Diagnosis of inflammation of the uterine appendages

Diagnosis of acute appendage damage is based on anamnesis data, characteristics of the course, results of clinical, laboratory and instrumental research methods.

Anamnesis

When studying the patient's medical history, attention should be paid to the characteristics of sexual life, previous transcervical diagnostic and/or therapeutic interventions, termination of pregnancy, genital surgeries, the presence and duration of use of an intrauterine device. It is necessary to identify a possible connection between the onset of the disease and the menstrual cycle: the rise of infection to the desquamation phase. If there are diseases with similar clinical manifestations in the medical history, clarify the duration of its course, the nature and effectiveness of therapy, predisposing factors (hypothermia, fatigue, etc.), the presence of menstrual cycle disorders and infertility.

Patients with acute salpingitis or salpingo-oophoritis complain of pain of varying intensity in the lower abdomen with characteristic irradiation to the sacrum, lower back and inner thighs, and much less often to the rectum. The pains arise quite acutely or intensify gradually over several days. In 60-65% of cases, women report an increase in body temperature and pathological vaginal discharge: bloody, serous, purulent. A complaint of chills should alert the doctor to the possibility of a purulent process in the appendages, and repeated chills should confirm this opinion. Many patients complain of vomiting at the onset of the disease, but repeated vomiting often indicates the spread of infection beyond the appendages. A complaint of frequent painful urination may indicate inflammation of the appendages caused by a specific infection ( gonococcus, chlamydia, mycoplasma).

Inspection

The patient's condition with non-purulent acute salpingitis or salpingo-oophoritis remains relatively satisfactory. Intoxication manifestations are usually absent. The color of the skin and mucous membranes is unchanged. The tongue is moist. The pulse rate corresponds to body temperature. Blood pressure is within normal limits. Palpation of the lower abdomen is painful, but there are no symptoms of peritoneal irritation.

In the presence of a purulent process in the appendages (pyosalpinx, pyovar, tubo-ovarian formation or tubo-ovarian abscess), the general condition of the patient is assessed as severe or moderate. The color of the skin, depending on the severity of intoxication, is pale with a cyanotic or grayish tint. The pulse is frequent, but usually corresponds to the body temperature, a discrepancy between these parameters appears with microperforation of the abscess into the abdominal cavity.

There is a tendency towards hypotension due to changes in volume indices: a decrease in the volume of circulating blood, plasma and erythrocytes.

The tongue remains moist. The abdomen is soft, moderate swelling of its lower sections may be noted. Symptoms of peritoneal irritation in the absence of a threat of perforation are not detected, but palpation of the hypogastric region is usually painful. Often, a formation emanating from the pelvic organs can be palpated there. The palpation border of the tumor is higher than the percussion border due to the fusion of the tubo-ovarian abscess with intestinal loops.

When examining the vagina and cervix with a speculum, purulent, serous-purulent, or bloody discharge can be detected. The results of a bimanual examination depend on the stage, degree of involvement, and duration of the inflammatory process in the appendages. In the early stages of acute serous salpingitis, structural changes in the fallopian tubes may not be determined; only soreness in the area of their location and increased pain when the uterus is displaced are noted. The progression of the process leads to an increase in inflammatory tissue edema, and soft, painful tubes begin to be palpated. If fimbriae stick together and the interstitial sections of the tubes become occluded, the inflammatory exudate accumulates in their lumen: sactosalpinxes are formed. These saccular formations often have the appearance of a retort and are palpated on the side and behind the body of the uterus. Simultaneous involvement of the fallopian tubes and ovaries in the inflammatory process leads to the formation of a single conglomerate of irregular shape and uneven consistency. In patients with exacerbation of long-standing salpingo-oophoritis, not accompanied by activation of endogenous infection, bimanual examination reveals thickened, slightly mobile, moderately painful, stringy appendages. Such cases are characterized by sharp pain in the lateral walls of the small pelvis, which indicates pelvic gangliolitis. Bimanual examination in purulent inflammation of the appendages makes it possible to detect a slightly enlarged uterus, painful, especially when it is mixed, often fused into a single conglomerate with enlarged appendages. In some cases, enlarged retort-shaped appendages can be palpated separately on the side and behind the uterus. Quite often, due to sharp pain, it is not possible to obtain clear data on the condition of the appendages. But it should still be remembered that purulent inflammation of the appendages in the remission stage of the inflammatory process is characterized by fairly clear contours, dense consistency, some mobility with fairly pronounced pain. In the acute course of the inflammatory process, the appendage formation has unclear contours and uneven consistency; it is usually motionless, closely associated with the uterus and sharply painful, the tissues surrounding the uterus and appendages are pastose.

Laboratory tests

Mandatory blood testing, including the dynamics of the disease, helps to establish the severity of the inflammatory process. An increase in the number of leukocytes over 9 • 10 ⁹ /l, ESR over 30 mm / h, a positive reaction to C-reactive protein (-+-+). The content of sialic acid is more than 260 units, an increase in the amount of haptoglobin in the blood serum to 4 g / l (with a norm of 0.67 g / l), a decrease in the albumin-globulin coefficient to 0.8.

Urine analysis reveals the initial signs of renal pathology, the so-called isolated urinary syndrome. In patients with tubo-ovarian abscess, it is expressed in proteinuria not exceeding 1 g/l, leukocyturia within 15-25 in the field of view; microhematuria; the appearance of 1-2 hyaline and/or granular cylinders. The appearance of urinary syndrome is associated with intoxication, impaired urine passage, and in some cases indicates irrational antibiotic therapy.

Instrumental diagnostics

Nowadays, transabdominal ultrasound scanning is a common method of examination in gynecological practice. In many cases, it helps in diagnosing acute inflammatory processes of the internal genital organs, but interpretation of echograms is difficult if the inflamed fallopian tubes are slightly enlarged, if there is an extensive adhesion process in the small pelvis, or if the patient has obesity of the anterior abdominal wall. When it is possible to visualize the fallopian tubes in acute salpingitis, they look like elongated, irregularly shaped, single-chamber fluid formations with a homogeneous internal structure and thin walls, located on the side or behind the uterus. The walls of the pyosalpinx have clear contours of medium echogenicity, purulent exudate is echo-negative. Ultrasound differential diagnostics of pyovaria and ovarian tumor is practically impossible due to the similarity of their echograms, which are presented as round-shaped formations of reduced echo-density with a fairly clear capsule. Tubo-ovarian abscess is localized as an irregularly shaped multi-chambered formation with unclear contours. A more accurate assessment of the condition of the internal genital organs will become available after the introduction of transvaginal echography into practical gynecology. With the help of this method, it will be possible to determine the slightest changes in different parts of the fallopian tube and in the structure of the ovary, identify the boundary between the altered appendages, recognize the nature of the exudate in them, and study in detail the structure of the tubo-ovarian abscess.

Laparoscopy is widely used as an additional diagnostic method for acute inflammatory diseases of the uterine appendages. It can not only clarify the diagnosis and determine the degree of damage to the fallopian tubes and ovaries, but also obtain material for bacterioscopic and bacteriological examination, separate adhesions, remove pus accumulations, ensure the delivery of antibiotics to the lesion, etc. The risk of laparoscopic examination is the possibility of spreading infection, which somewhat limits its use. It is recommended to use this method only in the case of acute abdomen of unknown etiology, but with a predominance of the clinical picture of acute inflammation of the uterine appendages. This approach turned out to be quite justified and allowed the authors to confirm the presence of an inflammatory process in the appendages in 69.8% of cases. in 16% - to identify surgical pathology, in 4% - to detect an ectopic pregnancy, ovarian apoplexy, torsion of the ovarian tumor pedicle, in 10% of women no pathology of the pelvic organs was detected. Our experience of using laparoscopy for the purpose of diagnosing inflammation of the uterine appendages allows us to fully share the authors’ point of view.

The laparoscopic picture gives a clear idea of the nature and spread of the inflammatory process in the small pelvis. A hyperemic, edematous fallopian tube with weak motor activity, from the free ampullar end of which a turbid discharge comes out, indicates the presence of acute catarrhal salpingitis. In case of purulent salpingitis, fibrinous or fibrinous-purulent deposits and pus flowing out of its lumen can be seen on the serous cover of the tube. A retort-shaped enlargement of the tube with a sealed ampullar end indicates the formation of pelvic peritonitis. The presence of pelvic peritonitis can be concluded from hyperemia of the parietal and visceral peritoneum with areas of hemorrhage, fibrinous and/or purulent deposits; turbid, hemorrhagic or purulent effusion in the retro-uterine space. When a pyosalpinx or tubo-ovarian formation ruptures, a perforation hole can be seen; in the case of an extensive adhesion process, this complication is indicated by abundant pus flowing from the area of the altered appendages.

There are 5 laparoscopic pictures: acute catarrhal salpingitis; catarrhal salpingitis with pelvic peritonitis; acute purulent salpingo-oophoritis with pelvic peritonitis or diffuse peritonitis; purulent inflammatory tubo-ovarian formation; rupture of pyosalpinx or tubo-ovarian formation, diffuse peritonitis.

Of particular importance for clinicians is the identification of the microbial factor that caused the acute inflammatory process. For this purpose, it is recommended to use express diagnostics more widely: light and fluorescent microscopy of smears of native material, examination of purulent exudate in transmitted ultraviolet rays, gas-liquid chromatography, and the method of indirect immunofluorescence. A more accurate idea of the etiology of the disease can be obtained using cultural research methods, both traditional and with the use of strict anaerobic technology. The time spent on bacteriological research pays off in the accuracy of the results obtained, ensuring the possibility of effective correction of antibacterial therapy. However, it should be remembered that the reliability of the results of bacteriological tests depends not only and not so much on the qualified work of laboratory services, but also on the correctness of material collection by clinicians. The true cause of the inflammatory process is reflected in the results of the study of exudate taken directly from the site of inflammation during laparotomy or laparoscopy. The reliability of the study of material obtained by puncture of the posterior vaginal fornix is somewhat lower.

Bearing in mind the increasing role of chlamydia in the etiology of acute inflammation of the uterine appendages, it is necessary to take this fact into account during examination, using available cytological and serological diagnostic methods. Bacteriological and bacteriological studies aimed at identifying possible gonococcal infection are still relevant.

Thus, a thorough study of the anamnesis, assessment of the general condition and data from a gynecological examination, as well as laboratory tests (clinical and biochemical blood and urine tests, bacteriological and bacterioscopic studies of exudate and pus), the use of ultrasound and, if necessary, laparoscopy make it possible to make an accurate diagnosis of acute inflammation of the uterine appendages, determine the severity and extent of the process, the nature of the pathogen and, consequently, carry out adequate therapy.