Purulent Salpingitis - Treatment

The following tactical principles are fundamental: for any form of purulent inflammation, treatment can only be complex, conservative-surgical, consisting of:

• preoperative preparation;
• timely and adequate volume of surgical intervention;
• intensive postoperative treatment.

Preoperative preparation in patients with purulent salpingitis should be aimed at relieving acute manifestations of inflammation and suppressing the aggression of the microbial pathogen, therefore drug therapy for purulent salpingitis is a basic treatment measure and includes several components.

1. When prescribing antibacterial therapy in everyday practice, we focus on the clinical course of the infection. Neisseria gonorrhoeae, Chlamydia trachomatis, aerobic and facultative anaerobic bacteria should be covered by the spectrum of antibacterial therapy.

It is recommended to use the following drugs or combinations that affect the main pathogens with mandatory intraoperative (during laparoscopy) intravenous administration and continuation of antibacterial therapy in the postoperative period for 5 days.

• Combinations of penicillins with beta-lactamase inhibitors, for example, augmentin, which is a combination of amoxicillin with clavulanic acid. A single dose of the drug is 1.2 g intravenously, the daily dose is 4.8 g, the course dose is 24 g with intraoperative (during laparoscopy) intravenous administration of 1.2 g of the drug.
• Second-generation cephalosporins in combination with nitro-imidazoles, for example, cefuroxime + clion (metronidazole): single dose of cefuroxime - 1.5 g, daily - 4.5, course - 22.5 g; clion (metronidazole) respectively 0.5; 1.5 and 4.5 g with intraoperative intravenous administration of 1.5 g of cefuroxime and 0.5 g of clion (metronidazole).
• Fluoroquinolones, for example, ciprofloxacin in a single dose of 0.2 g intravenously by drop, daily - 0.4 g, course - 2.4 g with intraoperative intravenous administration of 0.2 g of ciprofloxacin.

After completion of antibacterial therapy, all patients should undergo correction of the biocenosis with therapeutic doses of probiotics: lactobacterin or acylact (10 doses 3 times) in combination with stimulants of the growth of normal intestinal microflora (for example, hilak forte 40-60 drops 3 times a day) and enzymes (festal, mezim forte) in normal doses.

2. Infusion therapy in the amount of 1000 - 1500 ml of liquid per day, the duration of therapy is individual (on average 3-5 days). It includes:

• crystalloids - 5 and 10% solutions of glucose and substitutes that help restore energy resources, as well as electrolyte balance correctors - isotonic sodium chloride solution, Ringer-Locke solution, lactasol, ionosteril;
• plasma-substituting colloids - rheopolyglucin, hemodez, gelatinol, as well as ethylated 6% starch solution HAES-STERIL - 6 in a volume of 500 ml/every other day;
• protein preparations - fresh frozen plasma; 5, 10 and 20% albumin solutions.

3. The use of desensitizing and antihistamine drugs in a daily dose, pathogenetically acting in the acute inflammatory phase, is indicated.
4. The use of nonsteroidal anti-inflammatory drugs with anti-inflammatory, analgesic and antiaggregatory effects is pathogenetically justified. The drugs are prescribed after discontinuing antibiotics. Diclofenac (Voltaren, Ortofen) is recommended at 3 ml intramuscularly daily or every other day (5 injections per course).

Against the background of conservative treatment, it is necessary to evacuate purulent exudate in the first 2-3 days (surgical component of treatment).

The method of "minor" surgical intervention may vary and depends on a number of factors: the severity of the patient's condition, the presence of complications of the purulent process and the technical equipment of the hospital. The simplest method of removing purulent secretion is puncture of the uterorectal cavity through the posterior vaginal fornix.

However, the most effective method of surgical treatment of purulent salpingitis at the present stage should be considered laparoscopy, which is indicated for all patients with purulent salpingitis and certain forms of complicated inflammation (pyosalpinx, pyovar and purulent tubo-ovarian formation) if the disease has been going on for no more than 2-3 weeks.

The use of laparoscopy is mandatory in young, especially nulliparous patients.

Contraindications include the presence of complicated forms of the purulent process (pyovar, pyosalpinx, purulent tubo-ovarian formation) if the process has been going on for more than 3 weeks.

In complicated cases of purulent inflammation, the peritoneum of the small pelvis, the walls of adjacent intestinal loops and the omentum, fusing with each other, form a "conglomerate" that closes the entrance to the small pelvis and access to the affected appendages. That is why the possibility of laparoscopic treatment for complicated forms of diseases, which has been widely recommended lately, seems to us not only problematic, but also contraindicated.

The problems that arise during laparoscopy even for a highly qualified surgeon determine in most cases not only the low therapeutic value, but also the insufficient diagnostic value of this method, which, in addition to establishing the fact of severe purulent inflammation, does not provide additional information; at the same time, attempts to perform endoscopic intervention in conditions of a purulent-infiltrative process can lead to the occurrence of life-threatening complications, in particular damage to adjacent organs.

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