Inflammatory diseases of the pelvic organs are very common in gynecology. They are a consequence of or accompany infections of the female reproductive organs. The cause of PID is the causative agents of sexually transmitted infections: fungi, viruses, pyogenic microflora, pathogenic and opportunistic microorganisms.

Symptoms inflammatory diseases female genital organs are often poorly expressed, without pain and discomfort. If the pathology is not detected in time and treatment is not started, PID will lead to irreversible damage to the uterus, ovaries, fallopian tubes and cause serious gynecological and obstetric complications.

Etiology and classification of PID

Pelvic inflammatory disease occurs as a result of the ascending spread of infection from the vagina and cervical canal to the uterine lining, fallopian tubes, ovaries and peritoneum.

The most common infection is sexually transmitted. Aerobic and anaerobic bacteria, chlamydia, mycoplasma, gonococcus, and sometimes several microorganisms at once penetrate into the upper parts of the reproductive system with the help of spermatozoa.

The causative agents of septic infection can enter the genitals through blood or lymph from distant foci of inflammation, for example, with follicular angina, otitis media, purulent appendicitis.

Diseases that are caused by sexually transmitted infections are called specific. These include trichomoniasis, chlamydia, gonorrhea, syphilis, herpes and human papillomavirus infections, and others.

Conditionally pathogenic microorganisms are the cause of nonspecific inflammatory diseases: staphylococci, E. coli, streptococci, Pseudomonas aeruginosa, fungi and others. Normally, they are in an inactive state in the microflora of the body, but under certain conditions they become dangerous and cause disease.

Allocate pathologies of the lower and upper parts of the small pelvis. Diseases of the lower sections:

• Vulvitis is an inflammation of the vulva.
• Bartholinitis is an inflammation of the large gland of the vestibule of the vagina.
• Colpitis (vaginitis) is an inflammatory process of the vaginal mucosa. Often combined with vulvitis, urethritis.
• Endocervicitis is an inflammation of the mucous membrane of the cervical canal.
• Cervicitis is an inflammatory process of the cervix.

Diseases of the upper sections:

• Endometritis is an inflammation of the inner mucous membrane of the uterine cavity.
• Salpingitis is an inflammation of the uterine (fallopian) tubes.
• Oophoritis is an inflammation of the ovary.
• Salpingo-oophoritis or adnexitis - inflammation of the uterine appendages: tubes, ovaries, ligaments.
• Parametritis is an inflammation of the connective tissue around the uterus.
• Pelvioperitonitis is an inflammation of the pelvic peritoneum.
• Tubo-ovarian abscess is a purulent inflammation of the uterine appendages.

The causes of the onset and development of pathologies are:

• previously transferred infectious diseases;
• trauma, mechanical damage to the pelvic organs;
• inflammatory processes in adjacent organs: appendicitis, colitis, cystitis, urethritis, ICD;
• improper use of intravaginal tampons;
• surgical interventions for abortion, diagnostic curettage of the uterine cavity, the introduction of an intrauterine device;
• endocrine disorders;
• reaction to local contraceptives;
• long-term uncontrolled intake of antibiotics or hormonal drugs.

The provoking factors are hypothermia, constant stress, frequent colds, inadequate and inappropriate nutrition.

Clinical manifestations of PID

There are acute and chronic stages of pelvic inflammatory disease. The acute stage is rare. Symptoms for which you need to urgently undergo a gynecological examination:

• pulling and aching pains in the lower abdomen or lower back;
• itching and burning in the external genital area;
• the appearance of ulcers, blisters, warts or spots near the entrance to the vagina, anus, on the vulva;
• an increase in the inguinal lymph nodes;
• violation of menstrual function: delays, heavy and painful periods;
• vaginal discharge of a yellowish or greenish pus-like color with a pungent odor;
• pain when urinating;
• discomfort during intercourse;
• general weakness, fever (sometimes up to 40 ° C), nausea, vomiting.

More often, the disease does not manifest itself for a long time, a woman feels healthy for several weeks, months or even years. During this time, the disease becomes chronic. Therefore, women need to be examined by a gynecologist at least once a year.

Diagnosis and treatment of pelvic inflammatory disease in women

During the examination, the doctor reveals pain on palpation of the abdomen, uterus and appendages, takes a smear from the cervix and vagina for microflora, prescribes general blood and urine tests, smears for genital infections.

Not always smears and other tests reveal an infection, then an ultrasound of the pelvic organs is prescribed to determine inflammation of the fallopian tubes.

In some cases, a tissue biopsy may be required to clarify the diagnosis. Laparoscopy is especially indicative, which allows to assess the condition internal organs by visual inspection.

Complex therapy is used to treat VZMP in women. In mild uncomplicated cases, a specialist prescribes medication at home. If the disease is acute, or therapy is ineffective within 48 hours, hospitalization is required.

The therapeutic course necessarily includes taking broad-spectrum antibiotics and anti-inflammatory drugs. If necessary, the patient is prescribed painkillers, antifungal and antihistamines, as well as local procedures (douching, the use of vaginal suppositories), restorative physiotherapy.

Treatment must be completed in full, following all the doctor's prescriptions in order to avoid a recurrence of the disease.

If a sexually transmitted infection is detected, both partners must undergo treatment. During this period, it is recommended to refrain from intimate relationships. After completion of the course of treatment, a follow-up examination is carried out.

A surgical operation is performed in the absence of an effect from drug treatment purulent-inflammatory diseases, when the inflammatory process is complicated by the development of an abscess or phlegmon.

Folk remedies can increase immunity, relieve symptoms of inflammation: relieve pain, itching. They do not kill pathogens. Collections of medicinal herbs for oral administration, douching, vaginal tampons and baths are used only after consultation with your doctor.

Do not use folk remedies until a diagnosis is made. This can make diagnosis difficult.

Possible consequences

If PID treatment is not completed on time and completely, serious violations of the functions of the reproductive organs can occur. Even minor damage to the fallopian tubes can cause adhesions. Adhesions block the normal movement of eggs into the uterus. If the adhesions completely block the fallopian tubes, the sperm cannot fertilize the egg and the woman becomes infertile.

In addition, a damaged fallopian tube can block the egg, and after fertilization with a sperm, it does not enter the uterine cavity. If a fertilized egg begins to grow in the tube, it will lead to an ectopic pregnancy. WB can cause severe painful syndrome, life-threatening profuse bleeding, therefore, immediate medical attention is required.

Previously untreated PID can lead to pathologies such as threatened abortion, premature birth, intrauterine infection of the fetus, intrauterine growth retardation, and postpartum endometritis.

A long-developing inflammatory process causes purulent complications, in which surgery is necessary, up to the removal of the fallopian tubes and uterus.

Adhesions in the fallopian tubes and other pelvic organs can lead to chronic pelvic pain. Adhesions cause discomfort during intercourse, exercise, or ovulation.

The inflammatory process can affect adjacent organs and cause diseases such as proctitis, cystitis, pyelonephritis, paraurethritis and others.

Prevention of PID

To reduce the risk of inflammatory diseases of the pelvic organs, regularly, at least once a year, undergo gynecological examinations for the timely detection of signs of pathology of the pelvic organs.

Eliminate promiscuous sexual relations, use barrier contraception, observe the hygiene of the genitals: wash yourself in the morning and evening, before and after intimate contact, do not use other people's personal hygiene products.

Pelvic inflammatory disease is a spectrum of inflammatory processes in the upper reproductive tract in women and can include any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

ICD-10 code

N74 * Female pelvic inflammatory disease in diseases classified elsewhere

Causes of pelvic inflammatory disease

In most cases, sexually transmitted microorganisms, especially N. gonorrhoeae and C. trachomatis, are involved in the development of the disease; however, pelvic inflammatory disease can be caused by microorganisms that are part of the vaginal flora, such as anaerobes, G. vaginalis, H. influenzae, gram-negative enterobacteria, and Streptococcus agalactiae. Some experts also believe that M. hominis and U. urealyticum may be the etiological agent of pelvic inflammatory disease.

These diseases cause gonococcus, chlamydia, streptococcus, staphylococcus, mycoplasma, E. coli, enterococcus, proteus. Anaerobic pathogens (bacteroids) play a large role in their occurrence. As a rule, inflammatory processes are caused by a mixed microflora.

The causative agents of inflammatory diseases are most often brought in from the outside (exogenous infection); less often, processes are observed, the origin of which is associated with the penetration of microbes from the intestines or other foci of infection in a woman's body (endogenous infection). Inflammatory diseases of septic etiology occur when the integrity of tissues is disturbed (the entrance gate of infection).

Forms

Inflammatory diseases of the upper genital organs or inflammatory diseases of the pelvic organs include inflammation of the endometrium (myometrium), fallopian tubes, ovaries, and pelvic peritoneum. Isolated inflammation of these organs of the genital tract is rare in clinical practice, since they all represent a single functional system.

According to the clinical course of the disease and on the basis of pathomorphological studies, two clinical forms of purulent inflammatory diseases of the internal genital organs are distinguished: uncomplicated and complicated, which ultimately determines the choice of management tactics.

Uncomplicated forms include:

• acute purulent salpingitis,
• pelvioperitonitis,

Complicated - all encapsulated inflammatory tumors of the appendages - purulent tubo-ovarian formations.

Diagnosis of pelvic inflammatory disease

The diagnosis is made on the basis of the patient's complaints, data from the anamnesis of life and disease, the results of a general examination and gynecological examination. The nature of morphological changes in the internal genital organs (salpingo-oophoritis, endometritis, endomyometritis, tubo-ovarian abscess, pyosalpinx, inflammatory tubo-ovarian formation, pelvioperitonitis, peritonitis), the course of the inflammatory process (acute, subacute, chronic) are taken into account. The diagnosis must reflect the presence of concomitant gynecological and extragenital diseases.

During the examination, all patients must examine the discharge from the urethra, vagina, cervical canal (if necessary, flushing from the rectum), in order to determine the flora and sensitivity of the isolated pathogen to antibiotics, as well as discharge from the fallopian tubes, the contents of the abdominal cavity (effusion), obtained by laparoscopy or celiac disease.

To establish the degree of microcirculation disorders, it is advisable to determine the number of erythrocytes, aggregation of erythrocytes, hematocrit, the number of platelets and their aggregation. From the indicators of nonspecific protection, it is necessary to determine the phagocytic activity of leukocytes.

To establish the specific etiology of the disease, serological and immunoassay methods are used. If you suspect tuberculosis, you must put tuberculin reactions.

Of the additional instrumental methods, ultrasound, computed tomography of small organs, laparoscopy are used. In the absence of the possibility of performing laparoscopy, the puncture of the abdominal cavity is performed through the posterior fornix of the vagina.

Diagnostic Notes

Due to the wide range of symptoms and signs, the diagnosis of acute inflammatory diseases of the pelvic organs in women presents significant difficulties. Many women with pelvic inflammatory disease have mild to moderate symptoms that are not always recognized as pelvic inflammatory disease. Therefore, delay in diagnosis and delay in appropriate treatment leads to inflammatory complications in the upper reproductive tract. For a more accurate diagnosis of salpingitis and for a more complete bacteriological diagnosis, laparoscopy can be used. However, this diagnostic technique is often not available in either acute cases or in milder cases when symptoms are mild or vague. Moreover, laparoscopy is not suitable for detecting endometritis and mild inflammation of the fallopian tubes. Therefore, as a rule, the diagnosis of pelvic inflammatory disease is carried out on the basis of clinical signs.

Clinical diagnosis of acute inflammatory diseases of the pelvic organs is also not accurate enough. Data show that in the clinical diagnosis of symptomatic pelvic inflammatory disease, positive predicted values \u200b\u200b(PPVs) for salpingitis are 65-90% compared with laparoscopy as a standard. PPDs for the clinical diagnosis of acute pelvic inflammatory disease vary with epidemiological characteristics and the type of facility; they are higher for sexually active young women (especially adolescents), for patients visiting an STD clinic, or living in areas with a high prevalence of gonorrhea and chlamydia. However, there is no single anamnestic, physical or laboratory criterion that would have the same sensitivity and specificity for diagnosing an acute episode of pelvic inflammatory disease (i.e., a criterion that could be used to identify all cases of PID and to exclude all women without inflammatory diseases of the pelvic organs). pelvis). When a combination of diagnostic techniques that improve either sensitivity (identify more women with PID) or specificity (exclude more women who do not have PID), this happens only one at the expense of the other. For example, requiring two or more criteria excludes more women without pelvic inflammatory disease, but also reduces the number of women diagnosed with PID.

A large number of episodes of pelvic inflammatory disease remain unrecognized. While some women are asymptomatic with PID, others remain undiagnosed because the health care provider cannot correctly interpret mild or nonspecific symptoms and signs such as unusual bleeding, dyspareunia, or vaginal discharge ("atypical PID"). Due to the difficulties of diagnosis and the possibility of violation reproductive health women, even with a mild or atypical course of inflammatory diseases of the pelvic organs, experts recommend that medical workers use a "low threshold" diagnosis for PID. Even under these circumstances, the impact of early treatment of women with asymptomatic or atypical PID on clinical outcome is unknown. The presented recommendations for the diagnosis of inflammatory diseases of the pelvic organs are necessary in order to help medical professionals to assume the possibility of the presence of inflammatory diseases of the pelvic organs and to have additional information for the correct diagnosis. These recommendations are based in part on the fact that the diagnosis and management of other common cases of lower abdominal pain (eg, ectopic pregnancy, acute appendicitis, and functional pain) is unlikely to be worsened by empirical antimicrobial treatment for pelvic inflammatory disease by a healthcare professional.

Minimum criteria

Empiric treatment for pelvic inflammatory disease should be given to sexually active young women and others at risk of STDs, if all of the following criteria are met and no other cause of the patient's illness is present:

• Tenderness to palpation in the lower abdomen,
• Soreness in the area of \u200b\u200bthe appendages, and
• Painful traction of the cervix.

Additional criteria

An overestimated diagnostic estimate is often justified, since an incorrect diagnosis and treatment can lead to serious consequences. These additional criteria can be used to improve the specificity of the diagnosis.

The following are additional criteria that support the diagnosis of pelvic inflammatory disease:

• Temperature above 38.3 ° С,
• Pathological discharge from the cervix or vagina,
• Increased ESR,
• Elevated C-reactive protein levels
• Laboratory confirmation of cervical infection with N. gonorrhoeae or C. trachomatis.

Below are the defining criteria for the diagnosis of inflammatory diseases of the pelvic organs, which prove the selected cases of diseases:

• Histopathological detection of endometritis on endometrial biopsy,
• Ultrasound with a transvaginal probe (or with other technologies) showing thickened, fluid-filled fallopian tubes with or without free fluid in the abdomen, or the presence of a tubo-ovarian mass,
• Laparoscopic abnormalities consistent with PID.

Although the decision to initiate treatment may be made before a bacteriological diagnosis of N. gonorrhoeae or C. trachomatis infections is made, confirmation of the diagnosis emphasizes the need for treatment of sexual partners.

Treatment of pelvic inflammatory disease

If an acute inflammation is detected, the patient should be hospitalized in a hospital, where she is provided with a medical and protective regime with strict observance of physical and emotional rest. Prescribe bed rest, ice on the hypogastric region (2 hours at intervals of 30 minutes - 1 hour for 1-2 days), a sparing diet. They carefully monitor the activity of the intestines, if necessary, prescribe warm cleansing enemas. Patients benefit from preparations of bromine, valerian, sedatives.

Etiopathogenetic treatment of patients with pelvic inflammatory disease involves the use of both conservative therapy and timely surgical treatment.

Conservative treatment of acute inflammatory diseases of the upper genital area is carried out in a comprehensive manner and includes:

• antibacterial therapy;
• detoxification therapy and correction of metabolic disorders;
• anticoagulant therapy;
• immunotherapy;
• symptomatic therapy.

Antibacterial therapy

Since the microbial factor plays a decisive role in the acute stage of inflammation, antibiotic therapy is the determining factor in this period of the disease. On the first day of the patient's stay in the hospital, when laboratory data on the nature of the pathogen and its sensitivity to a particular antibiotic are still lacking, the presumptive etiology of the disease is taken into account when prescribing drugs.

In recent years, the effectiveness of treatment of severe forms of pyoinflammatory complications has increased with the use of beta-lactam antibiotics (augmentin, meronem, thienam). The "gold" standard is the use of clindamycin with gentamicin. It is recommended to change antibiotics after 7-10 days with repeated determination of antibiotics. In connection with the possible development of local and generalized candidiasis during antibiotic therapy, it is necessary to study hemo- and urocultures, as well as the appointment of antifungal drugs.

If oligoanuria occurs, an immediate revision of the doses of antibiotics used is indicated, taking into account their half-life.

Treatment regimens for pelvic inflammatory disease should empirically eliminate a wide range of possible pathogens, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci. Although a clinical randomized trial with short-term follow-up has shown the effectiveness of some antimicrobial regimens in achieving clinical and microbiological cure, there is little work evaluating and comparing the elimination of endometrial and fallopian tube infections or the incidence of such long-term complications as tubal infertility and ectopic pregnancy.

All treatment regimens should be effective against N. gonorrhoeae and C. trachomatis because negative tests for these infections in the endocervix do not exclude the presence of infection in the upper reproductive tract. While the need to kill anaerobes in women with PID is still controversial, there is evidence that this may be important. Anaerobic bacteria isolated from the upper reproductive tract in women with PID and in vitro derived from women clearly show that anaerobes such as B. fragilis can cause tubal and epithelial destruction. In addition, many women with PID are also diagnosed with bacterial vaginosis. In order to prevent complications, the recommended regimens should include drugs acting on anaerobes. Treatment should be started immediately upon establishing a preliminary diagnosis, since the prevention of long-term consequences is directly related to the timing of the appointment of the appropriate antibiotics. When choosing a treatment regimen, the physician should consider its availability, cost, patient acceptability, and the sensitivity of pathogens to antibiotics.

In the past, many experts have recommended that all PID patients be admitted to hospital so that parenteral antibiotic treatment can be given under the supervision of a physician in bed rest. However, hospitalization is no longer synonymous with parenteral therapy. There are currently no data available to show the comparative efficacy of parenteral versus oral treatment, or inpatient versus outpatient treatment. Until results of ongoing studies are available comparing parenteral hospital treatment with oral outpatient treatment in women with PID, clinical observation should be considered. The doctor makes the decision on the need for hospitalization on the basis of the following recommendations based on observational data and theoretical developments:

• Conditions requiring urgent surgical intervention, such as appendicitis,
• The patient is pregnant
• Unsuccessful treatment with oral antimicrobial drugs,
• Failure to comply with or tolerate an outpatient oral regimen,
• Severe illness, nausea and vomiting, or high fever.
• Tubo-ovarian abscess
• Having an immunodeficiency (HIV infection with low CD4 count, immunosuppressive therapy, or other medical conditions).

Most clinicians spend at least 24 hours of direct inpatient follow-up in patients with tubo-ovarian abscesses, followed by adequate parenteral treatment at home.

There is no conclusive data comparing parenteral and oral regimens. A lot of experience has been accumulated in the application of the schemes below. Also, there are multiple randomized trials demonstrating the effectiveness of each regimen. Although most studies used parenteral treatment for at least 48 hours after the patient showed significant clinical improvement, this regimen was randomly administered. Clinical experience should guide the decision to switch to oral treatment, which can be completed within 24 hours of the beginning of clinical improvement.

Scheme A for parenteral treatment

• Cefotetan 2 g IV every 12 hours,
• or Cefoxitin 2 g IV every 6 hours
• plus doxycycline 100 mg IV or orally every 12 hours.

NOTE. Given that infusion of drugs is associated with pain, doxycycline should be administered orally whenever possible, even if the patient is in the hospital. Oral and intravenous doxycycline treatment has the same bioavailability. If intravenous administration is required, the use of lidocaine or other fast-acting local anesthetics, heparin, or steroids, or prolonging the infusion time, may reduce infusion complications. Parenteral treatment can be discontinued 24 hours after the patient shows clinical improvement, and oral treatment with doxycycline 100 mg 2 times a day should be continued for up to 14 days. In the presence of a tubo-ovarian abscess, many doctors use clindamycin or metronidazole with doxycycline to continue treatment, more often than doxycycline alone. this contributes to a more effective overlap of the entire spectrum of pathogens, including anaerobes.

Clinical evidence for second- or third-generation cephalosporins (eg, ceftizoxime, cefotaxime, or ceftriaxone), which can replace cefoxitin or cefotetan, are out-of-date, although many authors believe they are also effective for PID. However, they are less active against anaerobic bacteria than cefoxitin or cefotetan.

Scheme B for parenteral treatment

• Clindamycin 900 mg IV every 8 hours
• plus Gentamicin - loading dose IV or IM (2 mg / kg body weight), followed by a maintenance dose (1.5 mg / kg) every 8 hours.

NOTE. Although the use of a single dose of gentamicin has not been studied in the treatment of pelvic inflammatory disease, its effectiveness in other similar situations is well established. Parenteral treatment can be interrupted 24 hours after the patient has experienced clinical improvement and then switched to oral treatment with doxycycline 100 mg 2 times a day or clindamycin 450 mg orally 4 times a day. The total duration of treatment should be 14 days.

For a tubo-ovarian abscess, many healthcare providers use clindamycin to continue treatment rather than doxycycline because it is more effective against anaerobic organisms.

Alternative parenteral regimens

There is limited data on the use of a different parenteral regimen, but the following three treatment regimens have been completed in at least one clinical trial and have been shown to be effective against a wide range of microorganisms.

• Ofloxacin 400 mg IV every 12 hours,
• or Ampicillin / sulbactam 3 g IV every 6 hours,
• or Ciprofloxacin 200 mg IV every 12 hours
• plus doxycycline 100 mg orally or IV every 12 hours.
• plus Metronidazole 500 mg IV every 8 hours.

Ampicillin / sulbactam with doxycycline had a good effect on N. gonorrhoeae, C. trachomatis, as well as anaerobes, and was effective in patients with tubo-ovarian abscess. Both intravenous drugs, ofloxacin and ciprofloxacin, have been studied as monotherapy drugs. Given the data obtained on the ineffective effect of ciprofloxacin on C. trachomatis, it is recommended to add doxycycline to treatment on a routine basis. Since these quinolones are active only against a part of anaerobes, metronidazole should be added to each regimen.

Oral treatment

There are few data on immediate and long-term outcomes for both parenteral and outpatient treatment. The use of the following regimens provides antimicrobial action against the most common etiological agents of PID, but clinical trials data on their use are very limited. Patients who do not show improvement with oral treatment within 72 hours should be re-evaluated to confirm the diagnosis and parenteral treatment should be prescribed to them on an outpatient or inpatient basis.

Scheme A

• Ofloxacin 400 mg 2 times a day for 14 days,
• plus Metronidazole 500 mg orally 2 times a day for 14 days

Oral ofloxacin used as monotherapy has been studied in two well-designed clinical trials and has been shown to be effective against N. gonorrhoeae and C. trachomatis. However, taking into account that ofloxacin is still not effective enough against anaerobes, the addition of metronidazole is necessary.

Scheme B

• Ceftriaxone 250 mg IM single dose
• or Cefoxitin 2 g IM plus Probenecid 1 g orally once at the same time,
• or Another third-generation parenteral cephalosporin (eg, ceftizoxime, cefotaxime),
• plus Doxycycline 100 mg orally 2 times a day for 14 days. (Use this circuit with one of the above circuits)

The optimal choice of cephalosporin for this regimen has not been determined; while cefoxitin is active against more anaerobic species, ceftriaxone is more effective against N. gonorrhoeae. Clinical trials have shown that a single dose of cefoxitin is effective in achieving rapid clinical response in women with PID, but theoretical evidence indicates the need for metronidazole supplementation. Metronidazole will also effectively treat bacterial vaginosis, which is often associated with PID. There are no published data on the use of oral cephalosporins for the treatment of PID.

Alternative outpatient schemes

There is limited information on the use of other outpatient regimens, but one regimen has been successful in at least one clinical trial against a wide variety of PIDs. When amoxicillin / clavulanic acid was combined with doxycycline, a rapid clinical effect was obtained, but many patients were forced to interrupt the course of treatment due to unwanted symptoms from the gastrointestinal tract. There have been several studies evaluating azithromycin in the treatment of infections of the upper reproductive tract, however, these data are not sufficient to recommend this drug for the treatment of inflammatory diseases of the pelvic organs.

Detoxification therapy and correction of metabolic disorders

This is one of the most important components of treatment, aimed at breaking the pathological circle of cause-and-effect relationships that arise in pyoinflammatory diseases. It is known that these diseases are accompanied by a violation of all types of metabolism, excretion a large number liquids; there is an imbalance of electrolytes, metabolic acidosis, renal-hepatic failure. Adequate correction of the identified violations is carried out in conjunction with resuscitation doctors. When carrying out detoxification and correction of water-electrolyte metabolism, two extreme conditions should be avoided: insufficient fluid intake and overhydration of the body.

In order to eliminate these errors, it is necessary to control the amount of fluid introduced from the outside (drink, food, medicinal solutions) and excreted in the urine and other ways. The calculation of the introduced rigidity should be individual, taking into account the specified parameters and the patient's condition. Correct infusion therapy in the treatment of acute inflammatory and purulent-inflammatory diseases is no less important than the appointment of antibiotics. Clinical experience shows that a patient with stable hemodynamics with adequate replenishment of the BCC is less susceptible to the development of circulatory disorders and the occurrence of septic shock.

The main clinical signs of BCC recovery, elimination of hypovolemia are CVP indicators (60-100 mm water column), diuresis (more than 30 ml / h without the use of diuretics), improvement of microcirculation (skin color, etc.).

Anticoagulant therapy

With widespread inflammatory processes, pelvioperitis, peritonitis, patients may have thromboembolic complications, as well as the development of disseminated intravascular coagulation syndrome (DIC).

Thrombocytopenia is currently considered one of the first signs of DIC. A decrease in the number of platelets to 150 x 10 3 / L is the minimum that does not lead to hypocoagulant bleeding.

In practice, the determination of the prothrombin index, the number of platelets, the level of fibrinogen, fibrin monomers and the blood coagulation time is sufficient for the timely diagnosis of DIC. For the prevention of DIC and with a slight change in these tests, heparin is prescribed at 5000 IU every 6 hours under the control of blood coagulation time within 8-12 minutes (according to Lee-White). The duration of heparin therapy depends on the speed of improvement of laboratory data and is usually 3-5 days. Heparin should be administered before clotting factors are significantly reduced. Treatment of DIC syndrome, especially in severe cases, is extremely difficult.

Immunotherapy

Along with antibacterial therapy in conditions of low sensitivity of pathogens to antibiotics, means that increase the general and specific reactivity of the patient's body are of particular importance, since the generalization of the infection is accompanied by a decrease in the parameters of cellular and humoral immunity. Based on this, substances that increase immunological reactivity are included in complex therapy: antistaphylococcal gamma globulin and hyperimmune antistaphylococcal plasma. To increase non-specific reactivity, gamma globulin is used. An increase in cellular immunity is facilitated by drugs such as levamisole, taktivin, thymogen, cycloferon. In order to stimulate immunity, methods of efferent therapy are also used (plasmapheresis, ultraviolet and laser irradiation of blood).

Symptomatic treatment

An essential condition for the treatment of patients with inflammatory diseases of the upper genital organs is effective pain relief using both analgesics and antispasmodics, and inhibitors of prostaglandin synthesis.

It is mandatory to introduce vitamins based on the daily requirement: thiamine bromide - 10 mg, riboflavin - 10 mg, pyridoxine - 50 mg, nicotinic acid - 100 mg, cyanocobalamin - 4 mg, ascorbic acid - 300 mg, retinol acetate - 5000 U.

The appointment of antihistamines is shown (suprastin, tavegil, diphenhydramine, etc.).

Rehabilitation of patients with inflammatory diseases of the upper genital organs

Treatment of inflammatory diseases of the genital organs in a woman necessarily includes a set of rehabilitation measures aimed at restoring the specific functions of the female body.

To normalize menstrual function after acute inflammation, drugs are prescribed, the action of which is aimed at preventing the development of algodismenorrhea (antispasmodics, non-steroidal anti-inflammatory drugs). The most acceptable form of introduction of these medicines are rectal suppositories. The restoration of the ovarian cycle is carried out by the appointment of combined oral contraceptives.

Physiotherapeutic methods in the treatment of inflammatory diseases of the pelvic organs are prescribed differentiated, depending on the stage of the process, the duration of the disease and the effectiveness of the previous treatment, the presence of concomitant extragenital pathology, the state of central and vegetative nervous system and age characteristics of the patient. Use of hormonal contraception is recommended.

In the acute stage of the disease at a body temperature below 38 ° C, UHF is prescribed to the area of \u200b\u200bhypogastrium and lumbosacral plexus using a transverse technique in a non-thermal dosage. With a pronounced edematous component, a combined effect of ultraviolet light on the panty area in 4 fields is prescribed.

In case of subacute onset of the disease, the appointment of a microwave electromagnetic field is preferable.

With the transition of the disease to the stage of residual phenomena, the task of physiotherapy is to normalize the trophism of the suffering organs due to changes in vascular tone, the final relief of edematous phenomena and pain syndrome... For this purpose, reflex techniques of exposure to currents of supratonal frequency are used. D "Arsonval, ultrasound therapy.

With the transition of the disease to the stage of remission, procedures for heat and mud therapy (paraffin, ozokerite) are prescribed for the area of \u200b\u200bthe panties zone, balneotherapy, aerotherapy, helio- and thalassotherapy.

In the presence of chronic inflammation of the uterus and its appendages in the period of remission, it is necessary to prescribe resorption therapy using biogenic stimulants and proteolytic enzymes. The duration of rehabilitation measures after acute inflammation of the internal genital organs is usually 2-3 menstrual cycles. A pronounced positive effect and a decrease in the number of exacerbations of chronic inflammatory processes are noted after spa treatment.

Surgical treatment of purulent-inflammatory diseases of the internal genital organs

The indications for surgical treatment of purulent-inflammatory diseases of the female genital organs are currently:

1. Lack of effect during conservative complex therapy for 24-48 hours.
2. Deterioration of the patient's condition during a conservative course, which may be caused by perforation of a purulent formation into the abdominal cavity with the development of diffuse peritonitis.
3. Development of symptoms of bacterial toxic shock. The volume of surgical intervention in patients with inflammatory diseases of the uterine appendages depends on the following main points:
   1. the nature of the process;
   2. concomitant pathology of the genital organs;
   3. age of patients.

It is the young age of patients that is one of the main points that determine the adherence of gynecologists to gentle operations. In the presence of concomitant acute pelvioperitonitis. With purulent lesions of the uterine appendages, the uterus is extirpated, since only such an operation can ensure complete elimination of the infection and good drainage. One of the important points in the surgical treatment of purulent inflammatory diseases of the uterine appendages is the complete restoration of normal anatomical relationships between the pelvic organs, the abdominal cavity and the surrounding tissues. It is imperative to revise the abdominal cavity, determine the state of the appendix and exclude interintestinal abscesses with a purulent nature of the inflammatory process in the uterine appendages.

In all cases, when performing an operation for inflammatory diseases of the uterine appendages, especially with a purulent process, one of the main principles should be the principle of mandatory complete removal of the focus of destruction, i.e., inflammatory formation. No matter how gentle the operation is, it is always necessary to completely remove all tissues of the inflammatory formation. The preservation of even a small portion of the capsule often leads to severe complications in the postoperative period, recurrence of the inflammatory process, and the formation of fistulas. During surgery, drainage of the abdominal cavity (koliutomy) is mandatory.

The condition for reconstructive surgery with the preservation of the uterus is, first of all, the absence of purulent endomyometritis or panmetritis, multiple extragenital purulent foci in the small pelvis and abdominal cavity, as well as concomitant severe genital pathology (adenomyosis, myoma) established before or during the operation.

In women of reproductive age, in the presence of conditions, it is necessary to extirpate the uterus while preserving, if possible, at least part of the unchanged ovary.

In the postoperative period, complex conservative therapy continues.

Follow-up observation

In patients receiving oral or parenteral treatment, significant clinical improvement (for example, a decrease in temperature, a decrease in tension in the muscles of the abdominal wall, a decrease in pain on palpation during examination of the uterus, appendages and cervix) should be observed within 3 days from the start of treatment. Patients who do not have such an improvement require a more accurate diagnosis or surgical intervention.

If the physician has opted for outpatient oral or parenteral treatment, follow-up and evaluation of the patient should be carried out within 72 hours using the above criteria for clinical improvement. Some experts also recommend re-screening for C. trachomatis and N. gonorrhoeae 4-6 weeks after completion of therapy. If PCR or LCR are used to control the cure, then a second study should be carried out one month after the end of treatment.

Sex partner management

Examination and treatment of sexual partners (who were in contact in the previous 60 days before the onset of symptoms) of women with PID is necessary because of the risk of reinfection and the high likelihood of detecting urethritis of gonococcal or chlamydial etiology. Men who are sex partners of women with PID, which are caused by gonococci or chlamydia, often have no symptoms.

Sex partners should be empirically treated according to a treatment regimen for both infections, regardless of whether the etiological agent of pelvic inflammatory disease has been identified.

Even in women-only clinics, healthcare providers must ensure that men who are sex partners of women with PID are treated. If this is not possible, the health care provider treating a woman with PID must be confident that her partners receive appropriate treatment.

Special notes

Pregnancy... Given the high risk of adverse pregnancy outcomes, pregnant women with suspected PID should be hospitalized and treated with parenteral antibiotics.

HIV infection... The differences in the clinical manifestations of PID in HIV-infected and uninfected women have not been described in detail. Early observations suggested that HIV-infected women with PID were more likely to need surgery. In subsequent, more comprehensive review studies of HIV-infected women with PID, it was noted that even with more severe symptoms than HIV-negative women, parenteral antibiotic treatment in such patients was successful. In another trial, the results of microbiological studies in HIV-infected and uninfected women were similar, with the exception of a higher detection rate for concurrent chlamydial infection and HPV infection, as well as cellular changes caused by HPV. HIV-infected, immunocompromised women with PID require more extensive therapy using one of the parenteral antimicrobial regimens described in this guideline.

For citation:Serov V.N., Dubnitskaya L.V., Tyutyunnik V.L. Inflammatory diseases of the pelvic organs: diagnostic criteria and principles of treatment // BC. Mother and child. 2011. No. 1. P. 46

Pelvic inflammatory disease (PID) is usually the result of an ascending infection from the endocervix, which can lead to the development of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscesses, and pelvioperitonitis. The causes of PID are the causative agents of sexually transmitted infections (STIs), such as Chlamydia trachomatis, Neisseria gonorrhoeae, as well as Mycoplasma genitalium, anaerobes and other microorganisms. PID is a common cause of morbidity in women. They are detected in one patient out of 60 under the age of 45 when examined by a general practitioner. Treatment started with a delay of only a few days significantly increases the risk of complications (infertility, ectopic pregnancy and chronic pelvic pain), which lead to significant treatment costs. PID can be presented as a single nosological form (endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvioperitonitis), and any combination of them.

Literature
1. Abramchenko V.V., Bashmakova M.A., Korkhov V.V. Antibiotics in obstetrics and gynecology. - St. Petersburg: Spetslit, 2000. - 220 p.
2. Rational pharmacotherapy in obstetrics and gynecology // Guide for practitioners, edited by V.I. Kulakova, V.N. Serov, M., "Litterra", 2005, S. 724-727.
3. Serov V.N., Tikhomirov A.L. Modern principles of therapy for inflammatory diseases of the female genital organs. Toolkit. M., 2002.
4. Handbook on obstetrics, gynecology and perinatology, edited by G.М. Savelyeva // M., "MIA", 2006, S. 487-501
5. Tikhomirov AL, Sarsania SI .. Complex treatment of mixed genital infections // Gynecology, 2004, Vol.6., N6, P.14-17.
6. Tyutyunnik V.L., Alieva S.A. Serov V.N. Antibiotic therapy for sexually transmitted diseases and treatment of its fungal complications. // Pharmateca. - 2003. - No. 11, (74). - S.20-26.
7. Ushkalova E.A. The use of azithromycin for the prevention and treatment of inflammatory diseases of the pelvic organs and urogenital chlamydia. // Pharmateca.- 2005.- No. 2, (98) .- S. 14-26.
8. Chebotarev V.V. Urogenital chlamydia: contemporary problems diagnostics, pathogenesis, treatment. // Venereology 2004.- № 1.- P.43-48.
9. Banikarim C., Chacko M.R. Pelvic inflammatory disease in adolescents. Semin Pediatr Infect Dis 2005 Jul; 16 (3): 175-80.
10. Beigi R.H., Wiesenfeld H.C. Pelvic inflammatory disease: new diagnostic criteria and treatment. Obstet Gynecol Clin North Am 2003 Dec; 30 (4): 777-93.
11. Blondeau J.M. The evolution and role of macrolides in infectious diseases. Expert. Opin. Pharmacother. 2002,3: 1131-51.
12. Burrington-Brown J., Fox L. et al. AHIMA e-HIM Personal Health Record Work Group. Defining the personal health record. AHIM releases definition, attributes of consumer health record.
13. Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. MMWR 2002; 51 (RR-6): 48-52.
14. Hyp J.M., Hook E.W. III, Goldie S.J. A refined estimate of the lifetime cost of pelvic inflammatory disease. Sex Transm Dis 2003; 30: 369-378.
15. Ness R.B., Trautmann G., Richter H.E., Randall H. et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial. Obstet Gynecol 2005 Sep; 106 (3): 573-80.
16. Performance Standards for Antimicrobial Susceptibility Testing. National Committee for Clinical and Laboratory Standards (NCCLS) 2001; 21: 1: 123.
17. Ross J. Pelvic inflammatory disease. Clin Evid 2004 Jun; (11): 2121-7.
18. Ross J.D. Is Mycoplasma genitalium a cause of pelvic inflammatory disease? Infect Dis Clin North Am 2005 Jun; 19 (2): 407-13.
19. Rubinstein E. Comparative safety of the different macrolides. Int. J. Antimicrob. Agents 2001; 18 (1): 71-6.

Diagnostics and treatment of inflammatory diseases of the pelvic organs in women is a specialized area of \u200b\u200bmedical care provided in the Mother and Child clinics. We have all the resources to carry out the necessary research, effective and safe treatment: conservative - medication and physiotherapy, operative - methods of minimally invasive surgery.

Therapy can be carried out on an outpatient basis and inpatiently. The leading clinics "Mother and Child" include inpatient departments with comfortable one-room and two-room wards. Our patients are women of any age.

Pelvic inflammatory disease (PID) is various diseases organs of the female reproductive system - the vagina, fallopian tubes, ovaries, cervix and uterine body, namely:

• Inflammation of the vagina (vaginitis);
• Inflammation of the vulva (vulvitis);
• Inflammation of the uterine appendages - fallopian tubes and ovaries (salpingo-oophoritis, adnexitis);
• Inflammation of the gland of the vestibule of the vagina (bartholinitis);
• Inflammation of the fallopian tube (salpingitis);
• Ovarian inflammation (oophoritis);
• Inflammation of the uterus (endometritis);
• Inflammation of the cervix (cervicitis).

The main cause of PID is genital infections - chlamydia, mycoplasma, ureaplasma, Trichomonas, so it is generally accepted in the international medical community that sexually active women under the age of 25 are most at risk.

Specialists "Mother and Child" add that women of any age, both having regular sex life and having sex in the past, can face pelvic inflammatory disease. The fact is that many of us are carriers of various infections, sometimes without even knowing about it, because a number of them are asymptomatic. Conditionally pathogenic microorganisms present in any woman, even not having sex, can cause PID. It is possible to diagnose the presence of one or another infection only with the help of special studies.

The body's protective resources, when we are healthy, are able, in the overwhelming majority of cases, to prevent the development of infection and, accordingly, disease. At the moment of weakening of immunity, during menstruation, in the postpartum period, after artificial termination of pregnancy, various diagnostic and therapeutic intrauterine manipulations, the “protective barrier” ceases to function in full force, infection may occur, or inflammation associated with opportunistic microorganisms may occur. It is worth noting that the infection can also be present in the woman's body for years and not manifest itself, and against the background of the listed factors, characteristic symptoms of both the infections themselves and PID, which they provoked, appear.

Possible symptoms of PID

• Pain syndrome: pain in the lower abdomen and back, in the perineum and genitals;
• Violation of the menstrual cycle: changes in the regularity and intensity of bleeding, spontaneous bleeding, pre-postmenstrual and acyclic spotting;
• Sexual dysfunction: pain in the pelvic area or external genitalia during intercourse, changes in libido, anorgasmia, infertility;
• Vaginal discharge: uncharacteristic discharge, mucous leucorrhoea, change in the smell of discharge;
• Dysuric syndrome: frequent and painful urination;
• General symptoms: fever, weakness, fatigue, psycho-emotional instability.

If you experience one or more of the listed symptoms, you should immediately contact a specialist and undergo a thorough examination of the body. The high competence of Mother and Child doctors, ultra-modern equipment, our own laboratories - all this allows us to diagnose all types of inflammatory diseases of the pelvic organs and genital infections.

Diagnostics of PID in "Mother and Child"

• Examination by a gynecologist;
• Laboratory tests: analysis of blood and smears from the genital tract for genital infections;
• Ultrasound examination (ultrasound);
• Endometrial biopsy (if indicated);
• Diagnostic laparoscopy (according to indications).

Based on the results of the examination, the doctor recommends an individually created program of effective treatment, which may include drug therapy, physiotherapy, surgery, or a set of therapeutic measures aimed at the speedy recovery of a woman. The choice of treatment tactics depends on the severity of symptoms, age, desire to preserve reproductive function. Treatment can be carried out on an outpatient basis or in a hospital setting, depending on the medical situation.

PID treatment at "Mother and Child"

• Drug therapy: antibacterial, anti-inflammatory, analgesic, anti-draining drugs;
• Non-drug therapy: magnetotherapy, electrophoresis, diadynamic currents, radon baths, thalassotherapy, phonophoresis;
• Surgical treatment: in the absence of the effect of conservative treatment, surgical intervention may be recommended - laparoscopic, hysteroscopic or laparotomy operations;
• Rehabilitation: treatment without fail includes observation in the postoperative period.

Specialists "Mother and Child" strongly recommend every woman annually, and after 35 years - 2 times a year - to visit a gynecologist and undergo the necessary laboratory tests of blood and smears from the genital tract, ultrasound examinations of the pelvic organs. Timely diagnosis is the key to recovery in the shortest possible time.

Inflammatory diseases of the pelvic organs in all their variety are “diagnoses” that we have been successfully overcoming for more than XX years. Taking care of a woman's health at every stage of her life is a key area of \u200b\u200bwork for every employee of the Mother and Child group of companies. Qualified specialists of our "Women's Centers" - gynecologists, endocrinologists, mammologists, urologists, reproductive specialists, surgeons - help women day after day to maintain and restore health and psycho-emotional balance.