Pelvic Inflammatory Disease

Inflammatory diseases of the female genital organs occupy the first place (55-70%) in the structure of gynecological diseases and are one of the causes of the violation of many functions of the organs and systems of the female body.

Classification

gyne-pain-pelvic-inflammatory-diseaseGyne-pain-pelvic-inflammatory-disease Depending on the causative agent, inflammatory diseases of the genital organs can be specific and nonspecific.

According to the clinical course, inflammatory processes are divided into acute with severe clinical symptoms, subacute with erased manifestations and chronic.

According to the localization of the pathological process, inflammatory diseases of the lower (vulvitis, bartholinitis, colpitis, endocervicitis, cervicitis) and upper sections (endomyometritis, scalping oophoritis, pelvic peritonitis, parametritis) of the genital organs, the boundary of which is the internal uterine mouth, are distinguished.

Nonspecific inflammatory diseases of the lower genital tract

Vulvitis is manifested by hyperemia and swelling of the vulva, purulent or serous-purulent discharge, an increase in the inguinal lymph nodes. In the chronic stage, the clinical manifestations subside, periodically, itching, burning. Diagnosis is based on complaints, anamnesis, gynecological examination. Additional methods include the bacterioscopic and bacteriological examination of detachable external genital organs to identify the causative agent of the disease. The treatment is carried out with general and local antibacterial drugs, taking into account the causative agent of the disease.

Bartholinitis – inflammation of the large gland vestibule. The inflammatory process in the cylindrical epithelium lining the gland and surrounding tissues quickly leads to blockage of its excretory duct with the development of an abscess. The patient complains of pain at the site of inflammation. Determined by hyperemia and edema of the excretory duct of the gland, purulent discharge when pressed. The formation of an abscess leads to deterioration. There are a weakness, malaise, headache, chills, fever up to 39 ° C, pains in the area of the Bartholin gland become sharp, throbbing. On examination, there is swelling and hyperemia in the middle and lower thirds of the labia majora on the affected side, a painful tumor-like formation that closes the entrance to the vagina. Treatment of Bartholinitis is reduced to the appointment of antibiotics, taking into account the causative agent of the disease, symptomatic means. During the formation of a Bartholin’s gland abscess, surgical treatment is indicated – the opening of the abscess with the formation of an artificial duct by filing the edges of the mucous membrane of the gland to the edges of the skin incision (marsupialization). After surgery, sutures are treated with antiseptic solutions for several days.

Colpitis – inflammation of the mucous membrane of the vagina, one of the most frequent diseases in patients of the reproductive period, caused by various microorganisms, may occur as a result of chemical, allergic, thermal, mechanical factors. In the acute stage of the disease, patients complain of itching, burning in the vagina, purulent or serosio-purulent discharge from the genital tract, pain in the vagina during intercourse (dyspareunia). Colpitis is often combined with vulvitis, endocervicitis, urethritis. Diagnosis of colitis is based on complaints, medical history, gynecological examination. To identify the causative agent of the disease using a bacteriological and bacterioscopic examination of vaginal discharge, urethra, cervical canal.

Treatment of colitis should be comprehensive, directed, to fight infection, elimination of associated diseases. Both local and general therapy is used. Topical treatment is often combined with general antibiotic therapy, taking into account the causative agent. After antibacterial therapy, eubiotics (bifidobacteria, lactobacterin, biovestin) are prescribed, which restore the natural microflora and acidity of the vagina.

Endocervicitis is an inflammation of the mucous membrane of the cervical canal, resulting from a cervical injury during childbirth, abortion, diagnostic curettage and other intrauterine procedures. Endocervicitis often accompanies other gynecological diseases as inflammatory (coleitis, endometritis, adnexitis), and non-inflammatory etiology (cervical ectopia, eroded ectropion). In the acute stage of the inflammatory process, patients complain of mucopurulent or purulent discharge from the genital tract, rarely at the dull pain in the lower abdomen. Bacteriological and bacterioscopic examination of secretions from the cervical canal with the aim of selecting therapy, as well as cytological examination of cervical smears, which detects cells of a cylindrical and multi-layered squamous epithelium without atypical signs, an inflammatory leukocytic reaction, helps to diagnose endocervicitis. Treatment of endocervicitis in the acute phase consists in prescribing antibacterial agents, taking into account the sensitivity of the causative agents of the disease. In the chronic stage with background diseases of the cervix after sanation of the genital tract, surgical methods are used – cryodestruction, radiosurgery, laser therapy, diathermocoagulation, cervix conization.

Nonspecific inflammatory diseases of the upper genital tract

Endometritis is an inflammation of the uterine mucosa with damage to both the functional and basal layer. Acute endometritis, as a rule, occurs after various intrauterine manipulations – abortions, scraping, the introduction of intrauterine contraceptives, as well as after childbirth. The inflammatory process can quickly spread to the muscular layer (endomyometritis), and in severe cases it can affect the entire wall of the uterus (panmetrit). Less common is the generalization of the process with the development of complications (parametritis, peritonitis, pelvic abscesses, thrombophlebitis of the pelvic veins, sepsis) or inflammation becomes subacute and chronic.

Chronic endometritis occurs more often due to inadequate treatment of acute endometritis, which is facilitated by repeated curettage of the uterus for bleeding, suture material after caesarean section, intrauterine contraceptives. The clinical course is latent. The main symptoms of chronic endometritis include violations of the menstrual cycle – abundant, prolonged menstruation (hyperpolymenorrhea) or metrorrhagia due to impaired regeneration of the mucous membrane and a decrease in uterine contractility. Patients are bothered by nagging, aching pain in the lower abdomen, serous-purulent discharge from the genital tract. Chronic endometritis can be suspected on the basis of anamnesis, clinic, gynecological examination (a slight increase and compaction of the uterus, serous-purulent discharge from the genital tract).

Salpingo-oophoritis (adnexitis) – inflammation of the uterus appendages (tube, ovary, ligaments), occurs either ascending or descending, secondarily with inflammatory-altered abdominal organs (for example, in appendicitis) or hematogenous. With upward infection, the infection penetrates from the uterus into the lumen of the fallopian tube, involving all layers (salpingitis) in the inflammatory process, and then in half of the patients, the ovary (oophoritis) along with the ligamentous apparatus (salpingoophoritis). Inflammatory exudate, accumulating in the lumen of the fallopian tube, can lead to an adhesive process and closure of the fimbrial region. Formed saccular formation of the fallopian tubes (saktosalpinksy). The accumulation of pus in the pipe leads to the formation of pyosalpinx, serous exudate – to the formation of hydrosalpinx.

When microorganisms penetrate the tissue of the ovary, purulent cavities (ovarian abscess) can form in it, with the fusion of which ovarian tissue melts. The ovary turns into a saccular formation, filled with pus (pyovar).

The clinic of acute salpingoophoritis (adnexitis) includes pain in the lower abdomen of varying intensity, an increase in body temperature to 38–40 ° C, chills, nausea, sometimes vomiting, purulent discharge from the genital tract, dysuric phenomena. The severity of clinical symptoms is due, on the one hand, to the virulence of the pathogens, and on the other, to the reactivity of the macroorganism.

Chronic adnexitis is a consequence of acute or subacute inflammation of the uterus. The reasons for the chronization of the inflammatory process include inadequate treatment of acute adnexitis, reduced body reactivity, properties of the pathogen. Chronic salpingo-oophoritis is accompanied by the development of inflammatory infiltrates, connective tissue in the wall of the fallopian tubes and the formation of hydrosalpinxes. Dystrophic changes occur in the tissue of the ovaries, microcirculation is impaired due to the narrowing of the lumen of the blood vessels, as a result of which the synthesis of sex steroid hormones is reduced. The disease has a protracted course with occasional exacerbations.

Treatment of inflammatory diseases of internal genital organs is carried out in a hospital.

The nature and intensity of complex therapy depends on the stage and severity of the inflammatory process, the type of pathogen, the immunobiological resistance of the macroorganism, etc. For the purpose of treating acute inflammatory processes of the internal genital organs, penicillin-type antibiotics, cephalosporins, fluorochipolones, aminoglycosides, linkosamines, macrolides, and tetracyclines are used.

Penicillin group antibiotics (oxacillin, ampicillin, amoxicillin, carbenicillin, ticarcillin, piperacillin) are considered the least toxic and are active against gram-positive and gram-negative anaerobes. However, many microorganisms have developed resistance to penicillins as a result of the synthesis of beta-lactamase, destroying the beta-lactam ring of penicillins. In this sense, penicillin combinations with beta-lactamase inhibitors (inhibitor-protected penicillins) – amoxicillin / clavulanate, ticarcillin / clavulanate, piperacillin / tazobactam, ampicillin / sulbactam are preferred.

Cephalosporins are also low toxic and effective against many pathogens of inflammatory diseases of internal genital organs, but are inactive or inactive against enterococci, methicillin-resistant staphylococci, chlamydia, mycoplasmas, and some anaerobes. Currently, third-generation cephalosporins (ceftriaxone, cefotaxime, cefoperazone) are used to treat acute endomyometritis, adnexitis, especially complicated.

Fluoroquinolone antibiotics have a broad spectrum of antimicrobial activity. They are most effective against gram-negative bacteria, less active against staphylococci, and have little effect on anaerobes. The most commonly used ciprofloxacin, ofloxacin.

Of the other antibiotics, gentamicin, netilmicin, amikacin (aminoglycosides), lincomycin, clindamycin (linkosamines), spiramycin, azithromycin, erythromycin (macrolides), doxycycline (tetracyclines) are prescribed.

It is advisable to combine antibiotics with nitroimidazole derivatives (metronidazole), which are highly active in the treatment of anaerobic infections.

Thus, for the treatment of acute inflammatory diseases of the internal genital organs, combinations of inhibitor-protected penicillins with doxycycline or macrolides are preferred; III generation cephalosporins with doxycycline or macrolides and metronidazole; lincosamines with aminoglycosides and doxycycline or macrolides.