Inflammation of the appendages of the uterus (salpingo-oophoritis): treatment

Treatment of acute inflammation of the uterine appendages should be carried out only in a hospital. This rule extends to patients with acute course of the process without vivid clinical manifestations. The earlier the patient is hospitalized, the more timely the adequate therapy will be started and the more likely to reduce the number of possible adverse effects that are typical for this type of disease. Attempts to treat patients on an outpatient basis, according to our observations, almost 3 times increase the percentage of such immediate and remote complications as the spread of the inflammatory process and the formation of purulent foci in the small pelvis, the chronic disease, the violation of menstrual and reproductive functions, the development of ectopic pregnancy.

Patients need physical and mental rest. Depending on the features of the course of the disease for 3-5-7 days are assigned bed rest. From the diet exclude spicy dishes. For women with acute inflammatory diseases of the internal genital organs, especially in the recurring course of the chronic process, a variety of psychoemotional disorders (sleep, appetite disorders, increased irritability, fatigue, etc.) are characteristic. Therefore, to participate in the treatment of patients it is desirable to involve a psychotherapist, prescribe sedatives, hypnotics.

The leading method of treatment of acute inflammation of the uterine appendages is antibacterial therapy. It is carried out both independently and in combination with surgical methods of treatment. Antibiotic therapy should be started as early as possible, t. C. Immediately after taking material for bacterioscopic, cytological and culture studies. Determining the nature of the flora and its sensitivity to antibiotics requires a certain time, and the appointment of antibacterial therapy, as already noted, is an emergency measure, therefore, drugs must be chosen empirically, guided by the following rules:

1. Take into account the clinical picture of the disease, which has its own characteristics with different pathogens.
2. Remember that in modern conditions, the inflammatory process is often caused by a mixed infection.
3. Do not forget about the possible biphasic course of the disease due to anaerobic infection.
4. Change the scheme of antibiotics, if after 3 days of treatment there is no clinical effect.

For example, for acute inflammation of the appendages of gonorrheal etiology, the following symptoms are characteristic: the relationship between the onset of the disease and menstruation; Multiple lesions; involvement in the process of appendages on both sides; frequent spread of infection to the pelvic peritoneum; blood or purulent discharge from the genital tract. Gonococci often coexist with Trichomonas and Chlamydia. The drug of choice in this situation is penicillin in combination with metronidazole or tinidazole in standard dosages. After confirming the presence of chlamydial infection, tetracycline antibiotics or macrolides are added.

Acute chlamydial salpingitis is distinguished by a relatively light, but protracted course. The main complaints of patients are pains in the lower abdomen of the aching nature, irradiating the lower back, the sacrum and inguinal areas. With the development of perihepatitis pains in the right upper quadrant join. Excretions from the genital tract are abundant, serous-purulent or purulent-sacral. As a rule, all the symptoms grow gradually. At half of patients at objectively serious process the temperature of a body remains normal or subfebrile. Chlamydial infection infrequently leads to the formation of tubo-ovarian formations, but because of the propensity to develop an adhesive process, it causes tubal infertility. Only early initiated etiotropic treatment can preserve the health and reproductive function of women. The most active action against chlamydia is caused by tetracyclines and macrolides, which must be administered at sufficiently high dosages for a long time.

Tetracycline and oxytetracycline dihydrate is prescribed orally 0.5 g (500 000 units) every 6 hours for 2-3 weeks, tetracycline hydrochloride - intramuscularly at 0,05-0,1 g 2-3 times a day for 10 days. Doxycycline hydrochloride (vibramycin) can be used, adhering to the following scheme: 3 days for 2 capsules (0.2 g) 3 times a day and (0 days for 1 capsule (0.1 g) 3 times a day.

Erythromycin is used inside by 0.5 g (500,000 units) 4 times a day for 10-14 days. Erythromycin phosphate is given intravenously at a dose of 0.2 g (200,000 units) every 8 hours for 7-10 days; the drug is diluted in 20 ml of isotonic sodium chloride solution and injected slowly over 3-5. Min.

The following features of the clinical course of the inflammatory process in the appendages indicate the need for antibiotic therapy aimed at the elimination of anaerobic infection: acute onset of the disease after childbirth, abortion, other intrauterine interventions or against a background of IUD characterized by fever, chills, severe pain syndrome. Anaerobic contamination may be indicated by a repeated worsening of the patient's condition, despite the ongoing standard antibiotic therapy ("two-step process"). At an objective inspection at anaerobic infection reveal the expressed infiltration of fabrics, formation of abscesses, an unpleasant putrefactive smell of exudate. Relatively low leukocytosis is accompanied by a slight decrease in the level of hemoglobin and a significant increase in ESR. In cases of the assumption of an anaerobic infection, the drugs of choice are metronidazole (flagyl, clion, trichopolum) and tinidazole (phasicin, tricanix). Metronidazole and its analogs are prescribed orally 0.5 g 3-5 times a day; thiiodazole - 0.5 g 2 times a day; course of treatment - 7-10 days. In severe cases, twice a day, 100 ml of metragol (500 mg) are intravenously administered intravenously.

A very effective property against anaerobes is clindamycin (Dalacin C), somewhat less - lincomycin and levomycetin. Clindamyin can be administered intravenously at 0.6-0.9 g at intervals of 6-8 h or inwards at 0.45 g 3-4 times a day. Linkomtsiia hydrochloride is administered intramuscularly at 0.6 g in 8 hours or orally - 0.5 g 3 times a day. Levomycetin is taken orally 0.5 g 3-4 times a day; Levomycetin succinate is administered intramuscularly or intravenously at 0.5-1 g at intervals of 8-12 hours.

If there are no clear clinical signs characteristic of a particular kind of infection, then before the results of laboratory tests are obtained, it is expedient to prescribe a combination of antibiotics that cover the most common spectrum of pathogens: gonococcus, chlamydia, gram-positive and gram-negative aerobes and anaerobes. In addition, when choosing a drug, it is necessary to take into account the rate of penetration of antibiotics into the affected organ and the half-life of them in the focus of inflammation. Similar requirements are met by the following combinations:

• - penicillins with aminoglycosides;
• - cephalosporins with aminoglycosides;
• - cephalosporins with tetracyclines;
• - lincomycin or clindamycin with aminoglycosides.

It should not be forgotten that semisynthetic penicillins, cephalosporins and aminoglycosides have a wide spectrum of action on gram-positive and gram-negative aerobic microorganisms, but are not sufficiently active against non-clostridial anaerobes, trash and mycoplasma. However, the newest penicillins (piperacillin, aelocillin) and cephalosporins (cefotaxime, cefoxitin) are effective against many forms of anaerobes. Antibiotics of the tetracycline series have a rather wide range of antimicrobial action, including against chlamydia and mycoplasmas. But do not affect anaerobic infection. Lincomycin and clindamycin are active against most gram-positive cocci, some gram-positive bacteria, many non-spore-forming anaerobes, mycoplasmas. Aminoglycosides are broad-spectrum antibiotics; they are effective against gram-positive and especially gram-negative bacteria, but do not affect chlamydia and anaerobes. Therefore, in patients with suspected possible anaerobic infection, it is advisable to supplement the combination of antibiotics with the appointment of metronidazole or tinidazole.

Doses of drugs depend on the stage and prevalence of the inflammatory process. With acute catarrhal salpingitis and salpingoophoritis without signs of inflammation of the pelvic peritoneum, it is sufficient to prescribe intramuscular injection of medium doses of antibiotics for 7-10 days:

• 1-2 million units of penicillin sodium or potassium salt every 6 hours;
• 1 g methicillin sodium salt also every 3 hours;
• 0.5 g of oxacillin or ampicillin sodium salt 4-6 times a day;
• 1 g of ampiox 3-4 times a day;
• 0.5 g of cephaloridine (chain) or cefazolin (kefzol) every 6 hours;
• 0.6 g of lincomycin hydrochloride after 8 hours, clindamycin phosphate (dalacin C) in the same dosage;
• 0.5 g of kanamycin sulfate 2-3 times a day;
• 0.04 g of sulphate gentamation 3 times a day.

Most tetracycline drugs are administered orally in tablets or capsules: tetracycline hydrochloride 0.2 g 4 times a day, metacycline hydrochloride 0.3 g 2 times daily, doxycycline hydrochloride 0.1 g also 2 times a day.

Acute adnexitis, pathogenetically associated with intrauterine manipulation, artificial abortion (especially community-acquired abortion), IUD, internal genital surgery, is suspected of the possibility of an anaerobic infection, therefore it is recommended that antimicrobial agents be supplemented with tinidazole or metronidazole. Metronidazole (flagyl, trichopolum, clion) is administered orally 0.5 g 3 times a day, tinidazole (phasicin, tricanix) - 0.5 g 2 times a day.

In acute purulent salpingitis or adnexitis, the intensity of antibacterial therapy should be increased, for which, by increasing the dose of antibiotics, one of them is expediently administered intravenously. The most rational combination, which provides a wide range of antibacterial action, speed and depth of penetration into the lesion, is considered intramuscular use of aminoglycosides with intravenous infusion of clindamycin. It is quite effective to combine intramuscular administration of aminoglycosides with intravenous infusion of penicillins or cephalosporins. Gentamycin sulfate is administered 80 mg every 8-12 hours, kanamycin sulfate 0.5 g every 6 hours. Drip intravenous infusions of clindamycin phosphate are administered 600 mg every 6-8 hours, benzylpenicillin sodium salt is administered at 5-10 million ED after 12 h, carbenicillin disodium salt 2 g after 4-6 h, ampicillin sodium salt 1 g after 4-6 h, cefaloridine or cefazolin - 1 g every 6-8 h. Combination of antibiotics is quite reasonable supplement with intravenous administration of metronidazole (metrogil) 500 mg 2-3 times a day, and with positive reactions to chlamydia - dock sicycline (100 mg in 12 hours also intravenously).

With a favorable clinical effect, intravenous antibiotics should be used for at least 4 days, and then you can switch to intramuscular and enteral administration of antibiotics. Antibiotikoteramiyu stop after 2 days after the normalization of body temperature, but not earlier than the 10th day from the start of treatment. In the absence of positive dynamics, it is necessary to revise the patient's treatment plan in a timely manner, i.e. No later than 48 hours. Control over the effectiveness of the therapy is performed on the basis of clinical and laboratory manifestations: body temperature, pain symptom, peritoneal signs, clinical and biochemical blood tests reflecting the acute phase of inflammation. If necessary, resort to laparoscopy.

To increase the effectiveness of antibiotic therapy in recent years, we have successfully used intrauterine injection of antibiotics according to the method of BI Medvedev and co-workers. (1986). We use different preparations of a wide spectrum of action, but more often - aminoglycosides: kanamycin sulfate, gentamycin sulfate, tobramycin, amikacin. Transcervical without expansion of the cervical canal, a long needle in the conductor is fed to the tube-corner region; the tip of the needle extends 1.5-2 mm; under the mucous membrane and partially in the muscle layer, then 2-3 ml of a solution containing a daily or single dose of an antibiotic is administered. Single-dose injections were used only in those cases when the course of the disease required the use of maximum quantities of the drug. Because of the impossibility of dissolving antibiotics in a limited volume of liquid (2-3 ml), only a part of the daily dose was administered intrauterine, replacing the rest with usual intramuscular injections. The course of treatment - 6-8 intrauterine injections once a day alternately in the right and left sides.

Sulfanilamide preparations and derivatives of nitrofuran currently do not occupy a leading place in the therapy of acute inflammation of the uterine appendages, they are used in those cases when laboratory studies confirm the resistance of pathogens to antibiotics. Usually prescribed sulfonamides are prolonged action, the use of which gives fewer side effects. Sulfapyridazine is taken orally once a day: 2 g on the first day of intake, 1 g in the following. The course of treatment is 7 days. Sulfamonomethoxin and sulfadimethoxin in cases of severe disease are used in the same dosages; with mild and moderate disease, the doses of the drugs are halved: 1 g on the first day of administration, and 0.5 g in the subsequent. A combined preparation of bactrim (biseptol), in 1 tablet or in 1 ampoule (5 ml) of which contains 400 mg of sulfamethoxazole and 80 mg of trimethoprim is used. With a mild and moderate inflammatory process, patients receive 2 tablets twice a day; in severe course - 2 ampoules of biseptol (10 ml) are diluted in 250 ml of isotonic sodium chloride solution or 5% glucose solution and injected intravenously every 12 hours. The course of treatment is 5-7 days. Preparations of the nitrofuran series (furagin, furadonin, furazolidon) appoint 0.1 g 4 times a day. Furagina potassium salt (solafur) can be administered intravenously by drop method in the form of a 0.1% solution of 300-500 ml per day. The course of treatment with nitrofurans lasts 7-10 days.

The duration of antibiotic therapy, especially in weakened patients, requires the preventive use of antimycotic agents. To this end, prescribe 3-4 times a day pills nystatin for 1 million units and levorin for 500 thousand units.

In a complex of therapeutic agents, it is rational to include pyrazolone derivatives that have analgesic, antipyretic and anti-inflammatory properties. These include antipyrine and amidopyrine, which are prescribed in tablets 0.25 g 2-3 times a day, butadione - 0.05 g 4 times a day, analgin - in tablets of 0.5 g or 1-2 injections ml of 50% solution.

The use of antihistamines, which produce an anti-inflammatory effect, is pathogenetically grounded. 2-3 times a day, patients receive dimedrol tablets of 0.05 grams or intramuscularly 1-2 ml of a 1% solution, diprazine (pipolphen) in tablets of 0.025 g or intramuscularly 1 ml of a 2.5% solution, suprastin to 0.025 g in tablets or 1 ml of a 2% solution intramuscularly, tavegil in tablets (0.001 g) or in injections (2 ml containing 0.002 g of substance). Increase the effect of antihistamines calcium and chloride, gluconate, 5-10 ml of a 10% solution of which is administered intravenously. GM Savelyeva and LV Antonova (1987) strongly recommend the use of histoglobulin, which is a combination of histamine chloride and y-globulin, which increases the body's ability to inactivate the free oppression of mines and increases the protective properties of blood. Gistaglobulin administered subcutaneously after 2-4 days for I-2-3 ml, the course of treatment - 3-6 injections.

In a complex of therapeutic agents, it is desirable to include sedatives, regulating the functions of the central nervous system, enhancing the action of analgesics, which have antispasmodic properties. Widespread are infusion and tincture of Valerian root, infusions and tincture of herb Leonurus, tincture of peony.

Inflammatory diseases of the uterine appendages often develop in women with a marked decrease in specific immune reactivity and a weakening of the nonspecific protective forces of the body. Etiotropic aitibiotikoterapiya leads to further disruption of processes that ensure the tolerance of the macroorganism to the effects of infection. Consequently, increasing the patient's resistance to infection is an important part of complex treatment. To this end, you can use a fairly wide arsenal of drugs:

• immunoglobulin antistaphylococcal: 5 ml intramuscularly every 1-2 days, for a course of 3-5 injections;
• human immunoglobulin is normal, or polyglobulin: 3 ml intramuscularly every 1-2 days, for a course of 3-5 injections;
• adsorbed staphylococcal anatoxin by 0.5-1 ml subcutaneously in the lower angle of the scapula after 3-4 days, on the course of 3 injections; A scheme for the administration of concentrated purified staphylococcal toxoid is also recommended: under the skin of the inguinal fold of the thigh every 3 days in increasing doses (0.1, 0.3, 0.5, 0.7, 0.9, and 1.2 ml), the drug is used after the acute effects of adnexitis subsiding;
• when confirming the staphylococcal origin of the disease, an excellent effect is given by intravenous drip injection of 200 ml of hyperimmune antistaphylococcal plasma, which, depending on the severity of the disease, is repeated 1-2-3 days later;
• pyrimidine and purine derivatives that increase the effectiveness of antibiotics, stimulate phagocytosis and the production of antibodies that have a pronounced anti-inflammatory and anabolic properties: among the pyrimidine derivatives, pentoxyl in tablets of 0.4 g 3 times a day and methyluracil in tablets of 0.5 g 3 times a day, and among purine - potassium orotate 0.5 g 2 times a day;
• enzyme protein nature lysozyme, which, along with the ability to stimulate the nonspecific reactivity of the body, has antibacterial and anti-inflammatory properties, is administered intramuscularly by 100 mg 2-3 times a day, the course is 7-10 days;
• vitamins B12, C and folic acid, enhancing the action of adjuvants, ie, drugs that increase the nonspecific protective forces of the body;
• Lipopolysaccharides of bacterial origin, of which the most studied is prodigiosan, activating cellular immunity, increasing the level of γ-globulin content, which has an adjuvant effect in the synthesis of antibodies: 0,005% solution of prodigiozan in an amount of 0.5-1 ml is administered intramuscularly at intervals of 4 days, course treatment - 3-4 injections;
• other drugs that stimulate immunological processes, in particular levamisole (decaris), thymalin, tactivin.

Levamisol acts mainly on cellular immunity factors, normalizing the function of T-lymphocytes and phagocytes. There are many schemes of drug administration. Uses the following schemes:

• 50 mg once a day for 3 consecutive days with a break of 4 days, for a course of 450 mg;
• on 150 mg I once a week, on a course also 450 mg.

Levamisol is contraindicated in case of unfavorable allergological anamnesis, severe liver and kidney diseases, and leukocyte count in peripheral blood below 4 • 10 ⁹ / l.

Timalin regulates the number and ratio of T- and B-lymphocytes, stimulates cellular immunity reactions, enhances phagocytosis, and accelerates regeneration processes. Assign it intramuscularly to 10 mg 2-3 times a day for 7-10 days.

Tactivin normalizes the quantitative and functional indices of the T-system of immunity. It is applied subcutaneously to 1 ml 1 time per day for 7-14 days.

Stimulation of factors of nonspecific protection and immunity can be carried out by means of autotransfusions irradiated with ultraviolet rays of blood (AOFOK). Along with the activation of complement and phagocytic activity of neutrophils, the normalization of lysozyme, the increase in the quantitative and functional characteristics of T and B lymphocytes, AUFOK has a diverse effect on the patient's body. Strong bactericidal and oxygenating effect, stimulating effect on the processes of hemopoiesis. And regeneration, a favorable effect on the rheological properties of blood and microcirculation are the basis for the widespread use of AUFO.K with the aim of arresting acute inflammatory diseases of female genital organs. The volume of irradiated blood is determined from the calculation of 1-2 ml per 1 kg of body weight of the patient. The rate of exfusion and infusion is 20 ml / min. The course of treatment - 5-10 sessions.

With the expressed phenomena of intoxication accompanying the development of acute inflammatory processes, infusion therapy with strict control of the ratio of the amount of solutions to be administered to the body and the secreted fluid (urine, sweat, secretion of liquid vapors by the lungs) is shown . If the excretory function of the kidneys is not violated, the maximum number of solutions is introduced at a rate of 30 ml / (kg • day). When the body temperature rises by 1 C, the amount of infusion liquid increases by 5 ml / (kg • day). With an average body weight of 60-70 kg a day, about 2,000 ml of liquid is injected intravenously.

It should be noted that detoxification effect can be achieved using 3 principles:

• the dilution of blood, at which the concentration of toxins decreases; for this purpose, you can use any plasma substitutes, including saline solutions and glucose;
• attraction of toxins from blood and interstitial space and their binding due to the formation of complexes (hemodes, neohemodes, polydes, neo-compensation) or adsorption on the surface of molecules (rheololiglucin, gelatin, albumin);
• excretion of toxins in the urine due to increased diuresis (mannitol, lasix).

In order for complex therapy of acute adnexitis to be successful, it is necessary to observe the rule of individual approach in each case of the disease. This applies not only to rational antibiotic therapy, as discussed above. All the components of treatment should be individualized.

In 60% of cases, for example, exacerbation of chronic inflammation of the appendages is not associated with activation of the infectious agent or with reinfection. It is provoked by nonspecific factors: overfatigue, hypothermia, stressful situations and extragenital diseases against the background of a decrease in the immunological reactivity of the woman's body. In the pathogenesis of recurrence of chronic adnexitis, a significant role is played by the processes of autosensitization and autoallergization, the disruption of the functions of the nervous system; a disorder of hemodynamics in the vascular pool of the small pelvis, a violation of the synthesis of steroid hormones by the ovaries. All this determines the individual choice of complex therapy. In such cases, there is no need for prolonged and massive antibiotic therapy. The emphasis is on the use of desensitizing, rheologically active, nonspecific anti-inflammatory drugs with simultaneous immunocorrection and adaptogens. Rational purpose of minimal doses of sex hormones, vitamins and the early addition of physiotherapy, taking into account the phase of the menstrual cycle.

With acute catarrhal salpingitis or salpingo-oophoritis occurring with mild clinical manifestations, in addition to the appropriate antibiotic therapy, it is sufficient to prescribe sedatives and antihistamines, pyrimidine or purine derivatives, vitamins. If the inflammatory process has a clinical course of moderate severity, then against the background of adequate antibiotic therapy, it is necessary to resort to parenteral administration of antihistamines, strengthening immunocorrection. It is justified to conduct sessions of AOFOK and detoxification infusions.

Objectively severe course of acute or exacerbation of chronic inflammatory process in the appendages of the uterus requires maximum use of all therapeutic agents. Intensive antibacterial, detoxification, desensitizing, immunocorrective therapy is performed with careful clinical observation under the control of laboratory tests. The choice of further treatment depends on which of the three options will develop the pathological process:

1. positive dynamics of clinical and laboratory manifestations;
2. further progression of the disease;
3. absence of significant changes in the patient's condition for 48 hours.

In the 1-st case, it is necessary to continue the therapy started, because it was adequate.

In the second case, the worsening of the patient's condition indicates a threat to either the already occurred perforation of the pyosalpinx, pyovar or tubo-ovarian formation. Proof of this complication are: a sharp increase in pain in the lower abdomen, accompanied by vomiting; hectic body temperature with chills; the appearance of peritoneal symptoms; Progressive enlargement of appendages with loss of sharpness of borders; a sharp deterioration in the leukocyte formula of peripheral blood; an increase in ESR. In this situation urgent surgical intervention is indicated.

In the third case, there is a need to clarify the state of the appendages to correct further therapy. In modern conditions, in such a situation, the method of choice is the therapeutic and diagnostic laparoscopy. When confirming acute catarrhal or purulent salpingitis, the area of the appendages is drained, followed by administration of antibiotics for 3-5 days.

If, during laparoscopy, a forming pyosalpinx is detected. Piovar or tubo-ovarian abscess, then the age of the patient should be taken into account in choosing the tactics of therapy, its desire to maintain reproductive function, it is necessary to take into account the accompanying pathology of the female genitalia (uterine myoma, endometriosis of the appendages, ovarian cysts, etc.). In women older than 35 years, as well as in patients of any age, in the presence of concomitant pathology of the genital organs, it is possible to confine the drainage to the focus of inflammation for further antibiotic therapy. Without reducing the intensity of general anti-inflammatory treatment, it is necessary to carefully monitor the dynamics of the process. If the patient's condition worsens, the question of urgent surgical intervention may arise. If the active inflammatory process can be eliminated, but the attachment will continue, the patient becomes a candidate for planned surgical intervention. In young women who do not have a concomitant pathology of the genital organs and want to maintain their reproductive function, it is advisable to perform a puncture of purulent formation during laparoscopy, evacuate the exudate, rinse and drain the cavity, thereby allowing antibacterial drugs to be delivered directly to the lesion in 3-5 days . The optimal option for such therapy is to exercise it under the control of dynamic laparoscopy.

Puncture of inflammatory formations can be realized through the posterior vaginal vault under the control of ultrasound (preferably transvaginal) examination or computed tomography. After aspiration of purulent exudate, the cavity is drained with a special catheter, or limited to the introduction of antibiotics. In the latter case, the puncture of the purulent formation can be performed 2-3 times at intervals of 2-3 days. Some authors insist on the inexpediency of this method of treatment, referring to the vastness of destructive changes in the appendages of the uterus when they purulent lesions. It seems to us that this opinion is reasonable only in cases of a recurrent course of the chronic inflammatory process with the formation of bilateral pyosalpinks or tubo-ovarian abscesses: However, if acute inflammation of the appendages with the formation of a one-sided abscess in the fallopian tube or ovary originated for the first time, if it is not a consequence of endomyometritis and does not combine with pelvioperitonitis, then you can count on the positive effect. Modern diagnostic methods (laparoscopy, transvaginal ultrasound, computed tomography) provide accurate diagnosis and careful puncture, and the newest antibacterial drugs successfully eliminate the infection. Some authors report the retention of patency of the fallopian tubes in 41.8% of women who underwent complex therapy using dynamic therapeutic-diagnostic laparoscopy, transabdominal or transvaginal drainage.

Acute inflammatory process in the appendages of the uterus in the vast majority of cases can be eliminated by conservative treatment methods: according to our data, in 96.5%. Indications for holocaust can be formulated as follows:

• suspicion of perforation of suppurative appendages;
• presence of pyosalpinx, pyovar or tubo-ovarian abscess on the background of IUD;
• complication of acute inflammation of the uterine appendages with purulent parametrite;
• inefficiency of complex treatment using laparoscopic drainage, conducted during 2-3 days.

Operations performed for inflammation of the uterine appendages are not standard either in terms of volume or technique. The nature of surgical intervention depends on:

• prevalence. Process in appendages (pyosalpinx, pyovar, tubo-ovarian formation, one-sided, bilateral lesion, involvement of parametric fiber);
• the severity of the adhesive process in the abdominal cavity;
• communication of the disease with childbirth, abortion, IUD;
• presence of concomitant diseases of the reproductive system;
• age sick.

Young women need to use the slightest opportunity to preserve reproductive function. The operation is limited to removing the altered organs: the uterine tube or appendages on the side of the lesion. However, if surgery for purulent inflammation of the appendages is performed in young women with postpartum, post-abortive endometriometritis or against the background of IUD, then the volume should be expanded to the extirpation of the uterus with both tubes. The ovary is removed only if there are pathological changes in it. Sharp infiltration of tissues of parametric fiber allows, instead of extirpation of the uterus, to limit its amputation, although this view is not shared by all. Tumor lesions of the ovaries, the body and the cervix require an adequate expansion of the operation.

The radical nature of surgical intervention increases with age of the woman. In women older than 35 years with unilateral defeat of the appendages, it is reasonable to remove the second fallopian tube. In women older than 45 years, if necessary, the surgical treatment of acute inflammatory diseases of the appendages makes sense to produce a pangysterectomy.

For the prevention of postoperative complications, mandatory drainage of the small pelvis or abdominal cavity is performed, in the implementation of which the principle of individual approach remains relevant. If there is no significant adhesion process, if there is no infiltration of the tissues of neighboring organs, if reliable hemostasis is performed, then it is enough to bring a thin drainage tube to the pelvis for antibiotics, the latter usually removed on the 4th day of the postoperative period.

With a pronounced adhesion process, extensive infiltration and increased tissue bleeding, adequate drainage is necessary to ensure the outflow of the wound secretion. A good effect can be achieved by draining the small pelvis through the posterior vaginal fornix (posterior colpotomy with supravaginal amputation of the uterus) or through an opening in the vaginal canal (with uterine extirpation). Simultaneously, through the counter-lines in the hypogastric areas, thin tubes are inserted for administration of antibiotics, and, if necessary, an analysis solution.

It is recommended to use the method of permanent aspiration-flushing drainage, which consists in the forced evacuation of liquefied wound exudate, pus and fibrin through the double-lumen silicone tubes in the postoperative period. The narrow lumen of the tube is intended for the introduction of Analyzing solutions, wide - for the evacuation of liquefied exudate. Aspiration is carried out automatically by the device OP-1 for 5-7 days. Drainage tubes can be brought to the lobe of a removable abscess through the vaginal arch or through the abdominal wall.

In the presence of extensive infiltration of tissues surrounding the purulent formation of the uterine appendages, drainage is successfully performed with the help of gauze pads, placed in glove rubber. In a conventional surgical glove, the fingers are cut off, almost at their bases, several holes with a diameter of about 1 cm are cut out on the palm and back of the glove. There are several gauze strips 2-3 cm wide and one thin silicone tube inside the glove. Gauze strips lead to each base of the finger, without going beyond it; The tube is withdrawn from the glove for a distance of 5-6 cm. Prepared glove-gauze drainage through the counter-line into the hypogastral. The area of the abdominal wall is brought to the ulcer bed and gently spread over its entire area. On the surface of the abdominal wall remain cuff gloves, ends of gauze strips and a silicone tube intended for the administration of antibiotics. Gauze drains, enclosed in a rubber glove, function well without getting lame, for 7 days or more, do not lead to the formation of pressure sores on the intestinal wall and are easily removed together with the glove. The tube for antibiotic administration usually lasts for 4 days and then is removed.

In the postoperative period it is necessary to continue intensive therapy in the following main directions:

• infection control taking into account the results of bacteriological studies and antibioticograms;
• infusion-transfusion therapy aimed at detoxification, normalization of protein and electrolyte balance, improvement of rheological properties of blood;
• the implementation of non-specific anti-inflammatory therapy, the use of desensitizing agents;
• influence on the immune status of the patient;
• vitamin therapy and the use of anabolic agents;
• adequate stimulation of bowel function.

[1], [2], [3], [4], [5],