Acute inflammatory diseases of the internal genital organs

Inflammatory processes of the pelvic organs (uterus, appendages, peritoneum) are the most common gynecological diseases. More than half of women seeking help at a women's consultation suffer from inflammation of the internal genital organs, and about 50 % of them require inpatient treatment. In the structure of diseases of a gynecological hospital specialized in providing emergency medical care, this pathology makes up from 17.8% to 28%, according to our data - 21.6%.

Constantly encountering such patients in their work, practicing physicians must have a clear understanding of the fact that at present, thanks to the development of new diagnostic methods, the understanding of the causative agents of inflammation, the state of reactivity of the macroorganism and, consequently, the characteristics of the course and effectiveness of treatment of the disease have expanded.

The spectrum of microbial flora causing inflammatory processes in the female reproductive system is quite diverse. Gonococcal infection has not lost its significance. According to foreign authors, in different regions of the world, gonococcus was isolated from 5-65% of women suffering from acute salpingitis.

The role of staphylococci and E. coli is still significant. Staphylococci can be isolated from the abdominal cavity in 14.8 % of cases, E. coli in 8.9%. In recent years, the proportion of non-spore-forming anaerobic flora has increased significantly: the frequency of detection of such flora exceeds 40%. The results of studies by foreign authors indicate the undoubted role of chlamydial infection in the occurrence of not only chronic, but also acute forms of inflammatory diseases of the internal genital organs of women: cultural or serological studies confirm the presence of C. trachomatis in 18-46% of cases. Inflammatory diseases of the pelvic organs can be caused by Mycoplasma hominis and Ureaplasma urealyticum. The proportion of mycoplasmal inflammations is 10-15%.

The information provided does not exhaust all possible etiologic agents that lead to inflammatory diseases of the internal genital organs. Cases of protozoan and viral infections are not so rare, there are cases of actinomycosis of the appendages. Endometritis and salpingitis are most often caused by the following types of microorganisms: gonococci, chlamydia, aerobic and anaerobic streptococci and staphylococci, mycoplasmas, Escherichia coli, enterococci, Proteus, bacteroids, Mycobacterium tuberculosis and actinomycetes.

Domestic and foreign authors unanimously emphasize that in modern conditions, the development of inflammatory processes is often caused by mixed flora, including associations of aerobes and anaerobes, as well as gonococcus, which is often combined with chlamydial infection.

Penetration of infection into the upper parts of the genital apparatus most often occurs in an ascending way from the vagina and cervix. Exogenous sexually transmitted infections (so-called transmissible diseases) spread in a similar way: gonorrhea, chlamydia, mycoplasmosis, viral and protozoan infections. Representatives of endogenous microflora vegetating in the vagina can penetrate into the uterus and its appendages in the same way.

According to modern concepts, the vaginal microflora of sick and healthy women who are sexually active is characterized by a great diversity, differing only in quantitative and qualitative indicators. It is represented by aerobes, both gram-positive (lactobacilli, corynebacteria, diphtheroids, various types of streptococci and staphylococci) and gram-negative (E. coli, Klebsiella, emterobacteria, Proteus). In addition, anaerobic flora is also isolated from the vagina of women, the predominant species of which are peptococci, peptostreptococci, bacteroids, fusobacteria, lactobacilli, etc. At the same time, anaerobic non-spore-forming flora significantly prevails over aerobic flora.

Although the microflora of the lower genital tract of healthy women is relatively stable, there are changes in its composition associated with the menstrual cycle and other features of the macroorganism. Thus, in the first phase of the menstrual cycle, E. coli, Bacteroides fragilis are isolated more often than in the second phase; the intensity of microflora growth increases during menstruation.

The mechanism of penetration of pathogens from the lower genital tract into the fallopian tubes has not been sufficiently studied to date. L. Keith et al. (1983) suggest the presence of three types of penetration: with trichomonads, with spermatozoa, and passive transport due to the suction effect of the abdominal cavity.

Gonococci with increased virulence penetrate quite easily through the intact protective system of the cervix. For the invasion of a purulent non-specific infection, an "entry gate" is required, i.e. tissue damage. These conditions are created during childbirth, abortions, such instrumental interventions as hysterosalpingography, hysteroscopy, hydrotubation. Particular importance is attached to intrauterine contraception. IUD leads to erosion of the endometrial surface, a local increase in fibrinolytic activity and the production of prostaglandins, which facilitate the spread of infection.

Currently, many authors draw attention to the increased likelihood of actinomycosis when using the IUD. The frequency of detection of Actinomyces israelii is influenced by the type of contraceptive and the duration of its stay in the uterus. The presence of copper in the IUD helps suppress factors that enhance the growth of these anaerobic microorganisms.

The chances of developing actinomycosis increase in women who use an IUD for more than 2 years.

It was said above that infection of the upper parts of the reproductive system, including the fallopian tubes, ovaries, and pelvic peritoneum, occurs in an ascending manner. However, the infection can spread through the lymphatic and venous vessels of the uterus or through the main bloodstream, as well as from adjacent organs of the pelvis or abdominal cavity. It should be noted that the spread of infection by hematogenous and lymphogenous routes is limited in conditions of early antibacterial treatment.

As a result of the damaging agent, the body responds, both directly - at the site of introduction, and generally - involving various systems and organs. An inflammatory process develops in the lesion, expressed in the destruction of the parenchyma with the release of biologically active substances, in vascular reactions with exudation, phagocytosis, physicochemical changes and a parallel increase in proliferative processes. The nature of the microbial flora affects the nature of pathogenetic changes in the lesion. Thus, inflammation of the appendages caused by anaerobic infection occurs with extensive tissue destruction and the formation of abscesses. Chlamydial infection leads to increased infiltrative and proliferative processes, contributing to the development of an extensive adhesive process. The general reaction of a woman's body to the introduction of an infectious agent includes changes in the functions of the peripheral and central nervous system, hormonal homeostasis, regional and general hemodynamics and hemorheology. Inflammatory changes in the female genital organs significantly change the immune and non-specific protective properties of the body. As is known, the state of immunity is assessed by the number and functional activity of T- and B-lymphocytes. In acute inflammatory processes of the internal genital organs, against the background of a relative decrease in the number of peripheral blood lymphocytes, there is a slight decrease in the content of T-lymphocytes and a marked increase in B-lymphocytes. Acute inflammation is characterized by a decrease in the functional activity of T-lymphocytes, which can be traced by a decrease in the ability of lymphocytes to blast transformation, especially during exacerbation of a long-standing chronic inflammatory process, especially in women over 35 years old, as well as against the background of leukocytosis of the peripheral blood exceeding 10 • 10 ⁴ g / l. In the acute course of inflammatory diseases of the internal genital organs, the content of all the main types of immunoglobulins in the blood serum increases significantly: IgA, IgM and IgG. Primary acute inflammation is characterized by a more pronounced increase in the level of IgM, and with an increase in the duration of the process, the content of IgG increases.

Symptoms of pelvic inflammatory diseases and the tactics of treatment approaches to them depend not only on the nature of the infectious agent, the age and previous health status of the woman, possible invasive diagnostic, therapeutic and other interventions on the reproductive system, but also on the localization of the lesion.

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