Inflammatory disease of the pelvic organs

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

[1], [2]

Causes of the inflammatory diseases of the pelvic organs

In most cases, the development of the disease involves sexually transmitted microorganisms, especially N. Gonorrhoeae and C. Trachomatis; However, the cause of inflammatory diseases of the pelvic organs may be microorganisms that are part of the vaginal microflora, such as anaerobes, G. Vaginalis, H. Influenzae, gram-negative enterobacteria and Streptococcus agalactiae. Some experts also believe that the etiological agent of inflammatory diseases of the pelvic organs may be M. Hominis and U. Urealyticum.

These diseases cause gonococci, chlamydia, streptococci, staphylococcus, mycoplasma, E. Coli, enterococci, proteus. An important role in their occurrence belongs to anaerobic pathogens (bacteroides). As a rule, inflammatory processes cause a mixed microflora.

The causative agents of inflammatory diseases are most often recorded from the outside (exogenous infection); Rarely observed processes whose origin is associated with the penetration of microbes from the intestine or other foci of infection in the body of a woman (endogenous infection). Inflammatory diseases of septic etiology occur when there is a violation of the integrity of the tissues (the entrance gate of the infection).

[3]

Forms

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

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

Uncomplicated forms include:

• endometritis,
• acute purulent salpingitis,
• pelvioperitonitis,

To the complicated - all opukmovannye inflammatory tumors of appendages - purulent tubo-ovarian formations.

Complications and consequences

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

[4], [5]

Diagnostics of the inflammatory diseases of the pelvic organs

The diagnosis is made based on patient complaints, the history of life and disease, the results of a general examination and gynecological examination. Consider the nature of morphological changes in the internal genital organs (salpingo-oophoritis, endometritis, endomyometritis, tubo-ovarian abscess, pyosalpinx, inflammatory tubo-ovarian formation, pelvic-peritonitis, peritonitis), the course of the inflammatory process (acute, subacute, chronic). The diagnosis should reflect the presence of concomitant gynecological and extragenital diseases.

All patients in the examination should examine the discharge from the urethra, vagina, cervical canal (if necessary, washings from the rectum) in order to determine the flora and sensitivity of the excretory to antibiotics, as well as the discharge from the fallopian tubes, the contents of the abdominal cavity (effusion), obtained by laparoscopy or laparoscopy.

To establish the extent of microcirculation disorders, it is expedient to determine the number of erythrocytes, aggregation of erythrocytes, hematocrit, the number of platelets and their aggregation. From the indices of nonspecific protection it is necessary to determine the phagocytic activity of leukocytes.

Serological and immunoenzymatic methods are used to establish the specific etiology of the disease. When suspected of tuberculosis, tuberculin reactions should be put.

Of the additional instrumental methods are used ultrasound, computer tomography of small organs, laparoscopy. If there is no possibility of performing laparoscopy, a puncture of the abdominal cavity is performed through the posterior vaginal fornix.

[6], [7]

Diagnostic notes

In connection with a wide range of symptoms and signs, diagnosis of acute inflammatory diseases of the pelvic organs in women presents significant difficulties. Many women with inflammatory diseases of the pelvic organs show slight or mild symptoms, which are not always recognized as inflammatory diseases of the pelvic organs. Consequently, the delay in the diagnosis and the postponement of appropriate treatment leads to inflammatory complications in the upper sections of the reproductive tract. To obtain a more accurate diagnosis of salpingitis and for more complete bacteriological diagnosis, laparoscopy can be used. However, this diagnostic technique is often not available in acute cases, nor in the more mild cases where symptoms are mild or vague. Moreover, laparoscopy is unsuitable for the detection of endometritis and poorly pronounced inflammation of the fallopian tubes. Consequently, as a rule, the diagnosis of inflammatory diseases of the pelvic organs is carried out on the basis of clinical signs.

Clinical diagnosis of acute inflammatory diseases of the pelvic organs is also insufficiently accurate. The data show that in clinical diagnosis of symptomatic pelvic inflammatory disease, positive predictive values (PPI) for salpingitis are 65-90% compared to laparoscopy as a standard. PPI for clinical diagnosis of acute inflammatory diseases of the pelvic organs vary depending on the epidemiological characteristics and type of medical facility; they are higher for sexually active young women (especially adolescents), for patients who go to STD clinics or live in areas with high prevalence of gonorrhea and chlamydia. However, there is no single anamnestic, physical or laboratory test that would have 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 inflammatory diseases of small organs pelvis). When combined diagnostic techniques that improve either sensitivity (identify more women with PID) or specificity (exclude more women who do not have PID), this happens only at the expense of the other. For example, the requirement of having two or more criteria excludes more women without pelvic inflammatory disease, but also reduces the number of identified women with PID.

A large number of episodes of pelvic inflammatory disease remain unrecognized. Although PID is asymptomatic in some women, in others it remains unrecognized, because the health worker can not correctly interpret such mild or nonspecific symptoms and signs as unusual bleeding, dyspareunia, or vaginal discharge ("atypical PID"). In connection with the difficulties of diagnosis and the possibility of violation of women's reproductive health, even with mild or atypical course of inflammatory diseases of the pelvic organs, experts recommend that medical workers use the "low threshold" of diagnosis for PID. Even under such circumstances, the impact of early treatment of women with asymptomatic or atypical PID on the clinical outcome is unknown. Presented recommendations for the diagnosis of pelvic inflammatory disease are necessary in order to help medical professionals to assume the possibility of inflammatory diseases of the pelvic organs and to have additional information for the correct 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) can hardly be impaired if the health care provider starts empirical antimicrobial treatment for pelvic inflammatory disease.

[8], [9], [10], [11]

Minimum criteria

Empirical treatment of pelvic inflammatory disease should be performed in sexually active young women and others at risk for STDs, in the presence of all the criteria below and in the absence of any other cause of the patient's illness:

• Soreness in palpation in the lower abdomen,
• Soreness in the appendages, and
• Painful traction of the cervix.

Additional criteria

An overestimated diagnostic score is often justified, since an incorrectly diagnosed diagnosis and treatment can lead to serious consequences. These additional criteria can be used to increase diagnostic specificity.

Below are additional criteria supporting the diagnosis of inflammatory diseases of the pelvic organs:

• The temperature is above 38.3 ° C,
• Pathological discharge from the cervix or vagina,
• Increased ESR,
• Elevated levels of C-reactive protein,
• Laboratory confirmation of 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 proved by the selected cases of diseases:

• Histopathological detection of endometritis with endometrial biopsy,
• Ultrasound transvaginal (or using other technologies) showing thickened, fluid-filled fallopian tubes with or without free fluid in the abdominal cavity or tubo-ovarian formation,
• Deviations detected by laparoscopy, corresponding to PID.

Although the decision to initiate treatment can be made before bacteriological diagnosis of infections caused by N. Gonorrhoeae or C. Trachomatis, confirmation of the diagnosis emphasizes the need for treatment of sexual partners.

[12], [13], [14]

Treatment of the inflammatory diseases of the pelvic organs

When an acute inflammation is detected, the patient should be hospitalized in a hospital, where she is provided with a medical-protective regime with strict observance of physical and emotional rest. Assign bed rest, ice on the hypogastric area (for 2 hours with interruptions of 30 minutes - 1 hour for 1-2 days), sparing diet. Carefully monitor the activity of the intestines, if necessary, prescribe warm cleansing enemas. Patients are useful drugs of bromine, valerian, 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 genitalia is carried out in a complex way and includes:

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

Antibiotic therapy

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

In recent years, the effectiveness of treatment of severe forms of purulent-inflammatory complications has increased with the use of beta-lactam antibiotics (augmentin, meronem, and thienes). The "gold" standard is the use of clindamycin with gentamycin. It is recommended to change antibiotics after 7-10 days with repeated determination of antibioticograms. In connection with the possible development of antibiotic therapy of local and generalized candidiasis, it is necessary to study hemo- and urocultures, as well as the appointment of antifungal drugs.

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

Schemes for the treatment of pelvic inflammatory disease should empirically provide the elimination of a wide range of possible pathogenic microorganisms, including N. Gonorrhoeae, C. Trachomatis, gram-negative optional bacteria, anaerobes and streptococci. Although in a clinical randomized trial with short-term follow-up, the efficacy of some antimicrobial therapy schemes has been proven to achieve clinical and microbiological cure, there is a small amount of work assessing and comparing the elimination of endometrial and fallopian tube infections or the frequency of such long-term complications as tubal infertility and ectopic pregnancy.

All treatment regimens should be effective against N. Gonorrhoeae and C. Trachomatis, negative tests for these infections in endocervix, do not exclude the presence of infection in the upper section of the reproductive tract. Although the issue of the need to destroy anaerobes in women with PID still remains controversial, there is evidence that this may be important. Anaerobic bacteria isolated from the upper parts of the reproductive tract in women with PID and dianas obtained in vitro clearly show that anaerobes such as B. Fragilis can cause tubal and epithelial destruction. In addition, many women with PID also have bacterial vaginosis. In order to prevent complications, the recommended regimens should include drugs acting on anaerobes. Treatment should be started immediately with the establishment of a preliminary diagnosis, since the prevention of long-term effects is directly interrelated with the timing of the appointment of appropriate antibiotics. When choosing a treatment regimen, the doctor should take into account its availability, cost, patient acceptability and the sensitivity of the pathogens to antibiotics.

In the past, many experts recommended that all patients with PID be hospitalized so that under parental conditions, parenteral antibiotic treatment could be performed under the supervision of a doctor. However, hospitalization is no longer synonymous with parenteral therapy. At present, there is no available data that would show the comparative efficacy of parenteral and oral treatment, or inpatient or outpatient treatment. Until the results of ongoing studies comparing parenteral inpatient treatment with oral ambulatory in women with PID are available, the data of clinical observations should be taken into account. The doctor decides on the need for hospitalization on the basis of the following recommendations, based on observational data and theoretical developments:

• Conditions that require urgent surgical intervention are not excluded, such as appendicitis,
• The patient is pregnant,
• Unsuccessful treatment with oral antimicrobials,
• Failure to comply with or carry out an outpatient oral regimen,
• Severely leaking disease, nausea and vomiting, or high fever.
• The tubo-ovarian abscess,
• The presence of immunodeficiency (HIV infection with low CD4 count, immunosuppressive therapy or other diseases).

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

There is no convincing data comparing parenteral and oral regimens. A lot of experience has been accumulated on the application of the following schemes. Also, there are multiple randomized trials demonstrating the effectiveness of each regimen. Although most studies used parenteral therapy, at least 48 hours after the patient's clinical improvement, this scheme was randomly assigned. Guidance on the decision regarding the transition to oral treatment, which can be performed within 24 hours from the beginning of clinical improvement, should be clinical experience.

[15], [16], [17]

Scheme A for parenteral treatment

• Cefotetan 2 g IV every 12 hours,
• or Cefoksitin 2 g IV every 6 months
• plus Doxycycline 100 mg IV or orally every 12 hours.

NOTE. Given that the infusion of drugs is associated with pain, doxycycline should be given orally, whenever possible, even if the patient is in the hospital. Oral and intravenous treatment with doxycycline has the same bioavailability. If intravenous administration is necessary, the use of lidocaine or other high-speed local anesthetics, heparin, or steroids or prolongation of the infusion time can reduce the infusion complications. Parenteral treatment may be discontinued 24 hours after the patient has had a clinical improvement, and oral treatment with doxycycline 100 mg twice a day should be continued up to 14 days. In the presence of a tubo-ovarian abscess, many clinicians use clindamycin or metronidazole with doxycycline to continue treatment, more often than doxycycline; this contributes to more effective overlapping of the entire spectrum of pathogens, including anaerobes.

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

Scheme B for parenteral treatment

• Clindamycin 900 mg IV every 8 hours
• plus Gentamicin - a shock dose of 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's clinical improvement, and then go on oral treatment with doxycycline 100 mg twice daily or with clindamycin 450 mg orally 4 times a day. The total duration of treatment should be 14 days.

In the tubo-ovarian abscess, many health professionals use clindamycin, not doxycycline, to continue treatment, because it is more effective against anaerobic microorganisms.

Alternative schemes of parenteral treatment

There are limited data on the use of another parenteral regimen, but the following three treatment regimens have been conducted, at least for a single clinical trial, and have shown efficacy against a wide range of microorganisms.

• Ofloxacin 400 mg IV every 12 hours,
• plus Metronidazole 500 mg IV every 8 hours.
• or Ampicillin / Sulbactam 3 g IV every 6 hours,
• plus Doxycycline 100 mg orally or iv every 12 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.

Scheme ampicillin / sulbactam with doxycycline had a good effect on N. Gonorrhoeae, C. Trachomatis, as well as anaerobes and was effective in patients with tubo-ovarian abscess. Both intravenous preparations - ofloxacin and ciprofloxacin have been studied as monotherapy drugs. Given the data on the ineffective effect of ciprofloxacin in C. Trachomatis, it is recommended that doxycycline is routinely added to the treatment. Since these quinolones are active only against a part of anaerobes, metronidazole should be added to each scheme.

[18], [19], [20], [21]

Oral treatment

There is little data on immediate and long-term outcomes of treatment, as in parenteral and outpatient regimens. The use of the following schemes provides an antimicrobial action against the most common etiologic agents of PID, but the clinical trial data on their use are very limited. Patients who do not have an improvement in oral therapy within 72 hours need to be reexamined to confirm the diagnosis and prescribe parenteral treatment in outpatient or inpatient settings.

Scheme A

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

Oralized ofloxacin, used as monotherapy, was studied in two well-planned clinical trials, and proved effective against N. Gonorrhoeae and C. Trachomatis. However, taking into account that ofloxacin is still not effective against anaerobes, it is necessary to add metronidazole.

Scheme B

• Ceftriaxone 250 mg IM once,
• or Tsefoksitin 2 g V / m plus Probenecid, 1 g orally once at a time,
• or Another parenteral cephalosporin of the third generation (eg ceftizoxime, cefotaxime),
• plus Doxycycline 100 mg orally 2 times a day for 14 days. (Use this scheme with one of the above schemes)

The optimal choice of cephalosporin for this regimen is not defined; while cefoxitine is active against a larger number of anaerobic species, ceftriaxone has a higher efficacy against N. Gonorrhoeae. Clinical trials have shown that a single dose of cefoxitine is effective for obtaining a rapid clinical effect in women with PID, but theoretical data indicate the need for adding metronidazole. Metronidazole will, also, effectively treat bacterial vaginosis, which is often associated with PID. Data on the use of oral cephalosporins for the treatment of PID are not published.

Alternative outpatient regimens

Information on the use of other outpatient treatment regimens is limited, but one regimen has undergone at least one clinical trial that has shown its effectiveness against a broad spectrum of agents of pelvic inflammatory disease. When amoxicillin / clavulanic acid was combined with doxycycline, a rapid clinical effect was obtained, but many patients were forced to discontinue treatment because of undesirable symptoms from the gastrointestinal tract. Several studies have been conducted to evaluate azithromycin in the treatment of infections in the upper reproductive tract, however, these data are not sufficient to recommend this drug for the treatment of pelvic inflammatory disease.

[22], [23], [24], [25]

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-effect relationships arising from purulent-inflammatory diseases. It is known that these diseases are accompanied by a violation of all types of metabolism, the removal of a large amount of fluid; there is an imbalance of electrolytes, metabolic acidosis, renal-hepatic insufficiency. Adequate correction of the revealed disorders is carried out together with the doctors-resuscitators. When carrying out detoxification and correction of water-electrolyte metabolism, two extreme conditions should be avoided: insufficient fluid administration and hyperhydration of the body.

In order to exclude these errors, it is necessary to control the amount of injected liquid from the outside (drink, food, medicinal solutions) and excreted in urine and other ways. The calculation of the injected rarity should be individual, taking into account the indicated parameters and the patient's condition. Proper infusion therapy in the treatment of acute inflammatory and purulent-inflammatory diseases is no less important than the appointment of antibiotics. Clinical experience shows that a patient with stable hemodynamics with adequate replenishment of BCC is less susceptible to the development of circulatory disorders and the onset of septic shock.

The main clinical signs of recovery of bcc, elimination of hypovolemia are indicators of CVP (60-100 mm of water), diuresis (more than 30 ml / h without the use of diuretics), improvement of microcirculation (skin color, etc.).

Pelvioperitonitis is observed quite often in the development of inflammatory diseases of the pelvic organs. Since inflammation of the peritoneum is marked by an increase in the extrarenal fluid loss and electrolytes, it is necessary to take into account the basic principles of replenishment of liquid and proteins. According to modern ideas, it is necessary to introduce both colloidal solutions (plasma, albumin, low-molecular dextrans) and crystalloid solutions (0.9% sodium chloride solution) with the calculation for 1 kg of body weight of the patient.

Crystalloid solutions use isotonic sodium chloride solution, 10% and 5% glucose solution, Ringer-Lock solution, polyionic solutions. Of low-molecular dextrans, colloidal solutions are used. 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 community-acquired abortion, along with liquid, lose a significant amount of electrolytes. In the process of treatment there is a need for a quantitative calculation of the introduction of basic electrolytes - sodium, potassium, calcium and chlorine. When introducing corrective doses of electrolyte solutions, the following should be adhered to:

1. Compensation of deficiency of electrolytes should be made slowly, by a drop method, avoiding the use of concentrated solutions.
2. Periodic monitoring of the acid-base state and electrolytes of blood serum is shown, since corrective doses are calculated only for extracellular fluid.
3. Do not try to bring their indicators to the absolute norm.
4. After achieving a stable normal level of serum electrolytes, only their maintenance dose is administered.
5. If the kidney function worsens, it is necessary to reduce the amount of injected liquid, reduce the amount of sodium introduced and completely eliminate the introduction of potassium. To conduct detoxification therapy, a technique of fractional forced diuresis is widely used to obtain 3,000-4,000 ml of urine per day.

Since septic states always exhibit hypoproteinemia due to a breakdown in protein synthesis, and also due to increased protein breakdown and the existing blood loss, the introduction of protein preparations is mandatory (plasma, albumin, protein).

[26], [27]

Anticoagulant therapy

With common inflammatory processes, pelvic pestitis, peritonitis, patients may have thromboembolic complications, as well as the development of the syndrome of disseminated intravascular coagulation (DVS).

Currently, one of the first signs of DVS is considered thrombocytopenia. Reducing the number of platelets to 150 x 10 ³ / L is the minimum that does not lead to hypocoagulation bleeding.

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

[28], [29]

Immunotherapy

Along with antibacterial therapy in conditions of low sensitivity of pathogens to antibiotics, the means that increase the general and specific reactivity of the patient's body acquire special importance, since generalization of the infection is accompanied by a decrease in the parameters of cellular and humoral immunity. On this basis, the complex therapy includes substances that increase immunological reactivity: antistaphylococcal gamma-globulin and hyperimmune antistaphylococcal plasma. To increase nonspecific reactivity, gamma globulin is used. Increased cellular immunity is promoted by such drugs as levamisole, tactivin, thymogen, and cycloferon. In order to stimulate immunity, efferent therapy methods (plasmapheresis, ultraviolet and laser irradiation of blood) are also used.

Symptomatic treatment

An essential condition for the treatment of patients with inflammatory diseases of the upper genital area is the effective analgesia using both analgesics and antispasmodics, and inhibitors of the synthesis of prostaglandins.

It is mandatory to introduce vitamins from the calculation of daily requirements: thiamine bromide - 10 mg, riboflavin - 10 mg, pyridoxine - 50 mg, nicotinic acid - 100 mg, cyanocobalamin - 4 mg, ascorbic acid - 300 mg, retinol acetate - 5000 units.

The appointment of antihistamines (suprastin, tavegil, dimedrol, etc.) is indicated.

Rehabilitation of patients with inflammatory diseases of the upper genital tract

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

For the normalization of menstrual function after acute inflammation, medications are prescribed whose action is aimed at preventing the development of algodismenosis (antispasmodics, non-steroidal anti-inflammatory drugs). The most acceptable form of administration of these drugs are rectal suppositories. Restoration of the ovarian cycle is performed by the appointment of combined oral contraceptives.

Physiotherapeutic methods in the treatment of inflammatory diseases of the pelvic organs are prescribed differentially, depending on the stage of the process, the duration of the disease and the effectiveness of the previous treatment, the presence of concomitant extragenital pathology, the state of the central and autonomic nervous system, and the age characteristics of the patient. Recommend the use of hormonal contraception.

In the acute stage of the disease at a body temperature below 38 ° C, UHF is administered to the hypogastric region and the lumbosacral plexus in a non-thermal dosage using a transverse procedure. When the edematous component is expressed, the combined effect of ultraviolet on the panty zone is assigned to 4 fields.

When subacute onset of the disease is preferable appointment of the electromagnetic field of microwave.

At the transition of the disease to the stage of residual phenomena, the task of physiotherapy is the normalization of the trophism of the suffering organs due to changes in vascular tone, the final relief of edematous phenomena and pain syndrome. To this end, reflex techniques are used to influence the tones of the tonal frequency. D'Arsonval, ultrasound therapy.

When the disease passes into the stage of remission, heat and mud treatment procedures (paraffin, ozocerite) are prescribed for the area of the panty zone, balneotherapy, aeroterapig, helio-and thalassotherapy.

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

Surgical treatment of purulent-inflammatory diseases of internal genital organs

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

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

It is the young age of patients is one of the main points that determine the adherence of gynecologists to sparing operations. In the presence of concomitant acute pelvioperitonitis In purulent lesions of the uterine appendages, uterine extirpation is performed, since only such an operation can ensure complete eradication of the infection and good drainage. One of the important moments of surgical treatment of purulent inflammatory diseases of the uterine appendages is the complete restoration of normal anatomical relationships between the pelvic organs, abdominal cavity and surrounding tissues. It is necessary to perform a revision of the abdominal cavity, to determine the condition of the appendix and exclude interintestinal abscesses in the purulent nature of the inflammatory process in the appendages of the uterus.

In all cases, when performing an operation for inflammatory diseases of the uterine appendages, especially in the purulent process, one of the main principles must be the principle of mandatory complete removal of the lesion focus, i.e. Inflammatory education. No matter how sparing the operation is, it is always necessary to completely remove all tissues of inflammatory education. Preservation of even a small portion of the capsule often leads to severe complications in the postoperative period, relapses of the inflammatory process, the formation of fistulas. When surgical intervention is mandatory, drainage of the abdominal cavity (kolyutomy).

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

In women of reproductive age, in the presence of conditions, it is necessary to perform extirpation of the uterus, preserving, if possible, at least part of the unchanged ovary.

In the postoperative period, complex conservative therapy is being continued.

Follow-up

In patients receiving oral or parenteral treatment, a significant clinical improvement (for example, a decrease in temperature, a decrease in the tension of the muscles of the abdominal wall, a decrease in soreness during palpation during the examination of the uterus, appendages and cervix) should be observed within 3 days from the start of treatment. Patients who do not have such improvement are required to clarify the diagnosis or surgical intervention.

If the physician chooses an outpatient oral or parenteral treatment, follow-up and examination of the patient should be performed within 72 hours, using the above criteria for clinical improvement. Some experts also recommend repeated screening for C. Trachomatis and N. Gonorrhoeae 4-6 weeks after completion of therapy. If PCR or LCR are used in the control of cure, a follow-up examination should be carried out one month after the end of treatment.

[30], [31], [32], [33]

Management of sexual partners

Examination and treatment of sexual partners (who were in contact in the preceding 60 days before the onset of symptoms) of women with PID are necessary because of the risk of reinfection and the high probability of revealing gonococcal or chlamydial etiology in them. Men who are sex partners of women with PID, caused by gonococci or chlamydia, often have no symptoms.

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

Even in clinics where only women are observed, health workers should ensure that men who are sex partners of women with PID are treated. If this is not possible, a medical professional who is treating a woman with PID should be sure that her partners have received appropriate treatment.

Special Remarks

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 in HIV-infected and uninfected women are not described in detail. Based on these early observations, it was suggested that in HIV-infected women with PID, surgical intervention is more likely. In subsequent, more comprehensive surveys of HIV-infected women with PID, it was noted that even with more severe symptoms than HIV-negative women, parenteral antibiotic treatment of such patients was successful. In another test, the results of microbiological studies in HIV-infected and uninfected women were similar, except for a higher incidence of concomitant Chlamydia infection and HPV infection, as well as, cellular changes caused by HPV. HIV-infected women with reduced immunity who have PID, require more massive therapy, which uses one of the parenteral antimicrobial treatment regimens described in this manual.