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Pelvio-peritonitis
Last reviewed: 04.07.2025

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Pelvioperitonitis - inflammation of the peritoneum of the small pelvis (pelvic peritonitis) - is almost always a secondary process and develops as a complication of inflammation of the uterus or its appendages. In some cases, pelvioperitonitis can be caused by perforation of the uterus (during abortion, diagnostic curettage), acute appendicitis, torsion of the ovarian cyst pedicle and other diseases and pathological processes in the small pelvis.
Causes pelvio-peritonitis
In surgical and gynecological practice, the term "peritonitis" is understood as acute inflammation of the peritoneum. Peritonitis is a severe complication of various acute diseases of the abdominal cavity organs, often leading to death. Gynecological peritonitis most often completes such destructive processes in the internal genital organs as:
- melting of the wall of the pyosalpinx, pyovar or purulent tubo-ovarian formation;
- various gynecological operations;
- criminal abortions, including those complicated by perforation of the uterine wall;
- necrosis of an ovarian tumor due to torsion of its stalk or rupture of the tumor capsule.
The main causes of pelvic peritonitis are:
- Bacterial infection of the peritoneum by infection from the lower parts through the uterus and fallopian tubes into the abdominal cavity (ascending infection in acute gonorrhea).
- The transition of the inflammatory process from the appendages (with an existing inflammatory tubo-ovarian formation) to the pelvic peritoneum. It is for purulent lesions of the appendages that the most severe course of pelvic peritonitis and its complications is characteristic, since, unlike acute specific, there is already a chronic purulent process. Pelvioperitonitis with purulent lesions of the appendages is recurrent: when the inflammation subsides, adhesions and adhesions remain between the peritoneum of the small pelvis and the appendage formation (chronic adhesive pelvic peritonitis), and with the next exacerbation, more and more sections of the pelvic peritoneum are involved in the process.
A special place in the clinic is occupied by acute pelvic peritonitis - the progression of the process with specific inflammation or a sharp activation of infection against the background of an existing chronic purulent focus in the uterine appendages as a result of the breakdown of compensatory immune reactions.
Acute pelvioperitonitis is, in fact, one of the forms of peritonitis (local, or limited, peritonitis). Acute pelvioperitonitis causes severe clinical manifestations in purulent inflammatory formations of the appendages and can at any time lead to serious complications, such as opening of the appendage abscess into neighboring organs, bacterial shock, and, less often, to diffuse peritonitis. The possibility of their development depends on the aggressiveness of the flora, the state of the immune system, and the prevalence of inflammatory changes in the pelvic peritoneum and their depth.
Pelvioperitonitis as a result of ascending gonorrhea should also not be underestimated, since with inadequate therapy it can be complicated by the formation of pelvic abscesses and the development of peritonitis.
There is no single classification of peritonitis to date. Depending on the prevalence of the inflammatory process, the following forms of peritonitis are distinguished:
- Local (limited and unlimited).
- Widespread (diffuse, diffuse and general).
Local limited peritonitis means an inflammatory infiltrate or abscess in any organ of the abdominal cavity. In gynecological practice, such a purulent formation may be pyosalpinx, pyovar, tubo-ovarian abscess. In local unlimited peritonitis, the process is localized in one of the pockets of the peritoneum. In gynecology, local unlimited peritonitis includes pelvioperitonitis, which can be closed due to the development of adhesions between intestinal loops, omentum and pelvic organs, or open - with free communication of the pelvic region with the overlying parts of the abdominal cavity.
In the case of widespread diffuse peritonitis, the process covers 2 to 5 anatomical areas of the abdominal cavity; in diffuse peritonitis, more than 5 but less than 9; in general, there is a total lesion of the serous membrane of the organs and walls of the abdominal cavity. Many modern surgeons and gynecologists combine the last two options into one - widespread diffuse peritonitis.
Depending on the nature of the exudate, serous-fibrinous and purulent pelvic peritonitis are distinguished. In the first case, the rapid development of the adhesive process and the delimitation of inflammation are characteristic. In purulent pelvic peritonitis, pus accumulates in the retro-uterine space. The amount of encapsulated pus can be significant and is called a "retro-uterine abscess".
It should be noted that in most cases of the disease, a detailed determination of the extent of the spread of the inflammatory process is possible only during laparotomy and has prognostic significance, and also dictates an adequate volume of surgery and drainage of the abdominal cavity. However, in all cases it is necessary to differentiate local and widespread peritonitis, since a fundamental difference in the tactics of therapy for these conditions is possible.
Pelvioperitonitis may be a consequence of the spread of infection to the peritoneum of the small pelvis in serous and purulent salpingitis, and almost always accompanies the development of pyosalpinx, pyovarium or tubo-ovarian abscess. It can occur in the following forms: serous, fibrinous and purulent, and the fibrinous-purulent form can turn into purulent.
The inflammatory reaction in the acute stage of pelvioperitonitis is characterized by microcirculation disorders, increased vascular permeability, serous exudate, and the release of albumin, fibrinogen, and formed elements from the vascular bed (leukodiapaedesis). Histamine, kinins, serotonin, and organic acids accumulate in the lesion, and the concentration of hydrogen and hydroxyl ions increases. A decrease in the damaging effect of the infectious agent is characterized by a decrease in microcirculation disorders, reduced exudation, and the formation of adhesions that limit the pathological process to the small pelvis. With continued damaging action of the microbial flora, dystrophic changes in the mesothelium intensify, exudation, and leukodiapaedesis increase: serous pelvioperitonitis becomes purulent. When purulent pelvioperitonitis occurs, the process is limited more slowly or does not occur at all: diffuse peritonitis develops.
Symptoms pelvio-peritonitis
The symptoms of the acute stage of pelvioperitonitis are similar to the initial stage of diffuse peritonitis. However, with pelvioperitonitis, these signs are less pronounced, and local phenomena usually prevail over general ones. The patient with localization of the inflammatory process in the area of the uterine appendages suddenly experiences a deterioration in the general condition. Pain in the lower abdomen increases. The body temperature rises sharply to 38-39 ° C. Nausea appears, sometimes single or double vomiting. An objective examination reveals a rapid pulse, slightly ahead of the temperature reaction. The tongue remains moist, may be coated with a white coating. The abdomen is slightly swollen in the lower sections, some tension of the muscles of the abdominal wall, positive symptoms of peritoneal irritation are also determined there. Intestinal peristalsis becomes more sluggish, but the abdominal wall always participates in the act of breathing. Vaginal examination in patients with pelvic peritonitis is difficult due to severe pain and tension in the lower abdomen. Severe pain that occurs with the slightest displacement of the cervix undoubtedly indicates the involvement of the peritoneum in the inflammatory process. In some patients, flattening or even overhanging of the vaginal vaults can be detected, indicating the presence of exudate in the small pelvis.
A clinical blood test for pelvioperitonitis should be performed multiple times during the day, and at the onset of the disease - every hour. Unlike peritonitis, pelvioperitonitis is characterized by moderate leukocytosis, a slight shift in the leukocyte formula to the left, a slight decrease in the number of lymphocytes, and an increase in ESR.
In unclear cases, it is advisable to resort to diagnostic laparoscopy and, if the diagnosis is confirmed, to introduce a microirrigator for antibiotics. Dynamic laparoscopy is recommended for diagnosis and monitoring of treatment effectiveness.
Generalized peritonitis, including gynecological peritonitis, is an extremely severe pathology characterized by early-onset endogenous intoxication. Without going into details of the complex, not fully understood pathogenetic mechanisms of intoxication development in peritonitis, it should be noted that as a result of exposure to biologically active substances, patients develop pronounced generalized vascular disorders, mainly at the level of the microcirculatory part of the vascular bed. Inadequacy of blood supply to organs and tissues leads to the development of general tissue hypoxia, disruption of metabolic processes and rapid occurrence of destructive changes in the kidneys, pancreas, liver, and small intestine. Disruption of the intestinal barrier function leads to further intensification of intoxication.
Stages
In 1971, K. S. Simonyan proposed a classification of peritonitis that reflected the dynamics of the pathological process. This classification has not lost its significance to this day. The author identified 3 phases of peritonitis: phase 1 - reactive, phase 2 - toxic, phase 3 - terminal.
In the reactive phase, compensatory mechanisms are preserved. There are no disturbances in cellular metabolism. There are no signs of hypoxia. The general condition is still relatively satisfactory. Patients are somewhat euphoric, excited. Moderate intestinal paresis is noted, its peristalsis is sluggish. Tachycardia is somewhat ahead of the body's temperature reaction. In the blood, there is moderate leukocytosis with a slight shift in the formula to the left.
The toxic phase of peritonitis is associated with increasing intoxication. The general condition of the patient suffers: she becomes lethargic, the color of the skin changes, vomiting and hiccups appear. Metabolic processes are disrupted, the electrolyte balance changes, hypo- and dysproteinemia develops. Intestinal peristalsis is absent, the abdomen is bloated. Leukocytosis increases with a shift in the leukocyte formula to the left, toxic granularity of neutrophils appears.
In the terminal phase, all changes are more profound. Symptoms of damage to the central nervous system predominate. The condition of patients is extremely serious, with severe inhibition and adynamia. The pulse is arrhythmic, there is severe dyspnea, and blood pressure is low. The motor function of the intestine is completely impaired.
The dynamics of pathological processes in peritonitis are extremely fast: 48-72 hours can pass from the reactive phase to the terminal phase.
Symptoms of peritonitis in gynecological patients have certain differences from similar complications in patients with surgical pathology. First of all, it is necessary to keep in mind the possible absence of vivid manifestations of peritonitis, both general and local. Local manifestations of peritonitis include the following symptoms: abdominal pain, protective tension of the abdominal wall muscles and other symptoms of peritoneal irritation, intestinal paresis. For gynecological forms of peritonitis, the most characteristic sign is persistent intestinal paresis, despite the use of epidural block or peripheral ganglion block.
The most characteristic general symptoms of peritonitis are: high fever, shallow rapid breathing, vomiting, restless behavior or euphoria, tachycardia, cold sweat, as well as changes in some laboratory parameters, which include pronounced leukocytosis in the peripheral blood with a sharp shift in the leukocyte formula to the left and toxic granularity of neutrophils, an increase in the leukocyte intoxication index of more than 4, an increase in the level of alkaline phosphatase, and a sharp decrease in the number of platelets.
Complications and consequences
Most often, in patients with purulent tubo-ovarian formations against the background of acute pelvic peritonitis, perforation into adjacent organs occurs with the formation of genital fistulas or the formation of interintestinal or subdiaphragmatic abscesses (33.7%).
Diffuse purulent peritonitis is currently rare - with significant perforation of the purulent appendage and massive influx of the infectious agent and is observed, according to our data, in 1.9% of patients.
Diagnostics pelvio-peritonitis
Blood tests show changes characteristic of a severe inflammatory process - leukocytosis, a shift in the leukocyte formula to the left, a high leukocyte intoxication index, and an increase in ESR.
Vaginal examination in the first days of the disease is of little use due to pain and tension of the anterior abdominal wall. Later, an infiltrate is detected in the small pelvis directly behind the uterus, protruding the posterior vaginal fornix. Fluctuation indicates the formation of a retrouterine abscess. The uterus is not enlarged, immobile, its displacement is sharply painful. The uterine appendages cannot be determined. The same changes are determined during a rectal examination. During ultrasound, fluid can be detected in the Douglas space.
The echographic criteria for pelvic peritonitis are:
- the presence of free fluid in the pelvic cavity, mainly in the Douglas pouch (echo-negative contents, reflecting the accumulation of purulent exudate, which does not have a capsule and changes shape when the position of the body changes);
- weakening of peristaltic waves.
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Differential diagnosis
Differential diagnostics of pelvioperitonitis should be carried out with diffuse peritonitis. In diffuse peritonitis, the general condition of patients worsens more, symptoms of peritoneal irritation are determined throughout the abdomen, and changes in the pelvic area are absent (according to vaginal examination).
Pelvioperitonitis is characterized by a prolonged wave-like course with short-term remissions. In most cases, with timely and correct treatment, pelvioperitonitis ends in recovery.
The disease leaves extensive cicatricial-adhesive rotations between the organs and the walls of the small pelvis. In complicated cases of pelvic peritonitis, diffuse peritonitis or pus breakthrough into hollow organs (intestines, bladder) may develop.
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Treatment pelvio-peritonitis
Once the diagnosis is made, treatment of peritonitis begins, which is necessarily carried out in 3 stages: preoperative preparation, surgical intervention and intensive care in the postoperative period.
Preoperative preparation takes 1 1/2-2 hours. During this time, the stomach is decompressed through a nasogastric tube; the subclavian vein is catheterized and infusion therapy is performed aimed at eliminating hypovolemia and metabolic acidosis, correcting water, electrolyte and protein balance, and detoxifying the body; cardiac agents are administered; adequate oxygenation is ensured. During preoperative preparation, intravenous administration of antibiotics in the maximum possible dosages is indicated, with mandatory consideration of the characteristics. of their side effects.
After sufficient preparation, the surgical intervention begins. The abdominal cavity is opened with a midline incision, which allows for careful revision of the abdominal cavity and pelvic organs, sanitation and wide drainage. The scope of surgical intervention is determined strictly individually in each specific case. The main requirement for it is complete removal of the source of infection. The abdominal cavity is washed with a 1:5000 furacilin solution, the washing fluid is removed with an electric suction pump. 150-200 ml of 0.25% novocaine solution is injected into the mesentery of the small intestine. If indicated, the intestines are unloaded, and preference should be given to closed decompression using a long transnasal Miller-Abbott tube. The next stage of the operation is drainage of the abdominal cavity. Vinyl chloride or silicone tubes are installed under the right and left domes of the diaphragm and in both iliac regions. At the same time, a thick elastic drainage tube is inserted into the area of the recto-uterine pouch through the open vaginal dome or colpotome opening. The abdominal wall incision is sutured tightly. Abdominal cavity sanitation continues in the postoperative period by fractional perfusion with iso-osmolar solutions with the addition of antibacterial drugs. 1.5-2 liters of dialysate are drip-injected through all drains, then all tubes are blocked for 1-2 hours, after which they are opened for outflow. The procedure is repeated 4-6 times a day. Dialysis is carried out for 3 days, the drains are removed on the 4th day. It should be emphasized that patients in the terminal or toxic stages of peritonitis require dialysis.
The postoperative period of peritonitis treatment is the final and extremely important one. Continuing infusion therapy should pursue the following goals:
- elimination of hypovolemia by administering colloidal solutions and protein preparations;
- replenishment of the loss of chlorides and potassium;
- correction of acidosis;
- ensuring the body's energy needs;
- antienzyme and anticoagulant therapy by combined administration of heparin and contrical;
- ensuring forced diuresis;
- fighting infection by using broad-spectrum antibiotics;
- prevention and treatment of functional insufficiency of the cardiovascular system;
- prevention and elimination of hypovitaminosis.
One of the central places in the treatment of peritonitis is the restoration of the motor-evacuation function of the stomach and intestines. For this purpose, nasogastric intubation is used; long-term epidural block; intravenous administration of cerucal 2 ml 3 times a day; ganglion blockers such as benzohexonium 0.5 ml of a 2.5% solution 4 times a day intravenously or intramuscularly; subcutaneous administration of 1 ml of a 0.1% solution of proserin.
To enhance the effectiveness of the therapy, it is rational to include UFOAC sessions in the complex of therapeutic measures. The effect of UFOAC increases if the composition of therapeutic measures is supplemented with hyperbaric oxygenation (HBO). All types of purulent-septic infections are accompanied by oxygen starvation of the body, which is quite successfully corrected by the use of hyperbaric oxygenation. In addition, HBO has bactericidal, bacteriostatic and antiseptic properties. HBO increases tissue P 02 in the lesion, which helps to enhance the effect of antibiotics. The role of HBO in relation to anaerobic pathogens is most demonstrative in this regard. The optimal HBO therapy regimen is a pressure of 1.5-3 atm (147.1-294.3 kPa), the duration of the session is 45-60 minutes, the course of treatment is 6-7 sessions daily or every other day.
UFOAC can be combined with extracorporeal hemosorption (HS). In the treatment of early peritonitis, HS is effective even when used alone. It has been noted that after a HS session, the patient's well-being improves, leukocytosis decreases, encephalopathy manifestations decrease, breathing normalizes, the level of bilirubin and creatinine in the blood decreases, and the protein content increases.
In recent years, there have been reports of successful treatment of septic conditions by perfusion through donor pig spleen, which is a powerful biological filter that absorbs and eliminates a large number of microorganisms and toxins circulating in the blood of patients. In addition, xenoperfusion of the spleen has a powerful immunostimulating effect.
Thus, only early diagnosis, precise use of the entire arsenal of means and methods of treatment, close cooperation between gynecologists, surgeons and resuscitators can ensure success in the treatment of such a severe pathology as peritonitis.
Treatment of pelvioperitonitis is usually carried out by conservative methods. The patient needs rest, a full sparing diet. Periodic application of an ice pack to the lower abdomen is recommended.
The leading role in the complex of therapeutic measures belongs to antibacterial therapy, which is carried out according to the same principles by which severe forms of acute inflammatory processes in the uterine appendages are treated. The purpose of detoxification is infusion-transfusion therapy, including protein solutions, rheologically active plasma-substituting drugs, saline solutions, glucose, and hemodez. In case of severe intoxication, 2-3 liters of fluid are administered during the day; in case of decreased diuresis, diuretics are prescribed.
The complex of therapeutic agents includes desensitizing, non-specific anti-inflammatory and pain-relieving drugs, vitamins. It is advisable to conduct sessions of ultraviolet irradiation of autologous blood.
Surgical treatment is required for pelvioperitonitis occurring against the background of pyosalpinx, pyovarium or tubo-ovarian abscess. In such cases, pelvioperitonitis is characterized by a prolonged and severe course, especially if it is caused by associations of aerobic infection with anaerobes, and is poorly amenable to conservative therapy.
Treatment of the two forms of pelvic peritonitis differs radically depending on the cause of its occurrence.
- In case of specific "ascending" pelvic peritonitis, treatment is carried out according to the principles that consist of preoperative preparation aimed at stopping acute inflammation, when the basic treatment measure is drug (antibacterial and infusion) therapy, and evacuation of purulent exudate (surgical component of treatment). The method of "minor" surgical intervention may be different. The easiest and simplest method of removing purulent secretion is puncture of the uterorectal pouch through the posterior vaginal fornix. However, the most effective method of surgical treatment at the present stage should be considered laparoscopy, which is indicated for all patients with pelvic peritonitis of "ascending" genesis, while its use is mandatory in nulliparous patients to improve the fertility prognosis. An adequate volume for laparoscopy is the evacuation of purulent exudate with its collection for bacteriological and bacterioscopic examination; sanitation and transvaginal (through the colpotome opening) drainage of the small pelvis. In the postoperative period, active aspiration-washing drainage is carried out for 2-3 days, antibacterial and infusion therapy is continued, resorption drugs are used with subsequent rehabilitation for 6 months.
- In the presence of acute pelvic peritonitis in patients with purulent formations of the uterine appendages, conservative treatment can be considered only as the first stage of complex therapy aimed at stopping the acute inflammatory process and creating optimal conditions for the upcoming operation. Peculiarities of the treatment of pelvic peritonitis include the need to prescribe antibacterial therapy in the preoperative period to prevent generalization of the process. The effect of detoxification and preparation of patients for surgery is significantly enhanced by the evacuation of purulent exudate. Drainage in this case should be considered only as an element of complex preoperative preparation, allowing the operation to be performed under conditions of remission of the inflammatory process. The main drainage operations are puncture and colpotomy, the latter is advisable to perform only in cases where subsequent aspiration-washing drainage is assumed, which allows for a greater effect. In other cases, a single puncture is enough.
The duration of preoperative preparation in patients with purulent tubo-ovarian formations and pelvic peritonitis depends on the effect of the therapy:
- In case of favorable course of the process and remission of purulent inflammation, intensive conservative treatment can last 5-6 days, since the stage of remission of the purulent process is considered optimal for surgery. It is not worth delaying the surgical intervention in such patients and especially discharging them from the hospital, since the time of new activation of the infection is unpredictable and its severity will be incomparably greater.
- If intensive therapy is ineffective, the patient must undergo surgery within the first 24 hours, as the likelihood of life-threatening complications increases.
- If negative dynamics appear (signs of generalized infection - diffuse purulent peritonitis or sepsis), emergency surgical intervention is necessary after preoperative preparation for 1-1.5 hours.