effects, drugs that activate blood circulation, enzyme and vitamin preparations.
Alternative method
Antihomotoxic therapy in the complex of treatment of subacute and first, infectious-toxic variants exacerbation of chronic salpingoophoritis includes:
- traumeel C © 1 tablet 3 times a day;
- hepel © 1 tablet 3 times a day;
- gynekohel© 10 drops 3 times a day;
- Spascuprel© 1 tablet 3 times a day and/or Viburkol 1 rectal suppository 3 times a day for 3–4 weeks.
Antihomotoxic therapy in the complex of rehabilitation measures for PID on menstrual days for 3 cycles includes:
- traumeel C © 1 tablet 3 times a day;
- gynecohel © 10 drops 2 times a day (at 9–10 and 15–16 hours).
To prevent adhesions for 3 cycles (except for menstruation), use:
- lymphomyosot© 10 drops 3 times a day;
- galiumhel© 10 drops 3 times a day.
Antihomotoxic therapy in complex therapy for the second variant of exacerbation of chronic salpingoophoritis includes the following drugs:
- Traumeel C© 1 tablet 3 times a day for 7–10 days or Echinacea compositum C© 2.2 ml 1–2 times a day IM for 3–5 days;
- gynekohel© 10 drops 3 times a day for 7–10 days, then 10 drops 2 times a day (at 9–10 and 15–16);
- Nervohel© 1 tablet 3 times a day;
- mucosa compositum© 2.2 ml once every 5 days IM No. 5;
- hepel© 1 tablet 1 time per day between 4 pm and 8 pm, except on days of taking mucosa compositum©;
- Lymphomyosot© 15 drops 3 times a day for 14 days.
For menstrual irregularities (scanty bleeding), in combination with atrophic endometrium according to ultrasound data and/or data histological examination Prescribe sequential estrogen progestogen drugs (fixed combination):
- in phase I, estrogen (estradiol) is taken;
- in phase II - estrogen in combination with gestagen:
Estradiol + estradiol and dydrogesterone (femoston 1/5©);
- conjugated estrogens + medroxyprogesterone (premella cycle©) 1 tablet daily without a break for 3–6 months;
-estradiol + medroxyprogesterone (divin©);
-estradiol / estradiol + levonorgestrel (klimonorm©);
-estradiol / estradiol + cyproterone (clymene©);
-estradiol / estradiol + norgestrel (cycloproginova©) 1 tablet daily for 21 days, then a break of 7 days and a new cycle for 3–6 cycles.
In these cases, estrogens are also used for 21 days:
- estradiol (in transdermal form: gels estrogel© 0.06% and divigel© 0.1% - 0.5–1.0 g/day, climar patches© 1 time
per week, in the form of octodiol© nasal spray, in tablet form estrimax©, estrofem© 1 tablet per day,
proginova© 1 tablet per day); - conjugated estrogens (K.E.S.©, Premarin© 1 tablet per day);
in combination with gestagens in phase II of the cycle from the 12th to the 21st day: - dydrogesterone (1 tablet 2-3 times a day);
- progesterone (1 tablet 2-3 times a day, in transdermal form - the gel is applied to the skin 1 time a day).
Alternative method
Antihomotoxic therapy drugs:
- Traumeel C© 1.1 ml 2 days in a row (possible injection into the projection points of the appendages);
- Traumeel C© 1 tablet (or 10 ml orally) 3 times a day;
- gynekohel© 10 drops 5–7 times a day for the first 3 days until the condition improves, then 10 drops 3 times a day
day; - Lymphomyosot© 15 drops 2 times a day. Duration of therapy is 3–4 weeks.
During the period of remission, to prevent unwanted pregnancy, sexually active adolescents are prescribed monophasic COCs.
SURGERY
Surgical treatment is performed if ineffective conservative therapy, as a rule, in the case of formation tubo-ovarian purulent formations.
Acute salpingoophoritis accompanied by peritonitis is also an indication for surgical treatment, Laparoscopic access is preferable, and one should strive for organ-preserving operations.
INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS
In case of PID in children, it is necessary to consult with specialists in a therapeutic profile if there is a suspicion of infection or inflammatory diseases of the urinary tract, consultation with a surgeon - to exclude acute surgical pathology of the abdominal organs (most often appendicitis), a phthisiatrician - to exclude inflammatory process of tuberculosis etiology.
APPROXIMATE DURATION OF DISABILITY
Period of incapacity for work in acute PID or during an exacerbation of a chronic inflammatory process is 7–14 days.
FOLLOW-UP
After completion of therapy in an outpatient or inpatient setting, the underlying disease is corrected biocenosis of the intestines and genitals, restoration of the menstrual cycle. In sexually active adolescents carry out correction of sexual behavior (use of COCs in combination with barrier methods for a period of at least 3 months). In the absence of signs of an inflammatory process, examination and study of clinical and biochemical blood counts are carried out after 1, 3, 6, 9, 12 months in the first year, then once every 6 months for 2 years.
INFORMATION FOR THE PATIENT
Girls with PID (and their parents) need to be informed that if their general health worsens, pain in the lower abdomen, increased body temperature, the appearance of discharge from the genital tract with an unpleasant odor you need to consult a doctor. In the presence of foci of chronic infection (chronic inflammatory diseases oropharynx, urinary system, gastrointestinal tract) requires observation by specialists of the appropriate profile. After suffered acute PID or in case of established chronic inflammation of the internal genitalia are necessary regular preventive examinations by a pediatric gynecologist.
FORECAST
With adequate treatment and rehabilitation, the prognosis is favorable.
PREVENTION
Prevention of PID in young girls is nonspecific and consists of sanitation of foci of chronic infection. In addition, it is possible to reduce the incidence of disease in sexually active adolescents through the use of mechanical means of contraception, reducing the number of sexual partners, combating drug addiction, and reducing the intake of alcoholic beverages. Regular testing for STIs is also necessary.
BIBLIOGRAPHY
Bokhman Y.V. Guide to gynecological oncology. - St. Petersburg: Foliant, 2002. - pp. 195–229.
Bryantsev A.V. Laparoscopy in the diagnosis and treatment of acute surgical pathology of the internal genital organs in girls: Dis. ...cand. honey. Sciences: 14.00.35 / SCCD RAMS; Bryantsev Alexander Vladimirovich; scientific hands L.M. Roshal, E.V. Uvarov. - M., 1999. - 179 p.
Kulakov V.I. Ways to improve obstetric and gynecological care in the country: Meetings of the V Russian Forum “Mother and child". - M., 2003. - 620 p.
Tikhomirov A.L., Lubnin D.M., Yudaev V.N. Reproductive aspects of gynecological practice / Ed. professors A.L. Tikhomirov. - Kolomna, 2002.
Trubina T.B., Trubin V.G. Infectious complications of medical abortion // Journal. obstetrics and women's diseases. - 1998. - Special. issue - P. 38–39.
Frolova I.I. Aspects of the etiology and pathogenesis of cervical intraepithelial neoplasia and cervical cancer
uterus // Issues of gynecology, obstetrics and perinatology. - 2003. - T. 2, No. 1. - pp. 78–86.
Boardman L.A., Peipert J.F., Brody J.M. et al. Endovaginal sonography for the diagnosis of upper genital tract infection // Obstet. Gynecol. - 1997. - Vol. 90. - R. 54.
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002 // Morb Mortal Wkly Rep. - 2002. - N51(RR6):1.
Kamwendo F., Forslin L., Bodin L., Danielsson D. Programs to reduce pelvic inflammatory disease - the Swedish experience // Lancet. - 1998. - Vol. 351 (Suppl. 3). - P. 25–28.
Pletcher J.R.; Slap Y.B. Pelvic inflammatory disease // Pediatr Rev. - 1998. - Vol. 19, N 11. - R. 363–367.
Henry Suchet J. Laparoscopic treatment of tuboovarian abscess: thirty years of experience // J. Am. Assoc. Gynecol. Laparosc. - 2002. - Vol. 9, No. 3. - R. 235–237.
V. N. Kuzmin
Doctor of Medical Sciences, Professor, MGMSU, Moscow
Pelvic inflammatory diseases (PID) are characterized by various manifestations depending on the level of damage and the strength of the inflammatory response. The disease develops as a result of penetration of a pathogen (enterococci, bacteroids, chlamydia, mycoplasmas, ureaplasmas, trichomonas) into the genital tract and in the presence of favorable conditions for its development and reproduction. Such conditions are created in the postpartum or post-abortion period, during menstruation, during various intrauterine manipulations (insertion of an IUD, hysteroscopy, hysterosalpingography, diagnostic curettage).
Existing natural defense mechanisms, such as anatomical features, local immunity, acidic environment vaginal contents, the absence of endocrine disorders or serious extragenital diseases, can in the vast majority of cases prevent the development of genital infection. An inflammatory response occurs to the invasion of a particular microorganism, which, based on the latest concepts of the development of the septic process, is usually called a systemic inflammatory response.
Acute salpingoophoritis
Refers to the most frequent illnesses inflammatory etiology in women. Every fifth woman who has suffered salpingo-oophoritis is at risk of infertility. Adnexitis can cause a high risk of ectopic pregnancy and pathological course of pregnancy and childbirth. The fallopian tubes are the first to be affected, and the inflammatory process can involve all layers of the mucous membrane of one or both tubes, but more often only the mucous membrane of the tube is affected, and catarrhal inflammation of the mucous membrane of the tube occurs - endosalpingitis. Inflammatory exudate, accumulating in the pipe, often flows through the ampullary opening into the abdominal cavity, adhesions form around the pipe, and the abdominal opening of the pipe closes. A saccular tumor develops in the form of a hydrosalpinx with transparent serous contents or a pyosalpinx with purulent contents. Further serous exudate hydrosalpinx resolves as a result of treatment, and purulent pyosalpinx can perforate into the abdominal cavity. The purulent process can capture and melt all large areas of the pelvis, spreading to all internal genitalia and nearby organs.
Inflammation of the ovaries (oophoritis) as a primary disease is rare; infection occurs in the area of the ruptured follicle, since the rest of the ovarian tissue is well protected by the covering germinal epithelium. In the acute stage, edema and small cell infiltration are observed. Sometimes in the follicle cavity corpus luteum or small follicular cysts Abscesses and microabscesses are formed, which, merging, form an ovarian abscess, or pyovarium. It is almost impossible to diagnose an isolated inflammatory process in the ovary, and this is not necessary. Currently, only 25-30% of patients with acute adnexitis have a pronounced picture of inflammation, the rest experience a transition to chronic form, when therapy is stopped after the clinic quickly subsides.
Acute salpingoophoritis is treated with antibiotics (preferably fluoroquinolones III generation- ciprofloxacin, tarivid, abactal), since it is often accompanied by pelvioperitonitis - inflammation of the pelvic peritoneum.
Endometritis
Acute endometritis always requires antibacterial therapy. The basal layer of the endometrium is affected by the inflammatory process due to the invasion of specific or nonspecific pathogens. Endometrial protective mechanisms, congenital or acquired, such as T-lymphocyte aggregates and other elements of cellular immunity, are directly related to the action of sex hormones, especially estradiol. These mechanisms act in conjunction with the macrophage population and protect the body from damaging factors. With the onset of menstruation, this barrier on a large surface of the mucous membrane disappears, which makes it possible to become infected. Another source of protection in the uterus is the infiltration of the underlying tissues with polymorphonuclear leukocytes and the rich blood supply of the uterus, which promotes adequate perfusion of the organ with blood and nonspecific humoral protective elements contained in its serum: transferrin, lysozyme, opsonins.
The inflammatory process can spread to the muscle layer, resulting in metroendometritis and metrothrombophlebitis with severe clinical course. The inflammatory reaction is characterized by a disorder of microcirculation in the affected tissues, expressed by exudation; with the addition of anaerobic flora, necrotic destruction of the myometrium may occur.
Clinical manifestations of acute endometritis: already on the 3-4th day after infection, an increase in body temperature, tachycardia, leukocytosis and a shift in the blood, an increase in ESR are observed. Moderate enlargement of the uterus is accompanied by pain, especially along its ribs (along the blood and lymphatic vessels). Purulent- bloody issues. Acute stage Endometritis lasts 8-10 days and requires quite serious treatment. With proper treatment, the process ends, less often it turns into a subacute and chronic form, and even less often, with self-administered indiscriminate antibiotic therapy, endometritis can take a milder abortive course.
Treatment of acute endometritis, regardless of the severity of its manifestations, begins with antibacterial infusion, desensitizing and restorative therapy.
Antibiotics are best prescribed taking into account the sensitivity of the pathogen to them; doses and duration of antibiotic use are determined by the severity of the disease. Due to the frequency of anaerobic infections, metronidazole is additionally recommended. Considering the very rapid course of endometritis, cephalosporins with aminoglycosides and metronidazole are preferred among antibiotics. For example, cefamandole (or cefuroxime, claforan) 1-2 g 3-4 times a day IM or IV drip + gentamicin 80 mg 3 times a day IM + Metrogyl 100 ml IV drip.
Instead of cephalosporins, you can use semi-synthetic penicillins (for abortive cases), for example, ampicillin 1 g 6 times a day. The duration of such combined antibacterial therapy depends on the clinic and laboratory response, but not less than 7-10 days. To prevent dysbiosis from the first days of antibiotic treatment, use nystatin 250,000 units 4 times a day or diflucan 50 mg per day for 1-2 weeks orally or intravenously.
Detoxification infusion therapy may include a number of infusion agents, for example, Ringer-Locke solution - 500 ml, polyionic solution - 400 ml, hemodez (or polydesis) - 400 ml, 5% glucose solution - 500 ml, 1% solution calcium chloride- 200 ml, unithiol with 5% solution ascorbic acid 5 ml 3 times a day. In the presence of hypoproteinemia, it is advisable to carry out infusions of protein solutions (albumin, protein), blood replacement solutions, plasma, red blood cells or whole blood, amino acid preparations.
Physiotherapeutic treatment occupies one of the leading places in the treatment of acute endometritis. It not only reduces the inflammatory process in the endometrium, but also stimulates ovarian function. When normalizing the temperature reaction, it is advisable to prescribe low-intensity ultrasound, inductothermy electromagnetic field HF or UHF, magnetic therapy, laser therapy.
Pelvioperitonitis
Inflammation of the pelvic peritoneum most often occurs secondary to the penetration of infection into the abdominal cavity from an infected uterus (with endometritis, infected abortion, ascending gonorrhea), fallopian tubes, ovaries, intestines, with appendicitis, especially with a pelvic location. At the same time, it is observed inflammatory reaction peritoneum with the formation of serous, serous-purulent or purulent effusion. The condition of patients with pelvioperitonitis remains satisfactory or moderate. The temperature rises, the pulse quickens, but the function of cardio-vascular system is almost not disturbed. With pelvioperitonitis, or local peritonitis, the intestine remains unbloated, palpation of the upper half of the abdominal organs is painless, and symptoms of peritoneal irritation are determined only above the pubis and in the iliac regions. However, patients note severe pain in the lower abdomen, there may be retention of stool and gas, and sometimes vomiting. The level of leukocytes is increased, the formula shifts to the left, the ESR is accelerated. Gradually increasing intoxication worsens the condition of patients.
Treatment of salpingoophoritis with or without pelvioperitonitis begins with a mandatory examination of the patient for flora and sensitivity to antibiotics. Most importantly, the etiology of inflammation should be determined. Today, benzylpenicillin is widely used for the treatment of specific gonorrheal process, although preference should be given to drugs such as Rocephin, Cephobid, Fortum.
The “gold standard” of antibacterial therapy for salpingoophoritis is the prescription of claforan (cefotaxime) at a dose of 1-2 g 2-4 times a day intramuscularly or one dose of 2 g intravenously in combination with gentamicin 80 mg 3 times a day (can Gentamicin is administered once at a dose of 160 mg IM). It is imperative to combine these drugs with Metrazdil, which is administered intravenously at a dose of 100 ml 1-3 times a day. The course of antibiotic treatment should be carried out for at least 5-7 days, you can vary mainly basic drugs by prescribing cephalosporins of the second and third generation (mandol, zinacef, rocephin, cephobid, fortum and others at a dose of 2-4 g per day).
In case of acute inflammation of the uterine appendages, complicated by pelvioperitonitis, oral administration of antibiotics is possible only after the main course of therapy and only if necessary. As a rule, such a need does not arise, and maintaining the previous clinical symptoms may indicate that inflammation is progressing and, possibly, a suppurative process is occurring.
Detoxification therapy is mainly carried out with crystalloid and detoxification solutions in an amount of 2-2.5 liters with the inclusion of solutions of hemodez, rheopolyglucin, Ringer-Locke, polyionic solutions - acessol, etc. Antioxidant therapy is carried out with a 5 ml solution of unithiol with a 5% solution of ascorbic acid 3 times a day intravenously.
In order to normalize the rheological and coagulation properties of blood and improve microcirculation, aspirin 0.25 g/day is used for 7-10 days, as well as intravenous administration of rheopolyglucin 200 ml (2-3 times per course). Subsequently, a complex of resorption therapy and physiotherapeutic treatment is used (calcium gluconate, autohemotherapy, sodium thiosulfate, humizol, plasmol, aloe, FIBS). From physiotherapeutic procedures for acute process ultrasound is appropriate, which causes analgesic, desensitizing and fibrolytic effects, as well as strengthening metabolic processes and tissue trophism, inductothermy, UHF therapy, magnetic therapy, laser therapy, and later - sanatorium-resort treatment.
Purulent tubo-ovarian formations
Among 20-25% of patients suffering from inflammatory diseases of the uterine appendages, 5-9% experience purulent complications requiring surgical interventions.
The following provisions regarding the formation of purulent tubo-ovarian abscesses can be highlighted:
chronic salpingitis in patients with tubo-ovarian abscesses is observed in 100% of cases and precedes them;
the spread of infection occurs predominantly through the intracanalicular route from endometritis (with IUD, abortion, intrauterine interventions) to purulent salpingitis and oophoritis;
there is often a combination of cystic transformations in the ovaries and chronic salpingitis;
there is a mandatory combination of ovarian abscesses with exacerbation of purulent salpingitis;
Ovarian abscesses (pyovarium) are formed mainly from cystic formations, often microabscesses merge.
Morphological forms of purulent tubo-ovarian formations:
pyosalpinx - predominant damage to the fallopian tube;
pyovarium - predominant damage to the ovary;
tubo-ovarian tumor.
All other combinations are complications of these processes and can occur:
without perforation;
with perforation of ulcers;
with pelvioperitonitis;
with peritonitis (limited, diffuse, serous, purulent);
with pelvic abscess;
with parametritis (posterior, anterior, lateral);
with secondary lesions of adjacent organs (sigmoiditis, secondary appendicitis, omentitis, interintestinal abscesses with the formation of fistulas).
Clinically differentiating each localization is almost impossible and impractical, since the treatment is fundamentally the same: antibacterial therapy in this case is given the leading place in terms of using the most active antibiotics, and by the duration of their use. At the core purulent processes lies the irreversible nature of the inflammatory process. Its irreversibility is due to morphological changes, their depth and severity caused by impaired renal function.
Conservative treatment of irreversible changes in the uterine appendages is unpromising, since it creates the preconditions for the occurrence of new relapses and aggravation of metabolic disorders in patients, increases the risk of upcoming surgery in terms of damage to adjacent organs and the inability to perform the required volume of surgery.
Purulent tubo-ovarian formations are associated with great difficulties both diagnostically and clinically. Nevertheless, a number of characteristic syndromes can be identified:
infectious;
early renal;
hemodynamic disorders;
inflammation of adjacent organs;
metabolic disorders.
intoxication;
Clinically, intoxication syndrome is manifested by the phenomena of intoxication encephalopathy: headaches, heaviness in the head and severe general condition. Dyspeptic disorders (dry mouth, nausea, vomiting), tachycardia, and sometimes hypertension (or hypotension with the onset of septic shock, which is one of its early symptoms along with cyanosis and facial hyperemia against the background of severe pallor) are noted.
The pain syndrome, present in almost all patients, is of an increasing nature, accompanied by a deterioration in general condition and well-being; pain during a special examination and symptoms of irritation of the peritoneum around the palpable formation are noted. Pulsating increasing pain, persistent fever with a body temperature above 38°C, tenesmus, loose stools, lack of clear contours of the tumor, lack of effect from treatment - all this indicates the threat of perforation or its presence, which is an absolute indication for urgent surgical treatment. The infectious syndrome is present in all patients and is accompanied in most of them by high body temperature (38°C and above). Tachycardia corresponds to fever, as well as an increase in leukocytosis, the ESR and leukocyte index of intoxication increase, the number of lymphocytes decreases, the shift to the left increases, the number of molecules of average mass increases, reflecting ever-increasing intoxication. Often, due to impaired urine passage, renal dysfunction occurs. Metabolic disorders manifest themselves in the form of dysproteinemia, acidosis, electrolyte disturbances, and changes in the antioxidant system.
The treatment strategy for this group of patients is based on the principles of organ-saving operations, which, however, provide radical removal main site of infection. Therefore, for each specific patient, the time and scope of the operation must be selected individually. Clarifying the diagnosis sometimes takes several days, especially in cases where there is a borderline variant between suppuration and acute inflammatory process or in the differential diagnosis of an oncological process. Antibacterial therapy is required at each stage of treatment.
Preoperative therapy and preparation for surgery include:
antibiotics (cephobid 2 g/day, fortum 2-4 g/day, reflin 2 g/day, augmentin 1.2 g intravenously once a day, clindamycin 2-4 g/day, etc.); they must be combined with gentamicin 80 mg IM 3 times a day and an infusion of Metragil 100 ml IV 3 times;
detoxification therapy with infusion correction of volemic and metabolic disorders;
mandatory assessment of the effectiveness of treatment based on the dynamics of body temperature, peritoneal symptoms, general condition and blood counts.
At the stage surgical intervention Antibacterial therapy must be continued. It seems particularly important to introduce one daily dose antibiotics are still on the operating table, immediately after the end of the operation. This concentration is necessary because it creates a barrier to the further spread of infection: penetration into the area of inflammation is no longer prevented by dense purulent capsules of tubo-ovarian abscesses. Betalactam antibiotics (cephobid, rocephin, fortum, claforan, tienam, augmentin) overcome these barriers well.
Postoperative therapy involves continuing antibacterial therapy with the same antibiotics in combination with antiprotozoal, antimycotic drugs and uroseptics. The duration of treatment depends on the clinical picture and laboratory data (at least 7-10 days). The discontinuation of antibiotics is carried out in accordance with their toxic properties, therefore gentamicin is often discontinued first after 5-7 days of therapy or replaced with amikacin.
Infusion therapy should be aimed at combating hypovolemia, intoxication and metabolic disorders. Normalization of motor skills is very important gastrointestinal tract(intestinal stimulation, HBOT, hemosorption or plasmapheresis, enzymes, epidural blockade, gastric lavage, etc.). Hepatotropic, restorative and antianemic therapy is combined with immunostimulating treatment (UVR, laser blood irradiation, immunocorrectors).
All patients who have undergone surgery for purulent tubo-ovarian abscesses require post-hospital rehabilitation in order to prevent relapses and restore specific body functions.
Literature
Abramchenko V.V., Kostyuchek D.F., Perfilyeva G.N. Purulent-septic infection in obstetrics gynecological practice. St. Petersburg, 1994. 137 p.
Bashmakova M. A., Korkhov V. V. Antibiotics in obstetrics and perinatology. M., 1996. P. 6.
Bondarev N. E. Optimization of diagnosis and treatment of mixed sexually transmitted diseases in gynecological practice: Abstract of thesis. dis. ...cand. honey. Sci. St. Petersburg, 1997. 20 p.
Ventsela R.P. Nosocomial infections. M., 1990. 656 p.
Gurtovoy B. L., Serov V. N., Makatsaria A. D. Purulent-septic diseases in obstetrics. M., 1981. 256 p.
Khadzhieva E. D. Peritonitis after caesarean section: Tutorial. St. Petersburg, 1997. 28 p.
Sahm D. E. The role of automation and molecular technology in antimicrobial susceptibility testing // Clin. Microb. And Inf. 1997. Vol. 3. No. 2. P. 37-56.
Snuth C. B., Noble V., Bensch R. et al. Bacterial flora of the vagina during the mensternal cycle // Ann. Intern. Med. 1982. P. 48-951.
Tenover F. Norel and emerging mechanisms of antimicrobial resistance in nosocomial pathogens // Am. J. Med. 1991. 91. P. 76-81.
The inflammatory process of the pelvic organs implies more than one specific disease, but a group of pathological currents in the body. These include:
- Inflammation of the fallopian tubes in a woman - salpingitis;
- Severe inflammation of the ovaries - oophoritis;
- Salpingoophoritis is an inflammatory process of the uterus, fallopian tubes and ovaries;
- Vaginitis (colpitis) is an inflammatory process in the vaginal mucosa;
- Bartholinitis is a pathology in which inflammation of the entrance (vestibule) of the vagina occurs;
- Vaginosis caused by penetration of pathogenic bacteria into the vagina;
- Parametritis is an inflammatory process of periuterine tissue;
- An inflammatory process of the abdominal cavity called pelvioperitonitis.
All these pathologies relate to severe acute inflammatory processes of the pelvic organs. Each of these pathologies has its own consequences, which affect the woman’s general well-being, reproductive function, sex life, etc.
Symptoms of inflammatory processes
If you experience at least one of the following symptoms, this means that you need to urgently consult your doctor. Self-medication or ignoring the disease is under no circumstances allowed. The consequences of untreated inflammatory processes of the pelvic organs can indeed be extremely severe, ranging from menstrual irregularities to infertility.
We list the main symptoms of inflammatory diseases of the pelvic organs:
- Swelling of the genital organs, increase in size -
- Redness of the labia -
- Itching in the vagina -
- Unpleasant nagging pain in the lower abdomen, extending to the lower back and inner part hip-
Video: Treatment of the pelvic organs with herbal medicine
Concomitant symptoms of the inflammatory process are irregular periods in women or complete disruption of the menstrual cycle. In this case, there may be pain when urinating, pain in the urethra. Against the background of general malaise, a woman may develop a gag reflex, diarrhea, and diarrhea. Physical state of fatigue, weakness, fever.
Causes of the inflammatory process
Why can a woman develop inflammatory processes in the vagina? Let's look at the main reasons for this phenomenon.
The inflammatory process may begin to develop after a recent surgical abortion or difficult childbirth (with complications). In some cases, the infection can enter the vagina from the inflamed, infected appendix, from the affected rectum.
A pathological course such as vulvitis appears due to mechanical damage (this can be scratching of the vagina due to severe itching, as a result - the appearance of abrasions and scratching). IN open wound, as is known, the infection penetrates faster and affects surrounding tissues.
Video: Chinese tampons. Operating principle
Endometritis, which is classified as an acute inflammatory process in the uterine mucosa, appears in a woman after a medical or surgical abortion, curettage of the uterine mucosa for medical reasons.
Factors influencing the occurrence of the inflammatory process
The main factors that influence the course of the inflammatory process are:
Video: 69 Treatment of diseases of the pelvic organs.
- Carrying out several abortions over 1-2 years;
- Intrauterine interventions;
- Long-term wearing of an intrauterine device;
- Surgical curettage of the uterus;
- Constant change of sexual partners;
- Previously untreated inflammatory processes of the pelvic organs;
- Difficult labor;
- Violation of personal hygiene rules (using other people's towels, soap, infrequent washing during the day).
Diagnosis of inflammatory process of the uterus
If a woman experiences unpleasant symptoms in the genital area, she should consult a gynecologist as soon as possible. You should not delay this, otherwise it can lead to serious consequences in the form of infertility.
An experienced gynecologist can determine the presence of an inflammatory process in a patient during a routine examination and questioning of symptoms. When the doctor begins to touch the uterus, you may experience painful sensations, which are quite difficult for a woman to tolerate.
To confirm the presence of an inflammatory process, it will be necessary to take smears of mucus from the vagina, as well as the cervix. During an infectious-inflammatory process in a woman, pathogens of the disease will be found in the vaginal mucus - viruses, infections, gardnerella, fungal microorganisms, trichomonas, gonococci, ureplasma, mycoplasma, coli and not only.
Video: Simonova Tatyana Viktorovna - Inflammatory diseases of the pelvic organs
You will also need to take a blood test - based on the results of the analysis, leukocytosis will be detected during the inflammatory process. According to an ultrasound examination, the patient will be found to have a pathological enlargement of the ovaries, the size of the appendages, as well as the formation of foci of purulent accumulation, infection and inflammation.
Treatment of inflammation in the vagina
If the patient is diagnosed with vulvovaginitis, then treatment will be exclusively outpatient. If the inflammatory process occurs in mild form, then in this case treatment can proceed at home with the help of drug therapy.
To eliminate the inflammatory process, the medications most often used are Metronidazole, Clindamycin, and Tinidazole. If a woman is diagnosed with inflammation in the vagina, her partner must also undergo treatment, otherwise such therapy will not make sense.
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