Parametritis

Parametritis is an inflammation of the parauterine tissue.

Diagnosis is not difficult. Treatment depends on the stage of the disease: in the acute stage - antibiotic therapy, in the suppuration stage - surgical treatment. The prognosis, excluding the septic form, is favorable.

[ 1 ], [ 2 ], [ 3 ]

Causes parametrization

It most often occurs as a complication of abortions (mainly out-of-hospital) and childbirth. Parametritis may occur with inflammation of organs adjacent to the uterus (rectum, appendix, etc.). In this case, pathogens penetrate into the parauterine tissue, usually by the lymphogenous route. With hematogenous infection of the parauterine tissue, parametritis may be a complication of general infectious diseases (flu, tonsillitis, etc.).

Risk factors

The development of the disease can be facilitated by surgical interventions (both vaginal - insertion of an intrauterine contraceptive, dilation of the cervical canal, diagnostic curettage, and abdominal - removal of interligamentary tumors of the internal genitalia, suppurating tumors).

[ 4 ], [ 5 ]

Pathogenesis

In most cases, parametritis develops against the background of purulent lesions of the uterine appendages due to the involvement of parametrial tissue in the inflammatory process. The route of infection is predominantly per continuitatem. Postpartum and postabortion parametritis is currently extremely rare. The route of infection of the tissue is lymphogenous. The inflammatory process in the tissue spreads further along the lymphatic vessels, as well as along the veins.

Symptoms parametrization

Symptoms of parametritis in most cases correspond to a severe inflammatory process. An early symptom is severe constant pain in the lower abdomen, radiating to the sacrum and lower back. As the disease progresses, the condition of patients worsens. Body temperature rises to 38-39° C; weakness, thirst, headaches are noted. Patients take a forced position - they bend and bring the leg to the stomach on the affected side.

The pulse corresponds to the temperature. Urination and defecation may be difficult.

During vaginal examination, a dense, immobile, painful infiltrate is detected on the side of the uterus, starting from the uterus and reaching the pelvic wall. The uterus is deviated to the healthy side.

Stages

The development and progression of parametritis goes through several stages.

1. The exudation stage corresponds to the initial period of parametritis.
2. The infiltration stage (exudate compaction) is the gradual replacement of the exudate with a dense (sometimes extremely dense) infiltrate. This occurs due to fibrin deposition. As a rule, the treatment undertaken stops acute inflammation in the appendage and helps to reduce the symptoms of concomitant parametritis. The course of parametritis in these patients is limited to the infiltration stage. The infiltrate in the parametrium area gradually decreases in size, but always leaves behind areas of residual infiltration.
3. The suppuration stage is characterized more often by the presence of multiple microabscesses in the infiltrate structure. In some rare cases (3.1%), total purulent melting of the parametrial tissue occurs.

During parametritis, the stages of infiltration, exudation and compaction (scarring) are distinguished. At the exudation stage, the infiltrate can suppurate with the development of purulent parametritis.

Forms

There are anterior, posterior and lateral parametrites. The latter are particularly common (about 90%).

Complications and consequences

When the parametric infiltrate suppurates, the patient's condition worsens, the pain increases sharply, the temperature becomes hectic, chills appear, a shift in the leukocyte formula to the left and an increase in LII are noted, and dysuric phenomena increase. Vaginal examination reveals softening and fluctuation of the infiltrate, overhanging of the vaginal vault. A short-term improvement in the patient's condition, the appearance of pus in the vagina (in urine or feces) indicate a breakthrough of the abscess.

Abscess formation always greatly aggravates the course of the underlying disease and can develop in different directions.

• Most often, purulent melting affects the lower sections of the parametrium and the retinaculum uteri area. The wall of the urinary bladder is involved in the process, pain occurs during urination, pyuria, which serves as a harbinger of the onset of perforation of the abscess into the urinary bladder.
• Less frequently, abscess formation and spread of pus goes "tongue" upward and forward in the direction of the round ligament, then in the form of a wide infiltrate along the lateral wall of the pelvis and above the inguinal (pupart) ligament. This localization of the abscess is called "Dupuytren's abscess". Above the inguinal ligament in these patients, a dense, sharply painful infiltrate is always determined, creating a visible asymmetry of the anterior abdominal wall, and hyperemia of the skin appears.
• The most dangerous variant of suppuration of parametrial tissue in patients with purulent diseases of the uterine appendages is, of course, the development of an abscess in the plexus lymphaticus spermaticus area - the so-called upper lateral parametritis. This is due to the fact that the effusion and pus spread along the posterior part of the parametrial tissue to the walls of the small and then large pelvis and from here, heading behind the cecum or sigmoid colon, can "tongue" up the paranephric tissue to the kidney, forming a paranephrotic and sometimes subdiaphragmatic abscess. Clinical manifestations of such parametritis usually begin with the development of periphlebitis of the external iliac vein, while severe forms of thrombosis may develop. The thigh on the affected side increases in size, starting from the inguinal ligament area, pronounced cyanosis appears, increasing towards the periphery, bursting pains in the leg. Swelling and pain decrease somewhat after 2-3 days, which coincides with the development of collateral outflow. The severity of the listed symptoms depends on the prevalence of thrombosis and the depth of vessel occlusion. It should be noted that with such complications, complete obstruction of the external iliac vein practically does not occur, but there is always a risk of thromboembolism. In this regard, the treatment of such women is particularly difficult and should include a full range of measures aimed at stopping phlebitis and phlebothrombosis, and preventing embolism.
• Another equally formidable complication is the spread of the purulent process to the perirenal tissue. At first, paranephritis occurs as a limited process, but then it quickly captures the entire fatty capsule, resulting in the development of phlegmon. Clinically, in the early stages, paranephritis manifests itself with symptoms of psoitis. The leg on the affected side is bent at the knee and hip joint and slightly brought to the stomach. When trying to straighten it, sharp pains in the iliac region intensify. At the same time, body temperature rises more and more (up to 39-40 ° C), a rapid hourly increase in the number of leukocytes begins, a neutrophilic shift is also noted, and the severity of intoxication increases. A swelling without sharp boundaries appears at the back in the kidney area, the contours of the waist are smoothed out.

Diagnostics parametrization

During vaginal examination, the main gynecological pathology is determined in patients, i.e. an inflammatory conglomerate of formations (uterus, appendages and adjacent organs) without clear identification of organs. In the presence of a bilateral process, the uterus is generally poorly contoured. During examination of the parametrium, infiltrates of varying consistency depending on the stage of the process are determined - from woody density at the infiltration stage to uneven with areas of softening during suppuration; infiltrates can have different sizes depending on the severity of the process or its phase. Thus, in the initial stages or at the resorption stage, infiltrates in the form of a cuff "envelop" the cervix and uterus, at the infiltration stage in severe processes they can reach the lateral walls of the pelvis, sacrum and pubis. The mucous membrane of the vaginal vault (vaults) in the area of cellular tissue infiltration is immobile, the vaults are shortened.

In operated patients, the infiltrate is located in the center of the pelvis above the stump of the cervix or occupies one half of the small pelvis. Complete immobility of the entire formation and the absence of clear contours are determined.

Signs of abscess formation in the parametrium are bursting or pulsating pain, hyperthermia, and often chills.

Parametrium abscesses (especially those resulting from postoperative complications) can perforate into adjacent hollow organs (distal parts of the intestine or bladder), in such cases symptoms of preperforation appear, and if treatment is not timely, symptoms of perforation of the abscess into the corresponding organs.

During vaginal examination, a conglomerate of organs is also determined in the pelvic cavity, which includes the affected appendages, uterus, omentum, intestinal loops. infiltrated bladder. Palpation does not allow determining the relative position of the organs included in this conglomerate, but it is always possible to identify signs characteristic of the developed complication:

1. the affected parametrium is infiltrated, acutely painful, the infiltrate can reach the pelvic bones and spread towards the anterior abdominal wall;
2. the lateral arch is sharply shortened;
3. the cervix is located asymmetrically relative to the midline and is shifted to the side opposite to the parametrium lesion and abscess formation;
4. It is practically impossible to displace the pelvic organs (conglomerate).

It is necessary to conduct a recto-vaginal examination, which is necessary to identify the prolapse of the infiltrate or abscess towards the rectum and determine the condition of the mucous membrane above it (mobile, limited mobility, immobile), which reflects the fact and degree of involvement of the anterior or lateral walls of the rectum in the inflammatory process.

The main additional diagnostic method is echography.

In addition to the above-described ultrasound criteria for damage to the uterus and appendages, patients with parametritis also have the following echographic signs of damage to the cellular spaces of the small pelvis:

• inflammatory infiltrates of the small pelvis are determined on the echogram as irregularly shaped echo-positive formations without a clear capsule and precise contours and boundaries; their sizes vary, in some cases the infiltrates reach the pelvic bones;
• Infiltrates are characterized by reduced echogenicity in relation to surrounding tissues and, when suppurating, contain in their structure one or more cystic formations with a clear capsule and thick heterogeneous contents.

According to our data, the information content of the computed tomography method in diagnosing parametrium abscesses was 80%, and in identifying panmetritis and pancellulitis - 68.88%.

In addition to the main pathology, the radiograph reveals reduced echogenicity of the parametric tissue, which may contain cavities with reduced density (purulent contents).

The development of infiltrative parametritis sometimes leads to significant deformations, compression of the ureter and the development of pronounced hydroureter and hydronephrosis, which requires catheterization of the ureter and placement of a urethral stent. Infiltrative parametritis causes the formation of urethropyeloectasis not only as a result of the formation of a mechanical obstacle to the outflow of urine, but also because in these cases there is a violation of the function of the neuromuscular apparatus of the ureter under the influence of the inflammatory process. It should be emphasized that in the process of examination by additional methods, pyelonephritis was detected in 78% of patients, which does not have classic clinical manifestations.

The severity of secondary renal disorders is directly dependent on the duration of the underlying disease, its severity, frequency and duration of relapses. It is important to emphasize that in all cases of progressive purulent process, the functional capacity of the kidneys continues to progressively deteriorate until the development of such a formidable disease as chronic renal failure.

Therefore, all patients with complicated forms of purulent inflammation in the presence of parametrium infiltrates are shown to undergo renal echography.

When hydronephrosis develops as a result of inflammatory stricture of the ureter or pyelonephritis, the diameter of the renal pelvis, as a rule, exceeds the norm (3 cm), while the ratio of the thickness of the parenchyma and the calyceal-pelvic system is shifted towards the latter and is 1.5:1 or 1:1 (with the norm being 2:1). The diagnosis of hydroureter is made if the diameter of the ureter is 1 cm or more.

Excretory urography is necessary for patients with hydronephrotic transformation of the kidneys of varying degrees or hydroureter, detected during ultrasound examination of the kidneys. Signs of ureteral stricture during excretory urography are clearly limited narrowing of the latter in the pelvic region.

To study kidney function, all patients with severe purulent-septic diseases of the internal genital organs are recommended to undergo radioisotope renography both before and after surgery. In severe purulent lesions, the isosthenuric or afunctional type of renographic curve predominates.

Cystoscopy is indicated for patients with parametritis and clinical symptoms of a threat of perforation into the bladder. In this case, bullous edema of the bladder mucosa is detected, corresponding to the inflammatory infiltrate and prolapsing towards the bladder, and vascular dilation.

Differential diagnosis

Differential diagnosis in patients with pelvic infiltrates is carried out primarily with malignant neoplasms of the uterus and appendages. Rapid progression of the disease, causal relationship with risk factors (especially with the use of IUD), prevailing laboratory criteria of purulent inflammation, pronounced regression of palpable pathological structures and laboratory parameters under the influence of complex anti-inflammatory and infusion therapy allow us to assume the inflammatory genesis of the disease, otherwise a timely consultation with an oncogynecologist is necessary, as well as the complete exclusion of physiotherapeutic methods of treatment until the diagnosis is clarified.

[ 6 ], [ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ], [ 13 ]

Treatment parametrization

Patients with parametritis are subject to mandatory hospitalization. Treatment of parametritis depends on the stage of the disease. In the acute stage, an ice pack is prescribed to the lower abdomen. Complex conservative therapy is carried out. At the stage of resolution (compaction), the treatment is supplemented with physiotherapy procedures (ultrasound, electrophoresis, etc.), biogenic stimulants.

In case of suppuration of parametritis, surgical treatment is indicated - opening of the abscess through the vaginal vault (colpotomy), drainage.

The transferred parametritis leaves pronounced cicatricial changes, shifting the uterus towards the side of the disease and sometimes accompanied by pain and menstrual dysfunction.