Purulent-inflammatory diseases of the pelvic organs

Pelvic inflammatory disease is an infection of the female reproductive organs. The reproductive organs include the uterus, fallopian tubes, ovaries, and cervix. Infections can be caused by different types of bacteria. Common symptoms include lower abdominal pain, vaginal discharge, fever, burning and pain when urinating, or menstrual irregularities.

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Causes purulent inflammatory diseases of the pelvic organs

The development and formation of purulent PID is based on many interconnected processes, ranging from acute inflammation to complex destructive tissue changes. Bacterial invasion is considered the main trigger for inflammation. And if in the pathogenesis of uncomplicated acute purulent inflammation (acute endomyometritis, salpingitis) the main role is played by bacterial invasion of a "new type of sexual infection" (gonococci, chlamydia, mycoplasma, viruses, opportunistic strains of aerobic and anaerobic pathogens), then in complicated forms of purulent inflammation the microflora is more aggressive and includes associations of the following pathogenic pathogens: gram-negative non-spore-forming anaerobic bacteria (Strongacteroides fragilis, Prevotella spр., Prevotella bivius, Prevotella disiens and Prevotella melaninogenica), gram-positive anaerobic streptococci (Peptostreptococcus spp.), aerobic gram-negative bacteria of the Enterobacteriacea family (E. coli, Proteus), aerobic gram-positive cocci (entero-, strepto- and staphylococci).

Currently, the main cause of the development of destructive, complicated forms of purulent inflammation, including generalized ones, is considered to be the long-term use of the intrauterine device, leading to the development of tubo-ovarian, and in some cases, multiple extragenital abscesses with an extremely unfavorable septic clinical course caused by Actinomycetes Israeli and anaerobes.

Next in descending order (by frequency) are severe purulent postpartum diseases, then purulent complications against the background of exacerbation of long-standing chronic diseases, then postoperative complications. More rare causes: suppuration of hematomas and the ovum during ectopic pregnancy, suppuration of tumors, primary destructive appendicitis with pelvic phlegmon, etc.

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Risk factors

In addition to bacterial invasion, the so-called provoking factors play a significant role in the etiology of the purulent process. This concept includes physiological (menstruation, childbirth) or iatrogenic (abortions, IUD, hysteroscopy, hysterosalpingography, operations) weakening or damage to barrier mechanisms, which contributes to the formation of entry gates for pathogenic microflora and its further spread.

The main factors contributing to the progression of the disease and the formation of complicated forms of purulent inflammation:

• unreasonably long-term conservative management of purulent gynecological patients;
• use for the purpose of treatment of palliative interventions that do not eliminate the source of destruction (punctures, drainage).

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Symptoms purulent inflammatory diseases of the pelvic organs

Features of the course of purulent PID at present:

• Increased virulence and resistance of microflora, mainly associative, in which anaerobic and gram-negative microorganisms are considered the main pathogens. At the same time, gonococcus as a causative agent of the purulent process not only has not lost its significance, but has also increased the degree of its aggression due to the accompanying microflora, in particular STIs.
• Changes in the clinical course of purulent diseases of the internal genital organs: at the present stage, they initially proceed as primarily chronic and are characterized by a long, recurrent course with extreme ineffectiveness of drug therapy. For example, in most women using IUDs, the manifestation of the disease occurs when there is already severe infiltrative damage to the genitals.

Most often, purulent salpingitis begins acutely, with an increase in temperature (sometimes accompanied by chills), the appearance of pain in the lower abdomen (typical localization of pain is the left and right hypogastric regions, with concomitant endometritis, so-called "median" pain is observed), profuse purulent leucorrhoea and pain when urinating. Soon, patients note symptoms of purulent intoxication (weakness, tachycardia, muscle pain, a feeling of dry mouth), dyspeptic, emotional-neurotic and functional disorders are added. Disorders of the rectum are most often manifested in the form of a symptom of "irritable" bowel (frequent loose stools). A common complaint is the presence of severe dyspareunia.

During a vaginal examination, pain is detected when moving the cervix, pastosity or the presence of a palpable formation of small size with unclear contours in the area of the appendages, as well as sensitivity when palpating the lateral and posterior fornices.

Laboratory tests: patients show leukocytosis with a moderate shift in the leukocyte formula to the left (band leukocytes 6–9%), increased ESR (20–40 mm/h), the presence of a sharply positive C-reactive protein, and hyperfibrinogenemia.

Echographic signs of acute purulent salpingitis: the presence of “dilated, thickened, elongated fallopian tubes, characterized by an increased level of sound conductivity; in every second patient, an accumulation of free fluid is noted in the recto-uterine pouch.”

A highly informative treatment and diagnostic procedure for purulent salpingitis (especially when laparoscopy is impossible) is still considered to be a puncture of the posterior vaginal fornix. The manipulation allows obtaining purulent exudate for microbiological examination and conducting a differential diagnosis with another urgent situation, such as an ectopic pregnancy or ovarian apoplexy.

According to G. strongalbi et al., the classic signs of acute purulent salpingitis are: the presence of abdominal pain, pain when moving the cervix and sensitivity in the area of the appendages in combination with at least one of the following additional signs (temperature>38 °C; leukocytosis>10.5 ⁹ /l and the presence of pus obtained by puncture of the posterior vaginal fornix).

Symptoms of complications in patients with purulent salpingitis

• Increased symptoms of purulent intoxication (the appearance of hectic fever, nausea, vomiting, constant feeling of dry mouth, severe muscle weakness).
• The appearance of symptoms of peritoneal irritation (pelvioperitonitis) predominantly in the lower abdomen. Vaginal examination in patients with pelvioperitonitis is uninformative due to severe pain during palpation. Moderate overhang and sharp pain in the vaults, especially the posterior one, which increases sharply with the slightest movement of the cervix, are determined. It is usually impossible to palpate small volumetric formations in the small pelvis.
• The appearance of a "feeling of sharp pressure on the rectum" and frequent defecation (indicates an abscess of the uterorectal pouch forming against the background of pelvic peritonitis). During a gynecological examination, a pathological formation of uneven consistency, without clear contours, prolapsing through the posterior fornix and anterior wall of the rectum, sharply painful upon palpation (the so-called "Douglas cry") is detected in the corresponding anatomical area.

Chronic (complicated) purulent inflammatory diseases of the pelvic organs

All encapsulated inflammatory adnexal tumors are classified as pyosalpinx, pyovarium, purulent tubo-ovarian formations and their further complications, caused by a number of factors: duration of the disease, stage of inflammation, depth of the destructive process and nature of damage to organs and systems. The main clinical symptom in this group of patients, in addition to pain and temperature, is the presence of initially severe purulent endogenous intoxication. Purulent leucorrhoea is observed in postpartum, post-abortion patients and patients with IUC (purulent endomyometritis). It should be noted that patients have severe neurotic disorders, while along with symptoms of agitation (increased irritability) against the background of intoxication, symptoms of CNS depression also appear: weakness, rapid fatigue, sleep and appetite disorders.

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Peculiarities of the course of the purulent process in patients with various etiological factors

The course of the purulent process against the background of wearing an IUD is particularly severe, while conservative, even intensive treatment is ineffective. Removing the IUD even at the earliest stages of the development of purulent inflammation of the uterine appendages does not help to stop the inflammation, curettage of the uterine cavity after removal of the IUD sharply aggravates the severity of the process.

Patients with purulent postoperative complications are characterized by 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.

For obstetric patients, the main clinical symptom is the presence of progressive purulent (necrotic) endometritis, which is not relieved even with adequate therapy: the size of the uterus does not correspond to the time of normal postpartum involution, there is no tendency for the cervix to form: the cervix hangs freely in the form of a "sail" into the vagina, easily passing one or two fingers. The presence of hematomas (infiltrates) in the parametrium and/or retrovesical tissue is an unfavorable clinical sign, sharply reducing the chances of a favorable outcome of conservative treatment in these patients.

One of the distinctive features of the clinical course of chronic purulent PID is the wave-like nature of the process. In the remission stage of the inflammatory process, clinical manifestations are not pronounced, of all the symptoms, mild or moderate intoxication remains. In the exacerbation stage, the main signs of acute purulent inflammation appear, and new complications often occur.

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

Diffuse purulent peritonitis develops quite rarely (3.1%), since the chronic purulent process is usually limited to the pelvic cavity due to numerous dense adhesions, the peritoneum and ligaments of the pelvis, the omentum and adjacent organs, i.e. the purulent-infiltrative, “conglomerate” type of inflammation prevails.

More often, as the disease progresses, complications of the purulent process such as parametritis, interintestinal abscesses, and purulent fistulas appear. The presence of parametritis in patients with purulent tubo-ovarian formations may be indicated by clinical signs:

• pain when urinating, pyuria (anterior parametritis);
• constipation, difficulty with defecation (posterior parametritis);
• renal dysfunction: occurrence of urinary syndrome, edema, decreased diuresis (lateral parametritis);
• the appearance of infiltrate and hyperemia of the skin above the inguinal ligament (anterior parametritis);
• manifestations of periphlebitis of the external iliac vein (swelling and cyanosis of the skin of the thigh, distending pain in the leg) - upper lateral parametritis;
• manifestations of paranephritis (in the early stages, manifestations of psoitis are characteristic: the patient is forced to lie down with his leg adducted) - 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 indicate the formation 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 may indirectly indicate the formation of a subphrenic abscess.

Perforation of a pelvic abscess (purulent tubo-ovarian formation, abscess of the utero-rectal space) into hollow organs is observed in patients with a long-term and recurrent course of the purulent process. It is preceded by the so-called "pre-perforation" state:

• deterioration of the general condition against the background of remission of the existing purulent inflammatory process;
• increase in temperature to 38–39 °C, chills;
• the appearance of pain in the lower abdomen of a “pulsating”, “twitching” nature;
• 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.

Multiple perforations into the adjacent section of the intestine lead to the formation of genital fistulas. Most often, fistulas 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. Appendageal-vesical fistulas are much less common, since the peritoneum of the vesicouterine fold and prevesical tissue melt much more slowly. Fistulas are often diagnosed at the stage of their formation according to the clinical picture of the so-called threat of perforation into the bladder.

During a vaginal examination, purulent tubo-ovarian formations in the acute stage are characterized by unclear contours, uneven consistency, complete immobility and severe pain. At the same time, they are always in a single conglomerate with the uterus, the palpation and determination of which are extremely difficult. 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 it retains uneven consistency and complete immobility.

In patients with concomitant parametritis, infiltrates of varying consistency (depending on the stage of the inflammatory process) are detected - from woody density at the infiltration stage to uneven, with areas of softening during suppuration. Inflammatory infiltrates can have different sizes. In severe cases, they reach the pelvic bones (lateral parts of the pelvis, sacrum, pubis) and can spread to the anterior abdominal wall and even paranephric tissue. Damage to the parametrium, especially its posterior parts, is especially well detected by rectovaginal examination, in which case the degree of damage to the rectum by the inflammatory infiltrate is indirectly assessed (the mucous membrane is mobile, limitedly mobile, immobile).

Forms

Abroad, the classification of G. Monif (1982) is mainly used, which includes acute inflammatory processes of the internal genital organs:

• acute endometritis and salpingitis without signs of inflammation of the pelvic peritoneum;
• acute endometritis and salpingitis with signs of peritoneal inflammation;
• acute salpingo-oophoritis with occlusion of the fallopian tubes and development of tubo-ovarian formations;
• rupture of the tuboovarian formation.

The Geneva International Statistical Classification of Diseases, Injuries, and Causes of Death (WHO, 1980) includes the following nosological forms of inflammatory diseases of the internal genital organs.

• Acute salpingitis and oophoritis:
  • abscess: fallopian tube, ovary, tubo-ovarian;
  • oophoritis;
  • pyosalpinx;
  • salpinitis;
  • inflammation of the uterine appendages (adnextumor).
• Acute parametritis and pelvic phlegmon.
• Chronic or unspecified parametritis and pelvic phlegmon:
  • abscess: broad ligament of the uterus, rectouterine pouch, parametrium, pelvic phlegmon.
• Acute or unspecified pelvic peritonitis.

From a practical point of view, the classification proposed by V.I. Krasnopolsky et al. is considered convenient, allowing to determine the tactics of management and prognosis of development and outcome of the disease. According to the clinical course of the disease and on the basis of pathomorphological studies, the authors distinguish two clinical forms of purulent inflammatory diseases of the genitals: uncomplicated and complicated.

• Uncomplicated forms include acute purulent salpingitis. With timely diagnosis and targeted therapy, the process may be limited to damage to the endosalpinx with subsequent regression of inflammatory changes and recovery. In the case of late or inadequate therapy, acute purulent salpingitis is complicated by pelvic peritonitis with partial delimitation of purulent exudate in the uterorectal pouch (Douglas abscess) or develops into a chronic or complicated form - pyosalpinx or purulent tuboovarian formation. In these cases, changes in all layers of the fallopian tube and ovarian stroma are irreversible, which is confirmed by the results of morphological studies.
• Complicated forms include all encapsulated inflammatory adnexal tumors: pyosalpinx, pyovar, purulent tubo-ovarian formations, while the prospects for subsequent childbearing are sharply reduced or problematic, and the patient's recovery can only occur after surgical treatment. With delayed surgical intervention and further progression of the process, severe purulent complications develop that threaten the patient's life: simple and complex genital fistulas, microperforations of the abscess into the abdominal cavity with the formation of interintestinal and subdiaphragmatic abscesses, purulent-infiltrative omentitis. The final outcome of the purulent process is sepsis.

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Diagnostics purulent inflammatory diseases of the pelvic organs

Even with the possibility of using the most modern research methods, the main diagnostic method that determines the professional qualification and clinical thinking of the doctor is clinical. All purulent diseases have specific symptoms reflected in subjective complaints or objective research data. The development of complications also "goes through" successive stages and they are clearly reflected by all patients when collecting information about the history of the disease, provided that the doctor knows the possible course of the disease and asks targeted questions. Even if the diseases have a similar clinical picture to a certain extent (for example, purulent salpingitis and purulent tubo-ovarian formations in the acute stage), there are always clinical signs (initiation of the disease, its duration, degree of intoxication, symptoms), allowing to clarify the primary clinical diagnosis.

In patients with purulent inflammatory diseases of the internal genital organs, a 3-stage examination system is advisable.

• In uncomplicated forms:
  • the first stage is a clinical examination, including bimanual examination, bacteriological and laboratory diagnostics;
  • the second stage is transvaginal ultrasound of the pelvic organs;
  • The third stage is laparoscopy for gynecological patients (hysteroscopy for postpartum patients).
• In complicated forms:
  • the first stage is a clinical examination, including bimanual and rectovaginal examination, bacteriological and laboratory diagnostics;
  • the second stage - transabdominal and transvaginal ultrasound of the pelvic organs, abdominal cavity, kidneys, liver and spleen, echocardiography, ultrasound with additional contrast of the rectum;
  • The third stage is an X-ray examination of the lungs, additional invasive examination methods: cystoscopy and colonoscopy, fistulography.

Laboratory diagnostics

At present, even in the presence of severe forms of purulent inflammation, "erased" laboratory symptoms are often observed, caused, among other things, by the use of massive antibacterial therapy and local sanitation. Therefore, it is inappropriate to focus on leukocytosis as the main marker of the purulent process (observed only in 1/3 of patients). In addition, leukopenia is noted in 11.4% of patients with severe forms of purulent PID in women. It is associated with the persistence of pathological autoantibodies to neutrophil membranes in the blood.

In general, these patients are most characterized by an increase in ESR, the presence of lymphopenia and anemia. Anemia is considered intoxication and its degree correlates with the severity of the patient's condition.

Peripheral blood indices reflect the stage of the purulent process. In the acute stage, leukocytosis, increased ESR (up to 60–70 mm/h), and C-reactive protein are most often detected. During remission of the purulent process, a decrease in the number of erythrocytes and hemoglobin, lymphopenia, and increased ESR are observed.

The prolonged course of the purulent process is accompanied by a disruption of protein (hypo- and dysproteinemia), mineral, lipid metabolism and enzymatic function of the liver.

Pronounced disorders of the hemostasis system (with a predominance of hypercoagulation processes) are observed in 35.7% of patients with complicated forms of purulent inflammation, disorders of the circulatory system - in 69.4% (hypokinetic type of blood circulation in 22% of patients, decreased contractile function of the myocardium in 13% and impaired cerebral blood flow velocity in 52% of patients).

The main additional diagnostic method is echography. Purulent tubo-ovarian formations are characterized by:

• their shape is often irregular, but still close to ovoid;
• the internal structure is characterized by polymorphism: it is heterogeneous and, as a rule, is represented by a medium-dispersed echo-positive suspension against the background of an increased level of sound conductivity;
• The contours of a purulent tubo-ovarian formation can be represented by: an echo-positive thick capsule with clear contours, a capsule with areas of uneven thickness and areas of sharp thinning, as well as a formation without clear contours; in this case, the absence of a vascular network inside the formation is revealed.

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Differential diagnosis

Acute salpingitis is differentiated.

• Acute appendicitis. The disease is not associated with the risk factors listed above; the disease occurs suddenly, the early sign is paroxysmal pain, initially localized in the navel or epigastrium, then in the cecum. Of decisive importance in the diagnosis of acute appendicitis is the identification of Sitkovsky's symptoms (increased pain in the right iliac region when the patient is lying on the left side) and Rovsing's symptoms (increased pain in the cecum with a push-like pressure in the left iliac region). Acute appendicitis is also characterized by an hourly increase in the number of leukocytes in a blood test during a dynamic study.
• Ectopic pregnancy, especially in the case of formation and suppuration of uterine hematomas, when the secondary inflammatory changes that join mask the original disease. Ectopic pregnancy is characterized by: menstrual cycle disorders (usually delayed menstruation followed by prolonged bloody spotting), pain radiating to the rectum, periods of short-term loss of consciousness (dizziness, fainting, etc.). Determination of hCG in the blood and urine (in the laboratory or by express tests) helps to make a differential diagnosis. In complex cases, performing a puncture of the posterior fornix or laparoscopy solves the diagnostic problem.

Purulent tubo-ovarian formations should be differentiated:

• with right-sided localization - with appendicular infiltrate;
• with predominantly left-sided localization of the process - with diverticulitis;
• with primary carcinoma of the tube;
• with ovarian cancer;
• with infiltrative forms of endometriosis.

Consultation with specialists

In some cases, there are indications for consultation with a surgeon, urologist, nephrologist, vascular surgeon (see the 3rd stage of examination for complicated forms).

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Treatment purulent inflammatory diseases of the pelvic organs

The goal of treatment of purulent-inflammatory diseases of the pelvic organs is to eliminate the purulent process (focus) in the abdominal cavity: preservation of life, health, and, if possible, reproductive, menstrual and hormonal specific female functions. The absence of treatment in all patients with purulent PID leads to severe complications (purulent peritonitis, sepsis) and mortality.

Indications for hospitalization

Absolute. All patients with purulent VZOT or suspected presence of these diseases (see risk groups and clinic) should be hospitalized. Delay in hospitalization, outpatient treatment, lack of timely surgical intervention only worsens the condition of patients and limits further organ-preserving treatment.

Non-drug treatment

In these patients, due to the severity of the pathology, it is not of decisive importance.

Drug and surgical treatment

In view of the severity of general and local changes in patients with purulent diseases of the pelvic organs and the extreme risk of generalization of the process, the following tactical provisions are considered important: for any form of purulent inflammation, treatment can only be complex, conservative-surgical, consisting of:

• pathogenetically directed preoperative preparation;
• timely and adequate volume of surgical intervention aimed at removing the source of destruction;
• intensive and rational management of the postoperative period, and the earlier surgical debridement of the lesion is performed, the better the outcome of the disease.

Tactics of managing patients with uncomplicated forms of purulent inflammation

Preoperative preparation in patients with purulent salpingitis is aimed at stopping acute manifestations of inflammation and suppressing the aggression of the microbial pathogen. For the treatment of patients with acute purulent salpingitis, it is advisable to use antibiotics (or their combinations) with mandatory intraoperative (during laparoscopy) intravenous administration and continuation of antibacterial therapy in the postoperative period for 5-7 days.

• Inhibitor-protected penicillins, such as amoxicillin + clavulanic acid (clavulanate). Single dose of the drug is 1.2 g intravenously, daily dose is 4.8 g, course dose is 24 g with intraoperative (during laparoscopy) intravenous administration of 1.2 g of the drug.
• Fluoroquinolones (second generation quinolones) in combination with nitroimidazoles (metronidazole), for example ciprofloxacin or ofloxacin in a single dose of 0.2 g intravenously by drip (daily dose 0.4 g, course dose 2.4 g) with intraoperative intravenous administration of 0.2 g of the drug.
• Third generation cephalosporins in combination with nitroimidazoles (metronidazole).

Also shown:

• infusion therapy (crystalloids, electrolyte balance correctors, plasma substitutes and protein preparations) in a transfusion volume of 1000–1500 ml/day. The duration of therapy is individual (on average 3–5 days);
• prescribing desensitizing and antihistamine drugs;
• the use of NSAIDs that have anti-inflammatory, analgesic and antiplatelet effects (the drugs are prescribed after discontinuing antibiotics);
• use of immunocorrectors from the first day of treatment. For this purpose, it is advisable to use sodium aminodihydrophthalazinedione according to the following scheme: on the 1st day, 0.2 g intramuscularly, then 0.1 g intramuscularly daily for 3 days, from the 5th day of treatment - 0.1 g 5 injections every other day (10 injections of the drug per course). All patients who have not received immunocorrective therapy in the hospital should be recommended to receive it on an outpatient basis upon discharge in order to prevent relapse of the purulent process.

Against the background of the conservative treatment, it is necessary to evacuate purulent exudate (surgical component of treatment) in the first 2-3 days. The most effective method of surgical treatment of purulent salpingitis at the present stage is considered to be laparoscopy, especially in young, nulliparous patients.

In case of purulent salpingitis, the adequate scope of intervention is adhesiolysis, sanation and transvaginal (through the colpotome opening) drainage of the small pelvis. In cases of purulent salpingo-oophoritis and pelvic peritonitis with the formation of an encapsulated abscess in the rectouterine pouch, the adequate aid is considered to be mobilization of the uterine appendages, emptying the abscess, sanation and active aspiration drainage through the colpotome opening. In case of formed pyosalpinx, it is necessary to remove the fallopian tube or tubes. In case of small pyovarium (up to 6–8 cm in diameter) and preservation of intact ovarian tissue, it is advisable to enucleate the purulent formation. In case of ovarian abscess, the ovary is removed. The indication for removal of the uterine appendages is the presence of irreversible purulent-necrotic changes in them. All operations must be completed with repeated thorough pelvic lavage and revision of the suprahepatic space to prevent the leakage of pus and blood. In order to create favorable conditions for reparation and active evacuation of exudate, it is advisable to perform active aspiration using the OP-1 device [19]. This is especially important in patients with pronounced purulent-necrotic changes, when large wound surfaces are formed after the separation of adhesions, which leads to the production of a significant amount of wound secretion and contributes to the formation of serous or purulent cavities, i.e., a protracted course of the disease and its relapses.

To perform aspiration-washing drainage (AWD), one or two double-lumen silicone rubber tubes with a diameter of 11 mm are brought to the areas of greatest destruction in the small pelvis and brought out through the colpotomy opening (or, if there are no conditions for colpotomy, through additional counter-openings in the hypogastric sections). A surgical suction (OP-O1) is connected. AWD is carried out by introducing a furacilin solution (1:5000) through the narrow lumen of the tube at a rate of 20 drops per minute and aspiration under a pressure of 30 cm H2O for 2-3 days, depending on the severity of the process with periodic jet washing of the tubes in the presence of purulent "plugs".

This method is a method of pathogenetic therapy that affects the primary focus. In this case:

1. active washing out and mechanical removal of infected and toxic contents of the abdominal cavity is carried out;
2. the hypothermic effect of cooled furacilin stops further growth of microbial invasion, helps relieve swelling in the affected organ and surrounding tissues, prevents the entry of toxins and microorganisms into the circulatory and lymphatic systems;
3. reliable outflow of washing fluid under negative pressure eliminates the possibility of accumulation of solution in the abdominal cavity, allows to clear the peritoneum from fibrin, necrotic detritus and reduce swelling and tissue infiltration;

An alternative is the technique of dynamic laparoscopy, starting from the 2nd day of the postoperative period with a frequency of 2 days. The technique allows monitoring the dynamics of the inflammatory process, separating the forming adhesions, delivering drugs directly to the source of infection, and performing programmed sanitation of the abdominal cavity.

In the postoperative period (up to 7 days), antibacterial, infusion and resorption therapy are recommended. It should be emphasized that patients with purulent salpingitis after the relief of acute inflammation need long-term rehabilitation aimed at preventing relapse of the disease and restoring fertility.

Tactics of managing patients with complicated forms of purulent diseases

The basic component is surgical treatment. "Points of application" of antibacterial therapy in patients with complicated forms of purulent PID are determined by special time periods of the complex and prolonged course of the disease. The use of antibiotics is advisable in the following clinical situations:

• in all patients with acute purulent infection (manifestation of the disease);
• in case of clinical manifestations of activation of subacute or chronic purulent infection and the emergence of a threat of abscess perforation or generalization of infection;
• intraoperatively in all patients for the purpose of perioperative protection and prevention of septic shock (the drug is administered in the maximum single dose);
• in the postoperative period in all patients.

In generalized forms of infection (peritonitis, sepsis), antibacterial therapy is prescribed immediately, continuing during the intraoperative (prevention of bacterial shock and postoperative complications) and postoperative periods.

Despite significant advances in microbiological diagnostics over the past 10–15 years, the initial choice of antibacterial therapy remains empirical. Depending on the severity of the disease, drugs are prescribed in average or maximum single and daily doses. The following drugs are appropriate for treating these patients.

• Inhibitor-protected penicillins, such as ticarcillin + clavulanic acid (timetin), piperacillin + tazobactam (tazocine). The advantage of these drugs is their high activity against aerobic and anaerobic bacteria, including enterococci and microorganisms producing β-lactamase.
• Third-generation cephalosporins in combination with nitroimidazoles (metronidazole). They have high activity against gram-negative bacteria, as well as staphylococci, but they have low antianaerobic activity, which requires their combination with antianaerobic drugs.
• Inhibitor-protected cephalosporins of the third generation (cefoperazone + sulbactam). A broad-spectrum drug that has, among other things, high antianaerobic activity.
• A combination of lincosamides and aminoglycosides, for example, a combination of clindamycin + aminoglycosides. Lincosamides are highly active against anaerobic and gram-positive coccal flora, aminoglycosides are active against gram-negative bacteria, while "pulse therapy" with aminoglycosides (administration of a daily dose in one go) has an advantage over traditional administration schemes (2-3 times a day) both in terms of clinical efficacy and lower nephro- and ototoxicity.
• Carbapenems: imipenem + cilastin (tienam) or meropenem (meronem) - drugs with the broadest spectrum of antimicrobial activity, including against strains of gram-negative bacteria resistant to cephalosporins. Detoxification and detoxification therapy are of primary importance in preoperative preparation. The effect of detoxification and preparation of patients for surgery is significantly enhanced by the evacuation of purulent exudate.

Indications for draining palliative operations (puncture or colpotomy) in patients with complicated forms of purulent inflammation:

• the threat of perforation of an abscess into the abdominal cavity or a hollow organ (in order to prevent peritonitis or the formation of fistulas);
• the presence of acute pelvic peritonitis, against which background surgical treatment is least favorable;
• severe degree of intoxication.

Once remission is achieved, patients need to be operated. Repeated punctures of the posterior fornix and colpotomies are inappropriate, as this contributes to the formation of appendovaginal fistulas. The duration of preoperative preparation is determined individually. The stage of remission of the purulent process is considered optimal for surgery.

Intensive conservative treatment should last no more than 5 days, and in the event of development of clinical manifestations of the threat of perforation - 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, including catheterization of the subclavian vein and transfusion therapy under the control of central venous pressure in a volume of at least 1200 ml of colloids, proteins and crystalloids in a volume of 1:1:1.

Indications for emergency intervention:

• perforation of an abscess into the abdominal cavity with the development of diffuse purulent peritonitis;
• perforation of an abscess into the bladder or the threat of it;
• septic shock.

The nature of surgical treatment differs from the tactics of managing patients with uncomplicated forms. Such patients are only indicated for laparotomy.

The scope of surgical intervention is individual and depends on the following main points: the nature of the process, concomitant genital pathology and the age of the patients. An idea of the scope of the operation should be formed before the operation after receiving the examination data and identifying the degree of damage to the uterus, appendages, determining the nature of complications and the presence of extragenital purulent foci. Indications for performing reconstructive surgery with preservation of the uterus are primarily the absence of purulent endomyometritis or panmetritis, multiple extragenital purulent foci in the small pelvis and abdominal cavity, as well as concomitant severe genital pathology (adenomyosis, myoma). In the presence of bilateral purulent tubo-ovarian abscesses complicated by genital fistulas, a pronounced extensive purulent-destructive process in the small pelvis with multiple abscesses and infiltrates of the pelvic and parametral tissue, confirmation of purulent endometritis or panmetritis, it is necessary to perform an extirpation of the uterus with preservation, if possible, of at least part of the unchanged ovary.

The basic principle of drainage is to install drains along the main routes of fluid migration in the abdominal cavity and small pelvis, i.e. the main part of the drains should be in the lateral canals and retro-uterine space, which ensures complete removal of the pathological substrate. It is advisable to use aspiration-washing drainage with the introduction of double-lumen drainage tubes:

• transvaginally through the open vaginal dome after extirpation of the uterus (drainages with a diameter of 11 mm);
• by means of posterior colpotomy with the uterus preserved (it is advisable to use a drainage with a diameter of 11 mm or two drainage with a diameter of 8 mm);
• transabdominally (in addition to transvaginal) through counter-openings in the meso- or epigastric regions in the presence of subhepatic or interintestinal abscesses - drains with a diameter of 8 mm.

The optimal vacuum mode in the apparatus for drainage of the abdominal cavity is considered to be 30–40 cm H2O. The average duration of drainage 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.

Principles of postoperative management

• Use of 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, pain relief should be carried out with narcotic analgesics during the first 3 days. To potentiate the effect, they should be combined with antihistamines and sedatives.
• Infusion therapy. To correct disorders in the postoperative period, both the quality of infusion media and the volume of infusion are important. The administration of colloids (400-800 ml/day), protein preparations at the rate of 1-1.5 g of native protein per 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, is 35-40 ml/kg/day. In severe complications (peritonitis, sepsis), the amount of fluid administered can be increased to 4-6 l (hypervolemia mode) with regulation of urination (forced diuresis). In septic shock, the amount of fluid administered should not exceed the amount of urine excreted by more than 800-1000 ml.
• Intestinal stimulation. Adequate "soft", physiological stimulation of the intestine is achieved by using, first of all, epidural blockade, secondly - adequate infusion therapy in the amount of normo- or slight hypervolemia, thirdly - due to the predominant use of metoclopramide, which has a regulating effect on gastrointestinal motility. In the treatment of intestinal paresis, hypokalemia correction also plays an important role. Potassium preparations must 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 are administered per day, taking into account its content in other solutions (fresh frozen plasma, hemodez, etc.).
• It is advisable to use protease inhibitors.
• In all patients, in the absence of contraindications, it is advisable to use low-molecular heparin - calcium nadroparin at a dose of 0.3 ml (285 IU of anti-Xa activity, respectively) under the skin of the abdomen for 5-7 days, as well as agents that improve the rheological properties of the blood. It is necessary to use compression stockings (elastic bandages), as well as pneumatic cuff compression from the first day of the postoperative period.
• Treatment with glucocorticoids. It is advisable to use prednisolone in a daily dose of 90-120 mg/day (depending on body weight) with a gradual reduction and withdrawal of the drug after 5-7 days.
• The use of NSAIDs is indicated (prescribed after discontinuing antibiotics).
• According to indications, therapy of organ disorders is carried out with hepatotropic [phospholipids + multivitamins (Essentiale)] and cardiological agents, antispasmodics, and extracorporeal detoxification methods (plasmapheresis) are used.
• Immunocorrection. It is advisable to use the drug aminodihydrophthalazion sodium, which also has a pronounced anti-inflammatory and antioxidant effect. The drug is used according to the following scheme: on the first day 0.2 g intramuscularly, then 3 days daily 0.1 g intramuscularly, then every other day 5 injections; then 2 times a week 0.1 g intramuscularly (course of treatment - 20 injections).

Further management

All patients who have suffered from purulent-inflammatory diseases of the pelvic organs require long-term rehabilitation.

Prevention

• Exclusion or drastic limitation of the use of the IUD, removal of the IUD without curettage of the uterine cavity against the background of antibacterial therapy.
• Expanding the use of barrier contraceptive methods.
• Timely hospitalization of patients with acute pelvic inflammatory disease, exclusion from outpatient treatment of patients with postpartum, post-abortion, post-operative infectious complications, as well as patients with complications of intrauterine urinary tract infection (except for the rehabilitation stage).
• Theoretical training of personnel, step-by-step training in surgical technique.
• Using optimal surgical technique and adequate suture material, performing surgical interventions with minimal surgical trauma and blood loss.
• The use of rational antibiotic prophylaxis and antibiotic therapy in gynecological patients.
• Timely use of a complex of active treatment and diagnostic measures in patients with complicated postpartum or postoperative period.
• Active tactics for treating patients with purulent inflammatory diseases of the internal genital organs, and first of all, timely surgical treatment.

[ 13 ], [ 14 ], [ 15 ], [ 16 ]

Forecast

With proper rehabilitation, the outcome of uncomplicated forms of purulent inflammation is clinical recovery, which does not exclude reproductive problems in patients. The consequences of purulent salpingitis are quite serious: disease progression (20%), relapses of the purulent process (20–43%), infertility (18–40%), chronic pelvic pain syndrome (24%), ectopic pregnancy (33–56%).

In patients with complicated forms of purulent inflammation, the absence of a fatal outcome and disability is considered a priority in the outcome of the disease; subsequently (when performing organ-preserving surgery), it is possible to use assisted reproductive technologies, and if only hormonal function is preserved, surrogacy.

It should be recognized that in the near future we should not expect a decrease in the number of purulent diseases of the genitals and postoperative purulent complications. This is due not only to the increase in the number of patients with immune and extragenital pathology (obesity, anemia, diabetes mellitus), but also to a significant increase in surgical activity in obstetrics and gynecology. In particular, this concerns a significant increase in the number of abdominal deliveries, endoscopic and general surgical operations.