home Folk remedies Inflammatory diseases of the pelvic organs. STD. pelvic pain. Pregnancy and pelvic inflammatory diseases

Inflammatory diseases of the pelvic organs. STD. pelvic pain. Pregnancy and pelvic inflammatory diseases

The female reproductive system has a rather complex structure. All the organs that make it up are in close connection with each other; accordingly, any disruption in the activity of one of them negatively affects the functioning of the others. And at the same time, the reproductive system shows particular sensitivity to the influence of both internal and external aggressive factors. So a huge number of women are faced with a diagnosis of inflammatory process in the pelvis, its symptoms and treatment, so that you know more, we will now look at it in a little more detail.

The inflammatory process in the pelvis can affect many organs, including the uterus, fallopian tubes, and ovaries. This term may cover various inflammatory diseases of the pelvic organs, represented by endometritis (inflammation of the uterus), cervicitis (inflammation of the cervix), salpingitis (inflammation of the fallopian tubes), oophoritis (inflammation of the ovaries), andexitis (salpingoophoritis - inflammation of the uterine appendages), as well as pelvioperitonitis (inflammation of the pelvic peritoneum) and some others. It is believed that the inflammatory process in the pelvis is the most common problem among all gynecological ailments.

Symptoms

Inflammatory diseases of the small pelvis manifest themselves in different ways. But all of these diseases cause painful sensations in the lower abdomen and can provoke menstrual irregularities in women (irregularity, profuseness, pain, etc.). In addition, some inflammatory processes cause itching and abnormal discharge from the vaginal cavity. The discharge can be curdled, bloody, mucopurulent. Sometimes they become simply abundant, and a yellowish tint may be visible in them. Also, the inflammatory process can give the discharge bad smell, turbidity, etc. In some cases, bleeding appears that is not associated with menstruation.

An acute inflammatory process usually leads to an increase in a person’s body temperature and weakness. The patient may also be concerned about other symptoms of intoxication, for example, headache, symptoms of aches, dizziness, racing blood pressure, feeling of nausea and even vomiting.

Many inflammations in the pelvis lead to a feeling of pressure in the lower abdomen. Also, pathological processes often cause redness, swelling and itching of the mucous membranes of the vulva and/or vagina. Many patients complain of pain during sex in the lower back. They may also be bothered by the problem of painful or difficult urination, and a frequent urge to urinate.

It is worth noting that the chronic form of inflammation in the pelvis most often occurs without severe symptoms. With such a disorder, a woman may experience only unexpressed and intermittent pain, which she does not consider as a reason to seek doctor’s help.

As a result, inflammation leads to the development serious problems with health, which can be represented by infertility, ectopic pregnancies, chronic pelvic pain, etc. And exacerbations of the disease over time can be provoked by any factors - banal hypothermia, colds, etc.

How is the inflammatory process in the pelvis corrected, what treatment is effective?

Therapy of the inflammatory process in the pelvis is carried out in inpatient department or outpatient. After determining the cause of the disease, the doctor selects the appropriate treatment tactics, focusing on the individual characteristics of the patient.

In most cases, correction of inflammation of the female genital organs involves antibacterial therapy. Antibiotics are selected taking into account the identified pathogen; in some cases, before receiving test results, the patient is prescribed a medicine with a wide spectrum of action. In case of serious inflammation antibacterial drugs administered in a hospital, intravenously. Doctors may prescribe the use of two or even more medications at the same time.

When affected by fungi, antibiotics do not have a positive effect; in this case, antifungal drugs are used - either only locally, or both locally and systemically (in the form of tablets). In some cases, such drugs are used prophylactically; the appropriateness of such therapy is determined by the doctor.

In addition, competent anti-inflammatory therapy can be carried out using non-steroidal anti-inflammatory drugs. They also have a good analgesic effect.

Also, treating the inflammatory process in the pelvis helps increase the body's resistance to the disease. To achieve this effect, multivitamin complexes and immunomodulators are usually used. If necessary, desensitizing therapy using antihistamines can be carried out. This treatment can reduce swelling, itching and burning. In addition, patients with an inflammatory process in the pelvis are recommended to adhere to a dietary diet; they are often prescribed physiotherapeutic procedures (after the acute inflammatory process subsides), as well as physical therapy.

In some cases, treatment of the inflammatory process in the pelvis is impossible without surgical intervention. Most often, surgeons perform manipulations to eliminate pus, perform drainage, or remove the uterine appendages.

Traditional treatment

To successfully eliminate inflammation in the pelvis, you can also use traditional medicine, the advisability of their use should be discussed with your doctor.

So the herb St. John's wort can be used for this. Brew a tablespoon of chopped herbs with a glass of just boiled water. Boil this product over low heat for a quarter of an hour, then strain. Accept ready-made decoction a quarter glass three times a day.

Pelvic inflammatory disease is a spectrum of inflammatory processes in the upper reproductive tract in women and can include any combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis.

ICD-10 code

N74* Inflammatory diseases of women pelvic organs for diseases classified elsewhere

Causes of pelvic inflammatory diseases

In most cases, sexually transmitted microorganisms are involved in the development of the disease, especially N. gonorrhoeae and C. trachomatis; however, pelvic inflammatory disease can be caused by microorganisms that are part of the vaginal microflora, such as anaerobes, G. vaginalis, H. influenzae, Gram-negative enterobacteriaceae, and Streptococcus agalactiae. Some experts also believe that M. hominis and U. urealyticum may be the etiological agent of pelvic inflammatory disease.

These diseases are caused by gonococci, chlamydia, streptococci, staphylococci, mycoplasmas, Escherichia coli, enterococci, and Proteus. An important role in their occurrence belongs to anaerobic pathogens (bacteroides). As a rule, inflammatory processes are caused by mixed microflora.

The causative agents of inflammatory diseases are most often introduced from the outside (exogenous infection); Less commonly observed are processes whose origin is associated with the penetration of microbes from the intestines or other foci of infection in a woman’s body (endogenous infection). Inflammatory diseases of septic etiology occur when tissue integrity is disrupted (entry gate of infection).

Forms

To inflammatory diseases upper section genital organs or pelvic inflammatory diseases include inflammation of the endometrium (myometrium), fallopian tubes, ovaries and pelvic peritoneum. Isolated inflammation of these organs of the reproductive tract is rare in clinical practice, since they all represent a single functional system.

Based on the clinical course of the disease and on the basis of pathomorphological studies, two types are distinguished: clinical forms purulent inflammatory diseases of the internal genital organs: uncomplicated and complicated, which ultimately determines the choice of management tactics.

Complications and consequences

Any form of inflammatory diseases of the upper female genital organs can be complicated by the development of an acute purulent process.

Diagnosis of pelvic inflammatory diseases

The diagnosis is established on the basis of the patient’s complaints, life history and disease, the results of a general examination and gynecological examination. The nature of the morphological changes in the internal genital organs (salpingo-oophoritis, endometritis, endomyometritis, tubo-ovarian abscess, pyosalpinx, inflammatory tubo-ovarian formation, pelvioperitonitis, peritonitis), and the course of the inflammatory process (acute, subacute, chronic) are taken into account. The diagnosis must reflect the presence of concomitant gynecological and extragenital diseases.

During examination, all patients must examine discharge from the urethra, vagina, cervical canal (if necessary, rectal washings) in order to determine the flora and sensitivity of the isolated pathogen to antibiotics, as well as discharge from the fallopian tubes, contents abdominal cavity(effusion) obtained during laparoscopy or transection.

To establish the degree of microcirculation disorders, it is advisable to determine the number of erythrocytes, erythrocyte aggregation, hematocrit, platelet count and their aggregation. From the indicators nonspecific protection the phagocytic activity of leukocytes should be determined.

To establish the specific etiology of the disease, serological and enzyme immunoassay methods are used. If tuberculosis is suspected, it is necessary to perform tuberculin tests.

From additional instrumental methods use ultrasonography, computed tomography of small organs, laparoscopy. If it is not possible to perform laparoscopy, a puncture of the abdominal cavity is performed through the posterior vaginal fornix.

Diagnostic notes

Due to the wide range of symptoms and signs, the diagnosis of acute inflammatory diseases of the pelvic organs in women presents significant difficulties. Many women with pelvic inflammatory disease have mild or moderate symptoms that are not always recognized as pelvic inflammatory disease. Consequently, a delay in diagnosis and delay in appropriate treatment leads to inflammatory complications in the upper reproductive tract. To get more accurate diagnosis salpingitis and laparoscopy can be used for a more complete bacteriological diagnosis. However, this diagnostic technique often not available for either acute cases or milder cases where symptoms are mild or vague. Moreover, laparoscopy is not suitable for detecting endometritis and mild inflammation of the fallopian tubes. Therefore, as a rule, the diagnosis of pelvic inflammatory diseases is carried out on the basis of clinical signs.

Clinical diagnosis of acute inflammatory diseases of the pelvic organs is also not accurate enough. Data show that in the clinical diagnosis of symptomatic pelvic inflammatory disease, positive predicted values (PPVs) for salpingitis are 65-90% compared with laparoscopy as the standard. The PPV for the clinical diagnosis of acute pelvic inflammatory disease varies depending on the epidemiological characteristics and type medical institution; they are higher for sexually active young women (especially teenagers), for patients visiting STD clinics, or living in areas with a high prevalence of gonorrhea and chlamydia. However, there is no single anamnestic, physical, or laboratory criterion that has the same sensitivity and specificity for diagnosing an acute episode of pelvic inflammatory disease (that is, a criterion that could be used to identify all cases of PID and to exclude all women without pelvic inflammatory disease). pelvis). When combining diagnostic techniques that improve either sensitivity (identify more women with PID) or specificity (exclude more women who do not have PID), one does so at the expense of the other. For example, requiring two or more criteria excludes more women without pelvic inflammatory disease but also reduces the number of women identified with PID.

A large number of episodes of pelvic inflammatory disease remain unrecognized. Although some women are asymptomatic, PID goes undiagnosed in others because health care providers are unable to correctly interpret mild or nonspecific symptoms and signs such as unusual bleeding, dyspareunia, or vaginal discharge (“atypical PID”). Due to the difficulties of diagnosis and the possibility of disruption of a woman’s reproductive health, even with a mild or atypical course of inflammatory diseases of the pelvic organs, experts recommend that medical professionals use "PID" for PID. low threshold" diagnostics. Even under such circumstances, the influence early treatment women with asymptomatic or atypical PID clinical outcome unknown. The presented recommendations for the diagnosis of inflammatory diseases of the pelvic organs are necessary in order to help medical professionals assume the possibility of having inflammatory diseases of the pelvic organs and have Additional information For correct setting diagnosis. These recommendations are based in part on the fact that the diagnosis and management of other common cases of lower abdominal pain (eg, ectopic pregnancy, acute appendicitis and functional pain) are unlikely to be worsened if a healthcare professional initiates empirical antimicrobial treatment for pelvic inflammatory disease.

Minimum criteria

Empirical treatment of pelvic inflammatory disease should be considered in sexually active young women and others at risk for STDs when all of the following criteria are met and there is no other cause for the patient's illness:

Pain on palpation in the lower abdomen,
Pain in the appendage area, and
Painful traction of the cervix.

Additional criteria

Overdiagnosis is often justified, since incorrect diagnosis and treatment can lead to serious consequences. These additional criteria can be used to increase the specificity of diagnosis.

The following are additional criteria that support the diagnosis of pelvic inflammatory disease:

Temperature above 38.3°C,
Pathological discharge from the cervix or vagina,
Increased ESR,
Increased level C-reactive protein,
Laboratory confirmation cervical infection caused by N. gonorrhoeae or C. trachomatis.

Below are the defining criteria for the diagnosis of inflammatory diseases of the pelvic organs, which are proven by selected cases of diseases:

Histopathological detection of endometritis on endometrial biopsy,
Transvaginal ultrasound (or other technology) showing thickened, fluid-filled fallopian tubes with or without free abdominal fluid or the presence of a tubo-ovarian mass,
Abnormalities found during laparoscopy consistent with PID.

Although the decision to initiate treatment can be made before a bacteriological diagnosis of N. gonorrhoeae or C. trachomatis infections is made, confirmation of the diagnosis emphasizes the need to treat sexual partners.

Treatment of pelvic inflammatory diseases

When identifying acute inflammation the patient should be hospitalized in a hospital, where she is provided with a medical and protective regime with strict adherence to physical and emotional rest. Prescribe bed rest, ice on the hypogastric region (2 hours at a time with breaks of 30 minutes - 1 hour for 1-2 days), a gentle diet. Carefully monitor bowel activity and, if necessary, prescribe warm cleansing enemas. Patients benefit from bromine, valerian, and sedatives.

Etiopathogenetic treatment of patients with inflammatory diseases of the pelvic organs involves the use of both conservative therapy and timely surgical treatment.

Conservative treatment of acute inflammatory diseases of the upper genital organs is carried out comprehensively and includes:

antibacterial therapy;
detoxification therapy and correction of metabolic disorders;
anticoagulant therapy;
immunotherapy;
symptomatic therapy.

Antibacterial therapy

Since the microbial factor plays a decisive role in acute stage inflammation, which determines during this period of the disease is antibacterial therapy. On the first day of the patient’s stay in the hospital, when there are still no laboratory data on the nature of the pathogen and its sensitivity to a particular antibiotic, the presumptive etiology of the disease is taken into account when prescribing drugs.

Behind last years effectiveness of treatment severe forms purulent-inflammatory complications increased with the use of beta-lactam antibiotics (Augmentin, Meronem, Thienam). The gold standard is the use of clindamycin with gentamicin. It is recommended to change antibiotics after 7-10 days with repeated determination of antibiograms. In connection with the possible development of local and generalized candidiasis during antibiotic therapy, it is necessary to study blood and urocultures, as well as prescribe antifungal drugs.

If oligoanuria occurs, an immediate review of the doses of antibiotics used is indicated, taking into account their half-life.

Treatment regimens for pelvic inflammatory disease should empirically eliminate a wide range of possible pathogens, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci. Although some antimicrobial regimens have been shown to be effective in achieving clinical and microbiological cure in clinical randomized trials with short-term follow-up, few studies have assessed and compared the elimination of endometrial and fallopian tube infections or the incidence of long-term complications such as tubal infertility and ectopic infertility. pregnancy.

All treatment regimens must be effective against N. gonorrhoeae and C. trachomatis, because negative tests for these infections in the endocervix do not exclude the presence of infection in the upper reproductive tract. Although the need to eliminate anaerobes in women with PID is still controversial, there is evidence to suggest that it may be important. Anaerobic bacteria isolated from the upper reproductive tract of women with PID and those obtained in vitro clearly show that anaerobes such as B. fragilis can cause tubal and epithelial destruction. In addition, many women with PID are also diagnosed with bacterial vaginosis. In order to prevent complications, recommended regimens should include drugs that act on anaerobes. Treatment should be started immediately upon establishing a preliminary diagnosis, since the prevention of long-term consequences is directly related to the timing of the prescription of appropriate antibiotics. When choosing a treatment regimen, the physician must consider its availability, cost, patient acceptability, and sensitivity of pathogens to antibiotics.

In the past, many experts recommended that all patients with PID be hospitalized so that bed rest, under the supervision of a physician, parenteral antibiotic treatment could be performed. However, hospitalization is no longer synonymous with parenteral therapy. There is currently no data available that shows comparative effectiveness parenteral and oral treatment, or inpatient or outpatient treatment. Until results from ongoing studies comparing parenteral inpatient versus oral outpatient treatment in women with PID become available, data should be considered clinical observations. The doctor makes a decision about the need for hospitalization based on the following recommendations, based on observational data and theoretical developments:

Conditions requiring urgent surgical intervention cannot be excluded, such as appendicitis,
The patient is pregnant
Unsuccessful treatment with oral antimicrobials,
Inability to comply with or tolerate an outpatient oral regimen,
Severe illness, nausea and vomiting, or high fever.
Tuboovarian abscess,
Presence of immunodeficiency (HIV infection with low CD4 count, immunosuppressive therapy or other diseases).

Most clinicians provide at least 24 hours of direct observation in the hospital for patients with tubo-ovarian abscesses, after which adequate parenteral treatment should be provided at home.

There are no convincing data comparing parenteral and oral regimens. Extensive experience has been accumulated in the use of the following schemes. There are also multiple randomized studies demonstrating the effectiveness of each regimen. Although most studies used parenteral treatment for at least 48 hours after the patient showed significant clinical improvement, this regimen was randomized. Clinical experience should guide the decision to switch to oral treatment, which can be made within 24 hours of the onset of clinical improvement.

Regimen A for parenteral treatment

Cefotetan 2 g IV every 12 hours,
or Cefoxitin 2 g IV every hour
plus Doxycycline 100 mg IV or orally every 12 hours.

NOTE. Considering that infusion administration of drugs is associated with painful sensations, oral doxycycline should be prescribed whenever possible, even if the patient is hospitalized. Oral and intravenous doxycycline treatments have similar bioavailability. If intravenous administration is necessary, use lidocaine or other fast-acting local anesthetics, heparin, or steroids or prolonging the infusion time may reduce infusion complications. Parenteral treatment may be discontinued 24 hours after the patient shows clinical improvement, and oral treatment with doxycycline 100 mg twice daily should be continued for up to 14 days. In the presence of a tubo-ovarian abscess, many doctors use clindamycin or metronidazole with doxycycline to continue treatment, more often than doxycycline alone, because this contributes to more effective coverage of the entire spectrum of pathogens, including anaerobes.

Clinical data on second- or third-generation cephalosporins (eg, ceftizoxime, cefotaxime, or ceftriaxone) that can replace cefoxitin or cefotetan are limited, although many authors believe that they are also effective in PID. However, they are less active in relation to anaerobic bacteria than cefoxitin or cefotetan.

Regimen B for parenteral treatment

Clindamycin 900 mg IV every 8 hours
plus Gentamicin - a loading dose IV or IM (2 mg/kg body weight), and then a maintenance dose (1.5 mg/kg) every 8 hours.

NOTE. Although the use of a single dose of gentamicin has not been studied in the treatment of pelvic inflammatory disease, its effectiveness in other similar situations is well established. Parenteral treatment can be interrupted 24 hours after the patient has shown clinical improvement, and then treated with oral doxycycline 100 mg twice daily or clindamycin 450 mg orally four times daily. The total duration of treatment should be 14 days.

For tubo-ovarian abscess, many health care providers use clindamycin rather than doxycycline for continued treatment because it is more effective against anaerobic organisms.

Alternative parenteral treatment regimens

There is limited data on the use of other parenteral regimens, but the following three treatment regimens have each been tested in at least one clinical trial and have been shown to be effective against wide range microorganisms.

Ofloxacin 400 mg IV every 12 hours,
or Ampicillin/sulbactam 3 g IV every 6 hours,
or Ciprofloxacin 200 mg IV every 12 hours
plus Doxycycline 100 mg orally or IV every 12 hours.
plus Metronidazole 500 mg IV every 8 hours.

The ampicillin/sulbactam regimen with doxycycline had a good effect against N. gonorrhoeae, C. trachomatis, as well as anaerobes and was effective in patients with tubo-ovarian abscess. Both intravenous drug- ofloxacin and ciprofloxacin have been studied as monotherapy drugs. Given the data obtained on the ineffective effect of ciprofloxacin on C. trachomatis, it is recommended to routinely add doxycycline to treatment. Since these quinolones are active only against some anaerobes, metronidazole should be added to each regimen.

Oral treatment

There is little data regarding the immediate and long-term outcomes of treatment, either with parenteral or outpatient regimens. The following regimens provide antimicrobial activity against the most common etiological agents of PID, but clinical trial data on their use are very limited. Patients who do not improve with oral treatment within 72 hours should be re-evaluated to confirm the diagnosis and given parenteral treatment in an outpatient or inpatient setting.

Scheme A

Ofloxacin 400 mg 2 times a day for 14 days,
plus Metronidazole 500 mg orally 2 times a day for 14 days

Oral ofloxacin, used as monotherapy, was studied in two well-designed clinical trials and was effective against N. gonorrhoeae and C. trachomatis. However, taking into account that ofloxacin is still not effective enough against anaerobes, the addition of metronidazole is necessary.

Scheme B

Ceftriaxone 250 mg IM once,
or Cefoxitin 2 g IM plus Probenecid 1 g orally once at the same time,
or Another third-generation parenteral cephalosporin (eg, ceftizoxime, cefotaxime),
plus Doxycycline 100 mg orally 2 times a day for 14 days. (Use this circuit with one of the above circuits)

The optimal choice of cephalosporin for this regimen has not been determined; while cefoxitin is active against more anaerobic species, ceftriaxone has more high efficiency against N. gonorrhoeae. Clinical trials have shown that a single dose of cefoxitin is effective in producing rapid clinical response in women with PID, but theoretical evidence suggests the addition of metronidazole. Metronidazole will also be effective in treating bacterial vaginosis, which is often associated with PID. There are no published data on the use of oral cephalosporins for the treatment of PID.

Alternative outpatient regimens

Information on the use of other outpatient treatment regimens is limited, but one regimen has undergone at least one clinical trial and has been shown to be effective against a wide range of pelvic inflammatory disease pathogens. When amoxicillin/clavulanic acid was combined with doxycycline, a rapid clinical effect was obtained, but many patients were forced to interrupt the course of treatment due to undesirable symptoms. gastrointestinal tract. Several studies have been conducted to evaluate azithromycin in the treatment of upper reproductive tract infections, however, these data are not sufficient to recommend this drug for the treatment of inflammatory diseases of the pelvic organs.

Detoxification therapy and correction of metabolic disorders

This is one of the most important components of treatment, aimed at breaking the pathological circle of cause-and-effect relationships that arise in purulent-inflammatory diseases. It is known that these diseases are accompanied by disorders of all types of metabolism, excretion large quantity liquids; electrolyte imbalance, metabolic acidosis, and renal and hepatic failure occur. Adequate correction of identified disorders is carried out jointly with resuscitators. When carrying out detoxification and correction of water-electrolyte metabolism, two extreme conditions should be avoided: insufficient fluid intake and overhydration of the body.

In order to eliminate these errors, it is necessary to control the amount of fluid administered from outside (drink, food, medicinal solutions) and excreted in urine and other ways. The calculation of the administered dose must be individual, taking into account the specified parameters and the patient’s condition. Correct infusion therapy in the treatment of acute inflammatory and purulent-inflammatory diseases is no less important than the prescription of antibiotics. Clinical experience shows that a patient with stable hemodynamics with adequate replenishment of blood volume is less susceptible to the development of circulatory disorders and the occurrence of septic shock.

The main clinical signs of restoration of blood volume and elimination of hypovolemia are indicators of central venous pressure (60-100 mm water column), diuresis (more than 30 ml/h without the use of diuretics), improvement of microcirculation (skin color, etc.).

Pelvioperitonitis is observed quite often with the development of inflammatory diseases of the pelvic organs. Since there is an increase in extrarenal fluid and electrolyte losses with peritoneal inflammation, the basic principles of fluid and protein replacement must be taken into account. According to modern concepts, both colloidal solutions (plasma, albumin, low molecular weight dextrans) and crystalloid solutions (0.9% sodium chloride solution) should be administered per 1 kg of patient body weight.

Crystalloid solutions include isotonic sodium chloride solution, 10% and 5% glucose solution, Ringer-Locke solution, and polyionic solutions. Low molecular weight dextrans are used from colloidal solutions. It should be emphasized that the total amount of dextrans should not exceed 800-1200 ml/day, since their excessive administration can contribute to the development of hemorrhagic diathesis.

Patients with septic complications of out-of-hospital abortion lose a significant amount of electrolytes along with the fluid. During the treatment process, there is a need to quantitatively calculate the introduction of basic electrolytes - sodium, potassium, calcium and chlorine. When administering corrective doses of electrolyte solutions, the following must be adhered to:

Compensation for electrolyte deficiency should be done slowly, dropwise, avoiding the use of concentrated solutions.
Periodic monitoring of the acid-base status and electrolytes of the blood serum is indicated, since corrective doses are designed only for extracellular fluid.
You should not strive to bring their performance to the absolute norm.
After achieving a stable normal level of serum electrolytes, only their maintenance dose is administered.
If renal function deteriorates, it is necessary to reduce the volume of fluid administered, reduce the amount of sodium administered and completely eliminate potassium administration. To carry out detoxification therapy, the method of fractional forced diuresis is widely used to produce 3000-4000 ml of urine per day.

Since hypoproteinemia is always observed in septic conditions due to impaired protein synthesis, as well as due to increased protein breakdown and existing blood loss, the administration of protein preparations is mandatory (plasma, albumin, protein).

Anticoagulant therapy

With widespread inflammatory processes, pelvioperitosis, peritonitis, patients may experience thromboembolic complications, as well as the development of disseminated intravascular coagulation (DIC).

Currently, thrombocytopenia is considered one of the first signs of DIC. A decrease in platelet count to 150 x 10 3 /l is the minimum that does not lead to hypocoagulable bleeding.

In practice, determination of the prothrombin index, platelet count, fibrinogen level, fibrin monomers and blood clotting time is sufficient for timely diagnosis ICE. For the prevention of DIC and with minor changes in these tests, heparin is prescribed at a dose of 5000 units every 6 hours under the control of blood clotting time within 8-12 minutes (according to Lee-White). The duration of heparin therapy depends on the speed of improvement of laboratory data and is usually 3-5 days. Heparin should be given before clotting factors have decreased significantly. Treatment of DIC syndrome, especially in severe cases, is extremely difficult.

Immunotherapy

Along with antibacterial therapy, in conditions of low sensitivity of pathogens to antibiotics, agents that increase the general and specific reactivity of the patient’s body become of particular importance, since the generalization of infection is accompanied by a decrease in cellular and humoral immunity. Based on this, complex therapy includes substances that increase immunological reactivity: antistaphylococcal gamma globulin and hyperimmune antistaphylococcal plasma. To increase nonspecific reactivity, gamma globulin is used. Drugs such as levamisole, tactivin, thymogen, and cycloferon help increase cellular immunity. In order to stimulate the immune system, efferent therapy methods (plasmapheresis, ultraviolet and laser irradiation of blood) are also used.

Symptomatic treatment

An integral condition for the treatment of patients with inflammatory diseases of the upper genital organs is effective pain relief using both analgesics and antispasmodics, and inhibitors of prostaglandin synthesis.

It is mandatory to administer vitamins based on daily requirement: thiamine bromide - 10 mg, riboflavin - 10 mg, pyridoxine - 50 mg, nicotinic acid - 100 mg, cyanocobalamin - 4 mg, ascorbic acid - 300 mg, retinol acetate - 5000 IU.

The prescription of antihistamines (suprastin, tavegil, diphenhydramine, etc.) is indicated.

Rehabilitation of patients with inflammatory diseases of the upper genital organs

Treatment of inflammatory diseases of the genital organs in women necessarily includes a complex rehabilitation measures aimed at restoring specific functions of the female body.

To normalize menstrual function after acute inflammation, it is prescribed medications, the action of which is aimed at preventing the development of algodismenorrhea (antispasmodics, non-steroidal anti-inflammatory drugs). The most acceptable form of administration of these drugs is rectal suppositories. Restoration of the ovarian cycle is carried out by prescribing combined oral contraceptives.

Physiotherapeutic methods in the treatment of inflammatory diseases of the pelvic organs are prescribed differentiatedly, depending on the stage of the process, the duration of the disease and the effectiveness of previous treatment, the presence of concomitant extragenital pathology, the state of the central and vegetative nervous system And age characteristics sick. The use of hormonal contraception is recommended.

In the acute stage of the disease, at a body temperature below 38° C, UHF is prescribed to the area of the hypogastrium and lumbosacral plexus using the transverse technique in a non-thermal dosage. In case of a pronounced edematous component, combined exposure to ultraviolet light is prescribed to the panty area in 4 fields.

In case of subacute onset of the disease, it is preferable to prescribe electromagnetic field Microwave.

When the disease passes into the stage of residual phenomena, the task of physiotherapy is to normalize the trophism of the suffering organs by changing vascular tone, final relief of edematous phenomena and pain syndrome. For this purpose, reflexive methods of exposure to supra-tonal frequency currents are used. D'Arsonval, ultrasound therapy.

When the disease enters the stage of remission, heat and mud therapy procedures (paraffin, ozokerite) are prescribed for the panty area, balneotherapy, aerotherapy, heliotherapy and thalassotherapy.

In the presence of chronic inflammation of the uterus and its appendages in the period of remission, it is necessary to prescribe resorption therapy using biogenic stimulants and proteolytic enzymes. The duration of rehabilitation measures after acute inflammation of the internal genital organs is usually 2-3 menstrual cycles. Expressed positive effect and a decrease in the number of exacerbations of chronic inflammatory processes is noted after sanatorium treatment.

Surgical treatment of purulent-inflammatory diseases of the internal genital organs

Indications for surgical treatment of purulent-inflammatory diseases of the female genital organs are currently:

Lack of effect during conservative treatment complex therapy within 24-48 hours.
Deterioration of the patient's condition during conservative treatment, which may be caused by perforation purulent formation into the abdominal cavity with the development of diffuse peritonitis.
Development of symptoms of bacterial toxic shock. The scope of surgical intervention in patients with inflammatory diseases of the uterine appendages depends on the following main points:
1. nature of the process;
2. concomitant pathology of the genital organs;
3. age of patients.

It is the young age of patients that is one of the main factors determining the commitment of gynecologists to gentle operations. In the presence of concomitant acute pelvioperitonitis, in case of purulent lesions of the uterine appendages, hysterectomy is performed, since only such an operation can ensure complete elimination of the infection and good drainage. One of the important points in the surgical treatment of purulent inflammatory diseases of the uterine appendages is full recovery normal anatomical relationships between the pelvic organs, abdominal cavity and surrounding tissues. It is imperative to perform an inspection of the abdominal cavity, determine the condition of the appendix and exclude interintestinal abscesses in case of purulent in nature inflammatory process in the uterine appendages.

In all cases, when performing surgery for inflammatory diseases of the uterine appendages, especially when purulent process, one of the main ones should be the principle of mandatory complete removal focus of destruction, i.e. inflammatory formation. No matter how gentle the operation, it is always necessary to completely remove all tissue of the inflammatory formation. Preservation of even a small portion of the capsule often leads to severe complications in postoperative period, recurrence of the inflammatory process, fistula formation. During surgery, drainage of the abdominal cavity (colyutomy) is mandatory.

The condition for reconstructive surgery with preservation of the uterus is, first of all, the absence of purulent endomyometritis or panmetritis, multiple extragenital purulent foci in the pelvis and abdominal cavity, as well as concomitant severe genital pathology (adenomyosis, fibroids) established before or during surgery.

In women of reproductive age, if conditions exist, it is necessary to perform hysterectomy while preserving, if possible, at least part of the intact ovary.

In the postoperative period, complex conservative therapy continues.

Follow-up

In patients receiving oral or parenteral treatment, significant clinical improvement (for example, a decrease in temperature, a decrease in muscle tension in the abdominal wall, a decrease in pain on palpation during examination of the uterus, adnexa and cervix) should be observed within 3 days from the start of treatment. Patients who do not experience such improvement require clarification of the diagnosis or surgical intervention.

If the physician chooses outpatient oral or parenteral treatment, follow-up and evaluation of the patient should be completed within 72 hours, using the above criteria for clinical improvement. Some experts also recommend repeat screening for C. trachomatis and N. gonorrhoeae 4 to 6 weeks after completion of therapy. If PCR or LCR are used to monitor cure, then a repeat study should be carried out one month after the end of treatment.

Management of sexual partners

Testing and treatment of sexual partners (who were in contact in the previous 60 days before the onset of symptoms) of women with PID is necessary because of the risk of reinfection and high probability detection of urethritis of gonococcal or chlamydial etiology. Male sexual partners of women with PID caused by gonococcus or chlamydia often have no symptoms.

Sexual partners should be treated empirically according to the treatment regimen for both infections, regardless of whether the etiological agent of pelvic inflammatory disease is identified.

Even in clinics that see only women, health care providers should ensure that men who are sexual partners of women with PID are treated. If this is not possible, health care providers treating a woman with PID should ensure that her partners receive appropriate treatment.

Special Notes

Pregnancy. Given the high risk of adverse pregnancy outcome, pregnant women with suspected PID should be hospitalized and treated with parenteral antibiotics.

HIV infection. Differences in the clinical manifestations of PID between HIV-infected and uninfected women have not been described in detail. Based on early observational data, it was suggested that HIV-infected women with PID were more likely to require surgical intervention. Subsequent, more comprehensive review studies of HIV-infected women with PID noted that even with more severe symptoms than in HIV-negative women, parenteral antibiotic treatment in these patients was successful. In another test the results microbiological research in HIV-infected and uninfected women were the same, with the exception of a higher frequency of detection of concomitant chlamydial infection and HPV infection, as well as cellular changes caused by HPV. Immunocompromised HIV-infected women with PID require more extensive therapy using one of the parenteral antimicrobial regimens described in this guide.

Inflammatory diseases of the female genital organs

Lecture outline

1. Classification of inflammatory diseases of the female genital organs.

2. Etiology.

3. Pathogenesis.

4. Clinical picture.

5 Diagnostics.

6. Differential diagnosis.

7. Tactics.

8. Treatment.

9. Rehabilitation of patients with inflammatory diseases of the pelvic organs.

Inflammatory diseases of the female genital organs occupy 1st place among all gynecological pathologies, they account for the largest number of patient visits to the antenatal clinic (60-65%) and hospitalizations in the gynecological hospital (40%).

According to Yu.V. Tsveleva et al. (1996) the incidence of salpingoophoritis has doubled over the past 10 years and is 10-13 cases per 1000 women per year. Women at a young age make up a large group of patients suffering from IDP. So, according to G.M. Savelyeva et al. (1990) of all patients with salpingitis, 70% are under 25 years of age, 75% are nulliparous women.

According to the American Center for Disease Control, about a million cases of acute inflammation of the uterine appendages are registered annually in the United States.

Inflammatory diseases of the pelvic organ in women are the entire spectrum of inflammatory processes in the lower and upper parts of a woman’s reproductive tract, individual nosological forms and in any possible combination.

Classification inflammatory diseases genitals

According to the clinical course:

II. Subacute

Sh. Chronic.

By severity:

I. Easy.

II. Average.

III. Heavy.

By localization:

I. Inflammation of the genital organs lower section:

1) vulva (vulvitis);

2) Bartholin gland (bartholinitis);

3) vagina (colpitis, vaginitis);

4) cervix:

a) exocervicitis (inflammation of the vaginal part of the cervix, covered with stratified squamous epithelium);

b) endocervicitis - inflammation of the mucous membrane, which passes into the cervical canal and is covered with columnar epithelium.

II. Inflammation of the genital organs of the upper section:

1. Body of the uterus:

a) endometritis (inflammation of the mucous membrane of the uterine body);

b) metroendometritis (inflammation of the mucous and muscular layers of the uterine body);

c) panmetritis (inflammation of all layers of the uterine wall);

d) perimetritis (inflammation of the peritoneum that covers the body of the uterus).

2. Uterine appendages:

a) salpingitis (inflammation of the fallopian tubes);

b) oophoritis (inflammation of the ovaries);

c) salpingoophoritis (inflammation of the fallopian tubes and ovaries), or adnexitis;

d) adnextumor (inflammatory tumor of the fallopian tubes and ovaries);

e) hydrosalpinx (inflammatory saccular tumor of the fallopian tube with accumulation of serous fluid in its lumen);

f) pyosalpinx (inflammatory tumor of the fallopian tube with accumulation of pus in its lumen);

h) pyovarum (inflammatory tumor of the ovary with purulent melting of its tissues);

g) perisalpingitis (inflammation of the peritoneal lining of the fallopian tube).

3. Pelvic tissue - parametritis (inflammation of the tissue that surrounds the uterus - lateral, anterior and posterior).

4. Pelvic peritoneum (pelvioperitonitis - inflammation of the pelvic peritoneum).

A correctly formulated diagnosis should indicate the characteristics of the clinical course, the localization of the process, which allows us to determine the principle of treatment, itsduration , diagnostic features, subsequent tactics.

The increase in incidence is associated with the sex revolution. The growth of vector-borne infections is increasing, i.e. sexually transmitted infections.

THAT. pelvic inflammatory disease (PID)- this is, first of all, an infectious process, in the occurrence of which various microorganisms can play a role. The range of pathogens that cause inflammation of the female genital organs is quite wide and includes:

Bacteria that usually colonize the vagina and lower cervical canal (endogenous flora);

Pathogens that are sexually transmitted.

Such pathogens as streptococcus, staphylococcus, E. coli, Proteus, gonococcus and others have not lost their importance. The role of anaerobic infection has been proven. Monoculture is 20%, polyanaerobes - 44%, obligate and facultative anaerobes - 37.7%.

In most cases, inflammatory processes are polymicrobial and mixed in nature. As a result, the disease loses its nosological specificity.

Yu.V. Tsvelev et al. (1996) when studying the microflora from the cervical canal in women with sluggish chronic salpingoophoritis, they obtained the following data (Table 1)

Table 1.

Composition of microflora isolated from the cervical canal of patients with chronic IDP

Microorganisms	Number of patients
Chlamydia
Staphylococcus
Escherichia coli
Mycoplasma
Ureaplasma
Trichomonas
Gardnerellas
Gonococcus
Fungi of the genus Candida
Herpes simplex virus
Cytomegalovirus

The cause of all inflammatory diseases of the genitals are microbes, not abortions, instruments as students answer in exams.

Routes of infection:

Sexual path. Germs are acquired in 99% of cases through sexual contact.

The lymphatic route is primarily from the intestines;

Hematogenous route - mainly tuberculosis, when the focus of infection in the genitals is the second focus, and the first focus is located extragenitally;

Along the length - for example, from the inflamed appendicular process, with colitis, with intestinal pathology;

Intracanalicular pathway for a specific infection (gonococcus).

Mechanism of transmission of infection:

Sperm are carriers of infection; they have a negative charge that attracts the microbe - thus they are a transport of microorganisms.

Flagellates - Trichomonas - are active transport for microbes.

There is also a passive way of spreading the infection. Microorganisms enter actively - sexually, and then passively spread through the genitals.

Factors contributing to the spread of infection:

Intrauterine interventions: abortion, diagnostic curettage, hysterosalpingography, all invasive procedures: probing of the uterine cavity, placement and removal intrauterine contraceptive device, childbirth and miscarriages.

Hypothermia

Weakening of the body as a result of chronic infection of an extragenital nature.

Protective factors of the body:

The vagina and its contents, that is, the biocenosis of the vagina

Leucorrhoea, which is secreted by the vaginal glands in an amount of 1-2 ml per day, is normal. Anything more is pathological leucorrhoea.

Vaginal microflora, which is represented by aerobes and anaerobes, but there is a dynamic balance between saprophytic groups and opportunistic groups (aerobic microbes predominate over anaerobic ones)

A sufficient content of lactobacilli - lactic acid fermentation rods, which create an acidic pH in the vagina due to their metabolism and the acidic pH environment is a protective barrier to the penetration of microorganisms.

Mucus plug is a bactericidal plug of the cervical canal; plays a huge role in preventing the generalization of infection: the mucus plug contains nonspecific antibodies as protective factors; By changing its viscosity, it prevents the penetration of microbes. For uterine cycle the viscosity of the plug changes: the viscosity decreases in the middle of the menstrual cycle, to facilitate the penetration of sperm and the ovulation process. Taking oral contraceptives increases the viscosity of the mucous plug, making it difficult for sperm to penetrate into the overlying parts of the genitals - this is one of the effects of contraception. Taking oral contraceptives, especially by women with chronic inflammatory diseases (CIID) of the genitals, reduces the risk of relapses and exacerbations of the inflammatory process.

Considering that sperm are active carriers of microorganisms, complicating the penetration of sperm reduces the risk of infection, i.e. taking oral contraceptives, especially in women suffering from CIH, has a double effect: contraception and prevention of relapses and exacerbations of infection.

Endometrium: The functional layer of the endometrium is shed monthly, the body is cleansed, and a lymphocyte shaft is formed in place of the shed endometrium. For the generalization of infection, the relationship between the macro- and microorganism is necessary. The aggressiveness of a microorganism determines its virulence and the reactivity of the macroorganism. In women with severe purulent complications, a study of the association of microbial flora revealed a predominance of anaerobic flora, the state of immunity, i.e. the state of the macro- and microorganism determines the further development of the disease. In virgins, acute salpingitis or acute salpingoophoritis can either be of tuberculous etiology or can penetrate from the intestine, lymphogenous or hematogenous.

Specific infections officially include gonorrhea, trichomoniasis and tuberculosis.

Chlamydial infection is conventionally classified as specific, although officially it is classified as nonspecific.

Bacterial vaginosis

The concept began to sound in the 80s. This disease is caused by a violation of the vaginal biocenosis, a disruption of the normal microflora of the vagina. Characteristic:

increase in anaerobic flora (Gardner's rods)

absence of lactobacilli

alkaline vaginal environment

Clinically, the woman is concerned about a significant increase in leucorrhoea; this is the main complaint. Less commonly, there may be itching or burning, increased leucorrhoea production in the absence of any signs of inflammation. When examined in the mirrors, we will not see any hyperemia or swelling of the vagina.

Synonymous with Gardner's disease, who first studied the microflora of the vagina, discovered rods - Gardnerella. They are almost always detected in bacterial vaginosis. But on this moment It is generally accepted that in the vaginal biocenosis, single mycoplasmas, ureplasmas and Gardner bacilli are normally found.

Considering that when examining the biocenosis of the vagina, we have an increase in the content of anaerobic infection and the pH of the vagina becomes alkaline, respectively, treatment follows. The vaginal environment can change not only due to infection, but also due to a decrease in estrogen, taking antibacterial drugs or contraception, against the background of hypovitaminosis.

Diagnostics. Positive amino test: when potassium hydroxide (KOH) is added to the discharge, a rotten fish odor appears (the discharge itself is odorless), which proves the presence of bacterial vaginosis.

Treatment

Trichopolum, since the anaerobic flora of Gardnerella predominates in the vaginal biocenosis, is sensitive to Trichopolum.

Douching with acidic solutions (boric acid, citric acid, potassium permanganate - 1-2 douchings), since the vaginal pH becomes alkaline. Frequent douching is harmful to the body, as it disrupts the vaginal biocenosis and contributes to the development of bacterial vaginosis. Frequent use vaginal tampons (during menstruation) are also harmful, since they also violate normal biocenosis vagina, and since women have microorganisms in the vagina, this will be a factor contributing to the occurrence of infection.

Clindomycin tablets 150 mg (capsules) 3 times a day and cream.

Restoring normal vaginal microflora: introducing lactobacilli by introducing tampons with lactobacterin (6-8 tampons, 1 tampon for no more than 4-5 hours).

Vitamin therapy for hypovitaminosis.

Inflammatory diseases of the lower genitalia

A. Vulvit - an inflammatory disease that develops mainly in girls. Infection is promoted by diaper rash, scratching, abrasions, endocrine pathology (diabetes mellitus), helminthic infestations, and childhood viral infections.

Clinic: pain, swelling of the vulva, purulent discharge.

Treatment: oral antibiotics, baths with disinfectant solutions (potassium permanganate, furacillin).

B. Bartholinitis - abscess of the Bartholin gland due to blockage of its excretory duct. There are false and true abscesses of the Bartholin gland:

False abscess. Being clogged and expanding, the duct turns into a Bartholin gland cyst, which, when an infection occurs, suppurates, and damage to nearby tissues does not occur, since the cyst has a capsule.

True abscess. The capsule and nearby tissues (fiber) are affected. Clinic: intoxication, fever, severe pain when moving, purulent discharge, combination with colpitis. Upon examination, a painful tumor of a certain size is determined in the area of one of the labia. Often the inguinal lymph nodes are enlarged and painful on palpation. Treatment: opening and drainage of the abscess (intravenous anesthesia).

Colpitis - inflammation of the vagina (vaginitis).

The clinical picture includes a triad of symptoms: pain, leucorrhoea, itching. Diagnosis after examination in the speculum: the vaginal mucosa is hyperemic, swelling, there may be erosive lesions, ulcers (Trichomonas mixed infection).

Cervicitis - inflammation of the cervical canal mucosa. The triad of symptoms is the same.

Pathogenesis

In the pathogenesis, the main role belongs to the aggressiveness of microbial agents and the resistance of the woman’s body, the peculiarity of her immunity.

The introduction of microbes causes alteration, they affect the vascular wall, the release of inflammatory mediators (histamine, serotonin, etc.) occurs, which leads to disruption of the MCR in the site of inflammation, and the cytokine system (a group of protein molecules) also plays a leading role in the regulation of intercellular relationships. .

The capillaries take on a convoluted shape, the lumen of the arteries narrows. Increased vascular permeability and tissue swelling develop. Immune complexes that have a damaging effect settle on the vessels, and exudation develops.

The inflammatory process and the body's response - systemic syndrome inflammatory reaction(SIRS) – systemic reaction of the body to the influence of various damaging factors (infection, trauma, surgery, etc.):

– temperature above 38oC or below 36oC

– Heart rate 90/min

– RR >20/min or hyperventilation (PaCO2 £ 32mmHg)

– Blood leukocytes >12´ 109/ml or<4´ 109/мл, или незрелых форм >10%

With the introduction of an anaerobic infection, the histological picture shows more pronounced tissue damage. In all cases, all 5 signs of inflammation are present.

Clinical picture inflammatory diseases genitals

In modern conditions, inflammatory diseases of the genitals have features that significantly distinguish them from the clinical picture of diseases 20 years ago. They are characterized by:

Erased clinical symptoms of the acute stage of the disease;

The advantage of chronic processes, and in recent years - the emergence of primary chronic diseases;

Persistent recurrent course of chronic processes;

The most common localization of the inflammatory process is in the uterine appendages;

Parametrial tissue is rarely affected;

Course of the disease (acute, subacute, chronic), severity (mild, moderate, severe), involvement of many tissues and organs (endocervix, endometrium, myometrium, endosalpinx, ovaries); the spread of the process to surrounding tissues (parametrium, peritoneum) largely depends on the reactivity of the woman’s body, but also on the pathogenic properties of the pathogens.

There are two clinical and pathogenetic variants of the inflammatory process.

First- infectious-toxic variant is characterized by the advantage of infectious-toxic manifestations as a result of penetration or activation of the pathogen (the appearance of pain, temperature reaction, exudative processes, intoxication).

Second the variant is characterized by persistent pain and signs of dysfunction of the vascular (mainly microcirculation), nervous, immune and endocrine systems.

The first option is observed in acute cases and exacerbations of chronic ones. The second option is typical for chronic course diseases.

Pain syndrome is the leading symptom of chronic inflammation, regardless of its location. Its morphological basis is fibrosis, tissue sclerosis, retraction of nerve ganglia into the process with the development of pelvic ganglioneuritis.

The pain is of a varied nature: dull, aching, pulling, intensifying, gradually or periodically. Against the background of chronic inflammatory processes, reflex pain in the lower abdomen is characteristic. diffuse, often localized in the right or left groin, with irradiation to the vagina, rectum, sacrum, and lower abdomen.

Other symptoms depend on the damage to the anatomical structures. Endocervicitis is characterized by abnormal vaginal discharge and is usually the beginning of an ascending infection. In this case, you can observe swelling and hyperemia in the area of the external os of the cervix.

General symptoms (fever, nausea, sometimes vomiting) are the result of acute damage to the fallopian tubes, ovaries or surrounding tissues (parametria, peritoneum). Inflammatory diseases of the genital organs can include any combination of endometritis, salpingitis, oophoritis, tubo-ovarian formations, and pelvic peritonitis.

The clinical picture of acute salpingoophoritis is characterized by the following symptoms: pain of varying intensity in the lower abdomen, aggravated by physical activity, radiating to the lower back, less often to the anus, inner thigh; increased body temperature, often to high levels, with chills; symptoms of general intoxication; increased amount of discharge from the genital tract, purulent in nature, with an unpleasant odor; frequent urination, sometimes with pain; there may be frequent loose stools, painful bowel movements. A similar clinical picture may be observed during exacerbation of chronic PVID.

table 2

Frequency of clinical and anatomical signs in chronic IDP

(according to Yu.V. Tsvelev et al., 1996).

Clinical and anatomical signs	Number of patients
Nagging pain in the lower abdomen
Menstrual irregularities
Pathological discharge from the genital tract
Itching and burning in the vagina and urethra
Painful sex life
Infertility
Miscarriage
Painful uterine appendages
Cystic ovarian degeneration
Cervical erosion
Cervicitis

Characteristic features of the clinical course of chronic IDP are: protracted, often recurrent course, resistance of the infectious process to traditional antibacterial therapy, the presence of immunosuppression, frequent complications (infertility, adhesions, formation of tubo-ovarian formations).

The clinical characteristics of chronic HPPM are characterized by a combination of typical symptoms and reproductive dysfunction presented in Table 2.

The infection enters the uterine cavity during menstruation, during sexual intercourse on the days of menstruation, during some medical procedures (curettage of the uterine mucosa, hydrotubation, etc.), during childbirth and abortion, as well as during common infectious diseases ( flu, etc.).

Endometritis - inflammatory process, localized only in the superficial layer of the endometrium, in deep tissues (basal layer of the endometrium, myometrium) - endomyometritis. A feature of endometritis is the frequent spread of infection into the fallopian tubes. Acute endometritis develops acutely. Body temperature rises, worsens general state, there is pain that radiates to the sacrum and groin, excessive serous-purulent or bloody-purulent discharge, and sometimes metrorrhagia. During vaginal examination, the uterus is enlarged and painful. In the case of acute endometritis, the functional layer of the endometrium is destroyed and necrotic, the epithelium is desquamated in some places, and a subepithelial shaft is formed deeper in the form of a large leukocyte infiltrate. Leukocytosis is observed in the blood, ESR increases.

The acute phase of inflammation, if properly treated, lasts about 5-7 days. The endometrial mucosa falls off and disintegrates, and along with it the accumulation of microorganisms disappears, sometimes self-healing is possible. But in most cases, the course of the disease progresses: the process spreads through the lymphatic and blood vessels to the uterine muscle. The peritoneum covering the uterus and surrounding tissue can also be involved in the process. In unfavorable cases, phlebitis and thrombophlebitis of the uterine vessels, and even sepsis, develop. Acute endometritis often ends in recovery, less often it turns into chronic endometritis (metroendometritis).

Clinical symptoms of chronic endometritis are less pronounced than in the acute period: body temperature is normal, mucopurulent discharge is light, low back pain is minor. There may be disturbances in the menstrual cycle such as menopause or metrorrhagia, which is associated with impaired contractile function of the uterus.

Salpingitis - the inflammatory process invades the fallopian tubes. Infection enters the fallopian tubes upward path from the uterus or descending - in case of penetration of pathogens from the peritoneum through the funnel of the fallopian tube. Lymphogenous and hematogenous routes of spread are possible. In the initial stage of the inflammatory disease, hyperemia, swelling of the mucous membrane and increased secretion of the epithelium develop in the wall of the fallopian tube. Catarrhal salpingitis develops. The wall of the tube thickens evenly, and the tube is easily palpated during vaginal examination.

As the process progresses, excessive secretion accumulates in the opening of the fallopian tube. The folds of the mucous membrane become swollen, thicken, the uterine part of the tube becomes impassable, and if the funnel of the fallopian tube is closed, excessive secretion stretches the walls of the tube, turning it into a saccular oblong tumor filled with serous contents - sactosalpinx or hydrosalpinx, often bilateral. If the cavity of the fallopian tube is filled with pus, it is called pyosalpinx. In the case of salpingitis, the peritoneum of the fallopian tube is drawn into the process, as a result of which adhesions are formed with surrounding organs, most often with the ovary, which is also drawn into the inflammatory process. Salpingoophoritis or adnexitis develops. If the pyosalpinx fuses with the ovary, in the thickness of which there is also an abscess, the septum between them resolves and a common cavity filled with pus is formed - tubo-ovarianabscess. The clinical course depends on the nature of the lesion. If an inflammatory process develops in the fallopian tubes and ovaries, the body temperature suddenly rises to 40 0. Patients complain of weakness, malaise, sleep and appetite disturbances. First, there is a sharp and then throbbing pain in the lower abdomen. Leukocytosis, a shift in the leukocyte formula to the left, an increase in ESR, and an increase in the number of leukocytes are noted.

Inflammatory diseases of the uterus and fallopian tubes can spread to the peritoneum with the development of perimetritis and periadnexitis. If inflammation progresses, the entire pelvic peritoneum is drawn into the process, and pelvioperitonitis develops. The disease begins with the appearance of high body temperature, chills, severe pain in the lower abdomen, nausea and vomiting. The pulse is frequent, weak and tense. Severe flatulence, intestinal paresis, stool retention or diarrhea, and sometimes frequent painful urination are often observed. The abdominal wall is tense, the Shchetkin-Blumberg symptom is sharply positive. During a blood test, leukocytosis, an increased number of neutrophils, lymphopenia, increased ESR, and low hemoglobin are determined.

At birth, a girl's vagina is sterile. Then, within a few days, it is populated by a variety of bacteria, mainly staphylococci, streptococci, and anaerobes (that is, bacteria that do not require oxygen to live). Before the onset of menstruation, the acidity level (pH) of the vagina is close to neutral (7.0). But during puberty, the walls of the vagina thicken (under the influence of estrogen, one of the female sex hormones), the pH decreases to 4.4 (i.e., acidity increases), which causes changes in the vaginal flora. In a healthy vagina non-pregnant woman More than 40 types of bacteria can “live”. The flora of this organ is individual and changes in different phases of the menstrual cycle. Lactobacilli are considered the most beneficial microorganisms of the vaginal flora. They inhibit growth and reproduction harmful microbes, producing hydrogen peroxide. The quality of protection they provide in this way exceeds the potential of antibiotics. The importance of normal vaginal flora is so great that doctors talk about it as a microecological system that ensures the protection of all reproductive organs women.

There are two main routes of transmission: domestic And sexual. The first is possible if the rules of personal hygiene are not followed. However, more often, infection occurs through sexual intercourse. The most common causative agents of pelvic organ infections are microorganisms such as gonococci, Trichomonas, and chlamydia. However, today it is clear that O Most diseases are caused by so-called microbial associations - that is, combinations of several types of microorganisms with unique biological properties.

Oral and anal sex, in which microorganisms that are not characteristic of these anatomical sections and change the properties of the microecological system, which was mentioned above, enter the man’s urethra and the woman’s vagina. For the same reason, protozoa and worms contribute to infection.

There are some risk factors that make it easier for microbes to “get” to the uterus and appendages. These include:

Any intrauterine interventions, such as the introduction of intrauterine devices, abortion operations;

Multiple sexual partners;

Sex without barrier methods of contraception (birth control pills, etc. do not protect against the transmission of infection, so before conception you must be examined to identify possible infectious diseases of the pelvic organs);

Inflammatory diseases of the female genital organs suffered in the past (there remains a possibility of persistence of a chronic inflammatory process and the development of vaginal dysbiosis - see sidebar);

Childbirth; hypothermia (the well-known expression “the appendages caught a cold” emphasizes the connection between hypothermia and decreased immunity).

DYSBACTERIOSIS OF THE VAGINA

There are so-called vaginal dysbiosis, in which the amount beneficial microbes- lactobacilli - decreases sharply or disappears altogether. Clinical manifestations of such conditions are often absent, therefore, on the one hand, women are in no hurry to see a doctor, and on the other hand, doctors often have difficulty establishing this diagnosis. Meanwhile, vaginal dysbiosis is associated with a significant number of obstetric and gynecological complications, which will be discussed below. The most common are the following vaginal dysbacteriosis:

Bacterial vaginosis. According to research, bacterial vaginosis is found in 21-33% of women, and in 5% of affected women it is asymptomatic. If the doctor made this diagnosis, it means that opportunistic microbes such as gardnerella, ureaplasma, mycoplasma, and enterococcus have entered the woman’s body.

Urogenital candidiasis. Urogenital candidiasis is also a type of vaginal dysbiosis. Its causative agent is the yeast-like fungi Candida. This disease is more common in women than in men. In addition to the vagina, it can spread to the urinary system, external genitalia, and sometimes urogenital candidiasis affects the rectum.

MANIFESTATIONS OF INFLAMMATORY DISEASES OF THE PELVIC ORGANS

Diseases of the female genital organs can be asymptomatic, but in most cases a woman complains of the following:

Pain in the lower abdomen;

Vaginal discharge (their nature depends on the type of pathogen);

Fever and general malaise;

Discomfort when urinating;

Irregular menstruation;

Pain during sexual intercourse.

HOW TO DIAGNOSIS

Making a diagnosis is not an easy task. First, the results of a general blood test are assessed. An increase in the level of leukocytes gives reason to suspect an inflammatory process. Upon examination, the gynecologist may reveal pain in the cervix and ovaries. The doctor also takes vaginal swabs to identify the causative agent of the infection. In difficult cases, they resort to laparoscopy: this is a surgical intervention in which special instruments are inserted into the pelvis through small incisions in the anterior wall of the abdomen, allowing direct examination of the ovaries, fallopian tubes and uterus.

CONSEQUENCES OF PELVIC INFLAMMATORY DISEASES

Before pregnancy. Let's start with the fact that inflammatory diseases of the female genital organs are the most common cause infertility. The infectious process affects the fallopian tubes and grows in them connective tissue, which leads to their narrowing and, accordingly, partial or complete obstruction. If the tubes are blocked, the sperm cannot reach the egg and fertilize it. With frequently recurring inflammatory processes in the pelvic organs, the likelihood of infertility increases (after a woman has suffered a single pelvic inflammatory disease, the risk of infertility, according to statistics, is 15%; after 2 cases of the disease - 35%; after 3 or more cases - 55%).

In addition, women who have had pelvic inflammatory disease are much more likely to develop an ectopic pregnancy. This occurs because the fertilized egg cannot travel through the damaged tube and enter the uterus for implantation. Laparoscopic restoration of fallopian tube patency is often used for tubal infertility. In difficult cases, in vitro fertilization is resorted to.

Pregnancy. If, nevertheless, pregnancy occurs against the background of an already existing inflammatory process in the pelvic organs, then it should be borne in mind that due to a completely natural decrease in activity immune system During pregnancy, the infection will certainly “raise its head” and its aggravation will occur. Signs of exacerbation that force a woman to see a doctor depend on the type of causative agent of a particular infection. Abdominal pain and vaginal discharge (leucorrhoea) are almost always a concern. In such a situation, the pregnant woman and the doctor will have to solve a difficult question: what to do with the pregnancy. The fact is that exacerbation of the inflammatory process is fraught with the threat of termination of pregnancy; such a pregnancy is always difficult to maintain. Moreover, the required antibacterial treatment is not indifferent to the developing fetus. If the infection is caused pathogenic microorganisms, especially related to the causative agents of sexually transmitted diseases (syphilis, gonorrhea), the doctor often recommends termination of pregnancy. If there is dysbacteriosis and a situation where opportunistic microorganisms have taken the place of the natural inhabitants of the female genital organs (see sidebar), the doctor will select treatment based on the sensitivity of the detected pathogens to antibiotics and the duration of pregnancy.

The situation deserves special mention when during pregnancy there is not an exacerbation of an existing inflammatory process, but infection and subsequent development of the infection. This is often accompanied by the penetration of an infectious agent into the fetus and intrauterine infection of the latter. Now doctors can trace the development pathological process in the fetus; the decision on the necessary measures is made depending on the characteristics of each specific case.

Persistent (untreated or undertreated) infectious process affecting the birth canal (i.e., cervix, vagina and external genitalia), there is a risk of infection of the child during childbirth, when healthy baby, having successfully avoided intrauterine contact with infection due to the protection of the membranes, becomes completely defenseless. In such cases, doctors often insist on a caesarean section.

Now it becomes clear why even healthy women must undergo examination twice during pregnancy to detect infectious diseases of the reproductive organs (examination of a smear from the vagina, and, if necessary, a blood test for the presence of antibodies to certain pathogens). And of course, existing diseases should be cured.

TREATMENT

Treatment tactics and medications are selected only by a doctor. During pregnancy, there are certain restrictions regarding the use of antibiotics, antivirals and some other drugs. You should definitely find out all this at a doctor's appointment. Naturally, the best option is a planned pregnancy, before which you and your partner go through everything necessary examinations and if a disease is detected, carry out treatment.

For the treatment of inflammatory diseases of the pelvic organs are used various antibiotics. After completion of treatment, a control smear is taken from the woman’s vagina to assess the effectiveness of therapy. During treatment, it is not recommended to be sexually active. When continuing sexual intercourse, a man must use a condom. At the same time, the woman’s sexual partner (or sexual partners) is treated, otherwise there is a high risk of re-infection. In difficult cases, the patient is hospitalized. In the clinic, as a rule, they begin to administer antibiotics intravenously, then move on to oral administration. It happens (in about 15% of cases) that the initially prescribed antibacterial therapy does not help, then the antibiotic is changed. 20-25% of women of reproductive age have relapses of the disease, so a woman who has suffered such a disease must change her life in such a way as to minimize the risk of recurrent diseases.

Diseases of the pelvic organs include pathologies of the 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 of the 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 an 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 are frequent urge to urinate, pain at the end of urination. If proper treatment of cystitis is not started in time, an ascending infection occurs, leading to pyelonephritis and other kidney damage. In addition, they register urolithiasis, in which calculi (stones) form not only in the kidneys, but also in the bladder, as well as various oncological diseases 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. Not the least role is played by tumor diseases rectum.
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. General rule: they 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. It could be ultrasound examination, radiography, CT scan. 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. In addition, it provides comprehensive information about the condition of the pelvic organs.