Adhesions in the small pelvis are the formations that often arise after operative or invasive interventions in the pelvis, which can disrupt the topic of the organs and cause a pronounced pain syndrome. The structure of spikes is a product of layering fibrin and other connective tissue elements. The course of the adhesive process in the small pelvis can be of varying degrees, from asymptomatic to severe clinical picture, which requires correct diagnosis and correction of this process.
The epidemiology of the development of adhesive processes of the small pelvis is such that more than 75% of surgical interventions are sooner or later complicated by the formation of adhesions, and this is every second woman who underwent surgery. The number of adhesions after an open cesarean section is twice as great as after laparoscopic operations. More than 45% of cases of pain in the abdomen and violations of the ovario-menstrual cycle are the consequence of the formation of adhesions in the small pelvis. Given the prevalence of the problem, it is necessary to take primary preventive measures in relation to the adhesive process in the small pelvis.
Causes of the adhesions in the pelvis
Speaking about the reasons for the formation of adhesions, it is first necessary to understand the pathogenesis of the formation of these elements. The mechanism of connective tissue regeneration is the same, regardless of the place of formation. When there is any tissue damage, the body tries to restore the structure of this damaged tissue. And in normal this process of regeneration is due to the intensive division of cellular structures. If the process of cellular regeneration does not have time to recover, then the organism replaces the tissue defect due to the intensive synthesis of fibroblasts and the formation of connective tissue. Heavy tissues from the connective tissue are strengthened with filaments of fibrin, which is formed as a result of damage to the vessels and the release of products of its degradation. Thus, in order to start the process of fibrin release and synthesis of connective structures, it is necessary to damage the vessel and the output of the plasma elements. Therefore, the main condition for the initiation of adhesions is damage to the peritoneum and the vessel. The main reason for the formation of an adhesive process in the small pelvis is any surgical intervention. At the same time, damage is caused by activation of cell synthesis and stimulation of regeneration by attracting mediators, which in turn lead to the activation of fibroblasts. As a result of these processes, fibrin synthesis is gaining strength, which can accumulate at the sites of regeneration and further deepening of these changes occurs. That is why postoperative adhesions in the small pelvis are so common.
Spikes in the small pelvis after caesarean section are very common, since this operation is very common, and it also leads to the above described processes. In this operation, it is precisely on the pelvic organs that undergoes surgery, followed by revision of the uterus and circumcision space, which is a factor of external intervention and this disrupts the processes of normal regeneration, followed by the formation of connective tissue bridges. They can attach not only to the uterus, but also to the ovaries, rectum, bladder, which contributes to the development of certain clinical symptoms.
But surgical interventions are not the only cause of this pathology. Chronic inflammatory processes of the pelvic organs are the second most common cause of the formation of adhesive processes. This creates very favorable conditions for maintaining a flaccid inflammatory process, which is maintained by constant proliferation. Thus, chronic inflammation in the ovary is accompanied by a constant presence of neutrophilic leukocytes, granulocytes, monocytes and fibroblasts - all these cells damage the normal structure of the peritoneum, which is a prerequisite for the constant proliferation and regeneration of connective cells and fibrin. Therefore, there are favorable conditions for the development of adhesions.
Another, not so frequent, cause of the formation of adhesions is a violation of the topic of the pelvic organs, which may be due to congenital malformations of the structure and location of the organs of the genitourinary system. In this case, disruption of the normal arrangement of organs is a provoking factor for the onset of the formation of adhesions.
Given all the possible causes of this pathology, it is necessary to identify a risk group from women who need to be monitored for adhesions. This will help reduce not only the problem with violations of the ovario-menstrual cycle, but also reduce female infertility, which can still be cured at this stage of fibroplastic changes. This group includes:
women after cesarean section, which is the main factor in the development of the processes of intensive regeneration of the peritoneum;
women who suffered an induced abortion;
inflammatory diseases of the ovaries - chronic or transferred acute adnexitis, oophoritis, ovarian apoplexy, cyst, ovarian excision or any surgical intervention on the uterus;
Hypoplasia of the uterus or ovaries of congenital or acquired etiology;
external genital endometriosis;
previous surgical interventions on the bladder, rectum or other pelvic organs;
All these risk factors are a potential threat to the development of the adhesion process in the small pelvis, so you need to take into account these causes and carry out preventive measures.
Symptoms of the adhesions in the pelvis
Very often this pathology develops asymptomatically and the changes progress to the extent of the absence of therapeutic measures. This is due to the fact that for the formation of clinical symptoms it is necessary that a certain body be involved in the process. And this happens very slowly, until the moment when the adhesions are significant and the strands from the walls of the small pelvis to the organs are formed. This violates their topic and normal function, which leads to the appearance of complaints in the future.
The first signs of the manifestation of the adhesion process in the small pelvis are most often manifested by pain syndrome. This is due to the fact that in the small pelvis there are many nerve plexuses and a huge number of nerve endings on the peritoneum of the small pelvis. Therefore, when the peritoneum is stretched, its irritation occurs, which is manifested by pain and heaviness in the abdomen. The pain with adhesions in the small pelvis has its own characteristics: the pain is blunt, constant, localized in the lower abdomen. They can intensify, in connection with menstruation, which can be due to compression of nerve endings with an increase in the uterus. Such a pain syndrome is not intensive and is difficult to treat with antispasmodics. The peculiarity of such pain is that they are of the same type and do not increase, do not have a progressive character. If the nature of the pain has changed or if the localization has changed, then it is worth thinking about it, because this can be a sign of complications.
Spikes in the small pelvis and pregnancy are a very important issue, especially for women of reproductive age. The localization of adhesions is very important in terms of the normal ovarian-menstrual cycle and the process of fertilization. If connective tissue is formed on the ovary, it prevents the release of the egg from the follicle, so the process of ovulation is defective. In this case, the egg simply does not reach the uterine cavity and fertilization does not occur. Therefore, adhesions on the ovaries can have clinical manifestations in the form of infertility. If the adhesions are localized between the pelvic wall and the fallopian tube, then the normal movement of the spermatozoon also interferes, which complicates the fertilization process, due to problems with the patency of the fallopian tubes. There are symptoms of a chronic inflammatory process of the tubes or ovaries, which is due to the maintenance of a chronic foci of infection. In this case, there are symptoms of a chronic intoxication process in the form of periodic or constant maintenance of subfebrile body temperature, lethargy and weakness, decreased efficiency, periodic or persistent weak pain syndrome. These symptoms should also be paid attention, since they can be indicative of such pathology. Therefore, a frequent cause of infertility without obvious violations of the normal function of the uterus and ovaries may be adhesive processes in the small pelvis. If the adhesions are localized on the wall of the uterus and the woman becomes pregnant, then during the growth of the uterus with the growth of the fetus, these adhesions can cause compression of organs and vessels, which can disrupt normal blood circulation. This should also be considered when planning a pregnancy.
Sometimes spikes in the small pelvis when localized on the ovaries can disrupt their normal work so much that the structure of the stroma and the glandular structure of the organ changes and a function is disrupted. This is manifested in the first place by violations of the ovario-menstrual cycle. Often these two pathologies do not bind together, but it must be remembered that such reasons can also be. In this case, violations occur in the form of failure of the function of the ovaries and it passes by the type of amenorrhea. Such delays can be up to two to three months, and then, when the amount of hormones is restored, normal menstruation can resume.
Symptoms of small pelvic adhesions can manifest themselves in the form of pathological discharge, if spikes are the cause of chronic inflammation. Such discharge can be green or yellow, in a small amount when the same ovary is inflamed. There may be bloody discharge, if the adhesions are accompanied by a change in the topic of the fallopian tubes and secondary traumatization. Then there may be minor bleeding after active physical exertion. But more often than not there is evidence of secondary processes.
The variety of clinical manifestations of the adhesion process in the small pelvis suggests that it is necessary to carry out very thorough diagnosis and differential diagnosis of the clinical symptoms of the disease for the correct therapeutic tactics.
It is very important for the clinical manifestations of pathology to localize and spread the process. Therefore, in order to better diagnose and predict the development of the clinic, several stages are distinguished:
Adhesive process is limited to only one space without serious deformations of the tubes and ovaries;
spikes encompass the ovaries, tubes, uterus;
Adhesive process deforms the uterine tube with a change in the topic and spread to the surrounding organs - the bladder, rectum.
The consequences and complications of adhesions in the small pelvis depend on the stage of the disease. The most important complication of such adhesions in women of childbearing age is infertility. This happens in case the process has spread to the fallopian tubes and caused a change in the topic of the organs. What is dangerous spikes in a small pelvis? The pronounced adhesion process can for a long time maintain chronic foci of infection in the ovary or tubes, which is important to consider in treatment. Then such chronic oophoritis and adnexitis are not amenable to treatment. Pronounced adhesions of the small pelvis with a significant progression of the process can lead to spread to the abdominal cavity and development of intestinal obstruction.
Diagnostics of the adhesions in the pelvis
Diagnosis of the adhesion process of the small pelvis is complicated due to the fact that this process is difficult to determine without visual confirmation. Therefore, the variety of complaints in this pathology must be brought to a preliminary diagnosis and using additional methods to establish a final diagnosis. Therefore, it is very important to establish and detail complaints, and also to find out the anamnesis of the patient's life.
It is necessary to learn about the nature of pain, localization, duration, reaction to analgesics, as well as to find out the dynamics of symptoms and whether they have changed in recent times. Such details of complaints are also needed for further differential diagnosis. From the history of life you need to find out what surgical interventions were in the woman, whether there were pregnancies and how the delivery was, as well as the presence of diseases of the ovaries and uterus. It is important to find out the time of the last menstruation, their regularity and character. Further, upon examination, it is possible to identify the indirect signs of the adhesion process. In bimanual palpation of the uterus, it is possible to determine its lack of mobility, and also with large sizes of adhesions, one-sided infiltration can be determined to be unhealthy or moderately painful. But we should not exclude this process, if there are no specific changes in the examination of a woman in mirrors, because the process is difficult to diagnose.
Analyzes that can be performed for the purpose of differential diagnosis, since there are no specific laboratory signs of this pathology. With a chronic inflammatory process in the ovary due to the formation of adhesions, it is possible to determine changes in the general blood test-leukocytosis with a neutrophil shift of the formula to the left, acceleration of the ESR. This should lead to the thought of a chronic inflammatory process. It is also necessary to carry out a study of the smear from the vagina to the bacterial flora - this will make it possible to identify the causative agent of this chronic infection. But the root cause of the inflammatory process, such as spikes, should always be borne in mind. Therefore, instrumental diagnostic methods are important.
Specific symptoms during instrumental diagnostics are not present, and the nature of the changes depends on the size of the adhesive conglomerates. Spikes in the conduct of ultrasound have the form of non-uniform echoes of different intensity, which are located in the form of strands from the walls of the small pelvis to the organs. But it is very difficult to differentiate and confirm these changes, so they prefer more informative methods.
Hysterosalpingography is a method in which a cavity of the uterus and tubes is filled with a contrast substance and an X-ray examination is performed. In this case, you can see any defects in the filling of pipes in the ampullar part and the degree of filling with contrast, which can be taken as a basis for diagnosing the adhesive process. You can determine the degree of violation of the topic of the uterus, fallopian tube and ovary due to the development of connective tissue and establish the stage of the disease.
But the main method of diagnosis and confirmation of adhesions in the small pelvis is laparoscopy. This is a visual method of diagnosis, which is that a camera is inserted into the cavity of the small pelvis through a special conductor, which allows you to directly see the nature of the changes and their prevalence. The diagnostic value of this method is increased due to the fact that it is possible to conduct simultaneous and operative intervention, in which the revision of the pelvic cavity is carried out. It is an affordable and minimally invasive method that can also be used for differential diagnosis of the volumetric process in the small pelvis, adhesions, congenital disorders of the pelvic organs.
Differential diagnosis of adhesions in the small pelvis is very wide due to the fact that complaints and symptoms can be very different. If the main complaint of a woman is infertility in the full study and exclusion of other causes, then it is necessary to differentiate the possible adhesion process and violations of the ovulation process. If the luteal phase is not sufficient, ovulation may not occur, which should be taken into account in the differential diagnosis of adhesions, which may be accompanied by a violation of the egg's yield. Therefore, to eliminate the hormonal causes of ovulation disturbance, hormonal screening should be performed, and only then think about mechanical factors.
When a significant conglomerate is found on the ovary or uterus of the adhesive etiology during palpation, differential diagnosis should be performed with tumor processes. In this case, the ovarian tumor is more often painless, does not shift and has no precise contours. Tumor or uterine myoma leads to deformation of the uterus itself, and it is localized in the thickness of the organ. Sometimes, in order to differentiate the tumor process, it is necessary to perform magnetic resonance imaging.
It often happens that there is a need to differentiate ovarian adhesions with a cyst. The main thing is ultrasound, which can accurately determine the changes characteristic for the cyst in the form of a cavity with clear edges and echo-negative contents.
Careful differentiation of complaints and conducting additional diagnostics is very important for establishing the diagnosis and choice of treatment tactics.
Treatment of adhesions in the small pelvis is necessary only if they cause any symptoms. Medical methods in this case should be used in case of exacerbation of processes, and if the process is not expressed, then physiotherapeutic and alternative methods have priority.
If there is a pronounced inflammatory process against the background of small pelvic adhesions, then it is necessary to conduct etiologic treatment. Therefore, the treatment should use a complex of antibiotics and anti-inflammatory drugs. The advantage belongs to an antibiotic, to which there is a sensitivity of the flora isolated from the vagina. Suppositories with spikes in the small pelvis have a good effect due to their local effect.
Neotrizol is a combined remedy that contains two antibacterial drugs (neomycin and ornidazole), an antifungal (miconazole) and a hormonal drug (prednisolone). Due to this composition it has a wide spectrum of action and due to local action it allows to get rid of the chronic inflammatory process. The drug is released in tableted pharmacological form and the dosage is one tablet per night for eight days. The way of using the drug - one vaginal tablet should be inserted into the applicator and inserted into the vagina at night using the applicator. After this, it takes some time to lie down in a horizontal position for the best action of the drug. Precautions - during pregnancy is not recommended treatment with this drug because of the hormonal content. Side effects occur rarely due to the local topical effect of the drug, but there may be dizziness and headache, as well as local burning and itching in the vaginal area.
Dicloberl is an anti-inflammatory drug that is used in complex therapy with an antibacterial drug in severe pain syndrome, as well as to accelerate the resolution of adhesions. This is achieved by activating the immune defense cells in the focus of inflammation and reducing edema. The active substance of this drug is diclofenac (a non-steroidal anti-inflammatory non-narcotic drug). The drug is available in the form of rectal suppositories, the dosage of the drug is 500 milligrams of the active substance in one candle. Method of application - one suppository per day should be used rectally. Side effects are possible with lesions of the stomach mucosa, esophagus, duodenum, which can be detected by epigastric pain syndrome. The effect of the drug on the blood system causes inhibition of the formation of uniform elements with the phenomenon of a decrease in all peripheral forms of blood cells. This can cause symptoms of dizziness, fainting, palpitations, decreased blood pressure, and swollen syndrome. Precautions - during pregnancy should not be used in the early stages.
Longidase is an enzyme preparation that can be used in the second stage of treatment, when the inflammatory process is treated. Lidase with adhesions in the small pelvis has a directed effect on the connective tissue, since it cleaves glycopeptide bonds. Due to this directional action helps to conduct specific proteolytic therapy. The active substance of the drug is hyaluronidase (a natural proteolytic enzyme). The drug is available in ampoules for intramuscular injection and dosage of the drug for 1500 and 3000 international units. The method of application of the drug is intramuscular, with 3000 units of action per day, the course of treatment from ten days to three weeks. You can repeat the course of treatment if necessary. Side effects are possible only in the form of allergic manifestations and irritations at the injection site. Precautions - during pregnancy and breast-feeding the drug is undesirable to use.
Terrylitin is a drug that contains proteolytic proteins. This agent has proteolytic activity in relation to connective tissue, so it can be successfully used to improve the dynamics of resorption of ovarian adhesions as a combination therapy. The drug is available in the form of vaginal suppositories, which improves their effect in local use. The way of using the drug - one candle vaginally twice a day. Side effects can be in the form of local symptoms of itching in the vagina. From systemic side effects it is possible to strengthen the heartbeat and a sensation of hot flush to the face. Precautions - Do not use tampons with the remedy in the event of damage to the uterus or after recent surgery.
These are the main medications that need to be used in certain situations as prescribed by the doctor.
Vitamins in the treatment of adhesions do not have a specific effect, but as a complex therapy they improve blood circulation and normalize the immune status, including local.
Vishnevsky's ointment from adhesions in the small pelvis does not have a specific effect on spikes, but can be used in the complex treatment of the inflammatory process.
Alternative treatment for pelvic adhesions
Alternative methods of treatment of this pathology are aimed at improving blood circulation, lymph flow in the small pelvis, which improves the processes of cell proliferation and the amount of connective tissue decreases. This can be used at any stage of the disease, as these methods are not so harmful and can be used for a long time. The main alternative recipes are as follows:
Leeches with soldering in the small pelvis is used due to their ability to improve blood circulation due to the increased influence on the blood coagulation system. The extract that secrete leeches has the ability to thin the blood, which improves blood circulation in the small pelvis and strengthens the process of resorption of adhesions. For such treatment it is necessary to contact specialists who are engaged in this treatment and know the exact methodology that can be done in many private clinics.
Compresses from medicinal herbs are very useful and effective in treating adhesions of the pelvic organs. For such compresses, you need to take the leaves of yarrow and morinda, pour them with hot water and make a compress of gauze tissue. Such a compress should be placed on the lower abdomen and covered with warm woolen cloth on top. The duration of action of such a compress should be at least two days. The course of treatment is ten days.
Very useful compresses using Kalanchoe, as this plant contains many vitamins and proteolytic agents that activate polysaccharides and promote the cleavage of their bonds. This helps more efficient resorption of adhesions. For the compress, you can use the Kalanchoe juice and add a few drops of Longidase from the ampoule to it - this enhances the useful properties of such a compress.
Herbal treatment also has its advantages, as they can be used in place of tea, which not only contributes to the treatment of adhesions, but also normalizes the work of female hormones and the function of the genital organs.
St. John's wort from adhesions in the small pelvis is highly effective, as it improves the trophism of all organs and normalizes the proliferative activity of cells. For a medical solution, take a liter of hot water and pour five tablespoons of leaves of dried St. John's wort with this water. Such a solution is infused for three hours, and then douching should be performed. It is better to do this at night with the help of a small pear. The course of treatment is three weeks.
Boron uterus is a plant that is widely used in gynecology, as it has many properties - antitumor, resorptive, anti-inflammatory. For the treatment use the water infusion of this herb, which is prepared according to the standard rules - for three tablespoons of dry herbs you need to take a liter of boiled water. You need to use half a cup of this tea twice a day, the course of treatment - seven days.
A solution from the oak bark helps to normalize metabolic processes in cells and to reduce the number of fibroblasts in the areas of adhesions formation. For cooking, take a hundred grams of dried oak bark, pour them with boiling water and boil for half an hour. Then, when the solution has cooled, you need to take 100 grams of this infusion instead of tea twice a day.
Homeopathic treatments for adhesions are also widely used:
Adonis vernalis is a homeopathic remedy of plant origin, which is effective with concomitant inflammatory diseases of the ovary. Dosage and the way of application of the preparation - seven granules three times a day, keep in the mouth until complete resorption. Side effects are possible in the idea of a cough that has a dry character. Precautions - patients with bronchial asthma need to use the drug with caution.
Calcium carbonate is a homeopathic remedy based on inorganic material. Used to treat adhesions in patients with a pronounced exudative component. Method of application - under the tongue, dosage - ten drops of solution three times a day. Adverse events occur rarely, allergic manifestations are possible.
Ratania is a one-component homeopathic preparation, the main active ingredient of which is a plant. The drug is recommended for the treatment of adhesions, which are accompanied by bloody discharge and broken ovario-menstrual cycle. The drug is released in the form of standard homeopathic granules and dosage of it - ten pellets three times a day. The way of application - under the tongue after eating after half an hour. Precautions - do not use for allergies to conifers. Side effects are in the form of a disorder of the menstrual cycle that passes after the correction of the dose.
Calendula is a homeopathic remedy based on the infusion of calendula, diluted in certain methods. The drug is available in the form of infusion, which is used as a compress. Method of application - gauze should be moistened in a solution and put on the night on the bottom of the abdomen. Precautions - with severe itching, the drug may cause increased symptoms.
Operative treatment of adhesions is used in the second and third stages of the disease, when adjacent organs are involved in the process. In this case, women who plan pregnancy, surgical intervention is recommended. The most accessible method is dissection of adhesions with a scalpel. But such surgery has a drawback, because after this spikes often re-form. There are also alternative methods - the use of an electric knife or laser excision. In addition to removing the adhesions, the "cauterization" of the cells of the connective tissue takes place in parallel, so the process of further synthesis is not so significant. This is the advantage of laser surgery - spikes are formed very slowly, but this method is not available everywhere. In the course of such an operation, special resorptives can be applied to the ovaries, which can permanently prevent further changes.
Laparoscopy of adhesions in the small pelvis can be used as the most accessible and effective method, in the absence of an alternative, since the intervention is minimal, and the dissection of adhesions can be performed very effectively.
Physiotherapeutic treatment of adhesions is performed in the absence of acute and chronic inflammation during remission. The most common method of physiotherapy is electrophoresis with enzymes - lidase, trypsin, chymotrypsin. These enzymes with the help of ions are able to penetrate deep into the adhesions and better to break their bonds. A course of seven to ten sessions of electrophoresis is recommended. Also, a good effect is revealed by magnetic therapy, which enhances the ionization of cells and also reduces the severity of the process.
Gymnastics with spasms in the small pelvis helps to normalize blood circulation and stretches the adhesions that form, thus, normalizes the normal position of the organs in the pelvis. Exercises should not be sharp, with an emphasis on working out the muscles of the pelvis and the press. Massage of adhesions in the small pelvis can also be used in complex treatment.
Bodyflex from adhesions in the small pelvis, according to many reviews of patients, helps in resolving the adhesion process and normalizes the function of all organs. This is a method that is a kind of aerobics using the technique of proper breathing, which saturates all cells with oxygen. It has a general toning and firming effect on the body, and also causes the cells to be renewed with sufficient oxygen, which is very important for active resorption of adhesions. Therefore, this method can be recommended, which is useful for the whole organism.
Prevention of the formation of adhesions in the small pelvis is nonspecific and includes timely diagnosis and treatment of inflammatory processes, avoidance of unscheduled surgical interventions and abortion, as well as timely consultation with the doctor and planning of pregnancy.
The prognosis of this pathology is favorable for life, but if a young woman develops such a problem, and in case of untimely treatment, complications of pregnancy can be expected, given that this process is irreversible. Therefore, you need to deal not only with primary prevention, but also secondary - it is better to treat spikes in the first stage.
Spikes in a small pelvis is a problem that is diagnosed, not as often as it can be a cause of violations of the ovario-menstrual cycle, pain syndrome and other pathologies of the female reproductive system. Therefore, the importance of this problem for diagnosis and timely treatment comes to the forefront, which is very important in the prevention of complications.
Last update: 25.06.2018
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Medical expert editor
Portnov Alexey Alexandrovich
Education: Kiev National Medical University. A.A. Bogomolets, Specialty - "General Medicine"
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Non-inflammatory syndrome of chronic pelvic pain (NSHTB, category IIIb according to the NIH classification) - observed more than 3 months. Periodic pain in the lower abdomen, in the perineum, external genitalia, lumbosacral region, accompanied or not accompanied by impaired urination.
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