Pyoinflammatory diseases of the pelvic organs

Pyoinflammatory diseases of the pelvic organs - infection of the reproductive organs of a woman. Reproductive organs include the uterus, fallopian tubes, ovaries and cervix. Infections can be caused by various kinds of bacteria. Common symptoms are pain in the lower abdomen, vaginal discharge, fever, burning and pain when urinating or disturbing the menstrual cycle.

[1], [2]

Causes of the pyoinflammatory diseases of the pelvic organs

The basis for the development and formation of purulent PID is a set of interrelated processes, ranging from acute inflammation and ending with complex destructive changes in tissues. The main trigger mechanism for the development of inflammation is considered bacterial invasion. And if the bacterial invasion of a "new type of sexual infection" (gonococci, chlamydia, mycoplasmas, viruses, opportunistic strains of aerobic and anaerobic pathogens) plays a major role in the pathogenesis of uncomplicated acute purulent inflammation (acute endomyometritis, salpingitis), then with complicated forms of purulent inflammation microflora is more aggressive and includes associations of the following pathogenic pathogens: Gram-negative non-spore forming anaerobic bacteria (strongacteroides fragilis, Prevotella sp., Prevotella bivius, Prevotella disiens and Prevotella melaninogenica), gram Positive anaerobic streptococci (Pep tostreptococcus 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, is the long-term use of IUDs, leading to tubo-ovarian and, in some cases, multiple extragenital abscesses with an extremely unfavorable septic clinical course caused by Actinomycetes Israeli and anaerobes.

Further, in decreasing order (in frequency), severe purulent postpartum diseases go on, followed by suppurative complications against the background of exacerbation of long-term chronic diseases, then - postoperative complications. Rareer causes: suppuration of hematomas and fetal eggs with ectopic pregnancy, suppuration of tumors, primary destructive appendicitis with pelvic phlegmon and others.

[3],

Risk factors

In addition to bacterial invasion, so-called provoking factors play an important role in the etiology of the purulent process. This concept includes the weakening or damage of the barrier mechanisms, which facilitates the formation of the entrance gate for pathogenic microflora and its further spreading, including physiological (menstruation, labor) or iatrogenic (abortions, IUDs, hysteroscopy, hysterosalpingography, operations).

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

• unreasonably prolonged conservative management of purulent gynecological patients;
• use to treat palliative interventions that do not eliminate the focus of destruction (puncture, drainage).

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

Symptoms of the pyoinflammatory diseases of the pelvic organs

Peculiarities of purulent PID current at the present time:

• Increased virulence and resistance of microflora, mainly associative, in which anaerobic and gram-negative microorganisms are considered to be the main pathogens. At the same time, gonococcus as a causative agent of the purulent process not only did not lose its significance, but also increased its aggression level due to concomitant microflora, in particular STI.
• Changes in the clinical course of purulent diseases of the internal genital organs: at the present stage they initially proceed as primary chronic and are characterized by a prolonged, recurrent course with extreme ineffectiveness of drug therapy. For example, in most women who use IUD, the manifestation of the disease occurs when there is already a severe infiltrative lesion of the genitals.

Most often, purulent salpingitis begins acutely, with an increase in temperature (sometimes accompanied by chills), the appearance of pains in the lower abdomen (typical localization of pains - left and right hypogastric areas, in the presence of concomitant endometriometritis observe so-called "median" pains), abundant purulent whitecaps and cuts urination. Soon, patients notice symptoms of purulent intoxication (weakness, tachycardia, muscle pains, a feeling of dryness in the mouth), dyspeptic, emotional-neurotic and functional disorders join. Disorders of rectal function are manifested more often as a symptom of the "irritated" gut (frequent loose stools). A common complaint is the presence of severe dyspareunia.

When a vaginal examination reveals soreness when moving around the cervix, pastose or the presence of palpable formation of small size with fuzzy contours in the appendages, as well as sensitivity to palpation of the lateral and posterior fornix.

Laboratory studies: patients with leukocytosis with a moderate shift of the leukocyte formula to the left (6-9% of stab wedges), 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 "enlarged, thickened, elongated fallopian tubes, characterized by an increased level of sound conductivity, in every second patient in the rectum-uterine cavity the accumulation of free fluid is noted."

Highly informative treatment and diagnostic procedure for purulent salpingitis (especially when it is impossible to perform laparoscopy) is still considered to be the puncture of the posterior vaginal fornix. Manipulation allows you to get a purulent exudate for microbiological examination and conduct a differential diagnosis with another urgent situation, such as ectopic pregnancy, ovarian apoplexy.

According to G. Strongalbi et al., The classic signs of acute purulent salpingitis: the presence of abdominal pain, tenderness in the movement of the cervix and sensitivity in 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 from 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, a constant sense of dryness in the mouth, a sharp muscle weakness).
• Appearance mainly in the lower abdomen of symptoms of irritation of the peritoneum (pelvioperitonitis). Vaginal examination in patients with pelvic peritonitis is poorly informative because of severe pain during palpation. Determine the moderate overhang and sharp soreness of the arches, especially the posterior, sharply increasing with the slightest movement behind the cervix. It is usually not possible to palpate small voluminous formations in a small pelvis.
• The appearance of "a feeling of sharp pressure on the rectum" and rapid defecation (indicates the formation of a utero-rectum groove that forms on the background of pelvioperitonitis). Gynecological examination in the corresponding anatomical area reveals the pathological formation of an uneven consistency, without distinct contours, prolapse through the posterior arch and the anterior wall of the rectum, which is sharply painful on palpation (the so-called "Douglas cry").

Chronic (complicated) purulent inflammatory diseases of the pelvic organs

All the encapsulated inflammatory adnexal tumors-pyosalpinx, pyovar, purulent tubo-ovarian formations and their further complications, are due to the duration of the disease, the stage of inflammation, the depth of the destructive process, and the nature of the damage to organs and systems. The main clinical symptom in this contingent of patients, except for pain and temperature, is the presence of initially severe purulent endogenous intoxication. Suppurative leucorrhoea is observed in postpartum, postabortion patients and patients with IUD (purulent endomyometritis). It should be noted the presence of severe neurotic disorders in patients, along with symptoms of excitation (increased irritability) against the background of intoxication, and symptoms of CNS depression appear: weakness, fatigue, sleep and appetite disorders.

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Peculiarities of purulent process in patients with various etiologic factors

The course of purulent process against the background of wearing IUD is particularly severe, while conservative, even intensive treatment is ineffective. Extraction of IUD even at the earliest stages of purulent inflammation of the uterine appendages does not contribute to the reduction of inflammation, scraping of the uterine cavity after removal of the IUD sharply exacerbates the severity of the process.

For patients with suppurative postoperative complications, the presence of transient paresis of the intestine, preservation or growth of the main signs of intoxication against the background of intensive therapy, as well as their resumption after a short "light" gap is characteristic.

For obstetric patients, the main clinical symptom is the presence of progressive purulent (necrotic) endometriometritis, which does not stop even with adequate therapy: the size of the uterus does not correspond to the time of normal postpartum involution, there is no tendency to the formation of the cervix: the cervix hangs freely in the vagina, freely passes one or two fingers. The presence of hematomas (infiltrates) in the parameter and / or zapuzubnoy cellulose is an unfavorable clinical sign that sharply reduces 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 considered the undulation of the process. In the stage of remission of the inflammatory process, the clinical manifestations are not expressed sharply, of all symptoms of intoxication of mild or moderate severity. In the acute stage, the main signs of acute purulent inflammation manifest themselves, and often new complications arise.

Most acute aggravation is accompanied by acute pelvioperitonitis, characterized by deterioration of the patient's general state and condition, hyperthermia, increased intoxication, the appearance of pain in the lower abdomen and weakly positive symptoms of irritation of the peritoneum. Acute pelvioperitonitis in patients with purulent tubo-thoracic formations can at any time lead to further serious complications, such as perforation of the abscess into neighboring organs, bacterial shock, and purulent peritonitis.

Purulent peritonitis is rare (3.1%), since the chronic purulent process is usually limited to the pelvic cavity due to numerous dense fusions, peritoneum and ligaments of the pelvis, gland and adjacent organs, i.e. Prevalent purulent-infiltrative, "conglomerate" type of inflammation.

More often with the progression of the disease, there are complications of the purulent process, such as parametritis, intestinal abscesses, purulent fistula. The presence of parametris in patients with purulent tubo-thoracic formations may be indicated by clinical signs:

• pain when urinating, pyuria (anterior parameter);
• constipation, difficulty in defecation (rear parameter);
• impaired renal function: the appearance of urinary syndrome, edema, decreased diuresis (lateral parameters);
• the appearance of infiltration and flushing of the skin over the puarth ligament (anterior parametrism);
• phenomena of periphlebitis of the external iliac vein (edema and cyanosis of the hip skin, dilating pain in the leg) - upper side parameter;
• manifestations of parainphritis (early manifestations of the manifestation psoyta: forced position of the patient with a reduced leg) - the upper lateral parametrite.

The appearance of pain in the mesohastral areas of the abdominal cavity, accompanied by the phenomena of transient intestinal paresis or partial intestinal obstruction (nausea, vomiting, stool retention), may indicate the formation of interintestinal abscesses.

The appearance on the side of the lesion of pain in the chest, soreness in the rib arch and neck at the projection of the diaphragmatic
Nerve can indirectly indicate the formation of a subdiaphragmatic abscess.

Perforation of the pelvic abscess (purulent tubo-ovarian formation, abscess utero-rectum space) in the hollow organs is observed in patients with a prolonged 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", "pulling" character;
• the appearance of tenesmus, a liquid stool (the threat of perforation to the distal parts of the intestine, and rarely to the small intestine adjacent to the abscess);
• the appearance of rapid urination, microhematuria or pyuria (threat of perforation in the bladder);
• the appearance of infiltration and pain in the area of the postoperative suture.

Multiple perforation in the adjacent intestinal tract leads to the formation of genital fistulas. The most common fistula is formed in different parts of the colon, more often in the upper ampullar department or rectosigmoid corner, less often in the blind and sigmoid colon. Pridatkov-cystic fistulae are encountered much less often, since the peritoneum of the vesicle-uterine fold and the pre-bubble tissue melt much more slowly. Fistulas are more often diagnosed at the stage of their formation at the clinic of the so-called threat of perforation in the bladder.

When conducting a vaginal examination, purulent tubo-ovarian formations in the stage of exacerbation are characterized by fuzzy contours, uneven consistency, complete immobility and pronounced soreness. In this case, they are always in a single conglomerate with the uterus, palpation and the definition of which is extremely difficult. Dimensions of suppurative purulent structures of the appendages are very variable, but in the acute stage of inflammation they are always somewhat greater than the true ones. In the remission phase, the conglomerate has more distinct contours, although it preserves the unevenness of the consistency and its complete immobility.

With concomitant parametritis, infiltrates of different consistency (depending on the stage of the inflammatory process) are determined in patients - from woody density in the stage of infiltration to uneven, with softening areas with suppuration. Inflammatory infiltrates can have different sizes. In severe cases, they reach the pelvic bones (lateral parts of the pelvis, sacrum, bosom) and can extend to the anterior abdominal wall and even the paranephric fiber. The defeat of the parameter, especially its posterior parts, is especially well revealed with rectal-vaginal examination, while indirectly assessing the degree of defeat of the inflammatory infiltrate of the rectum (the mucosa is mobile, limited mobile, immobile).

Forms

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

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

The Geneva International Statistical Classification of Diseases, Trauma and Causes of Death (WHO, 1980) has the following nosological forms of inflammatory diseases of the internal genitalia.

• Acute salpingitis and oophoritis:
  • abscess: fallopian tube, ovary, tubo-ovarian;
  • oophoritis;
  • pyosalpinx;
  • salpinite;
  • inflammation of the appendages of the uterus (adnecstumor).
• Acute parametritis and pelvic phlegmon.
• Chronic or unspecified parameter and pelvic phlegmon:
  • abscess: a broad ligament of the uterus, rectal-uterine cavity, parameter, pelvic phlegmon.
• Acute or unspecified pelvic peritonitis.

From a practical point of view, the classification proposed by V.I. Krasnopolsky et al., Allowing to determine the tactics of management and the prognosis of the 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 genitalia: uncomplicated and complicated.

• Uncomplicated forms include acute purulent salpingitis. With timely diagnosis and targeted therapy, the process can be limited to the endosalpinx lesion followed by a regression of inflammatory changes and recovery. In case of delayed or inadequate therapy, acute purulent salpingitis is caused by pelvic peritonitis with a partial delimitation of purulent exudate in the utero-rectal cavity (Douglas abscess) or passes into a chronic or complicated form - pyosalpinx or purulent tubo-ovarian 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 encysted inflammatory adnexal tumors: pyosalpinx, pyovar, purulent tubo-ovarian formations, and the prospect for subsequent childbearing is sharply reduced or problematic, and the patient can recover only after surgical treatment. With delayed surgical intervention and further progression of the process, severe purulent complications that threaten the life of the patient develop: simple and complex genital fistulas, microperforations of the abscess into the abdominal cavity with the formation of intestinal and subdiaphragmatic abscesses, purulent-infiltrative omentitis. The final outcome of the purulent process is sepsis.

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Diagnostics of the pyoinflammatory diseases of the pelvic organs

Even with the possibility of using the most modern methods of research, the main diagnostic method that determines the professional qualification and clinical thinking of a doctor is clinical. All purulent diseases have specific symptoms, reflected in subjective complaints or objective research data. The development of complications also "passes" successive stages and is 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 the setting of directed questions. Even if the diseases to a certain extent have a similar clinical picture (for example, purulent salpingitis and suppurative tubo-ovarian formations in the acute stage), there are always clinical signs (the initiation of the disease, its duration, degree of intoxication, symptomatology) that help 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 - clinical examination, including bimanual examination, bacteriological and laboratory diagnostics;
  • the second stage - transvaginal echography of the pelvic organs;
  • The third stage is laparoscopy for gynecological patients (hysteroscopy for postpartum patients).
•  With complicated forms:
  • the first stage - clinical examination, including bimanual and rectovaginal study, bacteriological and laboratory diagnostics;
  • the second stage - transabdominal and transvaginal echography of the pelvic organs, abdominal cavity, kidneys, liver and spleen, echocardiography, echography with additional contrasting of the rectum;
  • the third stage - radiographic examination of the lungs, additional invasive methods of examination: cysto- and colonoscopy, fistulography.

Laboratory diagnostics

Currently, even in the presence of severe forms of purulent inflammation, a "worn out" laboratory symptomatology is often observed, due, among other things, to the use of massive antibacterial therapy and local sanitation. Therefore it is inappropriate to focus on leukocytosis as the main marker of purulent process (observed in only 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 a persistence in the blood of pathological autoantibodies to neutrophil membranes.

In general, for these patients, the most typical increase in ESR, the presence of lymphopenia and anemia. Anemia is considered intoxicating and its degree correlates with the severity of the condition of the patients.

The parameters of peripheral blood reflect the stage of the purulent process. In the stage of exacerbation, leukocytosis, an increase in ESR (up to 60-70 mm / h), a C-reactive protein are more often detected. With the remission of the purulent process, a decrease in the number of erythrocytes and hemoglobin, lymphopenia, and increased ESR is observed.

Prolonged course of purulent process is accompanied by a violation of protein (hypo- and disproteinemia), mineral, lipid metabolism and enzymatic liver function.

Severe disorders of the hemostasis system (with a predominance of hypercoagulable processes) are noted in 35.7% of patients with complicated forms of purulent inflammation, circulatory system disorders - in 69.4% (hypokinetic circulation in 22% of patients, reduction in myocardial contractility in 13% and violation rate of cerebral blood flow in 52% of patients).

The main additional diagnostic method is echography. For purulent tubo-ovarian formations is characterized by:

• their form is often wrong, but still approaches ovoid;
• the internal structure differs polymorphism: it is non-uniform and, as a rule, is represented by an average dispersed echopositive suspension against the background of an increased level of sound conductivity;
• contours of purulent tubo-ovarian formation can be represented by: echopositive thick capsule with clear contours, capsule with areas of uneven thickness and areas of sharp thinning, and also formation without precise contours; while revealing the absence of a vascular network within the education.

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Differential diagnosis

Acute salpingitis is differentiated.

• Acute appendicitis. Unrelated connection of the disease with the previously listed risk factors; the disease occurs suddenly, the early sign is paroxysmal pain, initially localized in the navel or epigastric region, then in the region of the cecum. The decisive role in the diagnosis of acute appendicitis is the detection of symptoms of Sitkovsky (increased pain in the right iliac region when the patient is on the left side) and Rovsinga (increased pain in the cecal area with jerking pressure in the left ileal region). An acute appendicitis is also characterized by an hourly increase in the number of leukocytes in a blood test when tested in dynamics.
• Ectopic pregnancy, especially in the case of formation and suppuration of clogging hematomas, when secondary secondary inflammatory changes mask the underlying disease. For ectopic pregnancy are characterized by: violations of the menstrual cycle (more often delay in menstruation followed by prolonged bloody secretions of smearing nature), the presence of pain with irradiation in the rectum, periods of short-term impairment of consciousness (dizziness, fainting, etc.). Differential diagnosis is assisted by the determination of CGT in blood and urine (in the laboratory or by rapid tests). In difficult cases, performing a puncture of the posterior fornix or laparoscopy solves a 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 the primary carcinoma of the tube;
• with ovarian cancer;
• with infiltrative forms of endometriosis.

Consultation of specialists

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

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Treatment of the pyoinflammatory diseases of the pelvic organs

The purpose of treatment of pyoinflammatory diseases of the pelvic organs is the elimination of the purulent process (focus) in the abdominal cavity: preservation of life, health, if possible, genital, menstrual and hormonal specific female functions. Absence of treatment in all patients with purulent PID leads to severe complications (purulent peritonitis, sepsis) and lethality.

Indications for hospitalization

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

Non-drug treatment

In these patients because of the severity of the pathology is not critical.

Medical 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 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 focus of destruction;
• intensive and rational management of the postoperative period, and the earlier surgical sanitation of the focus was performed, the better the outcome of the disease.

Tactics of management of patients with uncomplicated forms of purulent inflammation

Preoperative preparation in patients with purulent salpingitis is aimed at arresting acute manifestations of inflammation and inhibiting the aggression of the microbial pathogen. To treat 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, for example amoxicillin + clavulanic acid (clavulanate). A single dose of 1.2 g IV, a daily dose of 4.8 g, a course dose of 24 g with intraoperative (with laparoscopy) intravenous injection of 1.2 g of the drug.
• Fluoroquinolones (quinolones of the second generation) in combination with nitroimidazoles (metronidazole), for example ciprofloxacin or ofloxacin in a single dose 0.2 g IV drip (daily dose 0.4 g, course dose 2.4 g) with intraoperative intravenous injection of 0, 2 g of the drug.
• Third generation cephalosporins in combination with nitroimidazoles (metronidazole).

Also shown:

• carrying out infusion therapy (crystalloids, electrolyte exchange correctors, plasma-substituting and protein preparations) in the volume of transfusions 1000-1500 ml / day. The duration of therapy is individual (average 3-5 days);
• the appointment of desensitizing and antihistamines;
• application of NSAIDs that have anti-inflammatory, analgesic and anti-aggregation effect (drugs are prescribed after antibiotic withdrawal);
• use 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 IM, then 3 days daily 0.1 g IM, from 5 days of treatment 0.1 g 5 injections every other day (for a course of 10 injections of the drug). All patients who did not receive immunocorrective therapy in the hospital should be recommended to discharge it on an outpatient basis in order to prevent the recurrence of a purulent process.

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

When purulent salpingitis adequate amount of intervention - adhesion, sanation and transvaginal (through the colpotomy orifice) draining the pelvis. In cases of purulent salpingo-oophoritis and pelvioperitonitis with formation of a blocked abscess in the rectum-uterine cavity, an adequate benefit is considered the mobilization of the uterine appendages, the emptying of the abscess, sanation and active aspiration drainage through the colpotomy. With the formed pyosalpinex, it is necessary to remove the fallopian tube or pipes. With pyovar small sizes (up to 6-8 cm in diameter) and preservation of intact ovarian tissue, it is advisable to produce a purulent formation. In ovarian abscesses, the ovary is removed. Indication for the removal of the appendages of the uterus is the presence in them of irreversible purulent-necrotic changes. All operations must be completed by repeated careful washing of the small pelvis and revision of the extrahepatic space to prevent the accumulation of pus and blood. In order to create favorable conditions for reparation and active evacuation of exudate, it is expedient to conduct active aspiration with the help of OP-1 apparatus [19]. This is especially important in patients with pronounced purulent necrotic changes, when after separation of the splices, large wound surfaces are formed, which leads to the production of a significant amount of wound secretion and promotes the formation of serous or purulent cavities, i.e. A protracted course of the disease and its relapses.

For conducting aspiration-flushing drainage (APD), one or two double-lumen tubes of silicone rubber with a diameter of 11 mm are fed to the zones of greatest destruction in the small pelvis and are led out through the colpotomy (or, in the absence of conditions for colpotomy, through additional counter-operations in the hypogastric departments) . Surgical suction is connected (OP-O1). APD is carried out by injecting a solution of furacilin (1: 5000) through a narrow tube lumen at a rate of 20 drops per minute and aspirating under a pressure of 30 cm of water. For 2-3 days depending on the severity of the process with periodic jet flushing of the tubes in the presence of purulent "plugs".

This method is a method of pathogenetic therapy, which affects the primary focus. Wherein:

1. active erosion and mechanical removal of the infected and toxic contents of the abdominal cavity;
2. hypothermic action of chilled furacilin stops further growth of microbial invasion, promotes removal of edema in the affected organ and surrounding tissues, prevents the entry of toxins and microorganisms into the circulatory and lymphatic systems;
3. a reliable outflow of the wash liquid at negative pressure excludes the possibility of accumulation of the solution in the abdominal cavity, allows to clean the peritoneum from fibrin, necrotic detritus, and to reduce the edema and infiltration of tissues;

An alternative is the method of dynamic laparoscopy, starting from 2 days postoperative period with a periodicity of 2 days. The technique allows you to monitor the dynamics of the inflammatory process, divide the formed spikes, bring the medications directly to the focus of the infection, conduct a programmed sanitation of the abdominal cavity.

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

Tactics of management of patients with complicated forms of purulent diseases

The basic component is surgical treatment. The "points of application" of antibacterial therapy in patients with complicated forms of purulent PID are determined by special time intervals of a 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);
• with clinical manifestations of activation of subacute or chronic purulent infection and the emergence of a threat of perforation of the abscess or generalization of the infection;
• intraoperatively in all patients for the purpose of perioperative protection and prevention of septic shock (the drug is administered at the maximum single dose);
• in the postoperative period in all patients.

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

Despite a significant breakthrough in microbiological diagnosis over the past 10-15 years, the initial choice of antibiotic therapy remains empirical. Depending on the severity of the disease, drugs are prescribed in the mean or maximum single and daily dose. For the treatment of these patients it is advisable to use the following drugs.

• Inhibitor-protected penicillins, for example ticarcillin + clavulanic acid (timentin), piperacillin + tazobactam (tazocine). The advantage of these drugs lies in 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 a high activity against gram-negative bacteria, as well as staphylococci, but they have low antianaerobic activity, which requires their combination with antineaerobic drugs.
• Inhibitor-protected cephalosporins of the third generation (cefoperazone + sulbactam). A broad-spectrum drug with, 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 against gram-negative bacteria, and the "pulse-therapy" with aminoglycosides (administration of a daily dose at a time) has an advantage over traditional appointment schemes (2-3 times per day) clinical efficacy, and lower nephro- and ototoxicity.
• Carbapenems: imipenem + cilastine (thienam) or meropenem (meronem) - drugs with the widest spectrum of antimicrobial activity, including against strains of Gram-negative bacteria resistant to cephalosporins. Detoxification and detoxification therapy is of paramount importance in the conduct of preoperative preparation. The effect of detoxification and preparation of patients for surgery is significantly increased when purulent exudate is evacuated.

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

• threat of perforation of the abscess into the abdominal cavity or hollow organ (to prevent peritonitis or fistula formation);
• the presence of acute pelvioperitonitis, against which surgical treatment is least favorable;
• severe degree of intoxication.

After reaching remission, patients should be operated on. Carrying out repeated punctures of the posterior fornix and colpotomy is inadvisable, since this facilitates the formation of an adnexa-vaginal fistula. The duration of preoperative preparation is determined individually. Optimal for the operation is the stage of remission of the purulent process.

Intensive conservative treatment should last no more than 5 days, and with the development of clinical manifestations of the threat of perforation - no more than 12-24 hours, if it is impossible to carry out palliative intervention to eliminate the threat of perforation.

In case of emergence of emergency indications for the operation for 1.5-2 hours, preoperative preparation is carried out, including catheterization of the subclavian vein and transfusion therapy under the control of CVP 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 the abscess into the abdominal cavity with the development of diffuse purulent peritonitis;
• perforation of the abscess in the bladder or its threat;
• septic shock.

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

The scope of surgical intervention is individual and depends on the following main points: the nature of the process, the concomitant pathology of the genitals and the age of the patients. Representations about the scope of the operation should be formed even before the operation after receiving the survey data and revealing the degree of uterus lesion, appendages, determining the nature of the complications and the presence of extragenital purulent foci. Indications for performing a reconstructive surgery with preservation of the uterus in the first place - the absence of purulent endometriometritis 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 purulent-destructive process in the small pelvis with multiple abscesses and infiltrates of pelvic and parametric fiber, confirmation of purulent endometriometritis or panmetritis, it is necessary to perform extirpation of the uterus, with at least part of the unchanged ovary.

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

• transvaginally through the open dome of the vagina after extirpation of the uterus (drains 11 mm in diameter);
• through posterior colpotomy with the preserved uterus (it is advisable to use drainage with a diameter of 11 mm or two drains with a diameter of 8 mm);
• transabdominal (additionally to the transvaginal) through the counterparts in the meso- or epigastric regions in the presence of subhepatic or intercigminal abscesses - drains 8 mm in diameter.

The optimum mode of discharge in the apparatus for draining the abdominal cavity is 30-40 cm of water. The average duration of drainage is 3 days. The criteria for cessation of drainage are the improvement of the patient's condition, the restoration of bowel function, the relief of the inflammatory process in the abdominal cavity, the tendency to normalize the clinical analysis of blood and body temperature.

Principles of conducting the postoperative period

• Application of adequate analgesia. The optimal method is the use of prolonged epidural anesthesia. If for any reasons not related to the presence of contraindications, there was no combined anesthesia during the operation, then this method of anesthesia and treatment should be applied in the postoperative period. If there are contraindications to the use of the DEA method during the first 3 days anesthesia should be carried out with narcotic analgesics. To potentiate the effects, they should be combined with antihistamines and sedatives.
• Infusion therapy. To correct violations in the postoperative period, both the quality of infusion media and the volume of infusion are important. The introduction 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 shown (in case of severe process the protein dose can be increased to 150-200 g / day); The remaining volume is replaced by crystalloids. The amount of liquid administered, provided that the kidney function is preserved, is 35-40 ml / kg / day. In severe forms of complications (peritonitis, sepsis), the amount of injected fluid can be increased to 4-6 l (hypervolemia) 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.
• Stimulation of the intestine. The soft, physiological stimulation of the intestine is adequate due to the application of the epidural blockade in the first place, the second one - adequate infusion therapy in the volume of normo- or insignificant hypervolemia, the third - due to the advantageous use of metoclopramide, which has a regulating effect on the gastrointestinal motility. Correction of hypokalemia also plays an important role in the treatment of intestinal paresis. To introduce potassium preparations is necessary under the control of its content in the serum slowly, in a diluted form, better in a separate vein. On average, 6-8 g of potassium are introduced per day, taking into account its content in other solutions (fresh frozen plasma, haemodez and others).
• It is expedient to use protease inhibitors.
• In all patients, in the absence of contraindications, it is advisable to use low-molecular-weight heparin-calcium supraparrin in a dose of 0.3 ml (285 IU of anti-Xa activity, respectively) under the skin of the stomach 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 the body weight) with a gradual decrease and cancellation of the drug after 5-7 days.
• The use of NSAIDs is indicated (prescribe after the abolition of antibiotics).
• According to the indications, organ damage therapy with hepatotropic [phospholipids + multivitamins (essenciale)] and cardiological agents is carried out, spasmolytics, extracorporeal methods of detoxification (plasmapheresis) are used.
• Immunocorrection. It is advisable to use the preparation of aminodihydrophthalazione 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 IM, then 3 days daily for 0.1 g IM, then a day later 5 injections; then 2 times a week for 0.1 g IM (treatment course - 20 injections).

Further management

All patients who have undergone purulent-inflammatory diseases of pelvic organs need long-term rehabilitation.

Prevention

• Exception or sharp limitation of IUD use, extraction of IUD without scraping the uterine cavity on the background of antibacterial therapy.
• Expansion of the use of barrier contraceptive methods.
• Timely hospitalization of patients with acute PID, exclusion from practice of outpatient treatment of patients with postpartum, postabortion, postoperative infectious complications, as well as patients with complications of IUD (except for the rehabilitation stage).
• Theoretical training of personnel, stage-by-stage training in surgical techniques.
• Use of optimal surgical technique and adequate suture material, conducting surgical interventions with minimal operational trauma and blood loss.
• The use of rational antibiotic prophylaxis and antibiotic therapy in gynecological patients.
• Timely application of a complex of active medical and diagnostic measures in patients with a complicated course of the postpartum or postoperative period.
• Active tactics of managing patients with purulent inflammatory diseases of internal genital organs, and in the first place - timely operative treatment.

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

Forecast

With properly performed 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: the progression of the disease (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 lethal outcome and disability is considered a priority in the outcome of the disease, later (with an organ-saving operation) it is possible to use assisted reproductive technologies, and with the preservation of only the hormonal function - surrogate motherhood.

It should be recognized that in the short term one should not expect a decrease in the number of purulent diseases of the genitals and postoperative purulent complications. This is due not only to an increase in the number of patients with immuno- and extragenital pathologies (obesity, anemia, diabetes mellitus), but also with a significant increase in operative activity in obstetrics and gynecology. It is, in particular, a significant increase in the number of abdominal births, endoscopic and general surgical operations.