Inflammatory diseases of the pelvic organs

Inflammatory diseases of the pelvic organs (PID) - infection of the upper sections of the female genital tract: the cervix, uterus, fallopian tubes and ovaries are involved in the process; may occur abscesses. Common symptoms and signs of the disease are lower abdominal pain, vaginal discharge, irregular vaginal bleeding. Long-term complications include infertility, chronic pelvic pain, ectopic pregnancy.

The diagnosis is based on clinical manifestations and PCR data on gonorrhea and chlamydia; microscopy with saline fixation; ultrasonography or laparoscopy. Treatment is carried out using antibiotics.

[1], [2], [3]

What causes pelvic inflammatory disease?

Inflammatory diseases of the pelvic organs are the result of the penetration of microorganisms from the vagina and cervix into the endometrium, fallopian tubes and peritoneum. Infection of the cervix (cervicitis) promotes the appearance of mucopurulent discharge. The most common inflammatory processes of the fallopian tubes (salpingitis), the uterine mucosa (endometritis) and ovaries (oophoritis).

Most inflammatory diseases of the pelvic organs cause Neisseria gonorrhoeae and Chlamydia trachomatis, these pathogens are sexually transmitted. Inflammatory diseases of the pelvic organs are also often caused by other aerobic and anaerobic bacteria, including infectious agents characteristic of bacterial vaginosis.

Inflammatory diseases of the pelvic organs are more common in women under the age of 35 years. Less inflammatory processes develop before menarche, after menopause and during pregnancy. Risk factors are previous diseases, the presence of bacterial vaginosis or any sexually transmitted infection.

Other risk factors, especially for PGD of gonorrhea or chlamydial etiology, are young age, color race, low socioeconomic status and frequent changes in sexual partners.

Symptoms of pelvic inflammatory disease

The most common manifestations of the disease: abdominal pain, fever, vaginal discharge, pathological uterine bleeding during or after menstruation.

Cervicitis. There is hyperemia of the cervix and contact bleeding. Characteristic of mucopurulent discharge; usually these are yellow-green discharge, which are easily detectable when viewed in mirrors.

Acute salpingitis. Characterized by the presence of abdominal pain, bilateral or unilateral, even if both tubes are involved in the process. Pain can also occur in the upper parts of the abdominal cavity. With increased pain, nausea and vomiting occur. Irregular uterine bleeding and fever occur in a third of patients. In the early stages of the disease, symptoms may be mild or nonexistent.

Later symptoms can be pain while moving the cervix. Sometimes there is dyspareunia or dysuria. In many patients, the symptoms are absent or minimal. Inflammatory diseases of the pelvic organs with infection of N. Gonorrhoeae usually proceeds more acutely and with more severe symptoms than the inflammatory process with infection of C. Trachomatis, which can proceed painlessly.

Complications. Acute gonococcal or chlamydial salpingitis can lead to the development of Fitz-Hugh-Curtis syndrome (perihepatitis, which causes pain in the right upper quadrant of the abdominal cavity). Infection can have a chronic course and is characterized by frequent exacerbations and unstable remissions. Tubo-ovarian abscess (accumulation of pus in the appendages) develops in about 15% of women with salpingitis. This can be accompanied by the presence of acute or chronic infection. The development of an abscess occurs as a result of inadequate or late-onset treatment. There may be severe pain, fever and peritoneal symptoms. An abscess perforation may occur, which is the cause of a progressive increase in the symptoms of the disease and can lead to septic shock. Hydrosalpinx (accumulation of serous fluid in the fallopian tube as a result of sealing the fimbrial part) often proceeds asymptomatically, but can cause a feeling of pressure in the lower abdomen, chronic pelvic pain or dyspareunia.

Tubo-ovarian abscess, pyosalpinx (pus accumulation in one or both fallopian tubes) and hydrosalpinx can be detected by palpation of tumors in the area of the uterine appendages and cause infertility.

Salpingitis promotes the development of adhesive process and obstruction of the fallopian tubes. Common complications of the disease are chronic pelvic pain, menstrual irregularity, infertility and increased risk of ectopic pregnancy.

Diagnosis of pelvic inflammatory disease

Inflammatory diseases of the pelvic organs can be suspected in women of reproductive age, especially with the presence of risk factors. Patients note the appearance of pain in the lower abdomen and the presence of incomprehensible vaginal discharge. We can assume the presence of PID, when patients have irregular vaginal bleeding, dyspareunia or dysuria. The most likely presence of PID, if the patient has pain in the lower abdomen from one or both sides, as well as increased pain when moving the cervix. When palpation of tumor-like formation in the appendages of the uterus, one can assume the presence of a tubo-ovarian abscess. Care must be taken to diagnose the disease, because even inflammatory processes with minimal clinical manifestations can lead to serious complications.

If there is a suspicion of pelvic inflammatory disease, PCR (which is almost 100% sensitive and specific) in the cervical canal should be diagnosed to detect N. Gonorrhoeae C. Trachomatis to perform a test to exclude pregnancy. If PCR can not be performed, it is necessary to take the crops. Allocations from the cervical canal can be examined using Gram staining or saline fixation to confirm suppuration, but these tests are insensitive and nonspecific. If the patient can not be adequately examined due to the presence of pain, ultrasonography should be performed as soon as possible. You can count the leukocyte formula, but it's not very informative.

If the pregnancy test is positive, then the patient should be examined for an ectopic pregnancy.

Other common causes of pelvic pain may be endometriosis, torsion of the appendages of the uterus, rupture of the ovarian cyst, appendicitis. In the presence of Fitz-Hugh-Curtis syndrome, differential diagnostics between acute cholecystitis and salpingitis should be performed when examining pelvic organs and ultrasonography.

If palpable tumors in the pelvic region are observed, there are clinical manifestations of inflammation, and there is no effect of antibacterial treatment within 48-72 hours, it is necessary to perform ultrasonography as soon as possible to exclude tubo-ovarian abscess, pyosalpinx and disorders not related to PID , ectopic pregnancy, torsion of the appendages of the uterus).

If, after ultrasonography, the diagnosis remains questionable, laparoscopy should be performed to obtain purulent peritoneal contents, which is the gold diagnostic standard.

[4], [5], [6], [7]

Treatment of pelvic inflammatory disease

Initially, antibiotics are prescribed empirically, with the aim of affecting N. Gonorrhoeae and C. Trachomatis, and then the treatment regimen is changed based on the laboratory data obtained. Patients with cervicitis and the presence of minor clinical manifestations of PID are not required to be hospitalized.

Bacterial vaginosis is often combined with gonorrhea and chlamydia, and therefore patients are subject to mandatory outpatient treatment. Sexual partners of patients with N. Gonorrhoeae or C. Trachomatis should undergo a course of treatment.

Indications for inpatient treatment are the following inflammatory diseases of the pelvic organs: severe inflammatory processes (eg, peritonitis, dehydration), moderate or severe vomiting, pregnancy, suspected pelvic tumors, and suspected acute surgical pathology (eg, appendicitis). In such cases, intravenous antibiotics are administered immediately after the results of the sowing are obtained, the treatment is continued for 24 hours after the elimination of the fever. With a tubo-ovarian abscess, hospitalization and more durable intravenous antibiotic therapy are necessary. Treatment is carried out by draining the abscess of the small pelvis through the vagina or anterior abdominal wall under the control of CT or ultrasound. Sometimes for the introduction of drainage, laparoscopy or laparotomy is performed. If suspicion of a ruptured tubo-ovarian abscess, urgent laparotomy is performed. In women of reproductive age, organ-saving operations are performed (in order to preserve the childbearing function).