Diagnosis of inflammation of the uterine appendages

Diagnosis of acute affection of the appendages is based on the history of the disease, the features of the flow, the results of clinical, laboratory and apparatus research methods.

Anamnesis

Studying the patient's anamnesis, one should pay attention to the characteristics of sexual life, previous transcervical diagnostic and / or therapeutic interventions, abortion, operations on the genitals, the presence and duration of use of the IUD. It is necessary to identify a possible relationship between the onset of the disease and the menstrual cycle: the ascent of infection into the desquamation phase. In the presence of a history of diseases with similar clinical manifestations, the duration of its course, the nature and effectiveness of therapy, predisposing factors (hypothermia, overfatigue, etc.), the presence of violations of the menstrual cycle and infertility.

Patients with acute salpingitis or salpingo-oophoritis complain of pain of varying degrees of intensity in the lower abdomen with characteristic irradiation into the sacrum, waist and inner thighs, much less often into the rectum. The pains occur quite sharply or intensify gradually over several days. In 60-65% of cases, women notice an increase in body temperature and pathological discharge from the vagina: blood, sacral, pus-like. Complaints about chills should cause the doctor to be wary about the possible development of a purulent process in the appendages, and repeated chills - to confirm it in this opinion. Many patients complain of vomiting, at the beginning of the disease, however, repeated vomiting often indicates the spread of infection outside the appendages. A complaint of frequent painful urination may indicate an inflammation of the appendages caused by a specific infection ( gonococcus, chlamydia, mycoplasma).

Inspection

The condition of the patient with non-acute acute salpingitis or salpingo-oophoritis remains relatively satisfactory. The manifestations of intoxication are usually absent. The color of the skin and mucous membranes is not changed. The tongue is wet. The pulse rate corresponds to body temperature. The arterial pressure is within the normal range. Palpation of the lower abdomen is painful, but the symptoms of irritation of the peritoneum are absent.

In the presence of a purulent process in the appendages (pyosalpine, pyovar, tuboovarial formation or tubo-ovarian abscess), the general condition of the patient is assessed: as severe or moderate severity. The color of the skin, depending on the severity of intoxication, is pale with a cyanotic or grayish hue. The pulse is frequent, but usually corresponds to the temperature of the body, the discrepancy of these parameters appears with the microperforation of the abscess in the abdominal cavity.

There is a tendency to hypotension due to changes in vollemic indicators: a decrease in the volumes of circulating blood, plasma and red blood cells.

The tongue remains moist. The abdomen is soft, there may be a mild swelling of its lower parts. Symptoms of irritation of the peritoneum in the absence of threat of perforation are not detected, however, palpation of the hypogastric region, as a rule, is painful. Often there it is possible to probe the formation, proceeding from organs of a small basin. The palpation border of the tumor is higher than the percutaneous one due to the fusion of the tubo-ovarian abscess with the bowel loops.

When examining the vagina and cervix with the help of mirrors, you can find purulent, protective, serous-purulent or bloody discharge. The results of bimanual examination depend on the stage, degree of involvement and duration of the inflammatory process in the appendages. In the early stages of acute serous salpingitis structural changes in the fallopian tubes can not be determined; there is only a painful area of their location and increased pain when the uterus is displaced. The progression of the process leads to an increase in the inflammatory edema of the tissues, and the soft, painful tubes begin to palpate. If there is a gluing of the fimbriae and occlusion of the interstitial sections of the tubes, the inflammatory exudate accumulates in their lumen: saktosalpinks are formed. These saccular formations often have the form of retorts and are palpated laterally and posteriorly from the uterine body. Simultaneous involvement in the inflammatory process of the fallopian tubes and ovaries leads to the formation of a unified conglomerate of irregular shape and uneven consistency. In patients with exacerbation of a long-term salpingo-oophoritis, not accompanied by activation of endogenous infection, bimanual examination reveals thickened, inactive, moderately painful, ciliate appendages. For such cases, a sharp pain in the lateral walls of the small pelvis is characteristic, which indicates a pelvic ganglionitis. Bimanual examination with purulent inflammation of the appendages makes it possible to detect a slightly enlarged uterus, painful, especially when mixed, often welded into a single conglomerate with enlarged appendages. In some cases, the enlarged retort-like appendages can be palpated separately from the side and back from the uterus. Quite often, because of the sharp pain, it is not possible to obtain clear data on the status of the appendages. But all the same it should be remembered that for purulent inflammation of the appendages in the stage of remission of the inflammatory process is characterized by fairly clear contours, a dense consistency, some mobility with a fairly pronounced soreness. In the acute course of the inflammatory process, the adnexa formation has fuzzy contours and uneven consistency; it, as a rule, is motionless, closely connected with the uterus and sharply painful, the tissues surrounding the uterus and appendages are pasty.

Lab tests

Mandatory blood testing, including the dynamics of the course of the disease, helps to determine the severity of the inflammatory process. An increase in the number of leukocytes over 9 • 10 ⁹ / L, ESR above 30 mm / h, a positive reaction to the C-reactive protein (- + - +). The content of sialic acid is more than 260 units, the increase in the amount of haptoglobin in the blood serum to 4 g / l (at a rate of 0.67 g / l), the decrease in the albumin-globulin coefficient to 0.8.

Urine examination reveals the initial signs of renal disease, the so-called isolated urinary syndrome. In patients with tubo-ovarian abscess, it is expressed in proteinuria, not exceeding 1 g / l, leukocyturia within 15-25 in the field of view; microhematuria; appearance of 1-2 hyaline and / or granular cylinders. The appearance of a urinary syndrome is associated with intoxication, a violation of the passage of urine, and in some cases indicates a non-rational antibiotic therapy.

Instrumental diagnostics

Today, transabdominal ultrasound scanning is a common method of research in gynecological practice. In many cases, it helps diagnose acute inflammatory processes of the internal genital organs, but the interpretation of the echogram is difficult if the inflamed uterine tubes are enlarged only slightly if there is an extensive adhesion process in the small pelvis or if the patient has obesity of the anterior abdominal wall. When in acute salpingitis it is possible to visualize the fallopian tubes, they have the appearance of elongated irregular forms of single-chamber fluid formations with a homogeneous internal structure and thin walls located laterally or posteriorly from the uterus. The walls of the pyosalpinx have clear contours of average echogenicity, purulent exudate is echo negative. Ultrasound differential diagnosis of piovaria and ovarian tumor is practically impossible due to the similarity of their echograms, represented by rounded formations of reduced echo density with a fairly clear capsule. The tubo-ovarian abscess is identified as an irregularly shaped multi-chambered formation with fuzzy contours. A more accurate assessment of the state of the internal genital organs will become available after the introduction into practical gynecology of transvaginal echography. With the help of this method it will be possible to determine the slightest changes in different departments of the fallopian tube and in the structure of the ovary, to reveal the boundary between the altered appendages, to recognize the nature of the exudate in them, to study in detail the structure of the tubo-ovarian abscess.

As an additional method of diagnosing acute inflammatory diseases of the uterine appendages, laparoscopy is widely used , with the help of which it is possible not only to clarify the diagnosis and determine the degree of damage to the fallopian tubes and ovaries, but also to obtain material for bacterioscopic and bacteriological research to split the fusion, remove pus accumulation, antibiotics to the lesion focus, etc. The risk of laparoscopic examination is the possibility of spreading the infection, which several granichivaet its application. It is recommended to use this method only with a picture of the acute abdomen of unexplained ethnology, but with the predominance of a clinic of acute inflammation of the uterine appendages. This approach proved to be completely justified and allowed authors to confirm the presence of the inflammatory process in the appendages in 69.8 % of cases. In 16% - to reveal a surgical pathology, in 4% - to detect ectopic pregnancy, ovarian apoplexy, torsion of the ovary tumor, in 10% of women, pelvic pathology was not detected. Our experience of using laparoscopy for the diagnosis of inflammation of the uterine appendages allows us to fully share the point of view of the authors.

The laparoscopic picture gives a clear idea of the nature and distribution of the inflammatory process in the small pelvis. Hyperemic, swollen, with weak motor activity, the fallopian tube, from the free ampullar end of which comes the turbid discharge, indicates the presence of acute catarrhal salpingitis. With purulent salpingitis on the serous cover of the tube, one can see fibrinous or fibrinous-purulent overlays and pus flowing out of its lumen. Retortoobraznoe increase in the tube with a sealed ampullar end indicates the formation of pelvioperitonitis. To conclude about the presence of pelvineuritonitis, hyperemia of the parietal and visceral peritoneum with sites of hemorrhages, fibrinous and / or suppurative layers allows; a murky, hemorrhagic or purulent effusion in the anterior space. When the pioalpinx rupture or tubo-vascular formation breaks, a perforation can be seen; In the vast adhesion process, this complication is indicated by the abundant supply of pus from the region of altered appendages.

There are 5 laparoscopic pictures: acute catarrhal salpingitis; catarrhal salpingitis with phenomena of pelvioperitonitis; acute purulent salpingo-oophoritis with phenomena of pelvic peritonitis or diffuse peritonitis; purulent inflammatory tubo-ovarian formation; rupture of pyosalpinx or tubo-ovarian formation, diffuse peritonitis.

A definite value for clinicians is the identification of a microbial factor that caused an acute inflammatory process. To this end, it is recommended to apply more rapid express diagnostics: light and luminescent microscopy of smears of native material, examination of purulent exudate in passing ultraviolet rays, gas-liquid chromatography, indirect immunofluorescence method. A more accurate picture of the etiology of the disease can be obtained by using culture methods of research, both traditional and using strict anaerobic techniques. The time spent on bacteriological research is paid for by the accuracy of the results obtained, which ensure the possibility of effective correction of antibacterial therapy. However, it should be remembered that the reliability of the results of bacteriological analyzes depends not only and not so much on the skilled work of laboratory services, but also on the correctness of the material intake by clinicians. The true cause of the inflammatory process is the results of a study of exudate taken directly from the focus of inflammation during abdominal or laparoscopy. Somewhat lower is the reliability of the study of the material obtained by puncturing the posterior vaginal fornix.

Bearing in mind the increasing role of Chlamydia in the etiology of acute inflammation of the uterine appendages, it is necessary to take this fact into account when examining, using available cytological and serological diagnostic methods. Bacterioscopic and bacteriological studies aimed at detecting possible gonococcal infection are still relevant.

Thus, a thorough examination of the history, assessment of the general condition and data of the gynecological examination, as well as laboratory studies (clinical and biochemical analyzes of blood and urine, bacteriological and bacterioscopic studies of exudate and pus), the use of ultrasound and, if necessary, laparoscopy, enable accurate diagnosis of acute inflammation of the appendages of the uterus, to determine the severity and extent of the process, the nature of the pathogen and, consequently, to implement adequate therapy.