Causes of purulent gynecological diseases

The basis of the development and formation of inflammatory diseases is a set of interrelated processes, ranging from acute inflammation to complex destructive tissue changes.

The main trigger for the development of inflammation, of course, is microbial invasion (microbial factor).

On the other hand, in the etiology of the purulent process, so-called provoking factors play a significant and sometimes decisive role. This concept includes physiological (menstruation, childbirth) or iatrogenic (abortion, IUD, hysteroscopy, hysterosalpingography, surgery, IVF) weakening or damage of barrier mechanisms, which contributes to the formation of the entrance gate for pathogenic microflora and its further spread.

In addition, it is necessary to emphasize the role of background diseases and other risk factors (extragenital diseases, some bad habits, certain sexual inclinations, socially determined conditions).

Analysis of the results of numerous bacteriological studies in gynecology performed over the past 50 years has revealed a change of microbes - the causative agents of such diseases over the years.

So, in the 30s-40s one of the main causative agents of inflammatory processes in the fallopian tubes was gonococci. Leading gynecologists of that time provide data on the release of gonococcus in more than 80% of patients with inflammatory diseases of the genitals.

In 1946, V.A. Polubinsky noted that the frequency of detection of gonococcus decreased to 30% and the associations of staphylococcus and streptococcus began to be detected more and more often (23%).

In the following years, gonococcus gradually began to lose its leading position among the leading pyogenic pathogens, and in the 40-60s streptococcus occupied this place (31.4%), while staphylococcus was detected in only 9.6% of patients. Even then, the importance of E. Coli as one of the causative agents of the inflammatory process of the uterus appendages was noted.

In the late 60s and early 70s, the role of staphylococcus as the causative agent of various human infectious diseases, especially after childbirth and abortion, increased. According to I.R. Zack (1968) and Yu.I. Novikov (1960), when sowing detached from the vagina, staphylococcus was found in 65.9% of women (in pure culture it was isolated only in 7.9%, in the rest his associations with streptococcus and Escherichia coli prevailed). As noted by T.V. Borim et al. (1972), in acute and subacute inflammation of the internal genital organs, staphylococcus was the causative agent of the disease in 54.5% of patients.

In the 70s, staphylococcus continued to play an important role, and the importance of gram-negative flora, in particular E. Coli, and anaerobic flora, increased.

In the 1970s and 1980s, gonococcus was the causative agent of 21–30% of patients with HDVDF, and the disease often became chronic with the formation of tubo-ovarian abscesses requiring surgical treatment. Similar information on the frequency of gonorrhea in patients with inflammatory processes of the uterus appendages is 19.4%.

Since the 1980s, most researchers are almost unanimous in their opinion that the leading initiator of purulent diseases of the internal genital organs are associations of nonspore-forming gram-negative and gram-positive anaerobic microorganisms, gram-negative aerobic and less often gram-positive aerobic microbial flora.

Causes of purulent inflammatory diseases of the internal genital organs

Probable pathogens
Optional (aerobes)			Anaerobic
Gram +	Gram -	Sexually transmitted infections	Gram +	Gram-
Streptococcus (group B) Enterococcus Staph, aureus Staph.epidermidis	E. Coli, Klebsiella, Proteus, Etiterobacter, Pseudomonas	N. Gonorrhoeae, Chlamydia trachomatis, M. Man U. Urealyticum, Gardnerella vaginalis	Clostridium Pepto-streptococcus	Вacteroides fragilis, Prevotella species, Prevotella bivia, Prevotella disiens, Prevotella melani-nogenica, Fusobacterium

Associations of pathogenic purulent pathogens include:

• gram-negative, non-sporogenous anaerobic bacteria, such as the group bacteroides fragilis, Prevotella species, Prevotella bivia, Prevotella disiens and Prevotella melaninogenica;
• Gram-positive anaerobic streptococci Peptostreptococcus spp. And gram-positive anaerobic spore-forming sticks of the genus Clostridium, and the proportion does not exceed 5%;
• aerobic gram-negative bacteria of the Enterobacteriacea family, such as E. Coli, Proteus;
• aerobic gram-positive cocci (entero-, strepto-and staphylococcus).

A frequent component in the structure of pathogens of inflammatory diseases of the internal genital organs is also a transmissible infection, primarily gonococcus, chlamydia and viruses, and the role of chlamydia and viruses in abscess formation has not been adequately assessed so far.

Scientists who studied the microflora in patients with acute inflammation of the pelvic organs, obtained the following results: Peptostreptococcus sp. Allocated in 33.1% of cases, Prevotella sp. - 29.1%, Prevotella melaninogenica - 12.7%, V. Fragilis- 11.1%, Enterococcus - 21.4%, streptococcus group B - 8.7%, Escherichia coli - 10.4%, Neisseria gonorrhoeae - 16.4%, and Chlamydia trachomatis - 6.4%.

The bacteriology of inflammatory diseases is complex and polymicrobial, with the most frequently isolated microorganisms — gram-negative facultative aerobes, anaerobes, Chlamydia trachomatis, and Neisseria gonorrhoeae, in combination with opportunistic bacteria that usually colonize the vagina and cervix.

Md Walter et al. (1990) in patients with purulent inflammation in 95% of patients isolated aerobic bacteria or their associations, 38% - anaerobic microorganisms, 35% - N. Gonorrhoeae and 16% - C. Trachomatis. Only 2% of women were sterile crops.

R.Chaudhry and R.Thakur (1996) studied the microbial spectrum of abdominal aspirate in patients with acute purulent inflammation of the pelvic organs. Polymicrobial flora prevailed. On average, 2.3 aerobic and 0.23 anaerobic microorganisms were isolated from one patient. Aerobic microflora included coagulase-negative staphylococci (isolated in 65.1% of cases), Escherichia coli (in 53.5%), Streptococcus faecalis (in 32.6%). Among the anaerobic flora, microorganisms of the Peptostreptococci type and the variety Vasteroides prevailed. A symbiosis of anaerobic and aerobic bacteria was observed only in 11.6% of patients.

It is argued that the etiology of inflammatory diseases of the pelvic organs is undoubtedly polymicrobial, but in some cases the specific pathogen is difficult to differentiate due to the nature of the cultivation, even during laparoscopy. All scientists are unanimous in their opinion that Chlamydia trachomatis, Neisseria gonorrhoeae, aerobic and facultative anaerobic bacteria should be covered by the spectrum of antibacterial therapy according to the clinical and bacteriological manifestations of each individual case.

It is believed that in the occurrence of OBZPM in modern conditions, the association of microorganisms (anaerobes, staphylococci, streptococci, influenza viruses, chlamydia, gonococci) is of greater importance (67.4%) than monocultures.

According to the research data, aerobic, gram-negative and gram-positive microorganisms are more often defined as microbial associations of different composition and, more rarely, monocultures; elective and obligate anaerobes are present in isolation or in combination with aerobic pathogens.

According to some doctors, predominant role (73.3%) belonged to opportunistic microorganisms (Escherichia coli, enterococcus, epidermal staphylococcus) and anaerobam-bacteroids were found in 96.7% of patients with HBMD. Among other microorganisms (26.7%), chlamydia (12.1%), mycoplasma (9.2%), ureaplasma (11.6%), gardnerella (19.3%), HSV (6%) were detected. In the persistence and chronization of the process, a certain role belongs to bacterial-like microorganisms and viruses. Thus, the following pathogens were isolated in patients with chronic inflammation: staphylococcus - 15%, staphylococcus in association with E. Coli - 11.7%, enterococci - 7.2%, HSV - 20.5%, chlamydia - 15%, mycoplasmas - 6.1%, ureaplasmas - 6.6%, gardnerella - 12.2%.

The development of acute suppurative salpingitis is associated, as a rule, with the presence of sexually transmitted infections, and above all with Neisseria gonorrhoeae.

F.Plummer et al. (1994) consider acute salpingitis a complication of a cervical gonococcal infection and the main cause of infertility.

DESoper et al. (1992) tried to determine the microbiological characteristics of acute salpingitis: Neisseria gonorrhoeae was isolated from 69.4%, Chlamydia trachomatis was obtained from endocervix and / or endometrium in 16.7% of cases. 11.1% had a combination of Neisseria gonorrhoeae and Chlamydia trachomatis. Polymicrobial infection was identified in only one case.

SEThompson et al. (1980) in a study of the microflora of the cervical canal and exudate obtained from a rectal uterine cavity of 34 patients with acute adnexitis women, found gonococcus in the cervical canal in 24 of them, in the abdominal cavity in 10.

RLPleasant et al. (1995) isolated anaerobic and aerobic bacteria in 78% of patients with inflammatory diseases of the internal genital organs, while C. Trachomatis was isolated in 10% and N. Gonorrhoeae in 71% of cases.

At present, the frequency of gonococcus infection has increased, but most researchers note that Neisseria gonorrhoeae is often not found in isolation, but in combination with another vector-borne infection (Chlamydia trachomatis, Mycoplasma hominis).

C.Stacey et al. (1993) found Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, or a combination of these microorganisms most often in the cervical canal, less often in the endometrium and less often in the tubes, but C. Trachomatis is mainly isolated from the tubes. There was clear evidence that N. Gonorrhoeae and C. Trachomatis are pathogens.

Interesting data J.Henry-Suehet et al. (1980), who, when performing laparoscopy in 27 women with acute adnexitis, investigated the microbial flora obtained from the distal tube. At the same time, in 20 patients, the pathogen of the disease turned out to be gonococcus in a monoculture, the rest - aerobic-anaerobic flora.

Acute inflammation of the pelvic organs is associated with gonococcal, chlamydial and anaerobic bacterial infection.

In patients with acute inflammation of the pelvic organs, Neisseria gonorrhoeae is isolated more frequently (33%) than Chlamydia trachomatis (12%), but none of these microorganisms prevailed in cases of complicated disease.

MGDodson (1990) believes that Neisseria gonorrhoeae is responsible for 1 / 2-1 / 3 of all cases of acute ascending infection in women, at the same time it does not diminish the role of Chlamydia trachomatis, which is also an important etiological agent. At the same time, the author concludes that acute inflammation is still polymicrobial, since along with N. Gonorrhoeae and / or C. Trachomatis, anaerobes like Bacteroides fragilis, Peptococcus and Peptostreptococcus and aerobes, especially of the Enterobacteriaceae type E. Coli, are often distinguished. Bacterial synergism, co-infection and the presence of antibiotic-resistant strains make adequate therapy difficult.

There is a natural resistance that protects the upper genital tract in women.

T. Aral, JNNesserheit (1998) believe that two leading factors contribute to the development of acute ascending infection in women: chronic chlamydial infection of the cervical canal and critical delays in determining the nature and treatment of cervical infection.

If the development of acute suppurative salpingitis is usually associated with the presence of a sexually transmitted infection, and especially with Neisseria gonorrhoeae, then the development of purulent-destructive processes in the appendages (complicated forms of suppurative inflammation) is associated with associations of gram-negative anaerobic and aerobic bacteria. In such patients, the use of antibiotics has almost no effect, and progressive inflammation, deep tissue destruction and the development of purulent infection lead to the formation of inflammatory tumors of the appendages.

Existing observations indicate that 2/3 strains of anaerobic bacteria, in particular Prevotella, produce beta-lactamase, which makes them extremely resistant to therapy.

The pathogenesis of purulent inflammatory diseases allowed us to understand the model of intra-abdominal sepsis of Vennstein. In the experimental model of intra-abdominal sepsis of Weinstein, the main role of pathogens was played not by transmissible infections, but by gram-negative bacteria, and above all E.coli, which are one of the main causes of high mortality.

An important role in the association of bacteria belongs to anaerobes, and therefore the prescribed therapy must have a high anti-anaerobic activity.

Among anaerobic bacteria, the most frequent pathogens are B. Fragilis, P. Bivia, P. Diisiens, and peptostreptokokki. B. Fragilis, like other anaerobes, is responsible for the formation of an abscess and is practically the universal etiological cause of abscess.

One-sided tubo-ovarian abscess in a 15-year-old girl, caused by Morganella morganii and requiring adnexectomy, was described by A. Pomeranz, Z. Korzets (1997).

The most severe forms of inflammation are caused by Enterobacteriaceae (gram-negative aerobic rods) and B. Fragilis (gram-negative anaerobic non-sporiferous rods).

Anaerobes can not only cause the inflammatory process of the uterine appendages in isolation, but also superinfect the pelvic organs.

Aerobic streptococci, such as group B streptococci, are also a frequent etiological cause of gynecological infections.

Analyzing the role of other pathogens of purulent inflammatory process, it can be noted that Streptococcus pneumoniae was considered the only causative agent of purulent inflammation in the early nineteenth century. It is known that he was often the cause of pneumonia, sepsis, meningitis and otitis media in children. There are 3 cases of peritonitis with the formation of tubo-ovarian abscesses in three girls, from whom S. Pneumoniae was subsequently isolated.

Enterococci are excreted in 5-10% of women with purulent-inflammatory diseases of the genital organs. The question of the participation of enterococci (gram-positive aerobic streptococci such as E. Faecalis) in the development of a mixed anaerobic-aerobic infection of purulent-inflammatory diseases of the genital organs remains controversial.

Data from recent years suggests a possible role for enterococci in maintaining mixed aerobic-anaerobic inflammation, which increases the likelihood of bacteremia. There are facts confirming the synergistic effect between Efaecalis and B. Fragilis. Experimental data also indicate that enterococci are involved in the inflammatory process as a copathogen with E. Coli.

Some authors associate the development of enterococcal infection with preoperative antibiotic prophylaxis or a long course of therapy with cephalosporins.

Other studies conducted in patients with intra-abdominal infection suggest that the detection of enterococci in an isolate culture can be considered as a factor indicating the lack of effectiveness of antibiotic therapy.

As mentioned above, the role of these bacteria is still controversial, although 5–10 years ago they began to speak of this pathogen as an impending serious problem. However, if today some authors believe that enterococci are not the initiating cause and do not have independent significance in a mixed infection, in the opinion of others, the role of enterococci remains underestimated: if these microorganisms were easily ignored 10 years ago, now they should be considered as one of the main pathogens of purulent inflammation.

In modern conditions, conditionally pathogenic flora with poorly expressed immunogenicity, a tendency to persistence in the body, plays an equally etiological factor.

The overwhelming majority of purulent inflammatory diseases of the uterus appendages are caused by their own conditionally pathogenic microflora, among which the obligate anaerobic microorganisms largely prevail.

Analyzing the role of individual participants in the purulent process, it is impossible not to dwell on chlamydial infection.

If in many developed countries there is currently a decrease in the frequency of gonorrheal infection, the level of inflammatory diseases of the pelvic organs of chlamydial etiology, according to numerous authors, is still high.

In the US, at least 4 million infected with Chlamydia trachomatis are detected every year, and in Europe at least 3 million. Due to the fact that 50-70% of these infected women have no clinical manifestations, the disease is an exceptional problem for public health programs, with In this case, women suffering from cervical chlamydial infection are at risk of developing pelvic inflammatory diseases.

Chlamydia is a microorganism pathogenic to humans that has an intracellular life cycle. Like many obligate intracellular parasites, chlamydia can alter the normal defense mechanisms of the host cell. Persistence is the long-term association of chlamydia with the host cell, when chlamydia is in it in a viable state, but not cultured. The term "persistent infection" means the absence of obvious growth of chlamydia, suggesting their existence in an altered state, different from their typical intracellular morphological forms. A parallel can be drawn between the persistence of chlamydial infection and the latent state of the virus.

The following facts serve as proof of persistence: approximately 20% of women with cervical infection caused by Ch. Trachomatis, have only minor signs of the disease or do not have them at all. The so-called "silent infections" are the most common cause of tubal infertility, and only 1/3 of infertile women have a history of pelvic inflammatory disease.

Asymptomatic persistence of bacteria can serve as a source of antigenic stimulation and lead to immunopathological changes in the tubes and ovaries. It is possible that in the process of prolonged or repeated chlamydial infection, persistent altered chlamydia antigens “trigger” the body’s immune response with a delayed hypersensitivity reaction even in cases where the pathogen is not detected by culture methods.

At present, the overwhelming majority of foreign researchers consider Chlamydia trachomatis to be a pathogen and a major participant in the development of inflammation of the internal genital organs.

Established a clear direct correlative relationship between chlamydia, inflammatory diseases of the pelvic organs and infertility.

C. Trachomatis has a weak intrinsic cytotoxicity and often causes diseases with more benign clinical signs that manifest themselves in the later stages of the disease.

L. Westxom (1995) reports that in developed countries, Chlamydia trachomatis is currently the most common causative agent of sexually transmitted diseases in young women. It causes about 60% of pelvic inflammatory diseases in women younger than 25 years. The effects of infection with Chlamydia trachomatis, confirmed by laparoscopic studies in 1282 patients, were:

• infertility due to tube occlusion - 12.1% (vs. 0.9% in the control group);
• ectopic pregnancy - 7.8% (against 1.3% in the control group).

Studies indicate that the main locus of chlamydial infection, the fallopian tube, is the most vulnerable among others (cervical canal, endometrium) of the genital organs.

APLea, HMLamb (1997) found that even with asymptomatic chlamydia, from 10 to 40% of patients with lesions of the urethra and the cervical canal subsequently have acute inflammatory diseases of the pelvic organs. Chlamydia increases the risk of ectopic pregnancy by 3.2 times and is accompanied by infertility in 17% of patients.

However, when studying world literature, we were unable to find indications that chlamydia can directly lead to abscess formation.

Experiments on rats demonstrated that N. Gonorrhoeae and C. Trachomatis cause an abscess to occur only in synergism with facultative or anaerobic bacteria. An indirect evidence of the secondary role of chlamydia in abscessing is the fact that the inclusion or non-inclusion in the treatment regimens of anti-chlamydia drugs does not affect the cure of patients, while the schemes that include the use of drugs affecting the anaerobic flora have significant advantages.

The role in the development of the inflammatory process of Mycoplasma genitalium is not defined. Mycoplasmas are opportunistic pathogens of the urogenital tract. They differ from both bacteria and viruses, although they approach the latter in size. Mycoplasmas are found among representatives of normal microflora, but more often with changes in the biocenosis.

D.Taylor-Robinson and PMFurr (1997) described six varieties of mycoplasmas tropic to the urogenital tract (Mycoplasma hominis, M.fermentans, M. Pivum, M. Primatum, M. Penetrans, M. Spermatophilum). Some species of mycoplasmas colonize the oropharynx, others - the respiratory tract (M. Pneumoniae). Due to orogenital contacts, mycoplasma strains can mix and enhance pathogenic properties.

There is ample evidence of the etiological role of Ureaplasma urealyticum in the development of acute and especially chronic non-gonococcal urethritis. The ability of ureaplasmas to cause specific arthritis and a decrease in immunity (hypogammaglobulinemia) is also certain. These conditions can also be attributed to the complications of STIs.

There is a strong tendency among physicians to treat mycoplasmas as pathogens of a number of diseases, such as vaginitis, cervicitis, endometritis, salpingitis, infertility, chorioamnionitis, spontaneous abortions and pelvic inflammatory diseases, in which mycoplasmas are significantly more common than in healthy women. Such a model, when the results of microbiological studies are interpreted unequivocally (gonococci are highlighted - therefore, the patient has gonorrhea, mycoplasma means mycoplasmosis), does not take into account complex transitions from colonization to infection. The same researchers believe that evidence for a specific infectious process should be considered only a massive growth of mycoplasma colonies (more than 10-10 CFU / ml) or at least a fourfold increase in antibody titer in the dynamics of the disease. This actually happens in case of postpartum bacteremia, sepsis, complications after abortion, which was documented in blood culture studies in the 60-70s.

Most practitioners, despite the dubious etiological role of mycoplasmas and the ambiguity of their pathogenetic action, in cases of detection of these microorganisms in the discharge from the cervical canal recommend the use of antibiotics that act on myco-and ureaplasmas. We have to admit that in some cases such therapy leads to success, since it is possible that the use of broad-spectrum antibiotics sanitizes the foci of infection caused by other pathogens.

JTNunez-Troconis (1999) did not reveal the direct effect of mycoplasma on infertility, spontaneous abortion and the development of intraepithelial cervical cancer, but at the same time he found a direct correlative connection between this infection and acute inflammatory diseases of the pelvic organs. The final conclusion about the role of Mycoplasma genitalium in the development of acute pelvic inflammatory diseases can be made only after its detection by polymerase chain reaction in the upper genital tract.

Genital herpes is a common disease. According to L.N. Khakhalin (1999), 20-50% of adult patients visiting venereal clinics have antibodies to the virus. Damage to the genital organs is caused by the herpes simplex virus of the second, less frequently of the first (with orogenital contacts) type. The external genital organs and the perianal region are most often affected, but cervicitis is diagnosed in 70-90% of cases.

The role of viruses in purulent inflammation of the internal genital organs is mediated. So far, their action remains insufficiently clear and is associated mainly with immunodeficiency, and it is with interferon deficiency.

In this case, A.A. Evseev et al. (1998) suggest that the bacterial flora plays a leading role in the development of the deficiency of the interferon system with a combined lesion.

LN Khakhalin (1999) believes that all people who suffer from recurrent herpes viral diseases have an isolated or combined defect in the components of a specific antiherpetic immunity — a specific immunodeficiency that limits the immunostimulating effects of all immunomodulators. The author believes that to stimulate the defective immune system of patients with recurrent herpes viral diseases is inappropriate.

Due to the widespread use of antibiotics and the long wearing of the IUD, an increasing role of fungi in the development of a purulent process has been noted. Actinomycetes are anaerobic radiating fungi that cause chronic infection of various organs and tissues (thoracic and abdominal actinomycosis, actinomycosis of the urinary organs). Actinomycetes cause the most severe course of the process with the formation of fistulas and perforations of various localizations.

Fungi are very difficult to cultivate and are usually associated with other aerobic and anaerobic microorganisms, while the exact role of actinomycetes in the formation of an abscess remains unclear.

O.Bannura (1994) considers that actinomycosis in 51% of cases affects the organs of the abdominal cavity, in 25.5% of the pelvic organs and in 18.5% of the lungs. The author describes two cases of complex purulent tumors of the abdominal cavity of gigantic sizes (tubo-ovarian abscesses with perforation, infiltrative lesion, stricture of the large intestine, and fistula formation).

J.Jensovsky et al. (1992) describe the case of the abdominal form of actinomycosis in a 40-year-old patient who had an incomprehensible fever for a long period and who repeatedly underwent a laparotomy due to the formation of abdominal abscesses.

N.Sukcharoen et al. (1992) report a case of actinomycosis during 40 weeks gestation in a woman who had a IUD for 2 years. The operation revealed a right-sided purulent tubo-ovarian formation measuring 10x4x4 cm, sprouting into the posterior fornix.

The quality of life that has deteriorated in recent years for the majority of the population of Ukraine (poor nutrition, malnutrition, stress) has led to almost a tuberculosis epidemic. In this regard, clinicians, including gynecologists, must constantly remember about the possibility of tuberculous damage to the internal genitalia.

So, Y.Yang et al. (1996) examined a large group of (1120) infertile patients. Among patients with tubal infertility, tuberculosis occurred in 63.6% of cases, while nonspecific inflammation - only in 36.4%. The authors described four types of tuberculosis injuries: miliary tuberculosis in 9.4%, tubo-ovarian formation in 35.8%, adhesions and petrification in 43.1%, nodular sclerosis in 11.7%. Complete tube occlusion was observed in 81.2% of patients with genital tuberculosis and in 70.7% with non-specific inflammation.

J.Goldiszewicz, W.Skrzypczak (1998) describe a tubo-ovarian abscess of tuberculosis with a lesion of regional lymph nodes in a 37-year-old patient who had had "mild" pulmonary tuberculosis in the past.

One of the main points in the pathogenesis of the inflammatory process is a symbiosis of pathogens. Previously it was believed that the relationship of anaerobes with aerobes is based on the principles of antagonism. Today there is a diametrically opposite point of view, namely: bacterial synergism is the leading etiological form of non-clostridial anaerobic infection. Numerous studies and analysis of the literature suggest that synergy is not a random mechanical, but physiologically determined combinations of bacteria.

Thus, the identification of pathogens is extremely important for the selection of antibacterial therapy, but various factors influence the results of bacteriological studies, namely:

• disease duration;
• features of material sampling: technique, thoroughness, sampling time (before antibiotic therapy is carried out with a fresh process, during or after it, during an exacerbation or remission);
• the duration and nature of antibiotic therapy;
• laboratory equipment.

Only cultures isolated from abdominal fluid or abscess contents should be examined, these are the only reliable microbiological indicators of infection. Therefore, during the preoperative preparation, we used the material for bacteriological studies not only from the cervical canal, vagina, urethra, but also directly from the abscess by its single puncture through the posterior vaginal fornix or during laparoscopy.

When comparing the microflora, we found quite interesting data: the pathogens obtained from the purulent focus and uterus were identical in 60% of patients, and as for the purulent focus, cervical canal and urethra, similar microflora was observed only in 7-12%. This once again confirms that the initiation of the involuntary process of appendages comes from the uterus, and also indicates the unreliability of the bacteriological picture when taking material from typical places.

According to the data, 80.1% of patients with purulent-inflammatory diseases of the internal genital organs, complicated by the formation of genital fistulas, isolated various associations of microbial flora, and in 36% of them aerobic-anaerobic with a predominance of gram-negative.

Purulent diseases, regardless of etiology, are accompanied by pronounced symptoms of dysbacteriosis, which is aggravated by the use of antibacterial drugs, and every second patient is allergized to the body, which limits the use of antibacterial drugs.

In addition to the microbial factor in the development of the inflammatory process and the severity of its clinical manifestations, an important role is played by provoking factors. They are the main mechanism of invasion or activation of the infectious agent.

The first place among the factors provoking purulent inflammation, occupy the IUD and abortion

Numerous studies indicate the negative impact of a particular method of contraception, especially of the IUD, on the development of the inflammatory process of the internal genitalia.

Only a small group of authors believe that with careful selection of patients for the introduction of the IUD, the risk of pelvic inflammatory diseases is low.

The frequency of inflammatory complications when using intrauterine contraception, according to various authors, varies considerably - from 0.2 to 29.9% of cases.

According to some doctors, inflammatory diseases of the uterus and appendages occur in 29.9% of carriers of the IUD, menstrual dysfunction - in 15%, expulsion - in 8%, pregnancy - in 3% of women, while the author considers inflammatory diseases the most dangerous complication use of the IUD, both at the time of their occurrence and development, and in connection with the long-term consequences for the reproductive function of women.

Endomyometritis (31.8%) and combined lesions of the uterus and appendages (30.9%) prevail in the structure of inflammatory complications against the background of the IUD.

The treatment of pelvic infection for a female carrier of the IUD is tripled, and for women who have not given birth, it is sevenfold.

The contraceptive effect of the IUD is to change the nature of the intrauterine environment, negatively affecting the passage of spermatozoa through the uterus - the formation in the uterus of the "biological foam" containing fibrin filaments, phagocytes and protein-splitting enzymes. IUDs stimulate the formation of prostaglandins in the uterus, which causes inflammation and permanent contraction of the uterus. Endometrial electron microscopy in carriers of the IUD shows inflammatory changes in its superficial regions.

Also known is the "wick" effect of the threads of the IUD - contributing to the persistent proliferation of microorganisms from the vagina and cervix to the overlying departments.

Some authors believe that the occurrence of inflammatory diseases in carriers of the IUD is associated with an exacerbation of an already existing chronic inflammatory process in the uterus and appendages.

According to the International Federation of Family Planning, women with chronic inflammatory diseases of the uterine appendages in history, as well as patients with a persistent microorganism during bacterioscopy should be considered at risk for the occurrence of inflammatory complications in the background of IUD.

It is believed that inflammatory diseases of the pelvic organs when wearing IUDs are associated with gonorrheal or chlamydial infection, and therefore, IUDs should not be used in women with signs of endocervicitis. According to the data of the authors, chlamydia was detected in 5.8% of carriers of the IUD, 0.6% of them subsequently developed an ascending infection.

Different types of IUDs differ in the degree of possible risk of inflammatory diseases of the pelvic organs. So, the most dangerous in this regard VSK type Dalkon, discontinued. For progesterone-containing IUDs, the risk of inflammatory diseases of the pelvic organs increases by 2.2 times, for copper-containing IUDs - by 1.9 times, for Saf-T-Coil - by 1.3 times and 1.2 times for Lippes loop.

It is believed that IUDs increase the risk of PID by an average of three times, while inert plastic models increase it by 3.3 times, and copper-containing IUDs - by 1.8 times.

It is not proven that the periodic replacement of a contraceptive reduces the risk of purulent complications.

According to some doctors, the greatest number of inflammatory complications is observed in the first three months after the introduction of the contraceptive, namely in the first 20 days.

The incidence of PID is reduced from 9.66 per 1000 women during the first 20 days after administration to 1.38 per 1000 women in a later period.

There is a clear correlation between the severity of inflammation and the duration of wearing IUD. Thus, in the structure of inflammatory diseases during the first year of the use of the contraceptive, salpingo-oophoritis amounted to 38.5% of cases; no patients with tubo-ovarian diseases were identified. With the duration of wearing the IUD from one to three years, salpingo-oophoritis was observed in 21.8% of patients, tubo-ovarian diseases were formed in 16.3%. With a duration of contraceptive wearing from 5 to 7 years, salpingo-oophoritis and tubo-ovarian diseases were 14.3 and 37.1%, respectively.

There are numerous reports of the development of inflammation, the formation of tubo-ovarian tumors and the abscess formation of appendages when using intrauterine devices.

Scientists point out that IUDs can colonize various microbes on themselves, of which E. Coli, anaerobes, and sometimes actinomycetes are particularly dangerous for abscessing. As a result of the use of intrauterine contraceptives, the development of severe forms of pelvic infection, including sepsis, has been noted.

So, Smith (1983) described a whole series of deaths in the UK associated with the use of the IUD, when the cause of death was pelvic sepsis.

Prolonged wear of the IUD may result in tubo-ovarian, and in some cases, multiple extragenital abscesses caused by Actinomycetis Israeli and anaerobes, with an extremely unfavorable clinical course.

6 cases of pelvic actinomycosis directly associated with the IUD are described. Due to the severity of the lesion, in all cases a hysterectomy was performed with bilateral or unilateral salpingoovarectomy. The authors did not find the dependence of the occurrence of pelvic actinomycosis on the type of IUD, but noted a direct correlation between the disease and the duration of the use of the contraceptive.

It is known that severe purulent inflammation of the internal genital organs often develops after spontaneous and especially criminal abortions. Despite the fact that the incidence of community-acquired abortions has now decreased, however, the most severe complications of the purulent process, such as tubo-ovarian abscesses, parametritis and sepsis, cause maternal mortality and take up to 30% in its structure.

Inflammatory diseases of the internal genital organs are considered to be common complications of artificially terminated pregnancy, and the presence of an STI increases the risk of complications of terminating pregnancy.

Spontaneous and artificial termination of pregnancy, requiring curettage of the uterus, are often the initial stage of severe infectious complications: salpingoophoritis, parametritis, peritonitis.

It was established that intrauterine intervention preceded the development of PID in 30% of patients, 15% of patients had previous episodes of pelvic inflammatory diseases.

The second most common (20.3%) cause of purulent inflammation in the pelvis is the complication of previous operations. At the same time, any abdominal or laparoscopic gynecological interventions, and especially palliative and non-radical surgeries for purulent diseases of the uterine appendages, can be a triggering factor. The development of purulent complications is undoubtedly due to errors in the course of surgery (left wipes in the abdominal cavity, drains or their fragments), as well as low technical performance of sometimes the most routine operations (insufficient hemostasis and the formation of hematomas, re-ligation ad mass leaving on stumps long silk or nylon ligatures in the form of "tangles", as well as long operations with a large blood loss.

Analyzing the possible causes of suppuration in the small pelvis after gynecological operations, use of inadequate suture material and excessive tissue diathermocoagulation are distinguished, and Crohn's disease and tuberculosis are considered risk factors.

According to the researchers, “small pelvic cavity infection” - infiltrates and abscesses of paravaginal fiber and urinary tract infection - complicated the postoperative period in 25% of patients who underwent uterus extirpation.

Reported that the frequency of infectious complications after surgery, hysterectomy (analysis of 1060 cases) is 23%. Of these, 9.4% are for wound infection and infection of the surgical area, 13% for urinary tract infection and 4% for infections not related to the surgical area (thrombophlebitis of the lower extremities, etc.). The increased risk of postoperative complications was significantly associated with the performance of the Wertheim operation, blood loss exceeding 1000 ml, and the presence of bacterial vaginosis.

According to some doctors in developing countries, in particular in Uganda, the level of postoperative purulent infectious complications is much higher:

• 10.7% - after surgery for ectopic pregnancy;
• 20.0% - after extirpation of the uterus;
• 38.2% - after a cesarean section.

A special place is currently occupied by inflammatory complications of laparoscopic operations. The introduction into clinical practice of endoscopic methods of treatment with the liberalization of indications for them, often inadequate examination of patients with chronic inflammatory processes and infertility (for example, lack of studies on STIs), the use of chromohydrotubation in the process of laparoscopy and often with the aim of hemostasis of massive diathermocoagulation led to the growth of inflammatory diseases mild to moderate severity, in which patients are treated on an outpatient basis, including powerful antibacterial agents, and Also, severe purulent diseases leading to hospitalization and reoperation.

The nature of these complications is extremely diverse - from exacerbation of existing chronic inflammatory diseases or the development of an ascending infection as a result of damage to the cervical barrier (hromohydrotubation or hysteroscopy) to suppuration of extensive hematomas in the pelvic cavity (hemostatic defects) and the development of fecal or urinary peritonitis due to an unrecognized injury to the intestine, urinary bladder or ureter in violation of the technique or technology of operation (coagulation necrosis or tissue damage during the separation of cf. Ation).

The use of massive coagulation with hysteroresectoscopy and penetration of reactive necrotic emboli into the vascular bed of the uterus can lead to the development of acute septic shock with all the ensuing consequences.

Unfortunately, at present there is no reliable accounting of these complications, many of them are simply silent; a number of patients are transferred or after discharge, they are admitted to surgical, gynecological or urological hospitals. The lack of statistical data leads to the lack of proper alertness regarding possible purulent-septic complications in patients using endoscopic methods of treatment and their late diagnosis.

In recent decades, in vitro fertilization (IVF) has been widely developed and spread throughout the world. Expansion of indications for this method without adequate examination of patients and sanitation (in particular, transmissible infections) has led to the recent emergence of severe purulent complications.

So, AJ. Peter et al. (1993), reporting a case of pyosalpinx, confirmed by laparoscopy after IVF-ET, list the possible causes of abscess formation:

• activation of persistent infection in patients with subacute or chronic salpingitis;
• puncture bowel during surgery;
• entry of cervicovaginal flora into this region.

The authors believe that the threat of infection after IVF-ET requires the prophylactic administration of an antibiotic.

SJ.Wennett et al. (1995), analyzing the effects of 2670 punctures of the posterior vault to collect oocytes for IVF, noted that every tenth woman had rather serious complications: 9% of patients had hematomas in the ovary or small pelvis, which in two cases required an emergency laparotomy (marked also a case of pelvic hematoma formation as a result of damage to the iliac vessels), 18 patients (0.6% of cases) developed an infection, half of them had pelvic abscesses. The most likely route of infection, according to the authors, is a skid during puncture of the vaginal flora.

SDMarlowe et al. (1996) concluded that all physicians involved in the treatment of infertility should be aware of the possibility of forming tubo-ovarian abscesses after transvaginal function to collect oocytes in the IVF program. Rare causes of abscess after invasive interventions include potential complications after insemination. So, S.Friedler et al. (1996) consider that a serious inflammatory process, including tubo-ovarian abscess, should be considered as a potential complication after insemination even without transvaginal extraction of oocytes.

Purulent complications occur after a cesarean section. Moreover, as a result of these operations, they occur 8-10 times more often than after spontaneous labor, occupying one of the first places in the structure of maternal morbidity and mortality. Mortality directly related to the operation is 0.05% (Scheller A., Terinde R., 1992). D.V.Petitti (1985) believes that the maternal mortality rate after surgery is currently very low, but still a cesarean section is 5.5 times more dangerous than a vaginal delivery. F.Borruto (1989) talks about the incidence of infectious complications after cesarean section in 25% of cases.

Similar data leads SARasmussen (1990). According to him, 29.3% of women had one or more complications after CS (8.5% intraoperative and 23.1% postoperative). The most frequent complications were infectious (22.3%).

P.Litta and P.Vita (1995) report that 13.2% of patients had infectious complications after a cesarean section (1.3% wound infection, 0.6% endometritis, 7.2% fever) etiology, 4.1% - urinary tract infection). Risk factors for the development of infectious complications, and above all endometritis, scientists consider the age of the puerperal, the duration of labor, premature rupture of the membranes of anesthesia and anemia (But less than 9 g / l).

A.Scheller and R.Terinde (1992) for 3799 cases of planned, emergency and “critical” cesarean sections noted serious intraoperative complications with damage to adjacent organs (1.6% of cases with planned and emergency CS and 4.7% of cases with "Critical" COP). Infectious complications were, respectively, 8.6; 11.5 and 9.9%, which could be explained by more frequent prophylactic use of antibiotics in the “critical” group.

Bladder damage (7.27% of patients) is considered the most common intraoperative complication, wound infection (20.0%), urinary tract infection (5.45%) and peritonitis (1.82%) as postoperative.

The third place among the provoking factors is spontaneous labor. A significant reduction in the number of spontaneous births, as well as the emergence of effective antibacterial drugs did not lead to a significant decrease in postpartum purulent complications, since adverse social factors sharply increased.

In addition to the above microbial and provoking factors (“entry gate for infection”), there are currently a significant number of risk factors for the development of inflammatory diseases of the internal genital organs, which can be a kind of collector of persistent infection. Among them it is necessary to single out: genital, extragenital, social and behavioral factors (habits).

Genital factors include the presence of the following gynecological diseases:

• chronic diseases of the uterus and appendages: 70.4% of patients with acute inflammatory diseases of the uterine appendages suffered from chronic inflammation. 58% of patients with purulent inflammatory diseases of the pelvic organs had previously been treated for inflammation of the uterus and appendages;
• sexually transmitted infections: up to 60% of confirmed cases of pelvic inflammatory diseases are associated with the presence of an STI;
• bacterial vaginosis: complications of bacterial vaginosis include preterm labor, postpartum endometritis, pelvic inflammatory diseases and postoperative infectious complications in gynecology; they consider anaerobic facultative bacteria to be in the vaginal flora of patients with bacterial vaginosis as an important cause of inflammation;
• the presence of urogenital diseases in the husband (partner);
• history of childbirth, abortion or any intrauterine manipulation of inflammatory complications, as well as miscarriage and the birth of children with signs of intrauterine infection.

Extragenital factors imply the presence of the following diseases and conditions: diabetes, disorders of fat metabolism, anemia, inflammatory diseases of the kidneys and urinary system, immunodeficiency states (AIDS, cancer, prolonged treatment with antibacterial and cytotoxic drugs), dysbacteriosis, and diseases requiring the use of antacids and glucocorticoids. In non-specific etiology of the disease is associated with the presence of extragenital inflammatory foci.

Social factors include:

• chronic stressful situations;
• low standard of living, incl. Inadequate and poor nutrition;
• chronic alcoholism and drug addiction.

Behavioral factors (habits) include some features of sexual life:

• early onset of sexual activity;
• high frequency of sexual contacts;
• a large number of sexual partners;
• unconventional forms of sexual contact - orogenital, anal;
• sexual relations during menstruation, as well as the use of hormonal, and not barrier contraception. For women who have used barrier methods of contraception for two or more years, inflammatory diseases of the pelvic organs are 23% less common.

It is believed that the use of oral contraceptives leads to eradicated endometritis.

It is believed that when using oral contraceptives, mild or moderate inflammation is due to a blurred clinical manifestation.

It has been suggested that douching for contraception and hygiene may be a risk factor for the development of acute inflammatory diseases of the pelvic organs. It is established that anal sex contributes to the appearance of genital herpes, warts, hepatitis and gonorrhea; hygienic douching increases the risk of inflammatory diseases. It is believed that frequent douching increases the risk of pelvic inflammatory diseases by 73%, the risk of ectopic pregnancy increases by 76% and may contribute to the development of cervical cancer.

Of course, these factors not only create the background against which the inflammatory process occurs, but also determine the characteristics of its development and course as a result of changes in the body's defenses.

[1], [2], [3], [4], [5]