Parametritis

Parametritis is an inflammation of the ovary cellulose.

Diagnosis is not difficult. Treatment depends on the stage of the disease: in acute - antibiotic therapy, in the stage of suppuration - surgical treatment. Forecast, excluding septic form, favorable.

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Causes of the parametrite

More often there is a complication of abortions (mostly community-acquired) and childbirth. Parametritis can occur with inflammation of neighboring organs (rectum, appendix, etc.). The causative agents in this case penetrate the peritoneal tissue, usually by a lymphogenous route. In case of hematogenous infection of periarticular tissue, the parametrite can be a complication of common infectious diseases (influenza, angina, etc.).

Risk factors

The development of the disease can be facilitated by surgical interventions (as vaginal - the introduction of intrauterine contraceptives, dilatation of the cervical canal, diagnostic curettage, and abdominal - removal of interligamentally located tumors of internal genitalia, suppurating tumors).

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Pathogenesis

In most cases, the parametris develops against a purulent lesion of the uterine appendages due to the involvement of parametric fiber in the inflammatory process. The path of infection is predominantly per continuitatem. The postnatal and postabortion parametrit is very rare at the present time. The path of infection of the cellulose is lymphogenic. The inflammatory process in the cellulose spreads further along the lymphatic vessels, as well as along the veins.

Symptoms of the parametrite

Symptoms of parametrite in most cases correspond to severe inflammatory process. The early symptom is pronounced constant pain in the lower abdomen, radiating to the sacrum and waist. With the progression of the disease, the condition of patients worsens. The body temperature rises to 38-39 ° C; weakness, thirst, headaches are noted. Patients take a forced position - bend and lead the leg to the abdomen on the side of the lesion.

Pulse corresponds to temperature. It can be difficult to urinate and defecate.

When vaginal examination on the side of the uterus, a dense, immobile, painful infiltrate is determined, starting from the uterus and reaching the pelvic wall. The uterus is rejected in a healthy way.

Stages

The development and progression of the parametrite passes through several stages.

1. The stage of exudation corresponds to the initial period of the parametrite.
2. The stage of infiltration (compaction of exudate) is the gradual replacement of exudate with a dense (sometimes extremely dense) infiltrate. This is due to the deposition of fibrin. Typically, the treatment cures acute inflammation in pridatkovoy education and contributes to the subsidence of the accompanying parametrite. The course of parametrite in these patients is limited to the stage of infiltration. The infiltrate in the parameter area gradually decreases in size, but always leaves areas of residual infiltration.
3. The stage of suppuration is characterized more often by the presence in the structure of the infiltrate of a multitude of microabscesses. In some rare cases (3.1%), total purulent melting of parametric fiber occurs.

During parametrita, the stages of infiltration, exudation and compaction (scarring) are isolated. At the stage of exudation, the infiltrate can be inflamed with the development of a purulent parametrite.

Forms

There are front, back and side parametrites. The latter are found especially often (about 90%).

Complications and consequences

With suppuration of the parametric infiltrate, the condition of the patients worsens, the pain sharply increases, the temperature becomes hectic, chills appear, the shift of the leukocyte formula to the left and the increase in LII are noted, and the dysuric phenomena intensify. With vaginal examination, softening and fluctuation of the infiltrate, overhanging the vaginal vault, are detected. The breakthrough of the abscess is indicated by a short-term improvement in the patient's condition, the appearance of pus in the vagina (in urine or feces).

Abscessing always sharply burdens the course of the underlying disease and can develop in different directions.

• Most often purulent melting captures the lower parts of the parameter and the area of retinaculum uteri. In the process, the wall of the bladder is involved, pain occurs when urinating, pyuria, which serves as a harbinger of the oncoming perforation of the abscess into the bladder.
• Less often the abscess and the spread of pus go "tongue" upward and forward towards the round ligament, then in the form of a broad infiltrate on the side wall of the pelvis and above the inguinal (puarth) ligament. This localization of the abscess is called the abscess of Dupuytren. Above the inguinal ligament, these patients always define a dense sharply painful infiltrate, creating a visible asymmetry of the anterior abdominal wall, there is skin hyperemia.
• The most dangerous variant of suppuration of parametric fiber in patients with purulent diseases of the uterine appendages is undoubtedly the development of an abscess in the area of the plexus limphaticus spermaticus - the so-called upper lateral parameter. This is due to the fact that the effusion and pus spread along the back of the parametric fiber to the walls of the small and then the large pelvis and from here, heading behind the blind or sigmoid colon, can "climb up" the paranephalic tissue to the bud, forming paranefrotic, and sometimes a subdiaphragmatic abscess. Clinical manifestations of such parametritis usually begin with the development of periphlebitis of the external iliac vein, with the development of severe forms of thrombosis. The hip on the side of the lesion increases in size, starting from the inguinal ligament area, pronounced cyanosis appears, amplifying to the periphery, and extending pain in the leg. Puffiness and pain somewhat decrease after 2-3 days, which coincides with the development of collateral outflow. The degree of severity of these signs depends on the prevalence of thrombosis and the depth of the occlusion of the vessel. It should be noted that with such complications of complete obturation of the external iliac vein is almost never, but there is always a risk of thromboembolism. In this regard, the treatment of such women is particularly complex and should include the whole complex of measures aimed at stopping phlebitis and phlebothrombosis, preventing embolism.
• Another no less formidable complication is the spread of the suppurative process to the periparticular tissue. Initially, paranephritis takes place as a limited process, but then it quickly captures the entire fatty capsule, resulting in the development of phlegmon. Clinically, in the early stages of parainfrequency manifests psoyita symptoms. The leg on the side of the lesion is bent at the knee and hip joint and is slightly brought to the stomach. When trying to unbend it, sharp pains in the ileum region intensify. Simultaneously, the body temperature rises (up to 39-40 ° C), a rapid hourly increase in the number of leukocytes begins, a neutrophil shift is noted, and the severity of intoxication is increasing. At the back of the kidney appears swelling without sharp edges, contours of the waist are smoothed.

Diagnostics of the parametrite

With vaginal examination in patients the main gynecological pathology is determined, i.e. Inflammatory conglomerate of formations (uterus, appendages and adjacent organs) without clear identification of organs. If there is a bilateral process, the uterus is generally poorly contoured. In the study of the parameter, infiltrates are determined different depending on the stage of the consistency process - from woody density in the stage of infiltration to uneven with softening areas with suppuration; Infiltrates can have different sizes depending on the severity of the process or its phase. So, in the initial stages or at the stage of resorption, infiltrates in the form of a clutch "envelop" the cervix and uterus, in the infiltration stage in severe processes they can reach the lateral walls of the pelvis, sacrum and bosom. The mucous arch (vaults) of the vagina in the area of fiber infiltration is immovable, the vaults are shortened.

In operated patients, the infiltrate is located in the center of the pelvis above the cervix or occupies one half of the small pelvis. The total immobility of the entire formation and the absence of precise contours are determined.

Signs of abscessing of parametric fiber are pains of a pulverizing or pulsating nature, hyperthermia, often chills.

Abscesses of the parameter (especially those that appeared as a result of postoperative complications) can perforate into adjacent hollow organs (distal intestine or bladder), in such cases the symptoms of preperforation appear, and in case of untimely treatment, the symptoms of perforation of the abscess to the appropriate organs.

When vaginal examination in the pelvic cavity is also determined by a conglomerate of organs, which includes the affected appendages, uterus, omentum, loops of the intestine. Infiltrated bladder Palpatrically it is not possible to determine the relative position of the organs that make up this conglomerate, but it is always possible to identify the characteristics characteristic of the developed complication:

1. the affected parameter is infiltrated, sharply painful, the infiltrate can reach the pelvic bones and spread towards the anterior abdominal wall;
2. lateral arch abruptly shortened;
3. the cervix of the uterus is asymmetrically relative to the midline and is shifted in the direction opposite to the lesion of the parameter and abscessed;
4. the organs of the small pelvis (conglomerate) practically can not be displaced.

It is obligatory to perform a rectal-vaginal examination, in which it is necessary to reveal the prolapse of the infiltrate or abscess in the direction of the rectum and determine the condition of the mucosa above it (mobile, limited mobile, immovable), which reflects the fact and extent of involvement in the inflammatory process of the anterior or lateral walls of the rectum.

The main additional diagnostic method is echography.

In addition to the above ultrasound criteria for the destruction of the uterus and appendages, the following echographic signs of lesion of the small cell pelvic spaces are observed in patients with parametritis:

• inflammatory infiltrates of the small pelvis are determined on the echogram in the form of an irregular form of echopositive formations without a clear capsule and precise contours and boundaries; their sizes are different, in some cases infiltrates reach the pelvic bones;
• infiltrates are characterized by reduced echogenicity in relation to surrounding tissues and, when suppurated, contain in their structure one or many cystic formations with a clear capsule and a thick heterogeneous content.

The informativeness of the method of computed tomography in the diagnosis of abscesses of the parameter, according to our data, was 80%, in the detection of pan metritis and pancellulitis - 68.88%.

On the roentgenogram, in addition to the main pathology, decreased echogenicity of the parametric fiber, the latter can contain cavities with reduced density (purulent contents).

The development of the infiltrative parametrite sometimes leads to significant deformations, compression of the ureter and the development of a pronounced hydroureter and hydronephrosis, which requires catheterization of the ureter and placement of the urethral stent. The infiltrative parameter causes the formation of urethropyeloectasis not only as a result of the formation of a mechanical obstruction to urinary outflow, but also because in these cases there is a disruption of the function of the neuromuscular apparatus of the ureter under the influence of the inflammatory process. It should be emphasized that during the examination by additional methods in 78% of patients we detected pyelonephritis, which has no classical clinical manifestations.

The severity of secondary renal impairment is directly dependent on the duration of the underlying disease, its severity, frequency and duration of relapse. It is important to emphasize that in all cases of progressive purulent process the functional ability of the kidneys continues to progressively deteriorate until the development of such a formidable disease as chronic renal failure.

Therefore, all patients with complicated forms of purulent inflammation in the presence of infiltrates of the parameter shows the conduct of kidney ultrasound.

With the development of hydronephrosis as a result of inflammatory stricture of the ureter or pyelonephritis, the diameter of the renal pelvis, as a rule, exceeds the norm (3 cm), while the ratio of the thickness of the parenchyma and the pelvis is shifted to 1.5: 1 or 1: 1 (at a rate of 2: 1). The diagnosis of the hydroureter is set if the diameter of the ureter is 1 cm or more.

Exercise of excretory urography is necessary for patients with hydronephrosis transformation of kidneys of various degrees or hydroureter, revealed by ultrasound examination of the kidneys. Signs of stricture of the ureter during excretory urography is a clearly limited narrowing of the ureter in the pelvic region.

To study the function of the kidneys, all patients with severe purulent-septic diseases of the internal genital organs before and after the operation are shown to perform radioisotope renorafion. In severe purulent lesions, the isostenuric or afunctional type of the renographic curve prevails.

Cystoscopy is indicated for patients with parametrite and clinical symptoms of perforation in the bladder. In this case, bullous edema of the mucous membrane of the bladder, corresponding to the inflammatory infiltrate and prolapse towards the bladder, dilates the vessels.

Differential diagnosis

Differential diagnosis in patients with pelvic infiltrates is carried out primarily with malignant neoplasms of the uterus and appendages. Rapid progression of the disease, causal connection with risk factors (especially with the use of IUDs), prevailing laboratory criteria of purulent inflammation, pronounced regression of palpable pathological structures and laboratory parameters under the influence of complex anti-inflammatory and infusion therapy suggest an inflammatory genesis of the disease, otherwise timely consultation of the oncogynecologist , as well as the complete exclusion of physiotherapeutic methods of treatment until the diagnosis is clarified.

[6], [7], [8], [9], [10], [11], [12], [13]

Treatment of the parametrite

Patients with parametrite are subject to mandatory hospitalization. Treatment parametrita depends on the stage of the disease. In the acute stage, a bubble with ice is assigned to the abdomen. Conduct a complex conservative therapy. At the stage of resolution (compaction), the treatment is supplemented by physiotherapeutic procedures (ultrasound, electrophoresis, etc.), biogenic stimulants.

When the paramete is suppurated, surgical treatment is shown - opening of the abscess through the vaginal vault (colpotomy), drainage.

The transferred parametrit leaves the expressed cicatricial changes displacing the uterus towards the disease and accompanied sometimes by pains, a violation of menstrual function.