Purulent tubo-ovarian masses

Microbial factor: unlike purulent salpingitis, which is usually caused by a specific infection, aggressive associative flora is released in patients with purulent tubo-ovarian formations.

There are two main variants of development of purulent tubo-ovarian formations:

1. may be the outcome of acute salpingitis with delayed or inadequate therapy (the third stage of development of the inflammatory process according to the classification of G. Monif (1982) - acute salpingo-oophoritis with occlusion of the fallopian tubes and the development of tubo-ovarian formations);
2. are formed primarily, without going through obvious clinical stages of acute purulent salpingitis.

Sudden onset of diseases with a pronounced clinical picture, general and local changes characteristic of acute inflammation of the internal genital organs, occurs in only one out of three women who become ill for the first time. 30% of women who have inflammation of the appendages that has already become chronic seek medical help for the first time.

In the last decade, according to numerous authors, a predominance of latent forms of inflammation with the absence of clinical and laboratory signs typical of acute inflammation has been noted.

Causes purulent tubo-ovarian masses.

Microbial factor: unlike purulent salpingitis, which is usually caused by a specific infection, aggressive associative flora is released in patients with purulent tubo-ovarian formations.

Risk factors

The provoking factors are:

1. VMC.
2. Previous operations.
3. Spontaneous labor.

Pathogenesis

There are two main variants of development of purulent tubo-ovarian formations:

1. may be the outcome of acute salpingitis with delayed or inadequate therapy (the third stage of development of the inflammatory process according to the classification of G. Monif (1982) - acute salpingo-oophoritis with occlusion of the fallopian tubes and the development of tubo-ovarian formations);
2. are formed primarily, without going through obvious clinical stages of acute purulent salpingitis.

Sudden onset of diseases with a pronounced clinical picture, general and local changes characteristic of acute inflammation of the internal genital organs, occurs in only one out of three women who become ill for the first time. 30% of women who have inflammation of the appendages that has already become chronic seek medical help for the first time.

In the last decade, according to numerous authors, a predominance of latent forms of inflammation with the absence of clinical and laboratory signs typical of acute inflammation has been noted.

Inflammatory diseases initially proceed as primary chronic diseases and are characterized by a long, recurring course with extreme ineffectiveness of drug therapy.

Symptoms purulent tubo-ovarian masses.

The main clinical symptom in this group of patients, in addition to pain and temperature, is the presence of signs of initially severe purulent endogenous intoxication. Purulent leucorrhoea is typical for patients whose abscesses were formed as a result of childbirth, abortions, and intrauterine menstruation. They are usually associated not with emptying of the appendage, but with the presence of ongoing purulent endometritis.

It should be noted that there are pronounced neurotic disorders, and along with symptoms of agitation (increased irritability) against the background of intoxication, symptoms of CNS depression also appear - weakness, rapid fatigue, sleep and appetite disturbances.

It should also be noted that the course of the purulent process against the background of IUD is particularly severe, and conservative (even intensive) treatment is ineffective. Removal of the IUD, including at the earliest stages of the development of purulent inflammation of the uterine appendages, not only did not contribute to the relief of inflammation, but often, on the contrary, aggravated the severity of the disease.

For patients with purulent complications after previous operations, the following clinical symptoms are typical: the presence of transient intestinal paresis, the persistence or increase of the main signs of intoxication against the background of intensive therapy, as well as their resumption after a short “clear” period.

Obstetric patients, along with changes in the uterine appendages, are characterized by signs indicating the presence of purulent endometritis, panmetritis, or hematomas (infiltrates) in the parametrium or retrovesical tissue. First of all, this is the presence of a large uterus, the timing of which clearly does not correspond to the period of normal postpartum involution. Also noteworthy is the lack of a tendency to form a cervix, and the purulent or putrid nature of lochia.

One of the distinctive features of the clinical course of purulent tubo-ovarian formations is the wave-like nature of the process, associated with the treatment being carried out, changes in the nature, form of the microbial pathogen, accompanying flora, immune status and many other factors.

Periods of exacerbation or activation of the process in such patients alternate with periods of remission.

In the remission stage of the inflammatory process, clinical manifestations are not clearly expressed; of all the symptoms, only mild or moderate intoxication remains.

In the acute stage, the main signs of acute purulent inflammation appear, and new complications often appear.

Most often, exacerbation is accompanied by acute pelvic peritonitis, characterized by deterioration of the patient's well-being and general condition, hyperthermia, increasing symptoms of intoxication, the appearance of pain in the lower abdomen, weakly positive symptoms of peritoneal irritation and other specific signs of pelvic peritonitis.

Acute pelvic peritonitis in patients with purulent tubo-ovarian formations can at any time lead to further serious complications, such as perforation of the abscess into adjacent organs or bacterial shock.

Diffuse purulent peritonitis in such patients develops extremely rarely, since the chronic purulent process, as a rule, is limited to the pelvic cavity due to numerous dense adhesions, the peritoneum and ligaments of the pelvis, the omentum and adjacent organs.

In purulent appendage formations, there are always characteristic changes in the adjacent sections of the intestine (swelling and hyperemia of the mucous membrane, pinpoint hemorrhages, sometimes in combination with erosions), and already at the early stages of the disease, the normal function of various sections of the intestine is disrupted. The nature and depth of changes in the intestine (up to narrowing of the lumen) are directly dependent on the duration and severity of the underlying inflammatory process in the uterine appendages.

Therefore, one of the most important features of the course of acute pelvic peritonitis in the presence of a purulent process in the appendages is the possibility of developing severe complications in the form of perforation of the abscess into hollow organs with the formation of fistulas. Currently, almost a third of patients with complicated forms of pelvic peritonitis have single or multiple perforations of pelvic abscesses. Single perforation of the abscess into the intestine, as a rule, does not lead to the formation of a functioning fistula and is determined during surgery as "purulent-necrotic fibrous destructive changes in the intestinal wall."

Multiple perforations into the adjacent section of the intestine lead to the formation of genital fistulas. It is important to emphasize that perforation of the abscess into the pelvic organs is observed in patients with a long-term and recurrent course of the purulent process in the uterine appendages. According to our observations, fistulas most often form in various sections of the large intestine, more often in the upper ampullar section or rectosigmoid angle, less often in the cecum and sigmoid colon. The intimate adjacency of these sections of the intestine directly to the capsule of the tubo-ovarian abscess and the absence of a layer of cellulose between them lead to more rapid destruction of the intestinal wall and the formation of fistulas.

Paravesical fistulas are much less common, since the peritoneum of the vesicouterine fold and prevesical tissue melt much more slowly. Such fistulas are often diagnosed at the stage of their formation (the so-called threat of perforation into the urinary bladder).

In all patients, appendovaginal fistulas occur only as a result of instrumental manipulations performed for the purpose of treating pelvic vaginal fistulas (multiple punctures of pelvic abscesses, colpotomy).

As a rule, parietal-abdominal fistulas are formed in patients with pelvic abscesses in the presence of a scar on the anterior abdominal wall (as a result of a previous non-radical operation in patients with pelvic abscesses or the development of purulent complications of other operations).

The breakthrough of an abscess into a hollow organ is preceded by the so-called "pre-perforation" state. It is characterized by the appearance of the following clinical manifestations:

• deterioration of the general condition against the background of remission of the existing purulent inflammatory process;
• increase in temperature to 38-39°C;
• the appearance of chills;
• the appearance of pain in the lower abdomen of a “pulsating”, “twitching” nature, the intensity of which increases significantly over time, and they change from pulsating to constant;
• the appearance of tenesmus, loose stools (threat of perforation in the distal parts of the intestine, less often in the parts of the small intestine adjacent to the abscess);
• the appearance of frequent urination, microhematuria or pyuria (threat of perforation into the bladder);
• the appearance of infiltrate and pain in the area of the postoperative suture.

In the case of a threat of perforation at any location of the abscess, laboratory tests reflect the activation of the infection and a sharp exacerbation of the inflammatory process; in the case of an accomplished perforation, chronic purulent intoxication.

The presence of parametritis in patients with purulent tubo-ovarian formations may be indicated by the following clinical signs:

• pain when urinating, pyuria (anterior parametritis);
• constipation, difficulty with defecation (posterior parametritis);
• renal dysfunction - the appearance of urinary syndrome, edema, decreased diuresis (lateral parametritis);
• the appearance of infiltrate and hyperemia of the skin above the inguinal ligament (anterior parametritis);
• periphlebitis of the external iliac vein, manifested by swelling and cyanosis of the skin of the thigh, distending pain in the leg (upper lateral parametritis);
• paranephritis, clinically characterized in the early stages by psoitis phenomena - the forced position of the patient with the leg adducted (upper lateral parametritis);
• phlegmon of the paranephric tissue - high hyperthermia, chills, severe intoxication, the appearance of swelling in the kidney area, smoothing of the waist contours (upper lateral parametritis).

The appearance of pain in the mesogastric regions of the abdominal cavity, accompanied by phenomena of transient intestinal paresis or partial intestinal obstruction (nausea, vomiting, constipation), may indirectly indicate the presence of interintestinal abscesses.

The appearance of chest pain on the affected side, soreness in the area of the costal arch and neck in the area of the projection of the phrenic nerve can serve as indirect evidence of the formation of a subphrenic abscess.

Peripheral blood indices reflect the stage of acuteness of the inflammatory process and the depth of intoxication. Thus, if in the acute inflammation stage the characteristic changes are leukocytosis (mainly due to band and young forms of neutrophils), increased ESR and the presence of a sharply positive C-reactive protein, then in remission of the inflammatory process the first to be noticed are a decrease in the number of erythrocytes and hemoglobin, lymphopenia with normal neutrophil formula indices and increased ESR.

Clinical features of purulent appendage formations in different age periods

• In adolescents:

Tuboovarian abscesses are considered to develop as a complication of purulent salpingitis in sexually active adolescents. Pain syndrome is not always expressed, palpation and laboratory data are scanty (no leukocytosis). An elevated ESR and echoscopic data can help establish a diagnosis. In adolescent patients with formed tuboovarian abscesses, signs of acute inflammation are less common than in the absence of inflammatory formations of the uterine appendages (purulent salpingitis). The disease often takes an atypical course, which leads to the development of severe complications.

• During pregnancy:

N. Sukcharoen et al. (1992) reported a case of a large right-sided purulent tubo-ovarian formation during pregnancy at 40 weeks in a woman who had previously used an IUD for 2 years. Microbiological examination revealed actinomycosis.

P. Laohaburanakit and P. Treevijitsilp (1999) described a case of peritonitis due to rupture of a tubo-ovarian abscess during 32 weeks of pregnancy. Extirpation of the uterus with appendages was performed. The newborn and mother had no postoperative complications.

• In postmenopause:

GHLipscomb and FWLing (1992) described 20 cases of tubo-ovarian abscesses in postmenopause. 45% of patients had previous intrauterine interventions, 40% of patients had a combination of malignant and purulent processes. In 60% of patients, the abscesses were unilateral, and 55% had a pronounced adhesive process. Every third patient (35%) had an abscess rupture. Based on their observations, the authors concluded that diagnosis of tubo-ovarian abscesses in postmenopause requires extensive clinical experience, since even abscess rupture and development of peritonitis are not accompanied by typical clinical signs, and only a study of the number of leukocytes in dynamics allows making a diagnosis. In addition, clinical thinking is traditionally not aimed at identifying purulent diseases in postmenopausal patients, since they are considered to be the prerogative of their reproductive period.

A long-term purulent process is always accompanied by dysfunction of almost all organs, i.e. multiple organ failure. This primarily concerns parenchymatous organs.

Most often, the protein-forming function of the liver suffers. With prolonged existence of purulent tubo-ovarian formations, severe dysproteinemia develops with albumin deficiency, an increase in the globulin fraction of protein, an increase in the amount of haptoglobin (a protein that is a product of depolymerization of the main substance of connective tissue) and a sharp decrease in the albumin/globulin coefficient (the figures were 0.8 before surgery, 0.72 after surgery and 0.87 at discharge with a norm of at least 1.6).

The long-term course of the purulent process significantly affects the function of the kidneys and urinary system. The main factors causing renal dysfunction are the violation of the passage of urine when the lower third of the ureter is involved in the inflammatory process, intoxication of the body with products of purulent tissue decay and massive antibiotic therapy to stop the inflammatory process without taking into account the nephrotoxic effect of drugs. The structure of the ureters of inflammatory genesis, according to research data (1992), is found in 34% of patients with complicated forms of purulent inflammatory diseases of the internal genitalia.

To assess the initial renal dysfunction, we consider it appropriate to use the term "isolated urinary syndrome" or "urinary syndrome." This term is widely used by therapists to denote the initial manifestations of renal pathology. According to some doctors, isolated urinary syndrome is most often manifested by proteinuria, sometimes in combination with microhematuria, cylindruria, or leukocyturia, and may be "... the debut of severe renal damage with subsequent arterial hypertension and renal failure." However, as a rule, such renal damage proceeds favorably, without a tendency to rapid progression, and completely disappears when the underlying disease is eliminated. At the same time, even renal amyloidosis that develops with a septic infection can manifest itself for a long time only by urinary syndrome, and it almost always proceeds without an increase in arterial pressure. The latter circumstance is explained by the action of such hypotensive factors as infection, intoxication, and fever.

Urinary syndrome in patients with purulent inflammatory diseases of the uterine appendages is expressed in proteinuria up to 1% (1 g / l), leukocyturia - over 20 in the field of vision, erythrocyturia (more than 5 erythrocytes in the field of vision) and cylindruria (1-2 granular and hyaline cylinders in the field of vision). The frequency of urinary syndrome in women with purulent lesions of the uterine appendages currently fluctuates, according to our data, from 55.4 to 64%. It should be added that a more detailed study of renal function (ultrasound of the kidneys, Zimnitsky, Roberg-Tareyev tests, radioisotope renography) allows us to identify its initial and latent forms. We found a violation of the functional capacity of the kidneys in 77.6% of patients with complicated forms of purulent inflammation.

Based on all of the above, we can conclude that purulent diseases of the uterine appendages are a polyetiological disease that causes severe disturbances in the homeostasis system and parenchymal organs.

[ 1 ], [ 2 ]

Diagnostics purulent tubo-ovarian masses.

In patients with formed encapsulated abscesses of the uterine appendages, during a vaginal examination, special attention should be paid to such symptoms of the disease as the contours of the inflammatory formation, its consistency, mobility, soreness and location in the pelvic cavity. A purulent formation of the appendages in an acute inflammatory process during a vaginal examination is characterized by unclear contours, uneven consistency, complete immobility and severe soreness. At the same time, it is always in a single conglomerate with the uterus, which is determined and palpated with great difficulty. The size of purulent formations of the appendages is very variable, but in the acute stage of inflammation they are always somewhat larger than the true ones.

In the remission stage, the conglomerate has clearer contours, although the unevenness of consistency and its complete immobility remain.

With concomitant parametritis, patients are found to have infiltrates of varying consistency depending on the stage of the process - from woody density at the infiltration stage to uneven with areas of softening during suppuration; infiltrates can have different sizes (in severe cases, they not only reach the lateral walls of the small pelvis, sacrum and pubis, but also spread to the anterior abdominal wall and paranephric tissue).

Damage to the parametrium, primarily its posterior sections, is particularly well detected during a recto-vaginal examination, which indirectly assesses the degree of involvement of the rectum in the process (the mucosa is mobile, limitedly mobile, immobile).

The main additional diagnostic method is echography. Currently, abscesses are identified echographically earlier than clinically. The following echographic signs are characteristic of patients with purulent tubo-ovarian formations:

1. Concomitant endomyometritis, manifested by the presence of multiple heterogeneous echo-positive structures in the uterine cavity, the presence of echo-positive structures on the walls of the uterine cavity more than 0.5 cm thick, diffuse changes in the structure of the myometrium in the form of multiple inclusions of reduced echogenicity with unclear contours (which reflects the presence of purulent endomyometritis with areas of microabscessing). If endomyometritis developed as a result of wearing an IUD, the contraceptive is clearly visible in the uterine cavity.
2. A pronounced adhesive process is determined in the pelvic cavity. In all cases, pathological appendage formations are fixed to the rib and the back wall of the uterus. In 77.4% of patients, a single conglomerate without clear contours is determined in the pelvic cavity, consisting of the uterus, pathological formation(s), intestinal loops and omentum fused with them.
3. The shape of inflammatory formations in complicated cases is often irregular, although it approaches ovoid.
4. The size of the formations varies from 5 to 18 cm, the area - accordingly from 20 to 270 cm ².
5. The internal structure of purulent inflammatory formations is characterized by polymorphism - it is heterogeneous and is represented by a medium-dispersed echo-positive suspension against the background of an increased level of sound conductivity. In no case did we manage to clearly differentiate the fallopian tube and ovary in the structure of the tubo-ovarian formation using echoscopic methods; only in 3 patients (8.1%) were tissue fragments resembling ovarian tissue determined.
6. The contours of the GVZPM can be represented by the following options:
   • echo-positive thick (up to 1 cm) capsule with clear contours;
   • echo-positive capsule with areas of uneven thickness;
   • echo-positive capsule with areas of sharp thinning;
   • a formation without clear contours (the capsule is not clearly visible throughout its entire length).
7. When studying the blood supply of purulent tubo-ovarian formations, the absence of a vascular network inside the formation was revealed. The blood flow indices in the ovarian artery had the following numerical values of vascular resistance: S/D - 5.9+/-0.7 and IR - 0.79+/-0.08. Moreover, no reliable differences in these indices were found in the groups of patients with tubo-ovarian formations with and without abscess perforation into adjacent organs.

The method of additional contrasting of the rectum significantly simplifies the task of diagnosing pelvic abscesses and lesions of the distal sections of the intestine. Additional contrasting of the rectum during ultrasound examination is carried out using a thin-walled balloon (condom) attached to a polyethylene rectal probe. Immediately before the examination, the probe is inserted into the rectum and advanced under ultrasound control to the "zone of interest" - most often the upper ampullar section of the rectum or the rectosigmoid section. Then, using a syringe, the balloon is filled with liquid (350-400 ml). The appearance (along with the bladder) of a second acoustic window (contrasted rectum) allows for a more precise orientation in the changed anatomical relationships and the determination of the positions of the pelvic abscess wall and the distal sections of the intestine.

The diagnostic capabilities of computed tomography in patients with purulent diseases of the genitals are the highest among all non-invasive research methods; the informativeness of the CT method in the diagnosis of abscesses of the uterine appendages approaches 100%. However, due to the low availability and high cost, the study is indicated for a limited number of the most severe patients - after previous operations or palliative interventions, as well as in the presence of clinical signs of pre-perforation or perforation.

On the tomogram, tubo-ovarian formations are defined as uni- or bilateral volumetric pathological structures, the shape of which is close to oval or round. The formations are adjacent to the uterus and displace it, have unclear contours, non-uniform structure and density (from 16 to 40 Hounsfield units). They contain cavities with reduced density, visually and according to densitometric analysis corresponding to purulent contents. In our studies, 16.7% of patients had gas bubbles in the structure of the formation. The number of purulent cavities varied from 1 to 5, in some cases the cavities were communicating. The thickness of the capsule was different - from sharply thickened (up to 1 cm) to thinned. Perifocal inflammation - infiltration of cellulose (cellulitis) and involvement of adjacent organs in the process - was observed in 92.7% of patients. A quarter (24.4%) of patients had a small amount of fluid in the utero-rectal space. Enlarged lymph nodes, easily detected by CT, were observed in almost half of the patients (41.5%).

Unlike acute purulent salpingitis, invasive diagnostic methods for purulent tubo-ovarian formations do not provide sufficient information and have a number of contraindications. A single puncture followed by colpotomy and aspiration-washing drainage is indicated only as part of preoperative preparation to clarify the nature of the exudate, reduce intoxication and prevent the formation of purulent genital fistulas.

The same applies to laparoscopy, which in some cases has contraindications and has low diagnostic value due to the pronounced adhesive-infiltrative process.

Difficulties caused by the involvement of various pelvic organs in the inflammatory process in inflammatory diseases of the uterine appendages, or complications associated with the production of laparoscopy itself in these patients, force gynecologists in some cases to switch to urgent laparotomy, which, of course, limits the use of laparoscopy. Thus, A.A. Yovseyev et al. (1998) provide the following data: in 7 out of 18 patients (38.9%), laparoscopy "transitioned" to laparotomy due to the severity of the adhesive process and the impossibility of examining the pelvic organs.

Differential diagnosis

In case of right-sided localization of purulent tubo-ovarian formation, differential diagnostics with appendicular infiltrate should be performed. Thus, according to research data, appendicular abscess was found in 15% of patients operated on for gynecological diseases. Careful collection of anamnesis allows to suspect the possibility of surgical disease before the operation, however, even with laparotomy in advanced cases it is difficult to find out the primary cause (right-sided tubo-ovarian formation with secondary appendicitis or vice versa). Tactically, this is not of fundamental importance, since the adequate volume of the operation in both cases is appendectomy and the corresponding gynecological volume of surgical intervention with subsequent drainage of the abdominal cavity.

In case of predominantly left-sided localization of the process, the possibility of diverticulitis should be kept in mind. Inflammation of Meckel's diverticulum is a rare disease in young women, which is practically not recognized until it is complicated by perforation or fistula formation. Due to the proximity of the left ovary to the sigmoid colon, perforation of the diverticulum into the ovary is possible with the formation of a tubo-ovarian abscess, which is difficult to distinguish from the "usual" one. The presence of the symptom of "irritable" colon, as well as diverticulosis, can help in making a diagnosis.

When making a differential diagnosis, it is always necessary to keep in mind primary tubal carcinoma, especially in the presence of genital tuberculosis.

Involvement of the intestine in the inflammatory process is often accompanied by the formation of adhesions and inflammatory strictures with partial or (less commonly) complete intestinal obstruction, while tubo-ovarian abscesses are difficult to distinguish from ovarian cancer or endometriosis.

[ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

Treatment purulent tubo-ovarian masses.

Treatment of patients with complicated forms of purulent diseases also consists of three main components, however, in the presence of an encapsulated purulent formation of the uterine appendages, the basic component that determines the outcome of the disease is surgical treatment.

In most cases, antibacterial therapy is not indicated for patients with complicated forms (chronic purulent-productive process). An exception to this rule is the presence of obvious clinical and laboratory signs of infection activation in patients, including the presence of clinical, laboratory and instrumental symptoms of abscess preperforation or infection generalization.

In these cases, antibacterial therapy is prescribed immediately, continued intraoperatively (prevention of bacterial shock and postoperative complications) and in the postoperative period.

The following drugs are used:

• combinations of beta-lactam antibiotics with beta-lactamase inhibitors - ticarcillin/clavulanic acid (timentin) in a single dose of 3.1 g, a daily dose of 12.4 g and a course dose of 62 g;
• combinations of lincosamines and aminoglycosides, for example lincomycin + gentamicin (netromycin) or clindamycin + gentamicin (netromycin) (lincomycin in a single dose of 0.6 g, daily dose of 2.4 g, course dose of 12 g, clindamycin in a single dose of 0.15 g, daily dose of 0.6 g, course dose of 3 g, gentamicin in a single dose of 0.08 g, daily dose of 0.24 g, course dose of 1.2 g), netromycin in a daily dose of 0.3-0.4 g intravenously; the combination of lincosamines and netromycin is more effective, has fewer side effects and is well tolerated by patients;
• third-generation cephalosporins or their combinations with nitro-imidazoles, for example, cefotaxime (claforan) + metronidazole or ceftazidime (fortum) + metronidazole (cefotaxime in a single dose of 1 g, daily dose of 3 g, course dose of 15 g, ceftazidime in a single dose of 1 g, daily dose of 3 g, course dose of 15 g, metronidazole (metrogyl) in a single dose of 0.5 g, daily dose of 1.5 g, course dose of 4.5 g);
• monotherapy with meropenems, for example, meronem in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g.

It should be remembered that lincosamines (bacteriostatics) and aminoglycosides (create a competitive block with muscle relaxants) cannot be administered intraoperatively.

Of primary importance in preoperative preparation is detoxification therapy with infusion media.

1. In case of severe intoxication, transfusion therapy should be carried out for 7-10 days (daily for the first three days, then every other day) in a volume of 1500-2000 ml per day. In case of moderate intoxication, the volume of daily transfusions is reduced by half (to 500-1000 ml per day).

Infusion therapy should include:

• 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 part of infusion therapy, it is recommended to use 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.

2. The use of disaggregants (trental, curantil) helps improve the rheological properties of blood. The latter are added, respectively, 10 or 4 ml intravenously to the infusion media.
3. The use of antihistamines in combination with sedatives is justified.
4. It is advisable to use immunomodulators: thymalin or T-activin, 10 mg daily for 10 days (100 mg per course).
5. According to the relevant indications, cardiac and hepatotropic agents are prescribed, as well as drugs that improve brain function (cardiac glycosides in an individual dose, Essentiale 5-10 ml intravenously, and Nootropil 5-10 ml intravenously).

The effect of detoxification and preparation of patients for surgery is significantly enhanced by evacuation of purulent exudate. Drainage 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. Indications for draining palliative operations (puncture or colpotomy) in patients with complicated forms of purulent inflammation are the threat of perforation of the abscess into the abdominal cavity or a hollow organ, severe intoxication and the presence of acute pelvic peritonitis, against which surgical treatment is least favorable.

It is advisable to perform colpotomy only in cases where subsequent aspiration-washing drainage is expected.

The duration of preoperative preparation should be strictly individual. The optimal stage for surgery is considered to be the remission stage of the purulent process. In the presence of abscess formation in the small pelvis, intensive conservative treatment should last no more than 10 days, and in the development of clinical signs of perforation threat - no more than 12-24 hours, if palliative intervention cannot be performed to eliminate the threat of perforation.

In case of emergency indications for surgery, preoperative preparation is carried out within 1.5-2 hours. It includes catheterization of the subclavian vein and transfusion therapy under the control of central venous pressure in a volume of at least 3,200 ml of colloids, proteins and crystalloids in a ratio of 1:1:1.

Indications for emergency intervention are:

• perforation of the abscess into the abdominal cavity with the development of diffuse purulent peritonitis (photo 3 on color insert);
• perforation of an abscess into the bladder or the threat of it;
• septic shock.

In all other cases, a planned operation is performed after the appropriate preoperative preparation in full. Laparotomy is indicated. The optimal method of pain relief, providing complete analgesia with reliable neurovegetative protection, as well as sufficient relaxation, is combined anesthesia - a combination of intubation anesthesia with long-term epidural anesthesia.

The extent of surgical intervention depends on the characteristics of the initiation of the purulent process (an unfavorable factor is the development of inflammation against the background of intrauterine menstruation, after abortions and childbirth due to the persistence of purulent endometritis or panmetritis even against the background of intensive preoperative treatment), its severity (unfavorable factors are the presence of bilateral purulent tubo-ovarian abscesses, as well as complications in the form of a pronounced extensive purulent-destructive process in the small pelvis with multiple abscesses and infiltrates of the pelvic and parametral tissue, fistulas, extragenital purulent foci) and the age of patients.

In the absence of aggravating factors, organ-preserving operations are performed.

If it is impossible to preserve menstrual and reproductive functions, it is necessary to “fight” to preserve the patient’s hormonal function - extirpation of the uterus should be performed, leaving, if possible, at least part of the unchanged ovary.

Technical features of performing operations in conditions of the purulent-infiltrative process.

1. The method of choice for abdominal wall incision is lower-midline laparotomy, which provides not only adequate access for revision and surgical intervention, but also the ability (for example, if it is necessary to empty interintestinal and subdiaphragmatic abscesses, intubate the small intestine, or identify surgical pathology) to freely continue the incision.
2. The first and obligatory stage of any operation for inflammatory formations of the uterine appendages is the restoration of normal anatomical relationships between the abdominal and pelvic organs. It is advisable to begin separation of adhesions with complete release of the free edge of the greater omentum, which is almost always affected by the inflammatory process. To do this, it is necessary to first separate the omentum from the parietal and visceral peritoneum with sawing movements by hand and then sharply under visual control, and then from the affected appendages. The separated omentum is often infiltrated to a greater or lesser extent, so its resection within healthy tissues should be considered justified. In the presence of purulent-infiltrative omentitis with abscess formation, resection of the omentum within the "healthy" tissue is obligatory. Attention should be paid to the need for careful hemostasis during resection of the omentum. It is advisable to bandage the stumps with preliminary stitching, since when eliminating the edema, slippage or weakening of the threads may occur, which will lead to a severe postoperative complication in the form of intra-abdominal bleeding.
3. The next stage is the release of inflammatory formations from the loops of the large and small intestine fused to them. We would like to draw the special attention of gynecological surgeons to the need to separate any adhesions only by sharp means. The use of gauze tampons and swabs in such cases to release adhesions is the main cause of intestinal wall trauma: its deserosis, and sometimes opening of the lumen. The use of thin, long dissecting scissors allows avoiding intestinal trauma in these patients. It should be emphasized that one cannot limit oneself to separating intestinal loops from the inflammatory formation. To ensure the absence of large and small inter-loop intestinal abscesses, it is necessary to conduct a revision of the entire small intestine. During the operation, a revision of the vermiform appendix is mandatory.
4. The isolation of the purulent formation of the uterine appendages from adhesions should begin, if possible, from the posterior wall of the uterus. It should be remembered that in most cases, purulent formations of the uterine appendages are "wrapped" in the posterior leaflet of the broad ligament of the uterus, thus separating from the remaining parts of the small pelvis and abdominal cavity. Such delimitation occurs on the right side counterclockwise, and on the left - clockwise. As a result, the inflammatory formation is located pseudo-intraligamentarily. In this regard, the isolation of purulent inflammatory formations should begin from the posterior surface of the uterus, as if untwisting the formation bluntly in the opposite direction. The inflammatory formation of the right appendages should be separated clockwise (from right to left), and the left - counterclockwise (from left to right).
5. The next stage of the operation is to determine the topography of the ureters. When performing hysterectomy in conditions of altered anatomical relationships (endometriosis, tubo-ovarian formations, atypical myomas), the ureters are injured in 1.5% of cases (from parietal injury to complete intersection or ligation). The left ureter is injured more often, the ratio between unilateral and bilateral injuries is 1:6. No more than a third of all injuries are recognized intraoperatively.

Uretero-genital fistulas always have a traumatic genesis, i.e. in all cases we can speak of a violation of the surgical technique as the only cause of this pathology.

As is known, the abdominal parts of the ureters are located retroperitoneally.

The ureters cross the common iliac vessels near their branching, then go backwards and to the side along the pelvic wall down to the bladder. Here the ureters are located at the base of the broad ligaments of the uterus behind the ovaries and tubes, then they pass under the vessels of the uterus and are 1.5-2 cm from the cervix. Then they go parallel to the uterine artery, cross it and go forward and upward, and at the point of intersection with the vessels and before entering the bladder, the ureters are only 0.8-2.5 cm from the cervix. Naturally, in conditions of a purulent-infiltrative process, the risk of injury or ligation of the ureter increases many times over.

The following manipulations pose a risk of injury to the ureter:

• ligation of a. hypogastrica,
• ligation of the infundibulopelvic ligament,
• ligation of uterine vessels,
• manipulations in parametria,
• separation of the walls of the vagina and bladder.

The main stages of the operation should never be rushed without mandatory preliminary revision and sometimes isolation of the ureter on the affected side. In such cases, the operation should begin with dissection of the round ligament of the uterus on the side of the affected appendages (preferably further from the uterus) and wide opening of the parametrium up to the infundibulopelvic ligament. If necessary, the ligament should be cut and ligated. Behind the infundibulopelvic ligament is the ureter, which is determined by palpation or visually. The ureter is gradually separated from the posterior leaflet of the broad ligament of the uterus in the direction of the urinary bladder. The ureter should be separated only within the palpable inflammatory formation, which completely excludes its trauma during subsequent separation of the adhesions.

If there is any suspicion of ureteral injury, the operation should not be continued without making sure that the target ureter is free. To do this, a solution of methylene blue should be injected into a vein. If the ureter is injured, the dye will appear in the wound. The resulting complication is corrected intraoperatively.

• By puncturing the ureter with a needle, the parametrium is drained.
• In case of a parietal wound, sutures are applied transversely with thin catgut, a catheter or stent is inserted into the ureter to drain urine, and the parametrium is drained.
• In case of short-term ligation or compression with a clamp (up to 10 min), after removing the ligature, a catheter or stent is inserted into the ureter to drain urine. The parametrium is drained. In case of longer compression, the injured area is resected and ureterocystoanastomosis is applied using the antireflux method of V.I. Krasnopolsky.
• When crossing the ureter, a ureterocystoanastomosis is performed using the antireflux technique of V.I. Krasnopolsky.

6. Further, the operation of appendage removal is performed in a typical manner. One of the main principles is the mandatory complete removal of the destructive focus, i.e. the inflammatory formation itself. No matter how gentle the operation is in these patients, it is always necessary to completely remove all tissues of the inflammatory formation. Preservation of even a small section of the capsule often leads to severe complications in the postoperative period, relapses of the inflammatory process, and the formation of complex fistulas. In conditions of purulent inflammation, isolated ligation of the ligaments with a "turn" and their preliminary suturing with absorbable suture material is advisable.
7. Peritonization is best performed using separate catgut or vicryl sutures with complete immersion of the ligament stumps.

Extirpation of the uterus in patients with purulent lesions of its appendages is associated with major technical difficulties. They are caused by pronounced edema and infiltration or, conversely, severe destructive changes in tissues, which leads to an atypical arrangement of vascular bundles, venous plexuses, deformations and displacements of the bladder and ureters.

Features of performing uterine extirpation in conditions of a purulent-infiltrative process.

1. Separation of adhesions and mobilization of the uterus and appendages are carried out according to the principles described above.
2. It is advisable to perform extirpation of the uterus without preliminary dissection and ligation of the uterosacral ligaments and uterine vessels. For this purpose, after dissection of the round ligaments, the corresponding infundibulopelvic ligament, the proper ligament of the ovary and tube (and, if necessary, two infundibulopelvic ligaments) and separation and displacement of the urinary bladder along the cervix of the uterus, straight long Kocher clamps are applied as close to it as possible, the cardinal ligaments are dissected, and then the tissues are sutured and ligated. The manipulation is performed under strict control of the topography of the urinary bladder. Additional prevention of injury to the urinary bladder and ureters is provided by dissection of the prevesical fascia (usually infiltrated) at the level of the ligated cardinal ligaments and its displacement together with the urinary bladder. The manipulation continues until both or one of the lateral walls of the vagina are exposed, after which the cutting off and removal of the uterus does not present any difficulties.
3. The question of the advisability of isolating the ureter is debatable.

Isolation of the ureter is considered justified in the clinical situations described below.

• In the presence of severe infiltrative processes in the parametrium with impaired urine passage and the development of hydronephrosis and hydroureter (according to preoperative examination or intraoperative revision). Early restoration of urine passage in the postoperative period serves as a preventive measure against inflammatory processes in the renal pelvis and calyces, and also promotes a more complete evacuation of toxic products from the patient's body.
• In cases of high risk of ureter injury, when the ureter is “pulled up” by the inflammatory infiltrate and is located in the intervention zone (primarily at the level of the intersection with the uterine vessels). During radical surgeries for genital cancer, when there is also an infiltrative process in the parametrium, intraoperative ureter injury reaches 3%. It is advisable to begin isolating the ureter from the infiltrate after dissection and ligation of the infundibulopelvic ligament almost at the site of its origin. This is where it is easiest to find an unchanged section of the ureter, since parametric infiltrates that compress the ureter are usually located in the lower and extremely rarely in its middle third. Next, the ureter should be separated from the posterior leaflet of the broad uterine ligament, after which the boundaries of the infiltrate and the ureter become clearly visible, and freeing the latter is no longer difficult.

4. The vaginal dome is sutured with separate or Z-shaped catgut or vicryl sutures, with the anterior sutures capturing the plica vesicouterina, and the posterior sutures capturing the plica rectouterine and sacrouterine ligaments, if the latter are not completely destroyed. Narrowing of the vaginal tube with tightening sutures should not be allowed, since the open vaginal dome is an excellent natural collector and evacuator of pathological exudate from the abdominal cavity and parametria in any position of the patient.
5. In conditions of edematous, infiltrated and inflammatory-changed tissues, we do not recommend applying a continuous peritoneal suture. Such a suture often cuts through, injures the peritoneum, does not ensure its tight fit and complete isolation of the surgical wound. In this regard, separate sutures should be applied for peritonealization, and absorbable ligatures should be used as suture material. Only the parametria are peritonized, the vaginal tube should remain open under any conditions.
6. Special attention should be paid to suturing the anterior abdominal wall. In purulent diseases, the regeneration and healing processes are always more or less disrupted, so there is a risk of partial and sometimes complete divergence of the sutures, and subsequently the formation of postoperative hernias of the anterior abdominal wall. For reliable prevention of postoperative eventrations in the early and postoperative hernias in the late postoperative period, it is advisable to suture the anterior abdominal wall with separate sutures made of nylon or caproag through all layers in two tiers (peritoneum-aponeurosis and subcutaneous tissue-skin). In cases where layer-by-layer suturing is possible, only separate nylon sutures should be applied to the aponeurosis, and separate silk sutures to the skin.

To prevent bacterial toxic shock during surgery, all patients are given a single administration of antibiotics that act on the main pathogens.

• Combinations of penicillins with beta-lactamase inhibitors - for example, timentin, which is a combination of ticarcillin with clavulanic acid at a dose of 3.1 g.

Or

• Third generation cephalosporins - for example, cefotaxime (claforan) at a dose of 2 g or ceftazidime (fortum) in the same amount in combination with metronidazole (metrogil) - 0.5 g.

Or

• Meropenem (meronem) in a dose of 1 g (for generalized infection).

Adequate drainage should ensure complete removal of pathological substrate from the abdominal cavity. The following methods of inserting drainage tubes are used:

• transvaginal through the open vaginal dome after extirpation of the uterus (drainages with a diameter of 11 mm);
• transvaginal via posterior colpotomy with the uterus preserved (it is advisable to use 11 mm diameter drains).

The optimal vacuum mode in the apparatus during abdominal cavity drainage is 30-40 cm H2O. The average duration of drainage in patients with peritonitis is 3 days. The criteria for stopping drainage are improvement of the patient's condition, restoration of bowel function, relief of the inflammatory process in the abdominal cavity, and a tendency toward normalization of clinical blood tests and body temperature. Drainage can be stopped when the rinsing waters are completely transparent, light, and do not contain sediment.

Principles of intensive care in the postoperative period.

1. Antibiotic therapy. Since the causative agents of purulent-septic infection are associations of microorganisms with a predominance of colibacillary flora, non-spore-forming anaerobes and gram-positive microbes, the antibiotics of choice are broad-spectrum drugs or combinations of drugs that affect the main pathogens. Depending on the severity of the disease, treatment is carried out with average or maximum permissible single and daily doses with strict adherence to the frequency of administration for 5-7 days.

The use of the following antibacterial drugs or their combinations is recommended:

• combinations of beta-lactam antibiotics with beta-lactamase inhibitors - ticarcillin/clavulanic acid (timentin) in a single dose of 3.1 g, a daily dose of 12.4 g and a course dose of 62 g;
• combinations of lincosamines and aminoglycosides, for example: lincomycin + gentamicin (netromycin) or clindamycin + gentamicin (netromycin);
  • lincomycin in a single dose of 0.6 g, daily dose of 2.4 g, course dose of 12 g;
  • chlindamycin in a single dose of 0.15 g, daily dose of 0.6 g, course dose of 3 g;
  • gentamicin in a single dose of 0.08 g, daily dose of 0.24 g, course dose of 1.2 g;
  • netromycin in a single daily dose of 0.3-0.4 g, a course dose of 1.5-2.0 g intravenously;
  • the combination of antibacterial drugs with netilmicin is highly effective, less toxic and more comfortably tolerated by patients;
• third generation cephalosporins or their combinations with nitroimidazoles, for example:
  • cefotaxime (claforan) + Klion (metronidazole) or ceftazidime (Fortum) + Klion (metronidazole);
  • cefotaxime (claforan) in a single dose of 1 g, daily dose of 3 g, course dose of 15 g;
  • ceftazidime (Fortum) in a single dose of 1 g, daily dose of 3 g, course dose of 15 g;
  • clion (metronidazole) in a single dose of 0.5 g, daily dose of 1.5 g, course dose of 4.5 g;
• monotherapy with meropenems, for example:
  • meronem in a single dose of 1 g, daily dose of 3 g, course dose of 15 g.

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), 1-2 tablets with each meal.

2. Adequate pain relief. The optimal method is the use of long-term epidural anesthesia. If, for any reason not related to the presence of contraindications, combined anesthesia was not used during the operation, then this method of pain relief and treatment should be used in the postoperative period.

If there are contraindications to the use of the DEA method, during the first three days, pain relief should be provided by narcotic analgesics administered at adequate intervals (4-6-8-12 hours). To potentiate the effect and reduce the need for narcotics, they should be combined with antihistamines and sedatives.

It is inappropriate to prescribe narcotic and non-narcotic analgesics together, since the analgesic effect of narcotics is sharply reduced when used with non-steroidal anti-inflammatory drugs.

3. Infusion therapy. For the correction of multiple organ dysfunctions in the postoperative period, both the quality of infusion media and the volume of infusions are important.

The administration of colloids (400-1000 ml/day) and protein preparations at a rate of 1-1.5 g of native protein/1 kg of body weight is indicated (in severe cases, the protein dose can be increased to 150-200 g/day); the remaining volume is replaced with crystalloids.

The amount of fluid administered, provided that renal function is preserved, should be 35-40 ml/kg of body weight per day.

When the body temperature increases by 1 degree, the amount of fluid administered per day should be increased by 5 ml/kg of body weight. Thus, the total amount of fluid administered per day with normal urination of at least 50 ml/h is on average 2.5-3 liters.

In severe forms of complications (peritonitis, sepsis), the amount of administered fluid can be increased to 4-6 liters (hypervolemia mode) with regulation of urine output (forced diuresis). In septic shock, the amount of administered fluid should not exceed the amount of excreted urine by more than 800-1000 ml.

The nature of the infusion media is similar to those used in the preoperative period, with the exception of the predominant use of ethylated starch colloids in the group, which have a normovolemic and anti-shock effect.

As part of infusion therapy, it is recommended to use ethylated 6 and 10% starch solution: HAES-STERIL-6 or HAES-STERIL-10 (plasma-substituting colloid) in a volume of 500 ml/day.

To normalize microcirculation, it is advisable to add disaggregants (trental, curantil) to infusion media.

4. Intestinal stimulation. Adequate is "soft", physiological stimulation of the intestine due to the use of, first of all, epidural blockade, secondly - adequate infusion therapy in the volume of normo- or slight hypervolemia, thirdly - due to the predominant use of metoclopramide preparations (cerucal, reglan), which have a regulating effect on the motility of the gastrointestinal tract.

In the treatment of intestinal paresis, correction of hypokalemia also plays an important role. Potassium preparations should be administered slowly, in a diluted form, preferably into a separate vein, under the control of its content in the blood serum. On average, 6-8 g of potassium is administered per day, taking into account its content in other solutions (fresh frozen plasma, hemodez, etc.).

5. Protease inhibitors. It is advisable to use 100,000 units of gordox, 75,000 units of trasylol or 30,000 units of contrical, which improves the proteolytic activity of the blood and potentiates the action of antibiotics.
6. Heparin therapy. All patients, in the absence of contraindications, should be given heparin at an average daily dose of 10,000 units (2.5 thousand units under the skin of the abdomen in the umbilical region) with a gradual reduction in the dose and discontinuation of the drug when the condition and coagulogram parameters improve.
7. Treatment with glucocorticoids is a debatable issue. It is known that prednisolone and its analogues have a number of positive properties:
   • suppress excessive formation of immune complexes with endotoxin;
   • have a detoxifying effect on endotoxin;
   • exhibit an antihistamine effect;
   • stabilize cell membranes;
   • have a positive myocardial effect;
   • reduce the severity of disseminated intravascular coagulation syndrome.

In addition, prednisolone has an apyrogenic effect and suppresses the functional activity of neutrophils less than other steroid hormones. Clinical experience shows that prescribing prednisolone in a daily dose of 60-90 mg with a gradual reduction and withdrawal of the drug after 5-7 days significantly improves the course of the postoperative period.

8. . The use of non-steroidal anti-inflammatory drugs with anti-inflammatory, analgesic and anti-aggregation effects is pathogenetically justified. The drugs are prescribed after discontinuing antibiotics and heparin. It is recommended to use diclofenac (Voltaren) 3 ml intramuscularly daily or every other day (5 injections per course).

At the same time, it is advisable to prescribe drugs that accelerate reparative processes: actovegin 5-10 ml intravenously or solcoseryl 4-6 ml intravenously by drip, then 4 ml intramuscularly daily.

9. Therapy of organ disorders with hepatotropic (essentiale, antispasmodics) and cardiological agents is carried out according to indications.

Prevention

As has already been said, the vast majority of complicated forms of purulent diseases of the internal genital organs occur against the background of wearing an IUD, therefore, we consider work in this direction to be the main reserve for reducing morbidity, and in particular:

• expanding the use of hormonal and barrier contraception methods;
• reasonable assessment of the risk of using IUDs;
• limiting the use of IUDs in young and nulliparous women;
• limiting the use of IUDs after childbirth and abortions;
• refusal to use IUDs in case of chronic inflammatory diseases of the genitals, STIs;
• compliance with the terms of wearing the IUD;
• removal of the IUD without curettage of the uterine cavity;
• in the development of an inflammatory process, removal of the IUD against the background of antibacterial therapy without curettage of the uterine cavity (in hospital).