Inflammatory diseases of the female sexual organs. “Acute” abdomen in gynecology.
INFLAMMATORY DISEASES OF THE FEMALE SEXUAL ORGANS
By Stelmakh L.
The rate of inflammatory diseases is over 60% of all gynecologic diseases and about 30% patients of female hospitals have the inflammatory processes of genital organs.
Normal flora has a significant role in defense against infection by genital pathogens. The female genital tract, especially the vaginal secretions, contain from 108 to 109 bacteria per gram of fluid examined. Lactobacilli produce lactic acid from glucose keeping the vagina at an acidic pH (3,8-4,2). Glycogen is metabolized by vaginal epithelial cells to glucose, which then serves as a substrate for Lactobacillus.
Normal vaginal microflora contains: Lactobacillus (70-90%), Staphylococcus epidermalis (30-60%), diphteroids (30-60%), Hemolytic Streptococci (10-20%), nonhaemolytic streptococci (5-30%), Escherichia coli (20-25%), Bacteroides (5-15%), Peptococcus (10-60%), Peptostreptococcus (10-40%), Clostridium (5-15%).
Presence of pathogenic flora without inflammation isn’t a sign of pathologic processes.
It is considered that normal vaginal flora is represented by Lactobacillus. But not only Lactobacillus acidophilus provide the self-cleaning of the vagina. The normal vaginal ecosystem of reproductive age women contains 7 kinds of Lactobacillus: L acidophilus (42,8%), L. Paracasei, L. Fermentum, L. Plantarum (10-18,6%), L.cateforme, L.corineformis, L. Brevis (2,5-5,7%), H2O2 producing Lactobacillus may play an important role in acting as a natural microbicide within the vaginal ecosystem.
Variation in vaginal colonization by Lactobacillus and other organisms
could relate to estrogen level metabolism products of vaginal microflora, vaginal
pH, and the type of Lactobacillus initially colonizing the vagina. Many endogenic
and exogenic factors may change the balance of the vaginal ecosystem. Some
vaginal microorganisms may cause the inflammation in certain conditions. Both
vaginal and cervical epithelial cells have the capacity to convert glycogen to
glucose, which is further metabolized to lactic acid. Vaginal acidity depends
on adequate levels of estrogens as well as the presence of lactic
acid-producing bacteria such as Lactobacilli. Concentrations of lactobacilli
are probably important determinants of vaginal pH as well. The increased
concentration of lactic acid producing bacteria in the vaginal fluid may
result in a lower pH which determines decreased susceptibility to infection.
Estrogens have a direct effect on the number of organisms and composition of
the bacterial flora. The mucosal surface provides protection from invading
pathogens. Mucous may act to eliminate a variety of pathogens or antigens.
Mucous also serves for attachment of immunoglobu-
lin A, lysozyme, lactoferrin and other biologically active substances. Mucous in the female genital tract is under hormonal control. Any abnormalities with low estrogen secretion and decreasing of estrogen level with age may damage defense mechanisms of the female genital tract. Using of contraceptives, shower can effect into vaginal ecosystem by changing vaginal pH, altering the vaginal fluid by direct dilution.
Bartholinitis is an inflammation of Bartholin’s gland (large gland of vaginal vestibule). It may be caused by Staphylococcus, E.coli and N. gonorrhea. Any type of the pathogen initiates ductal inflammation and obstruction that can lead to Bartholin’s abscess. There can be serous, serous-purulent, or purulent inflammation.
Obstruction of the opening of the main duct into the vestibule leads to abscess formation. Infection of Bartholin’s glands can lead to secondary infections, abscess or cyst formation. When the gland becomes full and painful, incision and drainage is appropriate. Patients with abscess usually require abscess incision with insertion of the catheter in abscess cavity. Recurrent infection from vaginal flora and mucous cyst formation are common sequelae of bartholinitis. If the infection of gland is caused by N.gonorrhea specific antibacterial treatment is prescribed.
Vulvitis is a vulvar inflammation. It may be primary and secondary. Primary vulvitis is caused by local irritants (including feminine hygiene sprays, deodorants, tight-fitting synthetic undergarments in women with obesity or diabetes mellitus. Secondary vulvitis are caused by accompanying discharge from vagina.
Reduced estrogens levels in reproductive age women, and more frequent in girls and menopause women may lead to vulvitis.
Clinic. Erythema, edema of vulva and skin ulcers are all indices of the infection.
Patient’s complains are itching or burning. Excoriation caused by the patient’s scratching of the skin of vulva are often seen in vulvar irritation.
inflammation and itching the main suspected cause must be removed. The therapy
includes local application of boric acid solution or KMnO4 solution.
Candidasis is treated with Gyno-paveril 150mg in suppositories —
3 days, or Orungal 100mg twice a day during 6-7 days orally, and then one capsule per day every first day of menstrual cycle during 3-6 cycles. Treatment with local antibiotics and steroids is successful.
Vaginitis (colpitis) is an inflammation of vagina. It is the most frequent cause of visits to gynecologists. It may be caused by staphylococcus, Streptococcus, E.coli and other.
Excessive vaginal discharge is associated with an identifiable microbiologic cause in 80% to 90%of cases. Hormonal or chemical causes account for most of the remaining cases. Vaginitis may be acute, subacute and chronic. There are two forms of vulvitis: purulent and granulosa-diffusional.
The main symptom is the increased, gray-white or yellow discharge generally serous or purulent with rancid odour. The patients complain of dysuria, vulvar itching, burning and dyspareunia. Examination may reveal edema or erythema of vulva and vagina, petechia or patches in the upper vagina or on the cervix. In case of chronic vaginitis all these signs are not so expressed.The cultures from vagina, cervix,urethra, ductus of Bartholin’s gland should be microscopically examined.
Treatment of nonspecific vaginitis is comlex:
l using of antiinflammatory medicines
l treatment of neuroendocrinologic and immunodificiency conditions
l treating of male sexual partner; patients should avoid sexual contacts while therapy
Local treatment includes using of syringing with antiseptic fluid (KmnO4, furacilin, chlorhexidin) no more than 3-4 days. In case of acute or chronic vaginitis laser therapy may be used.
Metronidazol (vaginal suppositories), chlorhinaldin, terginan, betadin, gyno-paveril may be prescribed. For normalization of vaginal ecosystem solkotrychovac, vagilak, Lactobacterin and Bifidumbacterin are used.
10-25% of all gynecologic patients have this disease. Among sexually transmitted diseases, bacterial vaginosis is diagnosed in 60-65% of women. Bacterial vaginosis is a result of an overgrowth of both anaerobic bacteria and the aerobic bacteria Gardnerella vaginalis. Anaerobes and G. vaginalis are normal inhabitants of vagina, but these bacteria overgrowth dominant of the normal Lactobacillus flora results in the appearance of a thin, fishy odor, gray vaginal discharge that adheres to the vaginal walls.
A small amount of vaginal discharge may be normal (2ml) particularly at the midcycle. Bacterial vaginosis causes an increased vaginal discharge (15-20ml), vulvar irritation, pruritus, dysuria and foul odour.
The diagnosis of bacterial vaginosis is based on the presence of the following characteristics of the discharge:
l pH is higher than 4,5
l a homogeneous thin appearance
l a fishy amine odour produced by anaerobes when 10% KOH is added
l presence of clue cells (vaginal epithelial cells to which organisms are attached)
Cultures aren’t helpful because anaerobes and Gardnerella vaginalis can be recovered from normal flora of healthy women, but the concentration of both bacteria is higher in patients with bacterial vaginosis . Factors that lead to overgrowth of G.vaginalis and anaerobes have not been identified.
Treatment includes elimination of anaerobic agent of microflora, inducement of local and general immunity and then the normal microflora should be renewed.
Oral using of metronidazol (Flagyl) 500mg twice a day for 7 days or by intravaginal Metrogel 0,75% cream twice a day for 5 days, 2% clindamycin cream (cleocin) once daily for 7 days.
For normalization of vaginal microflora the local bifidumbacterin insertion or 2-3% solution of Lactic acid is used. The treatment of the male parthner with metronidazol can be advocated only when bacterial vaginosis recurs, but effectiveness is not proven.
Endocervicitis is the inflammation of mucosa layer of the endocervix. Bacteria cause infection
Cervix is constantly exposed to trauma during childbirth, abortion.The abundant mucus secretion of the endocervical glands both with the bacterial ascend from the vagina creates a situation that is advantaging to infection. of the columnar epithelium. Chlamidia trachomatis, Mycoplasma, Trichomonada vaginalis, N. Gonorrhoeae, viruses, Candida, E.coli, Staphylococci cause endocervicitis.
The inflammatory process is chiefly confined to the endocervical glands. the squamous epithelium of the exocervix may be involved into the process called acute exocervicitis. The extent of endocervical involvement as compared with exocervical one appears to have some relation to the Chronic cervicitis manifestation is cervical erosion. Erosion indicates the presence around the cervical os a zone of infected tissue that has a granular appearance. It implies the loss of superficial layers of the stratified squamous epithelium of the cervix and overgrowth of infected endocervical tissues.
The inflammatory process stimulates a reparative attempt in the form of an upward growth of squamous epithelium, causing some of the ducts of the endocervical glands to be obstructed. Retention of mucus and other fluid within these glands results in the formation of nabothian cycts. These cysts are endocervical glands filled with infected secretion. Their ducts become secondarily included into the inflammation and reparative processes.
The most important in the diagnosis of chronic cervitis is the exclusion of the malignant process. Before the begining of treatment, examination with colposcope should be carried out. The cervicitis may appear as a reddish granulation raised above the surrounding surface, giving the impression of being papillary.
A Papanicolaou smear should be obtained and suspicious areas should undergo biopsy.
Treatment. Acute cervicitis is treated with appropriate antibiotics (it depends on bacterial agent). Local treatment of acute phase is a real danger of dissemination of infection. Laser therapy is used in treatment of acute and chronic cervicitis.
Electocautherization is the traditional treatment of chronic cervicitis, especially with erosion, cervical ulcers or ectropion. Nowadays cryosurgery or laser surgery has replaced electrocautherization.
Acute endometritis is an inflammation of endometrium (mucus layer of uterine). It may occur in such cases as: endometritis after uterine curettage or suction and puerperal endometritis. Endometritis is caused by bacterias, viruses, mycoplasmas. the most frequent the associations of 3-4 anaerobic bacteria and 1-2 aerobic are the main reason of endometritis.
Anaerobic bacteria compose a part of the normal cervicogenital flora. There are two known mechanisms which cause anaerobic infection: antibiotic selection that preferentially inhibits aerobic bacteria and tissual trauma that occurs after surgery which reduces the redox potencial. Anaerobes produce odorous metabolic products.
Uterus has endometrium factors of local immunity. there are T-lymphocytes and other factors of cellular imunity in endometrial stroma. Lymphocytes and neutrophiels normally appear in the endometrium in the second half of menstrual cycle; their presence does not necessarily constitute endometritis. The appearing of plasma cells represents immune response, usually to foreign bacterial antigen.
The organism should be cultured before applying of antimicrobal therapy. As anaerobes compose a part of normal flora, deep tissual cultures not contaminated by surface bacteria are required. Forty eight or more hours are required for anaerobe recovery, and treatment usually is based on clinical signs. There are nonspecific and specific endometritis. Specific endometritis is caused by M. Tuberculosis, N. Gonorrhea, Chlamidia trachomatis, Actinomyces.
Clinic. Fever is the characteristic feature in the diagnosis of endometritis, and it may be accompanied by uterine tenderness. If the infection has spread to the parametrium and adnexa, tenderness may be present there as well. Temperature elevation is probably proportionate to the extention of the infection and when confined to the decidua, the cases are mild and there is minimal fever. Chills may accompany fever. Women usually complain of abdominal pain. There is tenderness on one or both sides of the abdomen and parametrial tenderness is elicited upon bimanual examination. The uterus is lightly enlarged.
A leukocytosis and increased erythrocyte’s sedimentation rate is revealed in patient’ blood test. In some cases acute endometritis may become a chronic one.
Treatment. Various choices of initial antibiotic therapy are used. most of them are successful. Single-agent therapy has the benefit of easy administration; Cephalosporins such as cefotetan and cefoxitin are commonly used. A combination of ampicillin and aminoglycoside is also popular. The combination of clindamycin with gentamicin or metronidasol with unasyn (ampicillin with sulbuctam) and gentamicin is applied. It is desirable to provide additional antibiotic coverage if there has been no responce within 48 to 72 hours. Intravenous antibiotic therapy is continued until the patient is asymptomatic and afebrile period lasts for at least 24 hours.
Local uterine douching with antiseptic solution of chlorhexidin or furacilin has a good effect. In some cases uterine curettage is performed after temperature normalization.
Chronic endometritis is a sequale of untreated acute endometritis or nonadequate treatment of postabortion or purperal endometritis. The chronic endometritis sometimes is associated with the use of intrauterine device (IUD). In some cases it may occur without acute stage.
Clinic. The chronic endometritis results from organisms that are normally in lower genital tract (Protei, E. Coli, Staphylococcus, Mycoplasma). Bacteria that can be recovered are usually of low pathogenicity, but more virulent intrauterine bacteria occasionally cause the serous purulent’ discharge, abnormal uterine bleeding and moderate uterine tenderness. Diagnosis is based on anamnesis and clinical manifestation. It could not be diagnosed unless plasma cells are found in the endometrium. Ultrasonography can identify gas vesicules in uterine cavity, hyperechogenic places (local fibrosis, sclerosis) in basal layer of endometrium.
Treatment. A complex treatment is used. It includes a medicines for curing of accompaning deseases, desensibilisative medicines and additional general health measures, vitamines.
Physiotherapy has an important role. It improves pelvic hemodynamics. Diathermy on lower abdomen, electrophoresis with copper, zinc, ultrasound, inductothermy, laser radiation are used. If during physiotherapy the process becomes strained antibiotic therapy is recomended. While remission antibiotic using is not proved.
Physiotherapy promotes to activation of hormonal ovarian function. If effect is not enouph than a hormonal therapy is used (taking into account the patient’s age, term of deseases, degree of ovarian hypofunction). Health resort treatment is effective (balneologic therapy, mudcure resort).
Salpingoophoritis is the inflammation of the uterine tubes and the ovaries. Salpingoophoritis is the most frequent among all pelvic inflammatory deseases. Most cases of oophoritis are secondary to salpingitis. The ovaries become infected by the purulent material that escapes from fallopian tube. If the tubal fimbriae are adherent to the ovary, the tube and ovary together may form a large retort-shaped tubo-ovarian abscess.
Most patients with salpingoophoritis have lower abdominal, adnexal tenderness (unilateral or bilateral) purulent cervical exudate or purulent vaginal discharge.
Clinic. There are four stages of salpingoophoritis. The first — salpingitis without irritation (inflammation), of the peritoneum, the second — with signs of peritonitis, the third with occlusion of uterine tubes and tuboovarian abscess and the fourth is the rupture of tuboovarian abscess. During bimanual examination adnexal inflammatory mass is revealed.
The diagnosis of salpingoophoritis is based on the history, physical examination and laboratory tests. Besides that additional ultrasonography and laparoscopy can be used.
Laparoscopy provides the most accurate way to diagnose the inflammatory process and its stage. It should be used in cases when the diagnosis is unclear, especially in patients with severe peritonitis, to exclude a ruptured abscess and appendicitis. Besides diagnostic laparoscopy is used to provide treatment procedures.
Ultrasound can be used to distinguish the presence of an abscess from an inflammatory mass within the adnexal mass. It may also be helpful in defining mass in the obuse patient or if the bimanual examination is unsatisfactory because of the excessive tenderness.
Treatment. All patients with acute salpingoophoritis should be hospitalized. Adequate therapy of salpingitis includes the assessment of severity, antibiotic treatment, additional general health measures.
Before the culture test performing the antibiotic therapy is provide with broad spectrum antibiotics. The most effective is the combination of clindamicin with chloramphenicol, gentamicin and lincomicin, doxycyclin, clacid, cefobid, cyfran, claforan, dalacin C and unasyn.
When anaerobic agents are suspected metronidazol should be used, in severe cases intravenously. After temperature normalization and cessation of peritonitis signs antibacterial therapy is continued for 5 days. Detoxycation is indicated and is provided by using of 5% glucose solution, polyglucin, reopolyglucin, solutions of proteins, correction of pH balance by using of 4% solution of Sodium bicarbonates. Among physical methods of treatment cold on the lower part of the abdomen is used. Appropriate antibacterial treatment is combined with laparoscopy active drainage.
The tuboovarial abscess is drained of pus by puncture and rinsed with bacteriostatic solution and local application of antibiotics. In subacute stage aloe, ultraviolet radiation, authohaemotherapy is used. They prevent the chronic processes.
Chronic salpingoophoritis. In most cases chronic salpingoophoritis is the sequale of non treated acute process. Chronic stage of the process is characterized by tubal occlusion with periovarial adhesions, tubal dysfunction .
Clinic. The main complains of the patient are: mild tenderness in lower part of abdomen that becomes severe during menstruation. Pelvic nerves have more painful sensitivity (pelvic plexitis, ganglionevritis due to chronic inflammation). In some cases menstrual dysfunctions such as oligomenorrhea, polymenorrhagia, algodismenorrhagia occur. Changing in uterine tubes and hypofunction of ovaries lead to infertility or miscarriage. Secretory dysfunction like vaginal discharge or cervical exudate may be observed as a clinical finding of colpitis or endocervitis. Some patients complain of low libido, painful coitus, dysfunction of urinary bladder, liver tenderness.
Menstrual dysfunction (menorrhagia or metrorrhagia) is the most frequent symptom of chronic salpingoophoritis as a sequel of disorders of neurohomoral regulation of menstrual function. Metrorrhagia often occurs after cessation of menstruation and then the differential diagnosis should be made in case of ectopic pregnancy.
Diagnosis. Correct history taking (reveal of inflammation after abortion, delivery or dilatation and curettage) makes it possible to suspect the chronic inflammatory process. Primary chronic salpingoophoritis is found in more than 60% of cases. Some information gives physical examination and laboratory tests. Bimanual examination gives nonspecific information. Enlargement, consistency and degree of adnexa mobility should be examined. Sometimes because of peritubal and periovarian adhesions the sizes and mobility of adnexa are changed.
Additionally, ultrasound and laparoscopy, hysteroscopy should be held. Tomography or endoscopy may be used. Laparoscopy is the most informative diagnostic method to differentiate salpingoophoritis, external endometriosis, uterine myoma with inflammatory changes, cysts. Disorders of adjacent organs (bladder, intestine) while serous inflammation is present without structural changes. But women with disorders of urinary tract, gastro-intestinal tract must be additionally examined (urography, irrigoscopy).
Treatment of chronic salpingoophoritis is provided with minding of pathogenesis and clinic. Antibiotics are indicated in acute period, when there are signs of inflammation.
Nonsteroidal antiinflammatory drugs (voltaren, butadion) are prescribed. To stimulate immune system immunomodulators are used: (decaris, T-activin). FIBS, aloe, autohaemotherapy are also used. analgesia both by medicines and by reflextherapy is of great importance. Physiotherapy is conducted in hospital while in case of acute process and remission it can be used in ambulatory conditions. Ultrasound has analgetic and fibrinolityc influence and is prescribed in sinusoid and modulate of high frequency. Laserotherapy is also used. To escape chronic salpingoophoritis the acute salpingoophoritis must be treated in proper way and the quantity of abortion should be reduced.
Parametritis is an inflammation of parametrium. Inflammation of the whole pelvic cellular is called pelviocellullitis. According to international statistics these diseases are classified as acute parametritis or pelvic phlegmona.
Infection agents may be staphyloccocus, streptoccocus, E.coli, etc. It can be caused by one microbic agent or microbe association. It occurs after pathologic delivery, abortion, operation on genitals. The main way of infection spreading is lymphogenic. Morphologically parametritis is characterized by all signs of inflammation: dilation of blood and lymphatic vessels, peripheral edema, exudation. There are 3 stages in course of parametritis (infiltration, exudation, firming). Exudation may be serous, and very rarely it is purulent. Sometimes it undergo resorbtion and dissolves, sometimes a fibrose connective tissue grows and leads to uterine dislocation to the side of previous inflammatory process.
Clinic. Moderate tenderness in lower parts of abdomen, in back, high body temperature (38-39°C), tachicardia are found. Signs of peritoneal irritation and diminished or absent bowel sounds, especially associated with ileus, indicate more serious infection, including the possibility of abscess formation. Fever is a characteristic feature in the diagnosis of metritis and it is accompanied by uterine tenderness. Bimanually before or behind on left or right side of the uterus infiltration may be palpated. It is firm and immovable. Infiltration is classified into anterior, posterior and lateral.
Treatment begins from using antibiotic of broad coverage against a variety of common microorganisms and is usually prescribed without cultures.
Various choices of initial antibiotic therapy are used. most of them are successful. Cephalosporins such as cefotetan and cefoxitin are commonly used. A combination of ampicillin and aminoglucoside and also the combination of clindamycin with gentamicin are used.
A bottle with ice on the lower part of abdomen is used in case of infiltrative stage of disease. Biostimulators should be prescribed. Management of a persistent pelvic abscess includes drainage by colpotomy, or laparotomy. Intraabdominal rupture of pelvic abscess is a surgical emergency. Sepsis may occur in association with pelvic infection, with or without frank abscess formation. Phisiotheraputic precedures are used for rehabilitation.
Tuboovarian abscess (TOA) may occur as a complication of salpingoophoritis. It begins from acute purulent salpingitis when all layers of uterine tubes are involved into the process. The tubes characteristically become swollen and redden as the muscularis and serosa are inflamed. If exudate drips from the fimbriated ends of the tubes a pelvic peritonitis is produced then it can give rise to peritoneal adhesions. The swollen and congested fimbriaes may adhere to one another and produce tubal occlusion. The fimbriae may occlude tubes producing permanent tubal infertility. The swollen and congested fimbriae may adhere to ovary, trapping the exudate in the tube and giving rise to pyosalpinx or if the ovary becomes infected, a tuboovarian abscess. The mucosal folds may adhere to one another forming gland-like spaces that are filled with exudate. If the infection subsides after agglutination of the fimbria and closure of the peripheral end of the tube, secretion accumulates and distends the tube, forming pyosalpinx. Each recidive of chronic salpingoophoritis has more clinical manifestation and is treated with difficulty. TOA is associated with IUD, microbe association, chronic salpingoophoritis.
Intoxication in case of TOA leads to liver disorders. Decreasing of albumin-globulin index is observed while the level of general proteins is normal for a long time. The degree of these disorders depends on the time of duration of the process.
Clinic. Clinic of TOA depends on the volume of purulent damage of adnexa, duration of the process, disorders of adjacent organs. There are some syndromes which are divided into local syndrome (pain, purulent discharge, peritoneal symptoms and palpation of tuboovarian mass).
Inflammatory-intoxicative syndrome includes fever, tachycardia, nausea, vomiting. Luecocytosis, decreasing of albumin-globulin index, C-reactive protein are observed in blood. Immune syndrome ( decreasing of lymphocytes and monocytis in blood) is found.
Syndrome of adjacent organs disorders (dysuria, urinary frequency, menstrual disorders) is also possible.
abdominal pain occurs, pelvic peritonitis may be present. Pain can irradiate
to back, pelvic bottom, in the chest. In such cases the examinations should be
performed to exclude pneumonia, pancreatitis, cholecystitis. Musclar defance
which prevents abdominal palpation in the lower quadrants, adnexa are tender to
various degrees and cervix movement may cause pain in case of bimanual
examination. The adnexa often are either adherent to the posterior aspect of
the uterine or prolapsed in cul-de-sac, which may pull the uterine into a
retroverted position. Toa is
characterized by pain and tenderness, fever or chills, tempera-ture rises up 39°C, blood pressure decreases. Abdomen takes part in breathing, and it is painful in lower parts. In
blood analysis elevated white blood count
(9-10х109/ l) erythrocytes’ sedimentation rate more than 30mm/hour, positive C-reactive protein, decreasing of albumin-globulin index till 0,8 are observed.
Sometimes there can be urinary syndrome with proteinuria, leucocyturia. There may be disorders of filtrative kidney’ function, even unuria. Changing of albumin-globulin index and hypofybrinogenemia characterizes the liver dysfunction.
Diagnosis is based on clinic, bimanual examination, laboratory analyses and additional methods of investigation (ultrasound, laparoscopy).
Treatment. tuboovarian abscess is treated by antibiotics, desensibilisative and nonsteroidal antiinflammatory medicines, detoxication and immunostimmulation. Best of all one should combine taking of penicillin with tetracyclins. When anaerobic infection is suspected metronidazole is used. Daily punctions of tuboovarian abscesses are indicated to remove purulent containts.
Indications to surgical removal of tuboovarian abscess are:
l abscence of efficiency of complex treatment with usage of punctions during 2-3 days
l suspicion on tuboovarian abscess perforation; volume of surgical intervention depends on process’ spreading, woman’s age and extragenital pathology
Pelvioperitonitis is an inflammation of pelvic peritoneum.The polymicrobial infection such as Escherichia coli and other aerobic, enteric, gramnegative rods, group of b-hemolytic staphylococci, anaerobic, streptococci, Bacteroides species, staphylococci, mycoplasms cause the process. Pelvioperitonitis occurs secondary. Primary process is in uterine tubes, ovaries, uterus and parametrium. In most cases purulent damage of uterine adnexa lasts with pelvioperitonitis. Infection can be spread by limphogenic or blood vessels, and from uterine tubes in case of salpingitis, especially gonococcial infection.
Clinic characterizes the acute inflammation. high temperature, severe lower abdominal pain, fever or chills, tachycardia are common. There can be nausea and sometimes vomiting. Muscular defence and rebound tenderness are the symptoms of peritoneal irritation. Anterior abdomen wall takes part in breathing act.Tender adnexa are present at bimanual examination. Cervical motion causes pain. Posterior fornix is painfull.
Laboratory tests reveal increasing of white blood cell count and erythrocyte sedimentation rate. C-reactive protein levels may appear. Generall blood test should be done 4-5 times per day to diagnose transformation of pelvioperitonitis to peritonitis.
Treatment. All the patients should be hospitalized. Ideally, the antibiotic should be selected according to the organism present in the fallopian tube or uterus, but in most cases empiric therapy must be used. Treatment includes intravenous doxycycline and either cefoxitin or cefotetan or intravenous clindamycin and gentamicin for at least 4 days followed by oral clindamicin or tetracyclin for 10-14 days. Hospitalized patients who have peritonitis but do not have adnexal abscess usually respond rapidly to the regimens. In the presence of an adnexal abscess, even if the systemic manifestations are mild, antibiotics which eliminate B.fragilis should be selected because most pelvic abscesses contain this organism. Clindamycin, metronidazol, cefoxitin, or impinem should be used to treat pelvic abscess. If there is an intrauterine device it should be removed as soon as therapy is started. Surgery is indicated in the case of ruptured pyosalpinx or ovarian abscess. Colpotomy drainage usually is preferable when unruptured midline cul-de-sac abscess is present. Laparotomy is required for such problems as unresolved abscess or adnexal mass that does not subside, surgery should be limited to the most conservative procedures that will be effective. Unilateral abscess respond to unilateral salpingoophorectomy.
Pelvic Inflammatory Disease
Pelvic inflammatory disease, or PID, is an infection of a woman's pelvic organs (uterus, fallopian tubes, and ovaries). PID can affect the fallopian tubes (the tubes that carry eggs from the ovary to the uterus, or womb). It can also involve the tissues in and near the uterus and ovaries.
Image PID can be treated and cured with antibiotics. If left untreated, PID can lead to serious problems like infertility (not being able to get pregnant), ectopic pregnancy (pregnancy in the fallopian tube instead of the uterus), constant pelvic pain, and other problems.
PID is caused by bacteria. Bacteria can move upward, from a woman's vagina or cervix (opening to the uterus, or womb) into her fallopian tubes, ovaries and uterus, causing infection. Many types of bacteria can cause PID. But, bacteria found in two common sexually transmitted diseases (STDs) - gonorrhea and chlamydia - are the most frequent causes of PID. After being infected, it can take from a few days to a few months to develop PID.
Although rare, a woman can develop PID without having an STD. No one is sure why this happens, but normal bacteria found in the vagina and on the cervix can cause PID.
Women who are more likely to develop PID include:
- Women who have had a sexually transmitted disease (STD), especially gonorrhea and chlamydia.
- Sexually active women under age 25.
- Women who have more than one sex partner. The more sex partners a woman has, the greater her risk of getting PID. Also, if a woman's sex partner has other sex partners, her risk for PID increases.
- Women who douche. Douching may flush bacteria into the uterus, ovaries, and fallopian tubes, causing infection. Douching can also hide the signs of an infection. A woman could have an STD or other infection and not know it. This could stop her from seeking treatment.
- Women who have an intrauterine device (IUD) may be at a slightly greater risk of PID than women who use other types of birth control. But this risk is greatly lowered when women are tested and treated for any infections before getting an IUD.
Pelvic inflammatory disease (PID
Alternative names PID; Oophoritis; Salpingitis; Salpingo-oophoritis; Salpingo-peritonitis
Causes, incidence, and risk factors
The majority of pelvic inflammatory disease cases are caused by the same bacteria that lead to sexually transmitted diseases (such as chlamydia, gonorrhea, mycoplasma, staph, strep).
Although the cause of PID most commonly spreads through sex, bacteria may also enter the body after gynecological procedures such as the insertion of an intrauterine device (IUD), childbirth, miscarriage, therapeutic or elective abortion, and endometrial biopsy.
In the United States, nearly 1 million women develop PID each year. It is estimated that 1 in 8 sexually active adolescent girls will develop PID before reaching age 20. Since PID is frequently underdiagnosed, statistics are probably greatly underestimated.
Risk factors include:
- Sexual activity during adolescence
- Multiple sexual partners
- Past history of PID
- Past history of any sexually transmitted disease
- Insertion of an IUD
Birth control pills are thought in some cases to lead to cervical ectropion, a condition that allows easier access to tissue where bacteria may grow. However, birth control pills may protect against PID by stimulating the body to produce a thicker cervical mucous, which makes it harder for semen to carry bacteria to the uterus.
The most common symptoms of PID include:
- Vaginal discharge with abnormal color, consistency or odor
- Abdominal pain
- Fever (not always present; may come and go)
Other nonspecific symptoms that may be seen with PID include:
- Irregular menstrual bleeding or spotting
- Increased menstrual cramping
- Menstruation, absent
- Increased pain during ovulation
- Sexual intercourse, painful
- Bleeding after intercourse
- Low back pain
- Lack of appetite
- Nausea, with or without vomiting
- Frequent urination
- Pain with urination
Note: There may be no symptoms. People who experience ectopic pregnancies (pregnancies where the embryo implants in the fallopian tubes instead of the uterus) or infertility are often found to have silent PID, which is usually caused by chlamydia infection.
You may have a fever and abdominal tenderness. A pelvic examination may show that you have cervical discharge, pain with movement of the cervix during the exam, a cervix that bleeds easily, or uterine or ovarian tenderness.
Tests and procedures may include:
- ESR (sed rate)
- Wet prep or wet mount microscopic examination
- Serum HCG (pregnancy test)
- Endocervical culture for gonorrhea, chlamydia, or other organisms
- Pelvic ultrasound or CT scan
Treatment If you are diagnosed with mild PID, you may be given antibiotics and told to closely follow-up with your health care provider.
More severe cases may require you to stay in the hospital. Antibiotics are first given by IV, and then later by mouth. Surgery may be considered for complicated, persistent cases that do not respond to antibiotics. Any sexual partner(s) must also be treated. The use of condoms during treatment is essential.
Complications PID infections can cause scarring and adhesions of the pelvic organs, possibly leading to infertility, ectopic pregnancy, and chronic pelvic pain.
- Practicing safer sex behaviors
- Following your doctor's recommendations after gynecological procedures
- Getting prompt treatment for sexually transmitted diseases
The risk of PID can be reduced by getting regular STD screening exams. Couple can be tested for STDs before beginning sexual relations. Testing can detect STDs that may not be producing symptoms yet.
Pelvic Inflammatory Disease (PID)
Pelvic inflammatory disease (PID) is caused by a type of bacteria, often the same type that is responsible for several sexually transmitted diseases, such as gonorrhea and chlamydia. In some cases, PID develops from bacteria that has traveled through the vagina and the cervix by way of an intrauterine device (IUD).
PID can affect the uterus, fallopian tubes, and/or the ovaries. It can lead to pelvic adhesions and scar tissue that develops between internal organs, causing ongoing pelvic pain and the possibility of an ectopic pregnancy (the fertilized egg becomes implanted outside the uterus). Left untreated, infertility can develop. In fact, PID is currently the leading cause of female infertility. If left untreated, PID can also lead to chronic infection. In addition, if PID is not diagnosed early enough, peritonitis and inflammation of the walls of the abdominal and pelvic cavity may develop.
The following are the most common symptoms of PID. However, each individual may experience symptoms differently.
Symptoms of PID include:
- diffuse pain and tenderness in the lower abdomen
- pelvic pain
- increased foul-smelling vaginal discharge
- fever and chills
- vomiting and nausea
- pain during sexual intercourse
Symptoms may be mild enough that the condition may go undiagnosed.
The symptoms of pelvic inflammatory disease may resemble other conditions or medical problems. Always consult your physician for a diagnosis.
How is PID diagnosed?
In addition to a complete medical history and physical and pelvic examination, diagnostic procedures for PID may include the following:
- microscopic examination of samples from the vagina and cervix
- blood tests
- Pap test - test that involves microscopic examination of cells collected from the cervix, used to detect changes that may be cancer or may lead to cancer, and to show noncancerous conditions, such as infection or inflammation.
- ultrasound - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs.
- laparoscopy - a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic area, the physician can determine the locations, extent, and size of the endometrial growths.
- culdocentesis - a procedure in which a needle is inserted into the pelvic cavity through the vaginal wall to obtain a sample of pus.
Treatment for PID:
Specific treatment for cervicitis will be determined by your physician based on:
- your age, overall health, and medical history
- extent of the disease
- type and severity of the symptoms
- your tolerance for specific medications, procedures, or therapies
- expectations for the course of the disease
- your opinion or preference
Treatment for PID usually includes oral antibiotics, particularly if there is evidence of gonorrhea or chlamydia. In cases of severe infection, hospitalization may be required to administer intravenous antibiotics. Occasionally, surgery is necessary.
Specific inflammatory diseases
To specific inflammatory diseases of the female reproductive organs belong tuberculosis and sexually transmitted diseases. According to the WHO’s classification, there are 21 such diseases. Their frequency has been risen for the last years.
(the WHO’s classification)
Classic venereal diseases
1. Syphilis Treponema pallidum
2. Gonorrhea Neisseria gonorrhoeae
3. Chancroid Hemophilus ducrei
4. Lymphogranuloma venereum Chlamydia trachomatis
5. Donovanosis, or granuloma inguinale Callimmantobacterium granulomatis
3,4,5 are mostly in tropic countries
Other sexually transmitted infections
A — that affect mostly genital tract
1. Syphilis Treponema pallidum
1. Urogenital chlamydiasis Chlamydia trachomatis
2. Urogenital trichomoniasis Trichomonas vaginalis
3. Urogenital mycoplasmosis Mykoplasma hominis
4. Candidosis vulvovaginitis Candida albicans
5. Genital herpes Herpes simplex virus
6. Genital warts Papillomavirus hominis
7. Molluscum contagiosum Molluscovirus hominis
8. Bacterial vaginosis Gardnerella vaginalis та iншi збудники
9. Urogenital shigellosis of homosexualists Shigella species
10. Pediculosis pubis Phthyrus pubis
11. Scabies Sarcoptes scabiei
B — With mostly affection of other organs
1. Infection, caused by HIV Human immunodeficiency virus
2. Hepatitis B Hepatitis B virus
3. Cytomegalovirus infection Cytomegalovirus hominis
4. Amebiasis Entamoeba hystolytica
5. lambliosis Giardia lamblia
Gonorrhea is a contagious disease caused by Neisseria gonorrhoeae. Among the specific inflammatory diseases of the female genital tract gonorrhea takes the second place and is in 5-25% of cases of all STDs.
Etiology and pathogenesis. Gonorrhea is caused by Neisseria gonorrhea (fig. 92). The causative agent was found in 1879 by A. Neisser. Gram-negative N. gonorrhea is not stable in the outer surrounding and dies quickly at the influence of antiseptic solutions, boiling, drying, but it is rather stabile in human organism. In uncomfortable conditions they transform into L-forms, which can transform into the usual form in the favourable conditions. In case of chronic gonorrhea, N. gonorrhoeae are situated mostly in leukocytes and out of the cells, in case of the acutening of the process they are found in the leukocytes.
N. gonorrhea affects mostly those parts of urogenital tract, that are covered with cylindric epithelium: mucosa of urethra, cervical canal, Bartholin’s glands ducts, mucosa of uterine cavity, uterine tubes, ovarian epithelium, peritoneum. During the pregnancy, childhood and menopausal period there can be gonorrheal vaginitis.
The source of infection is a person with gonorrhea.
Ways of infecting:
l the disease is sexually transmitted
l homosexual contacts, orogenital contacts
l very rarely through sponges, towels, underwear
l during labour from mother (infected eyes, vagina in girls)
Incubational period lasts for 3-7 days, sometimes for 2-3 weeks.
According to the stage of spreading the process the gonorrhea of lower part of genital organs (gonorrheal urethritis, endocervicitis, Bartholinitis, vulvovaginitis) and gonorrhea of upper parts — gonorrhea ascendens (endometritis, salpingitis, pelvioperitonitis) is classified.
According to duration there are such forms of gonorrhea:
l fresh gonorrheal infection with acute, subacute, torpid passing, which lasts less than two months
l chronic gonorrheal infection, lasting more than two months
l latent gonorrheal infection
In women the clinic of gonorrhea depends on the localization of the process, virulency of causative agent, age of woman, organism’s reactivity, stage of the disease (chronic, acute).
Fresh gonorrhea in acute forms has expressed clinical manifestations. Subacute form is characterized by subfebrile condition, sometimes by expressed clinical symptoms, which appeared two weeks before. Torpid gonorrhea in acute form has mild clinical manifestations or is asymptomatic, but N. gonorrhoeae are found in the patient. Latent form is diagnosed when there is no bacteriologic and bacterioscopic confirment, no symptoms, but person is a source of infection. Chronic gonorrhea lasts for more than 2 months, or without establishing of the beginning.
Gonococcal urethritis. Clinical manifestation appears within 3-5 days after infection and is characterized by dysuria. Variable degrees of edema and erythema of the urethral meatus, purulent or mucopurulent discharge are present.
Gonococcal Bartholinitis. It may occur when N. gonorrhea with vaginal discharge infects the Bartholin’s gland. It is manifested by edema, erythema around the duct’s os. When the occlusion occurs, pseudoabscess or Bartholin’s abscess which are accompanied by purulent process symptoms can develop.
Gonococcal endocervicitis. Inflammatory process develops in mucosal layer of the cervical canal. Examination reveals edema and erythema of vagina and part of the cervix. There is a red crown around the cervical os and a mucopurulent cervical discharge.
Gonococcal proctitis occurs very rarely. Rectum is involved into the process in the result of contamination with the infected genital discharge. Clinic includes tenesmus and rectal pain.
Gonococcal endometritis is the first stage of the ascendant gonorrhea with infection of basal and functional layer of endometrium. It is manifested by lower abdominal pain, high body temperature, sometimes nausea, vomiting. Pain often has spasmatic character. Discharge is sanguine-purulent or mucopurulent. Uterus is painful at palpation. Chronic endometritis is characterized by menstrual disorders.
Gonococcal salpingitis is the infection of the fallopian tubes, mostly bilateral. In acute stage the pain in lower part of abdomen is common. It becomes stronger, motion, nausea, vomiting. Menstrual disorders can occur.
Gonococcal pelvioperitonitis — a specific inflammation of pelvic peritoneum and is a sequel of salpongoophoritis. The onset is acute. Severe lower abdominal pain, peritoneal irritation symptoms, vomiting, meteorism, constipation, high body temperature can be found. Gonococcal inflammation is characterized by the tendency to adhesion process, that leads to localization of inflammation in pelvis.
Gonorrhea during pregnancy is often asymptomatic. It can lead to complication of pregnancy, labor and is a risk factor both for the fetus and for the newborn. Possible complications for mother (chorioamnionitis, subevolution of uterus, endometritis) and fetus (premature delivery, unophthalmia, intrauterine sepsis, death) can occur. Artificial abortion is dangerous because of possibility of the uterus, ovaries, tubes infection and other complications.
Gonorrhea in children. Mechanism of infection: during delivery when a child passes through infected birth canal, or intrauterine through amnionic fluid, and from ill mother to child while looking after it. Elder children may be infected while using common toilet, sponge, bath.
Gonorrhea in girls is acute with the expressed edema and erythema of mucosal membrane, mucopurulent discharge, frequent and painful urination, itching. There can be high body temperature. In girls gonorrhea causes the same complications as in women.
Peculiarities of the gonococcal infection:
l increasing of quantity of capsular and l-forms of n. gonorrhea
l decreasing of sensitivity to penicillin antibiotics
l large percentage of asymptomatic and torpid forms
l frequent relapsing as a sequele of inadequate treatment
l urogenital infection is often mixed (gonococci, chlamidias, trichomonades, mycoplasmas, candides)
This should be taken into account during treatment.
Diagnosis of the process is based on the data of complex examination. The disease is characterized by urethritis, bartholinitis, endocervicitis, bilateral salpingitis, proctitis, pelvioperitonitis. But diagnosis of gonorrhea can’t be confirmed without laboratory tests.
Diagnosis of gonorrhea is confirmed by positive results of bacterioscopic and bacteriologic tests of cervical, vaginal, urethral discharge. To acuten the chronic process the so-called “provocation” is conducted:
1) 0,25% solution of argentum nitrici on mucosal membrane of the cervix, vagina and urethra is applied
2) introducing of gonovaccine, pyrogenal, prodigiozan
Smears must be taken on the 2-4th day of the menstrual cycle and after provocation in 24, 48, 72 hours, that allows to reveal N. gonorrhea.
Treatment is provided in special clinic. Sometimes the patient is treated by the venerologist in ambulatory.
To reveal another sexually transmitted diseases clinical and laboratory examination must be performed. While prescribing medicines the clinical form, complications and severity of the process should be taken into consideration.
The main medicines in gonorrhea treatment are antibiotics. Gonococcal infection very often is accompanied with trichomoniasis, chlamidiasis, candidiasis, mycoplasmosis.
Antibiotics that have influence on the following agents such as: ciprofloxacin, doxycyclin, trobicyn, sumamed, cephtriaxon, afloxacin in combination with metronidazol, tiberal, naxogyn should be prescribed. The dose of antibiotics is taken according to the methodical instructions of the Ukraine MHP and annotation of medicines.
Gonovaccine is used after ineffective antibiotic treatment and relapse in the latent fresh torpid and chronic form of the disease (200-300 mln. of microbe bodies, in 2-3 days intramuscularly). During pregnancy immunotherapy and antibiotics with negative influence on a fetus are not used.
For toilet of external genital organs 0,002% solution of chlorhexidine, recutan, baliz-2 are prescribed. Local treatment of chronic gonorrhea is conducted after disappearing of the signs of acute inflammation. In chronic and subacute stages physiotherapeutic methods are used: laser radiation, paraffinotherapy, mud-cure, diathermy, inductothermy, U.H.F-therapy.
The control of the results of treatment: disappearing of subjective signs and microbe agents in all the infected organs and discharge. On the 7-10th day after medical therapy the bacterioscopic and bacteriologic methods are used to confirm the results of treatment. If there is no N. gonorrhea in the material, then the combined provocation is conducted: injection of gonovaccine (500 mln. of microbe bodies), instillation of 1% Lugol’s solution in urethra, 0,5% solution of argentum nitrate into cervical canal. Discharge from this organ should be examined during 3 days. Smears are taken during menstruation and then after provocation in 24, 48, 72 hours. Such examinations are provided during 2-3 menstrual cycles. Women which have contacts or work with children are not allowed to work.
Prophylaxis. Using of condom is the most effective prevention method. If the sexual intercourse has happened without it, then the external genital organs should be washed with water and soap, and after urination syringing with 0,05% chlorhexidin solution should be performed.
Urogenital trichomoniasis is caused by Trichomonas vaginalis and is a result of their invasion into the lower part of genital tract and urethra.
Ethiology. Trichomonas vaginalis is a flagellate protozoan and it is transmitted by sexual intercourse. It is not stable in outer environment, dies in few seconds under the influence of antiseptic solutions, in water it dies during 15-45 minutes, and also when they wash hands with soap, it is sensitive to drying. In human organism Trichomonas vaginalis can exist in 3 forms: common one (pear-shape form), amebiform with the expressed phagocytosis action (it can phagocytise mycoplasmas, N. gonorrhea and other bacteria that caused the recurrence of mycoplasmas or gonorrhea. this is the most spread disease among all the sexually transmitted ones. Its frequency rate reaches 50-70% of sexually active women. According to the WHO statistics, 10% of world population suffer from trichomoniasis. Non-sexual transmission is very seldom: when they use sponges, underwear, towels.
Incubation period lasts for 5-15 days. the main places of trichomonas parasitizing are mucose membranes of vagina, cervical canal, uterus cavity, uterine tubes, Bartholin gland’s duct, urethra, urinary bladder.
Inflammatory process develops in the infected mucous membrane: edema, hyperemia, exudation, desquamation affects epithelial cells.
Clinical manifestations. Vaginitis, urethritis, endocervicitis, proctitis are the most common manifestations, ascendant infection meets rarely.
Forms of genital trichomoniasis:
l fresh (acute, subacute and torpid forms)
l chronic trichomoniasis (with torpid form and duration of more than 2 months)
l trichomonas carriage (is characterized by the absence of symptoms, while Trichomonas vaginalis are present)
At acute and subacute forms women complain of foamy vaginal discharge with foul odor, vulvar itching, dysuria.
Objective data: erythema, maceration, vulva, perineum scratching, cervical erosion, erythema and edema of vaginal mucosa, foamy purulent discharge. At torpid forms clinical manifestations are mild or absent.
Chronic trichomoniasis is characterized by vaginal discharge, itching, but there are no inflammatory manifestations, there can be frequent relapsing.
Diagnosis. Diagnosis is confirmed by anamnestic data, objective examination, vaginal smears.
Peculiarity of the mixed trichomoniasis-gonococcal infection is the longer incubation period. At first trichomoniasis and after gonorrhea is treated.
Treatment. The main principles are:
l treatment of the woman and her sexual partner
l avoiding of intercourse until the patient and her partners are cured
l using of antitrichomonades treatment with local treatment, and hygienic procedures: shaving hair on pubis, everyday changing of underwear
l treatment of accompanying diseases of genital organs
Antitrichomonade remedies are metronidazole (trichopol, clion, metragil, flagil), fasigyn (tinidazol), atrican, naxogyn, tiberal, solkotrichovak, tergynan.
Recently for treatment of trichomoniasis metronidazole should be prescribed. on the first day they use 0,25g 4 times a day, on the next days — 0,25g 3 times a day. All dosage on treatment course is 5-6 g. Tinidazole is used in such regimen after meals:
l once 2 g (4 tablets each 0,5 g)
l 0,5g every 15 minutes 4 times
l 0,15g twice a day during 7 days
Naxogyn is used in dose of 500 mg twice a day 6 days. During pregnancy and breast-feeding all these medicines are contraindicated.
Clion-D is used in the form of vaginal tablets 1 tabl. for night during 10 days. Locally antiseptic solution can be used: baliz-2, 0,002% solution of chlorhexidin, trichomonacid.
Control of the treatment is fulfilled during 2-3 menstrual cycles.
Prophylaxy. To prevent trichomoniasis condom using is recommended. If the sexual intercourse has happened without the condom, then the external genital organs should be washed with water ans soap, and after urination syringing with 0,05% chlorhexidin solution should be performed.
Urogenital chlamidiasis (chlamidiosis urogenitalis) is a rather spread infectional disease, which is transmitted mostly sexually. In women it can be manifested as urethritis, vaginitis, bartholinitis, endocervicitis, cervical erosion, endometritis, salpingitis, pelvioperitonitis, proctitis etc. It can occur even in the newborns (infected during labor). Chlamidial infection occurs in 50% of cases among women with the inflammatory processes, besides these chlamidias are often accompanied by gonorrhea (40%) and trichomoniasis (40%). According to the WHO statistics nearly 90 millions of the new infected are registered annually. The reason of its wide spreading is mild duration, complicated diagnostics and treatment. More often the women of 20-30 years age become ill.
Ethiology and pathogenesis: Infective agent of urogenital chlamidiasis is gram-negative bacteria, Chlamydia trachomatis, preferentially it infects columnar epithelium and reproducts itself intracelluarly. There are two main forms of chlamidia — elementary body and reticular body.
Elementary bodies are the infective form of the agent, which transmit the infection, can exist outcellularly. The cell can be penetrated with few elementary bodies, that have tendency to conflowing, making one particle. During 48-72 hours infected cells are destroyed. Elementary bodies come out from cells and infect the new ones. Reticulative bodies are vegetative forms of chlamidia and are the result of reproduction in the infected cells, a new generation of elementary bodies. practically they don’t cause the infection. Microscopy allows to identify both kinds of bodies. Chlamidia has a complicated antigenic structure. It is very sensitive to disinfectant substances. At 35-37°C during 24-26 hours outcellular chlamidia become nonvirulent, at temperature 95-1000C they die during 5-10 minutes. In cotton material they can survive up to 2 days at temperature 19-20°C.
The source of infection is the ill person.
Ways of transmission:
l intrapartum (passing through the infected birth canal)
l nonsexual way (polluted hands, instruments, underwear, toilet, etc.)
Besides infection of urogenital organs, Chlamidia trachomatis can cause pharyngitis, conjunctivitis, perihepatitis, otitis, pneumonia, other diseases (Reiter’s syndrome).
Clinical manifestations. Incubational period lasts from 5 to 30 days. The main primary form of chlamidial infection is endocervicitis with mild symptoms or without any. In acute stage purulent or mucopurulent discharge from the cervix, edema and erythema of the vaginal part of the cervix are observed. In chronic stage there is the mucopurulent discharge and pseudoerosion of the cervix.
Chlamidial urethritis can be asymptomatic or it manifests itself by dysuria. There are no specific symptoms for clinical diagnostics of chlamidiasis.
Salpingitis, caused by Chlamidia trachomatis, is characterized by the same symptoms like the process caused by other bacteria.
The sequale of chlamidial salpingitis is infertility.
Diagnosis is based on the history (both partners are ill, there is the infertility). Residual diagnosis is established after revealing chlamidias in the scrap from the cervix and vagina. The most exact are immuno-enzyme and immunofluorescent methods.
Treatment. It is necessary to cure the woman and her sexual partner. The woman should avoid sexual intercourses, alcohol, psychical and physical overload.
Medicines from the tetracyclin group are prescribed (doxycyclin, rondomicyn, morphocyclin), sumamed, tarivid, macrolids (clacid, erythromycin).
To prevent candidosis diflucanum in dose 150 mg is used, nistatin or levorin (2.000.000 IU per day during treatment) are prescribed. Fromilid (clarythromycin), an acid-resistant antibiotic from macrolid group is recommended. An important property of this drug is its possibility to cell penetration, that’s why fromilid is 8 times more active, than erythromycin. It doesn’t suppress immune system, activates phagocyto-macrophagal system and some enzymes, that take part in destroying of pathogenic bacterias. The dose of fromilid is 500 mg twice a day during 7-14 days in case of fresh incomplicated chlamidiosis. In chronic forms the treatment course must be elongated till 3-4 weeks.
At urogenital chlamidial infection medicines from ftorchinolon group, ciprofloxacin (ciprinol) are used. Ciprinol is prescribed in the dose of 0,5g orally or 0,2g intravenously each 12 hours during 10-14 days. During treatment the ultraviolet irradiation including sun radiation are contraindicated.
Treatment of chlamidiasis demands from the doctor and patient accurate fulfilling of all the indications (dose and duration of the therapy), especially at chronic, long-lasting forms of disease. At the same time accompanying urogenital diseases should be treated. To reduce side effects of antibiotics hepatoprotectors, antioxydants, polivitamins are used.
Ethiology. Microbal agents are Mycoplasma hominis, Mycoplasma genitaloum, Ureaplasma urealiticum.
In the etiology of the inflammatory diseases of female genital organs the associaton of mycoplasmosis with trichomoniasis, N. gonorrhea, chlamidia trachomatis, anaerobes is of great importance.
Mycoplasmas are transmitted sexually and they are highly spread among the population.
Clinic. Mycoplasmas infection can occur in acute and chronic form, and has no symptoms, which are specific for this agent. It is often found in healthy women. Mycoplasmosis is characterized by torpid course, sometimes the latent forms of the reproductive system inflammation are observed. The agents may be activated under the influence of menstruation, oral contraceptives, pregnancy, delivery. Ureaplasma is identified in the patients with vaginitis, cervicitis, urethritis, in association with other bacteria the symptoms are typically and described in the part “Nonspecific inflammatory diseases of the female genital organs”.
Diagnosis. To reveal ureaplasmas the bacteriological method is used. Material is taken from the purulent discharge of Bartholin’s glands, from uterine tubes at salpingitis, tuboovatian tumors at pelvic inflammatory disease. Test on the urease is done (colour index). It is based on the property of ureaplasms to product urease, that changes the pH and the colour of indicator. Serological diagnosis is also used. Immunogram in diagnosis of mycoplasmosis and other infection (chlamidia, gonorrhea, trochomoniases, herpes simplex virus) is indicated.
Treatment. Using of antimicrobal medicines from macrolid group (erythromycin, sumamed, roxitromycin), Tetracyclin group (tetracyclin, doxycyclin), fluorochinolones (ciprofloxacin) is etiotropic treatment. They are prescribed for not less than 10-14 days with the following laboratory control. Another course of treatment is immunity stimulation (immunoglobulin, levamizol, T-activin, ginseng tincture).
Prophylaxis. examination of the risk group (prostitutes, women with infertility, inflammatory processes of genital organs), and keeping to the same measures for preventing sexually transmitted diseases are used.
Candidiasis is a polyorganic disease, caused by yeast fungi (Candida albicans, C. glabrata, C. tropicalis). It can be transmitted sexually. The most frequent localization is in vagina, vulva, but there can be candidiasis endocervicitis, endometritis, salpingitis.
l endogenous long lasting diseases, such as diabetes mellitus, avitaminosis
l exogenous factors, that predispose fungal colonization and decrease the general reactivity of the organism (long treatment with antibiotics) and local immunity in vaginal mucosa
l high virulency of candidas
There are such kinds of candididas vulvovaginitis:
l antibiotics-induced (as a result of antibiotic treatment)
l as a sequale of changes in different systems of the organism (diabetes, pregnancy, using of estrogens)
On the suppressed immunity of the organism fungi, that were previously saprophites, become pathogenic. They adher to vaginal epithelial cells, causing superficial inflammation and desquamation of vaginal cells. Genital candidiasis mostly doesn’t cause a deep damage of mucosa and spreading of the process, but if the agent has high virulence, it can penetrate into intra- and subepithelium parts. in some cases there can be dissemination of candidiasis.
Clinical manifestations: Candidiasis vulvovaginitis is characterized by vulvar itching, pruritus, cottage-cheese-like discharge.
Examination reveals edema and erythema of genital mucos with whitish adherent discharge, that include pseudomicelium of fungi, exfoliated epithelial cells and leukocytes.
Diagnosis. Diagnosis is based on the clinical manifestations, vaginal examination, colposcopy, bacterioscopic and bacteriological methods.
Treatment. Acute form is treated by orungal 200 mg twice a day during 3 days; at chronic form they use 100 mg twice a day during 6-7 days, then during 3-6 menstrual cycles 1 capsule on the first day of menstrual cycle is taken. High effectiveness is observed while using diflucan in dose 150 mg per 1 reception, and gyno-pevaril — one suppository (150 mg) during 3 days. In case of relapse one suppository (50 mg) twice a day for 7 days and application of gyno-pevaril creme on glans penis during 10 days is recommended. The next step of treatment is normalization of vaginal ecosystem.
Prophylaxis: rational antibiotic treatment with keeping to optional doses and duration of the therapy course, in-time using of antimycotic medicines with the preventive aim. Avoiding of premarriage and extramarital relationships, condom using for preventing fungal colonization of the female genital tract.
Agent of AIDS is retrovirus, which affect immune system of organism.There are two types of Human immunodeficiency virus, that caused acguired immunodeficiency syndrome (AIDS): HIV-1 and HIV-2.
HIV-1 is spread in all the countries of the world. HIV (human immunodeficiency virus) is very sensitive to heating, while at boiling it dies immediately, as well as after applying of 70% ethanol, 0,2% solution of natrii hypochlorate and other desinfective solution. But this virus survives in its dried form during 4-6 days in 22°C temperature, in lower temperature even more. The source of infection is the ill person or viral carrier. People with AIDS are infective all over the life.The quantity of people with HIV in many times prevalents the quantity of ill person with AIDS. Infected person becomes contagious in a very short time — 1-2 weeks after infection.
The ways of infection:
l sexual, which insures natural viral transport from one person to another, as well as sequel of homosexual contacts
l parenteral way of infection occurs when they break the sanitary rules making injections, especially intravenous, when injections are made with one syringe, with changing only the needle
l professional way of infection of medical personnel occurs when blood of the person with AIDS contacts with lesioned skin (microtrauma, fissure etc) or mucosal layer during manipulations (injections and others)
l transfusional way occurs very rarely, when the infected blood is transfused to the healthy person
l transplacental — from the infected mother to the child
So, HIV infection can be transmitted from people to people in direct contact: “blood to blood” or “blood to sperm”. Transmission of virus through saline during kissing is less possible. The virus isn’t transmitted by insect stings.
Clinical manifestations of AIDS: Incubation period can last from 1 month to 10 months or even to years. Clinical manifestations may vary, they can be divided into some periods. In 30-50% of the inspected persons in 2-4 weeks an acute period can be observed: fever, tonsillitis, enlarging of neck lymphatic nodes, liver, spleen. This lasts for 7-10 days, and then the disease becomes latent. The only sign of illness at this time may be the enlarged peripheral lymphatic nodes. They are movable, not connected with tissues, some of them are painful at palpation. Such enlarging of the nodes can indicate to the AIDS, if it lasts for more than 1,5-2 months. Later the so-called AIDS-associated or premorbid complex of symptoms is developed. It can last from 1 to 6 months during some years. In this time many different symptoms and diseases which are not specific for AIDS (up to 200) are developed. That is the long-term fever, generalized enlarging of peripheral lymphatic nodes, periodical diarrhea, weight loosing (more than 10%), oral cavity candidiasis, leukoplakia of tongue, folliculitis, different skin lesions.
This period lasts wave-likely while health becomes better till the clinic remission, when person considers himself absolutely healthy.
The last period is AIDS. In such persons different infectious diseases occur (up to170) on the base of immunodeficiency, caused by HIV-infection. Nervous system is damaged (in 30-90% of patients), poor orientation, bad memory and demention are develops. Pneumocystic pneumonia (lung inflammation) occurs up to 60% with severe, sometimes with fulminant passing. In 60% of cases severe and long-termed diarrhea is observed. Kaposhi’s sarcoma very often progresses and becomes the reason of death at young age In significant part of patients having AIDS, malignant processes like lymphoma and others are developed as a result of virus influence on immune mechanism of human being. Skin and mucosa are damaged with candida fungi (candidiasis, herpes simplex and circular herpes virus with severe, relapsing duration, they don’t undergo to usual methods of treatment.
Diagnosis. In AIDS the following diagnosis are mentioned:
l epidemiological history (homosexualism, drug abuse, prostitution, intravenous injections etc.)
l a long-term enlargening of peripheral lymphatic nodes, loosing of body weight, long-term fever and diarrhea
l revealing of antibodies to HIV in blood by immunofluorescent analysis and others. 5 ml of venous blood is taken, and it is kept in refrigerator at the tempreature of +2 — +4°C. Serum is taken out after appearing of the blood the clot and sent to the laboratory not later than in 1-3 days
Treatment. There are no medicines for treating AIDS. But remedies, that inhibit development of the disease are used. Nowadays there is an effective preparation for treatment of HIV infection and AIDS — Krixivan (protease inhibitor). Triple therapy of Krixivan base (krixivan+AZT+ZTS) has high effectiveness, decreases quantity of viruses in blood to lower level. Immunostimulators, immunomodulators, symptomatic therapy depending on the pathology is used.
l sanitary and educational work among inhabits
l avoiding of pre- and extramatrial relationships
l using of condoms (decrease the transmission in 200-500 times)
l prophylaxis of drug abuse, parenteral (subcutaneous or intravenous) injectons of medicines
l proper sterilization of medical instruments, using syringes and needles of single use
l using special defence agents by medical workers contacting with patients’ blood and other biological substances (special closes, double gloves, goggles, masks)
l control of donor blood
The quantity of viral diseases of genital organs has been significantly incincreasing for the last time, especially among young people.
Viral infections can occur in latent form, with less symptoms and with expressed clinical manifestation. That’s why it is very difficult to diagnose them. These diseases have especially negative influence on the pregnancy. There is a risk of viral transmission to fetus.
They can cause fetus diseases or defects of development, leading to fetus death or miscarriage. Every pregnant woman with miscarried fetus must be examined on these infections presence, because in the majority of such women Cytomegalovirus, Gripp virus, Hepatitis A and B virus, Papillomavirus are revealed. Besides the influence on fetus, according to the recent investigations, viral infection causes malignant growth in the female genital organs.
Herpesvirus diseases of genital organs are caused by Herpes simplex virus, mostly of the second type (HSV-2). Source of the infection are infected persons and carriers. It may be revealed in young sexually active women. It can be transmitted during orogenital contact. The virus is located mostly in mucos membranes of urogenital tract in men and cervical canal in women, also in the nervous ganglions of lumbar and sacral parts of sympathetic nervous system. Genital herpes is transmitted sexually. During pregnancy it may cause miscarriage and malformations.
Genital herpes is considered to be all-life persistant infection, that’s why it has a relapsing passing.
Clinical manifestations. According to the clinical signs, the disease duration is divided into typical, non-typical, and asymptomatic one (viral carrier).
Typical passing of the disease is characterized by genital and extragenital signs. Extragenital signs: rising tempreature, mialgias, headache, nausea, viral rash on face, bad sleep. Genital signs are present on the lower parts of genital system — vulva, vagina, cervix, near urethra os perineum. Single or plural vesicles up to 2-3 mm in size, with erythema and edema, which exist for 2-3 days appear in mucous membranes. After vesicle rupture erosion with incorrect form, covered with yellow discharge appears. The erosion re-epitheliazes without scars in 2-4 weeks.
Patients complain of pain, irritation, itching in area with viral lesions.
Clinical manifestations are in three forms:
l I — acute primary
l II — chronic recurrent
l III — atypic
Depending on the localization, genital herpes is divided into three stages:
l the first one — herpes lesions of external genital organs
l the second — herpes lesions of the vagina, cervix, urethra
l the third — herpes lesions of the uterus, adnexa, bladder
Diagnosis is based on history taking, complaints, objective examination, revealing of HSV-2 or its antibodies in the patient’s serum.
The most informative method of identification is isolation of the virus from discharge of the cervix, vagina, uterine cavity, urethra. For express-diagnosis a method of fluoriscine antibodies and immunoperoxydase method are used. There is electro-microscopic method of HSV-2 identification and the method of viruses inoculation on tissue culture with the following studying of their properties.
Treatment is difficult because of the relapses of the disease and possibility of reinfection.
Antiviral medicines belong to three main groups (according to the action mechanism):
l replication inhibitors of viral nucleic acid
l interferon and compounds, that have interferon-inductive action
l compounds with other antiviral action
difficulties of treatment are caused by virus peculiarities (they are obligate intracellular parasites).
As a result of investigation of virus nature on molecular level, new medicines were created. They have the influence on viral growth and development of the virus. They are Zovirax (acyclovir, valacyclovir), Alpizarin, Foscarnet, Valtrex, Herpevir. Acyclovir is used in dose of 600-1200 mg per day, orally or intravenously.
Local therapy by 3% Megasin ointment, 3% Bonaphton or 3% Alpizarin is also used.
For treatment of the recurrent herpes antiviral medicines, herpal vaccines, antirecidive immunotherapy are used.
Ethiology. Condylomas acuminata are caused by Human Papillomavirus of 16 and 18 types. They are transmitted sexually (fig. 98). Resistant to disinfective agents viruses may be killed by high temperature during sterilization. Incubational period of condyloma acuminata lasts from 1 to 9 months. The disease often occurs in sexually active persons. Papillomavirus causes genital cancer. These patients have in 1-2 thousands times more chances to acquire a malignant process, than healthy people. Condylomas acuminata can transform into cancer in 6-26% of cases.
Clinical manifestations: On the onset of disease single pink, sometimes grey warts, with thin pedicle, rarely with wide base appears on skin surface of labia majora, perineal area and mucosal layer of urethra, anus, vagina, cervix. Condylomas acuminatum can grow significantly and fuse (fig. 99). They looks like cauliflower, with lobular structure, and have long-term duration. Some patients with long-term duration of the process can have big condylomas, like tumor. They can be complicated by abnormal vaginal discharge, due to the secondary vaginal infection. Condylomas may cause some difficulties at walking, intercourse. During pregnancy and delivery they can cause bleeding. In 15-17% of patients regression may occur, especially during pregnancy.
Clinical diagnosis. Lobular surface, soft consistency, thin pedicle should be taken into consideration.
Differential diagnosis for genital warts includes condylomata latum, which have wide base, brown or red colour, and no lobular structure. Also other manifestations of syphilis are present there.
Treatment. If genital warts are large, laser vaporization is performed. It is more effective, than criodestruction or surgical diathermy. For treatment of small condylomas 30% solution of podophyllin, condilin or resorcin are used. Modern effective remedy is Solcoderm.
Infectional agent is Human cytomegalovirus. The percentage of the infected women according to the world literature is very high. In Western Europe it is from 50 to 85%. Among pregnant women with usual miscarriage 70% are infected.
after invasion cytomegalovirus persists in organism for a long time, spreading by saline and sexual contacts.
Clinical manifestations. The main signs of the infection are extragenital symptoms: CNS-lesions, thrombocytopenia, liver disorders, pneumonia. Infecting of the fetus during pregnancy leads to intrauterine development defects (microcepfalus, deafness), diseases of the newborn (cerebral paralysis, miasthenia). It is manifested by cervicitis, cervical erosions, vaginitis, vulvitis and other inflammatory diseases, that have subclinical passing.
Diagnosis: Blood and urine tests for virus presence are performed. Cytoscopic analysis of saline and urine sediments are based on the properties of Cytomegalovirus to penetrate into the cells and to make big intranuclear inclusions. Infected cell becomes bigger, it is the so-called cytomegalovirus cell, “an owl’s eye”.
Serological methods: indication of antibodies components to HCMV (1:8 and more is considered to be positive).
Non-direct immunofluoriescence method and DNA-diagnostics (chain polymerize reaction) are used.
Treatment. The main purpose is the correction of the immune system disorders. Preparations for immunity stimulation (Levamizol, T-activin, Immunoglobulin, Ginseng tincture) are used. Application of ointment and injection of leukocyte interferon, immunoglobulin with high titred cytomegalovirus antibodies (“Citotect”) into cervix are used. Wide spectrum of antiviral preparations (Valtrex, Acyclovir, Ribavirin, Gancyclovir, Bonaphton) are less effective.
Prophylaxis. Avoiding of pre- and extramarital sexual contacts, using of condom, keeping the rules of personal hygiene.
Tuberculosis of genital organs
Genital tuberculosis is the secondary disease. Very often clinical focus is in lungs. The disease is caused by Mycobacteria tuberculosis, which is transmitted hematogenically from lungs or intestine to genital organs. Mostly women from 20 to 40 years of age become ill.
Tuberculosis infection is found in 5-8% of patients with inflammatory diseases of genital organs, and in 1-3% of patients with salpongoophoritis.
Mycobacteria tuberculosis contaminate into genital organs mostly in childhood, but clinical manifestations appear in the pubertyperiod, with the beginning of sexual life and after supercooling.
Tuberculosis damages uterine tubes (85-90%), rarely uterus and ovaries and more rarely — the cervix, vagina, external genital organs.
According to Aburela E. and Petersuc B. (1975) classification, there are four main forms of specific process in the female genital organs:
l tuberculosis of genital organs with microdamages mostly with productive character, and latent duration
l tuberculosis of genital organs with macrodamages mostly with exudative-proliferative or caseous character, and lasts like salpingoophoritis and endometritis, accompanying with ascites or adhesive peritonitis
l associative tuberculosis of genital organs and tuberculosis of other organs (lungs, kidneys) or tuberculosis of genital organs, combined with the other gynecological diseases (endometriosis, sclerocystic ovaries, uterine myoma)
l clinically curable genital tuberculosis with posttuberculosis changes (petrification, adhesions, degeneration)
Pathomorphological examination reveals inflammatory changes. morphological specificity of them is in presence of tuberculous granuloma in productive phase of inflammation a focus of caseous decomposition with exudative phase of the process. If antituberculosis medecines are used in exudative inflammation phase, the exudate resolves with complete or almost complete renewing of tissue structure. destruction of the tissue is substituted by the connective tissue in productive phase of the process. separation of the focus from intact tissue take place in case of caseous damage resolvation of perifocal infiltration and fibrose transformation of the destruction zone with the capsule. In such focus Mycobacterium tuberculosis can stay for a long time and in some cases it causes relapsing.
Clinical manifestation. at “small” forms of tuberculosis pain syndrome is absent. Dominant sign may be menstrual dysfunction (hypomenorrhea or algodysmenorrhea). Pain appears in case of large damage. Almost all the patients with genital tuberculosis suffer from reproductive disorders, i.e. primary or secondary infertility, ectopic pregnancy.
If the changes in endometrium are significant, amenorrhea (uterine form) can develop.
General changes in the patient’s organism are accompanied by the signs of tuberculosis intoxication: disorders of general state, weakness, sweating, subfebrile temperature.
Diagnosis. Diagnosis is based on the history data (contact with tuberculosis patients, previous tuberculosis of bones, lungs, bronchitis, pneumonia, long-lasting subfebrile condition), objective examination (tuberculosis changes in organs or their sequel), bacteriological examination, additional methods of examination, including histological. For confirming the diagnosis of tuberculosis special tests are used (Mantu, Koch’s). The Mantu test identifies only the specific sensitization of the patient and has less diagnostic value. For diagnosis the Koch’s test is important. general, local and focal reactions appear after subcutaneous injection of 20 IU of tuberculin in patients with tuberculosis. General one is manifested by high temperature, headache, weakness. Focal reaction manifests itself in 48-72 hours by enlarging of adnexal infiltration, they become more painful.
The Koch’s test can be confirmed by changes in hemogram (high quantity of leukocytes at the expence of the low amount of monocytes, eosinophiles and lymphocytes), proteinogram (low amount of albumin and high amount of globulines), immunogram. C-reactive protein and high level of sialic acid appear in blood.
Bacteriological method is very important, it is in revealing of Mycobacterium tuberculosis in uterine and adnexal tissue. Material for inoculation is discharge from uterus and vagina, punctate from ovarian tumor or tissues taken during laparoscopy.
Laparoscopy is a valuable method, it allows to perform visual examination of abdominal cavity and to take tissual samples for bacteriological and histological analysis.
Rentgenological examination of genital organs and thoracic cavity are necessary, especially in patients with first manifestations of the process in the uterus or adnexa . Hysterosalpingography allows to estimate uterine cavity state, uterine tubes, their permeability and other changes, caused by tuberculosis.
Histological examination of endometrium after uterine cavity curettage is important, too.
Ultrasonic echography for estimation of morphological changes in uterus and its adnexa is also used.
Treatment of genital tuberculosis is complex and includes rational regimen, dietotherapy, vitamins, symptomatic therapy and climatic health-resort cure.
The main is the antibiotic therapy. Antituberculosis agents, being in use now, are: Rifampicin, PASA, Ethambutol, preparations of izonicotine acid. For preventing mycobacterium persistation, combination of remedies (Izoniazide + Rifampicin) are used. If the process is revealed for the first time, or it has acute or subacute passing, three preparations are prescribed: antibiotic, one preparation of izonicotine acid (Izoniazide, Saluzid) and PASA. The last one has not only bacteriostatic action, but also prevents from development of microorganisms resistention to antibiotics and preparations of izonicotine acid, that’s why they can be used for a long time. Treatment lasts for 1,5-2 years, during the first 3-6 months the combination of 3 medicines is used, and later on for 6-8 months 2 agents are taken. After that supportive therapy is performed till 2 years.
Intramuscular and oral usage of medicines are combined with injection of some dose of medicine in focus of lesion. Lidase with antibiotics and hydrocortisone are used for this purpose by means of colpocentesis to the damaged organ. These medicines may be used during hydrotubations. 1% solution of chimotripsin is used through posterior fornix and by electrophoresis. In some cases surgical treatment is used. In spring and autumn antirecidive therapy is performed.
Rehabilitation of such patients is provided in specialized health resorts (Odessa, Alupka). For resolvation of residual affects after tuberculosis physiotherapy and pelotherapy are used.
Pelvic Inflammatory Disease
Pathophysiology: In PID, the upper female genital tract is infected by direct spread of microorganisms ascending from the vagina and cervix. The cervix produces mucus that usually protects against upward spread, but bacteria may penetrate the cervical mucus and cause widespread extension of infection.
- In the US: PID affects 11% of women of reproductive age. Approximately 1 million women experience an episode of PID per year, and 20% of these women require hospitalization for treatment. The disease produces 2.5 million office visits and 125,000-150,000 hospitalizations yearly.
- Internationally: Public health efforts implemented in Scandinavia to decrease the prevalence of sexually transmitted diseases (STDs) have been quite effective.
Mortality/Morbidity: A delay in diagnosis or treatment can result in long-term reproductive sequelae, such as tubal infertility. Each repeat episode of PID doubles the risk for tubal factor infertility. Women with a history of PID have a 7- to 10-fold increased risk for ectopic pregnancy (tubal pregnancy) compared with women with no history of PID. Chronic pelvic pain can also follow PID and occurs in 25-75% of women.
Sex: PID is an infection of the female genital tract.
Age: PID may occur more
frequently in adolescents (ie, 15-19 y), but it can occur in any patients who are
sexually active. Age distributions vary with geographic location and etiology.
Young age at first intercourse increases risk for PID.
History: Patients can present with a variety of symptoms, ranging from lower abdominal pain to dysuria. A direct correlation exists between the incidence of STDs and pelvic inflammatory disease (PID) in any given population.
- Pain is present in more than 90% of documented cases and is by far the most common presenting symptom.
- Usually, pain is described as dull, aching, and constant; it begins a few days after the onset of the last menstrual period and tends to be accentuated by motion, exercise, or coitus.
- Pain from PID usually lasts less than 7 days; if pain lasts longer than 3 weeks, the likelihood that PID is the correct diagnosis declines substantially.
- Abnormal vaginal discharge is present in approximately 75% of cases.
- Unanticipated vaginal bleeding coexists in about 40% of cases.
- Temperature higher than 38°C (30%), nausea, and vomiting manifest late in the clinical course of the disease.
Physical: The sensitivity of the pelvic examination is only 60%. The Centers for Disease Control and Prevention (CDC) recommends the following minimal clinical criteria for the diagnosis of PID in sexually active young women: uterine/adnexal tenderness or cervical motion tenderness.
Additional criteria may be used to enhance the specificity of the minimum criteria:
- Temperature higher than 101°F (38.3°C)
- Abnormal cervical or vaginal mucopurulent discharge
- Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein level
- Laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis
Causes: The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of STD. PID is also more prevalent among unmarried women and individuals who are young at first intercourse. The IUD confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but then it decreases to baseline thereafter. Women who are not sexually active have a very low incidence of upper genital tract infection, as do women who have undergone tubal sterilization.
- C trachomatis: C trachomatis, an intracellular bacterial pathogen, is the predominant STD organism causing PID. Clinically, infection with this obligate intracellular parasite may manifest as mucopurulent cervicitis.
- Cytomegalovirus (CMV): CMV has been found in the upper genital tracts of women with PID, suggesting a potential role of CMV in PID.
- Endogenous microflora: In iatrogenically induced infections, the endogenous microflora of the vagina predominate.
- Gardnerella vaginalis
- Haemophilus influenzae
- Enteric gram-negative organisms (Escherichia coli)
- Peptococcus species
- Streptococcus agalactiae
- Bacteroides fragilis: This can cause tubal and epithelial destruction.
- Pregnancy: PID is rare in pregnancy.
- N gonorrhoeae: In the United States, the role of N gonorrhoeae as the primary cause of PID has decreased.
- Mycoplasma genitalium: M genitalium has been isolated in the endometrium and fallopian tubes of women who have PID.
During the course of her lifetime, every woman develops several adnexal masses. The normal functioning ovary produces a follicular cyst 6-7 times each year. In most cases, these functional masses are self-limiting and resolve within the duration of a normal menstrual cycle. In rare situations, they persist longer or become larger than 7 cm in diameter. At this point, they become a pathological condition.
While most of these masses develop in menstruating women, their presence must be considered in both prepubertal girls and postmenopausal women, particularly when associated with pain.
History of the Procedure: In the past, physicians relied on the findings of a pelvic examination to diagnose an adnexal mass. With the introduction of transabdominal or vaginal ultrasonography, Doppler color scans, CT scans, MRI scans, and positron emission tomography scans, the identification and evaluation of adnexal masses become entirely different. These radiologic tests allow physicians to identify subclinical masses and to delineate the internal structure of the mass (eg, wall complexity, mass contents).
Problem: The following masses pose the greatest concern:
- Those larger than 7 cm in diameter
- Those that persist beyond the length of a normal menstrual cycle
- Those that have solid components
- Those that have a complex internal structure
- Those that are associated with pain
Frequency: Determining the frequency of adnexal masses is impossible because most develop and resolve without clinical detection. Importantly, keep in mind those masses that are clinically important and their relationship to the age of the woman.
In girls younger than 9 years, 80% of ovarian masses are malignant and are generally germ cell tumors. During adolescence, 50% of adnexal neoplasms are adult cystic teratomas. Women with gonads that contain a Y chromosome have a 25% chance of developing a malignant neoplasm. Endometriosis is uncommon in adolescent women but may be present in as many as 50% of those who present with a painful mass. In sexually active adolescents, one must always consider a tubo-ovarian abscess as the cause of an adnexal mass.
In women of reproductive age who have had adnexal masses removed surgically, the masses are found to have characteristic pathology. Ten percent of masses are malignant; most tumors in patients younger than 30 years have a low malignant potential. Thirty-three percent are adult cystic teratomas, and 25% are endometriomas. The rest are serous or mucinous cystadenomas or functional cysts.
Historically, postmenopausal women with clinically detectable ovaries were felt to be at great risk of having a malignant neoplasm. With the introduction of radiologic testing, many smaller masses have been identified; therefore, the risk of malignancy may be only 10-20%. Radiologic testing allows the architecture of the mass to be determined, which greatly decreases the need to operate on benign masses in this age group.
In all age groups, the physician must consider the possibility of uterine masses or structural deformities. Pregnancy is a frequent cause of a pelvic mass and must be considered in all menstruating women.
Pathophysiology: The pathophysiology is not well understood for most adnexal masses; however, some theories have been proposed. Functional cysts may be the result of variation in normal follicle formation. Adult cystic teratomas (dermoid) may be the result of an abnormal germ cell. Endometriomas are thought to result from retrograde menstruation or coelomic metaplasia. The exact cause of epithelial neoplasms is unknown, but recent studies have suggested a complex series of molecular genetic changes is involved.
Clinical: A woman presenting with an adnexal mass is most often unaware of the mass, and, as such, she will report no relevant history. Those women who have symptoms note urinary frequency, pelvic or abdominal pressure, and bowel habit changes due to the mass effect on these organs. Girls younger than 10 years frequently present with pain, as do older women who have infected masses or endometriosis. Women with twisted masses also have acute pain.
When a woman presents with the symptoms of abdominal bloating, gastrointestinal upset, and pelvic pressure, she should be considered a likely candidate for a malignant adnexal mass.
The clinical presentation can be quite variable, with many presenting symptoms, including the following:
- Pain is seen in virtually all girls younger than 10 years but is also common in older women who have masses associated with infection, torsion, rupture, trauma, or rapid growth.
- Bloating generally results from a mass effect or the presence of ascites.
- The leading clinical presentation is asymptomatic. Tumors are found (1) at the time of a pelvic examination, (2) at the time of a radiologic examination for another diagnosis, or (3) at the time of a surgical procedure.
Most adnexal masses present as asymptomatic, small, and simple cystic masses. Nearly all of these resolve spontaneously; therefore, care must be taken to not overreact to such a finding. Surgeons who rush these women into surgery often create more pathology than they cure. Any surgery performed on adnexal structures can result in impaired fertility.
On the other hand, these same asymptomatic masses can be early ovarian cancers that require immediate attention. The use of radiologic testing often helps determine which women require attention.
The use of cancer antigen 125 (CA125) test values to screen for the presence of cancer should be discouraged. A large Swedish study has shown that approximately 50% of women with stage I ovarian cancer have a normal CA125 test value. In addition, a very high false-positive rate can be caused by pregnancy, endometriosis, cirrhosis, and pelvic or other intra-abdominal infections.
Urgent care in gynaecology.
In gynecological practice there happen the diseases which need emergency service. Foremost these diseases are followed by bleeding:
ovarian (internal bleeding) apoplexy,
inevitable abortion or incomplete abortion,
dysfunctional uterine bleeding,
traumas of sexual organs (external bleeding).
Cystoma crus torsion and rupture of pyosalpinx also need emergent care.
Very often women’s life depends on doctor’s quick orientation in the situation and on his employing of organizational and medical arrangements.
Pregnancy is called ectopic when it fertilized ovum implants outside the borders of uterine cavity.
Ectopic is one of the most serious gynecological diseases, because its interruption is followed by considerable intraperitoneal bleeding and needs emergency service.
Etiology. Anatomic changes in tissues of uterine tube that appear in the result of inflammatory processes are the main causes of the violation of ovum transport and ectopic pregnancy. Inflammation of mucous membrane, its edema and presence of inflammatory exudate in acute and chronic stages may cause dysfunction of uterine tubes. After this adhesions and closing of ampular end of the tube are formed. Damaging of muscular layer and changes in innervation of the tube lead to changes of its peristalsis and delay of fertilized ovum passing through it. Considerable anatomic changes in tubal layer or adjacent tissues cause abortions, operative interventions into the organs of true pelvis. Ectopic pregnancy frequently happens in women with genital infantilism, endometriosis, tumor of the uterus and uterine adnexa. Usage of intrauterine contraceptives increases the risk of ectopic pregnancy. There are scientific datas that toxic influence of exudate in tube at its chronic inflammation causes speed-up trophoblast maturing, that’s why the proteolitic enzymes activize, and implantation comes before fertilized ovum enters the uterus. In case of the slow development of trophoblast an ovum is implanted in lower uterine (placenta praevia) segments or outside uterine cavity — in its cervix (cervical pregnancy).
Classification of ectopic pregnancy. Depending on that, where a fertilized ovum has implanted tubal pregnancy, ovarian pregnancy, abdominal pregnancy, pregnancy in rudimentary uterine horn, intraligamentaory (between folds of wide uterine ligament) and cervical pregnancy are distinguished.
In majority of cases (98,5 %) the tubal pregnancy occurs. Interstitial pregnancy happens in interstitial portion of tube, isthmic — in isthmus and ampullar — in ampullar portion.
According to clinical duration unruptured and interrupting ectopic pregnancy are distinguished. Interrupting of ectopic pregnancy happens by type of tubal abortion or by type of uterine tube rupture.
Duration of ectopic pregnancy. After implantation of fertilized ovum in woman’s organism there appear changes, typical for normal uterine pregnancy: yellow pregnancy body is developed in ovary, decidual membrane is generated in uterine, uterus becomes soft and enlarges under the influence of ovarian hormones. All these signs are typical for pregnancy. The chorionic gonadotropin is also produced. One can find gonadotropin by means of appropriate researches. Pregnancy test is positive. Women have presumptine pregnancy signs: nausea, appetite changes and so on.
A fertilized ovum, that has been implanted into endosalpinx, goes over the same development stages, as in case of uterine pregnancy. The chorion villi are generated. At first they grow into mucous layer of the tube, then, without finding sufficient conditions for development, they grow into its muscular layer. While the size of fertilized ovum increases, the walls of tube stretch. The chorion villi, invading deeper, bring on its destruction. A layer of fibrinoid necrosis is generated. For Werth’s figure of speech, “a fertilized ovule digs in tube wall not only nest for oneself, but the grave”. The wall of uterine tube can not create favourable conditions for fetal development, that’s why within 4-7 weeks interrupting of ectopic pregnancy takes place.
Tubal pregnancy is interrupted for type of uterine tubal rupture or for type of tubal abortion, depending on the method the embryo is going out into abdominal cavity. In case of rupture of uterine tube destruction of its wall takes place in the result not of mechanical tension and rupture, but in the result of corrosion by chorion villi. At pregnancy interrupting for type of tubal abortion exfoliating of the embryo from tube walls and its passing into abdominal cavity through the ampular end takes place.
Unruptured ectopic pregnancy
Difficulty of diagnosis is connected with absence of symptoms which differ ectopic pregnancy from the uterine one. Sometimes women can feel uterine pain in the lower part of abdomen. During bimanual research one can palpate the enlarged tube, but sometimes it is not possible to do that because only at the end of the second month the tube reaches the size of an ovum and soft elastic consistence gives no possibility to palpate it distinctly.
A differential diagnosis of unruptured ectopic pregnancy is made in case of uterine pregnancy of early terms, cyst, ovary cystoma and hydrosalpinx.
Elastic organ is palpated in case of either ovarian cystoma near the uterine or in case of unruptured tubal pregnancy, in which uterus is not enlarged, reaction to the chorionic gonadotropin (CG) is negative. There is no ischomenia.
In case of hydrosalpinx in adnexal region elastic organ is also found, but uterine is not enlarged, women do not complain on ischomenia, reaction on CG is negative.
Diagnosis difficulties appear owing that uterus continues to enlarge because of the development of decidual envelope and hypertrophy of mucose fibres, but uterus falls behind in dimensions typical for the certain pregnancy term.
Tests for chorionical gonadotropin determination in such cases give a possibility to establish the pregnancy presence, but they don’t give answer to the question about its localization. In some cases one can make diagnosis of unruptured ectopic pregnancy with ultrasonic research. In this case embryo is absent in uterine cavity. The diagnosis can be confirmed by means of laparoscopy . Urgent hospitalization for complex examination and supervision is necessary in case when there is suspicion for unruptured ectopic pregnancy. The patient has to stay under the careful supervision of medical personnel. One should inform a doctor in case when there appear some changes in woman’s state, especially when there are the symptoms typical for internal bleeding.
After entering stationary it is necessary to define blood type, and also rhesus-factor of the patient immediately.
Clinic. In case of tubal abortion exfoliating of an embryo from tube wall and its passing into abdominal cavity take place . The clinic of tubal abortion is displayed by colicky pain, that is localized in one of iliac parts and irradiates into thigh, rectum and sacrum. Sometimes pain appears in supraclavicular part — frenicus-symptom. If embryo drives out from the tube at once, sometimes it is followed by considerable bleeding, giddiness and loosing of consciousness. Sometimes exfoliating of embryo ceases for a while, pain stops disturbing, however the pain is soon renewed. This can repeat once or twice, then the tubal abortion lasts for a long time. Blood, that outflow from the tube, accumulates in cul-de-sac and causes the feeling of pressure on rectum.
Discharge from external genitals have spotting character, and is brown in colour. Sometimes the scraps of decidual membrane can go out and sometimes decidual membrane goes out wholly.
Diagnosis. The diagnosis of tubal abortion is not very simple. Carefully studied past history is of a great importence. Doubtful and probable signs of pregnancy are present. Anaemia is common due to intensive blood loss, arterial pressure decreases abruptly and pulse accelerates. Abdomen is flatulent, its participation in breathing act is limited. In lateral abdominal parts blunting percusion sound is determined, during palpation there are the symptoms of peritoneal irritation.
During speculum examination is revealed cyanosis of vaginal mucosa and uterine cervix, typical are the secretions, described previously. At bimanual examination one can find that uterus is enlarged, but it does not correspond to menstruation delay term, isthmus allotment is soft, cervix motions are painful. In adnexa region from one side one can palpate an organ of elastic consistence with unclear contours. Back vault is smoothened or even prominent.
Differential diagnosis of tubal abortion. In the cases, when there is no considerable intraperitoneal bleeding, tubal abortion should be differentiated with uterine abortion in early term, exacerbation of salpingo-oophoritis, dysfunctional uterine bleeding and cystoma crus torsion.
At uterine abortion there is a permanent colicky pain, that irradiates into lumbar part. Discharge is bright or dark red coloured.
At tubal abortion pain is periodic, colicky, ordinarily it is followed by dizziness, and irradiates into rectum.
When percussion blunting of sound in lateral part of the abdomen is found in ectopic pregnancy and tympan is in case of uterine abortion.
Secretions from vagina in tubal abortion appear after pain attact, they are dark, of poor amount, in case of uterine abortion they are bright red and considerable.
General woman’s state in tubal abortion does not correspond to external hemorrhage, but in uterine abortion it does. Bimanual examination in case of tubal abortion gives a possibility to find a formation nearby the uterus, uterus does not correspond to pregnancy term, whereas in case of uterine abortion uterine size correspond to pregnancy term and ovaries are not altered.
There are some differences between the inflammatory process of uterine adnexa and tubal abortion. In case of inflammatory process there are no menses delays, reaction on CG is negative.
Unlike tubal abortion pain during this disease appears gradually, there is no dizziness. Pain is not colicky, but permanent.
In case of tubal abortion with a long abortion duration one can observe subfebryle temperature, whereas in case of acute uterine adnexa inflammation temperature is high in most cases.
Some blood loss at tubal abortion gives rise to BP lowering, in inflammatory process BP is normal. In case of abortion pulse is higher, temperature rises rarely.
In case of tubal abortion abdomen is slightly flatulent, but soft and painful during palpation on one side, during percussion blunting sound is observed in lateral departments. In case of inflammatory process examination of abdomen gives the identical symptoms, however there is no blunting of percussion sound.
Bloody secretions in inflammatory processes of ovaries can be rarely found. Unlike the secretions of tubal abortion, they are bright, sometimes with purulent admixtures.
During bimanual examination enlargement of uterus with unclear adnexa contours from one side testifies about tubal abortion rather than about inflammation of ovaries, in which uterus is not enlarged and ovaries are palpated as enlarged from both sides. Often in tubal abortion sagging of back vault is found.
In spite of great amount of differences, which give a possibility to make a differential diagnosis between tubal abortion and inflammatory process of ovaries, sometimes it is very hard to distinguish them. US and specially culdocentesis are importent in such case. In case of tubal abortion during puncture blood is received and in inflammatory processes one can get serous or a purulent liquid.
If one couldn’t manage to specify diagnosis and the general woman’s state is satisfactory, they hold on resolvent and hemostatic therapy during 5-7 days with careful clinical supervision. In tubal abortion all phenomena (colicky character of pain, bloody secretions) progress and at inflammatory process improvement of general state is observed.
Tubal abortion differs from cystoma crus torsion. In case of cystoma torsion there is no menses delay, reaction on chorionic gonadotropic is negative, bloody discharge and signs of internal bleeding are absent. Cystoma torsion is found by abdomen palpation. US and sometimes endoscopy is used as individual method.
Differential diagnosis between tubal abortion and appendicitis. In appendicitis a patient does not complain of menses delay, there are no signs of pregnancy. At tubal abortion pain is periodic, colicky, with one side localization. In appendicitis it apears at first in epigastria, and lateral then it localizes in right iliac region and it is accompanied by nausea and vomiting, that are rare in case of tubal abortion. Bloody excretions and signs of internal bleeding are absent. Palpation of the abdomen in acute appendicitis expresses tensity of the front abdomen, whereas in case of tubal abortion it is insignificant and sometimes it is absent. The Schotkin-Blumberg’s and Rovzing signs testifies acute appendicitis while frenicus-symptom is absent. During bimanual examination in case of acute appendicitis uterus and ovaries are not enlarged. If much time has passed since the beginning of the disease, one can not always palpate them because of irritation of pelvic peritoneum. An infiltrate is palpated above and it is not possible to reach it through vagina.
A blood analysis in case of appendicitis gives leucocytosis with shift to the left, there is no anemia, whereas at tubal abortion blood picture is typical for anemia. After all, a culdocentesis can be a diagnostic criterion.
When clear differentiation is impossible, it is necessary to make laparotomy.
Clinic. Tube rupture develops more frequently in that case, when pregnancy is localized in isthmus or interstitial department . Clinics displays by severe internal bleeding, shock and acute anaemia.
Disease begins after menses delay with acute pain in lower abdomen, which appears suddenly. It is localized in iliac areas and irradiates into rectum and sacrum. This pain is followed by momentary loosing consciousness. After this patient remains adynamic. During the attempt to get up she can lose her consciousness again.
Patient has all signs typical for internal bleeding: acute pallor, cold sweat, coldness of lower limbs, feeling of weakness, sometimes there is a threadlike pulse. The abdomen is flatulent, its participation in breathing act is limited. There is blunting of percussion sound in lateral abdominal region. Palpation of the abdomen is very painful. There are signs of peritoneal irritation.
Diagnosis. During speculum examination cyanosis of mucous membrane of vagina is found. Bloody excretions are present, though not always. They are dark-coloured and look like coffee-grounds.
At bimanual examination cervical motion is always painful, there appears bulging and acute pain of the posterior pouch. Uterus body is enlarged insignificantly and along its side painful organ with unclear contours can be palpated, sometimes it is pulsatory. One should remember, that it is not always possible to palpate uterus and ovaries because of acute pain during gynecological examination.
Following signs can help in diagnosis of ectopic pregnancy:
l Laffon’s sign — consecutive shift of pain feelings: at first in suprabrachial part, then shoulder, then pain spreads into back part, scapulars, under sternum
l Elecker’s sign — abdominal-ache presence, that is followed by its irradiation into shoulder and scapulars on tubal rupture side
l Gertsfield’s sign — urging to urination appears during tubal rupture moment
l Kulenkampf’s sign — intensive pain during percussion of anterior abdomenal wall
At vaginal research such signs are determined:
l Landau’s sign — intensive pain during speculum or fingers inserting into vagina
l Golden’s sign — uterine cervix pallor
l Bolt’s symptom — acute pain during an attempt to displace uterine cervix
l Gudell’s sign — soft consistence of cervix
l Promptov’s sign — woman feels acute pain during an attempt to displace uterus up by inserted into vagina and rectum fingers. At appendicitis examination per rectum causes pain in rectouterine pouch
l Goffman’s sign — uterus displacement into contrary from altered tubal side. During examination uterus easily comes into normal position, and when examination is over it returns into its previous position
At long blood presence in abdominal cavity its partial resorbtion takes place and transformed bilirubin deposits in skin cells. That’s why there appear such signs:
l Gofshteter’s sign — presence of blue-green or blue-black colouring of skin in navel region
l Kuschtalov’s sign — yellow skin colouring of palms and soles, specially in fingers area
At tubal rupture clinic of internal bleeding progresses, that’s why, after careful taking of anamnesis, doctor can make a diagnosis at once. However intensity of internal bleeding depends on the individual placing of vessel which feed a tube and some patients after its rupture, in spite of abdominal-ache, giddiness, do not apply to a doctor at once. At the same time, lack of expressed symptoms can bring doctor into mistake, illness progresses. That’s why for confirmation of diagnosis of interrupted ectopic pregnancy culdocentesis, during which blood is received should be made obligatorily. However it is necessary to remember, that in 10-15% of all cases a culdocentesis does not confirm the diagnosis. In the case, if general patient state is not satisfactory, endoscopic examination should be done.
l history taking
l physical examination with typical symptoms
l pelvic examination
l test on pregnancy
l ultrasonic diagnostics
l in complicated cases culdoscopy or laparoscopy are performed
Management. Each woman with suspicion on ectopic pregnancy should be hospitalized and must stay in stationary until clinical confirmation or refuse of suspicion on ectopic pregnancy.
Rare forms of ectopic pregnancy
Ovarian pregnancy, intraligamentous pregnancy, abdominal pregnancy, cervical pregnancy and pregnancy in rudimentary uterine horn belong to the rare forms of ectopic pregnancy.
Ovarian pregnancy. At such localization pregnancy develops either in follicle (follicular pregnancy), or upon the ovarian surface. Progressing of pregnancy is followed by pain, peritoneum tension, that covers an ovary. Interrupting comes in early terms. In rare cases pregnancy can reach late terms.
Abdominal pregnancy is primary and secondary. At primary one fertilized ovum is implanted immediately in abdominal cavity — on peritoneum, omentum, bowels, liver. Secondary abdominal pregnancy develops as a result of reimplantation of fertilized egg in cavity of small pelvis after proceeding from uterine tube by reason of tubal abortion. Abdominal pregnancy can be interrupted in early terms, bringing the picture of acute abdomen, but sometimes it can reach the late terms. A fetus is palpated right under the abdominal wall, its heart beat is clearly auscultated, enlarged uterus is determined separately from the fetus. In-term birth of living child is possible. Operation is in fetus and placenta removal but there appear considerable technical difficulties with compartment of placenta from internal organs.
Intraligamentorus pregnancy. If tubal pregnancy, chorion villi don’t grow into the abdominal cavity, but into side of broad ligament of the uterus, separating it, embryo comes into space between leaves of lig. latum uteri and continues to develop between them. Embryo, protected by leaves of the broad ligament, can develop to late terms ) or even to full-term, however more frequently interruption of such pregnancy in 2-3 months term takes place. At its interrupting a big haematoma accumulates, and if the leaves of the broad ligament are ruined in the result of chorion villi penetrating, bleeding into abdominal cavity can appear.
Pregnancy in rudimentary uterine horn. The rudimentary uterine horn can have junction with the cavity. In that case impregnated ovum is able to come there (fig. 82). Progressing pregnancy doesn’t give special symptomatics. During palpation a tumor-like organ, adjacent to uterus is determined, sometimes on a crus. It is mobile and painless. Muscular layer of rudimentary horn is developed insufficiently as compared with miometrium, but it is developed much better in comparison with the uterine tube, that’s why pregnancy in rudimentary horn is interrupted in later terms. Bleeding at such localization of ectopic pregnancy is considerable, that’s why quick transportation of a woman into medical establishment is necessary. Diagnosis and operation are of particular importance.
Treatment. Just after confirming the diagnosis decision about operative treatment is taken. During hospitalization into stationary patients blood type and rhesus-factor is immediately determined, so that one can stop blood loss and shock. Amount of transfused blood is determined according blood loss and general state of a patient.
The altered uterine tube is removed during the operation. Conservative-plastic operations are made recently for saving of reproductive function of women. In absence of expressed anatomic changes in tube and at satisfactory woman’s state embryo is removed from the tube, the tube is sutured. If pregnancy interrupting took place not long ago, blood is not hemolized, and there is a necessity for immediate blood transfusion. The blood, taken from abdominal cavity may be reinfused.
Patient rehabilitation in postoperation period (physiotherapy, usage of biostimulators) is of a great importance. After making organo-saving operations it is necessary to care about tubal passability by means of hydrotubation. It is desirable to hold 2-3 courses of rehabilitation therapy during 6 months with following sanatorium-health-resort cure.
Ovarian apoplexy is blood effusion into ovary parenchyma, which is followed by bleeding into abdominal cavity.
Apoplexy causes are not clearly determined. It can develop in any day of ovarian-menstrual cycle or after menses delay, but more frequently it can happen in the middle of the cycle. The provoking factors are sexual act, trauma of the abdomen, operative intervention, mechanical pressing of the vessels by pelvis tumor.
Clinic. Disease begins suddenly, with pain frequently in one of the iliac region, which often spreads through the abdomen and irradiates into rectum, inguinal areas, sacrum and legs. The symptoms of internal bleeding appear, shock with loss of consciousness is common. The body temperature is normal. During abdominal palpation it is flatulent, patient can feel pain in lower abdomen in one or both sides.
Diagnosis. Previous diagnosis is made on the basis of carefully taken anamnesis and complaints. Disease onset data of physical and also vaginal examination are taken into consideration.
Bimanual research gives a possibility to set gynecological nature of the disease. Bulding (in case of severe bleeding) and pain of vaginal fornixes is present. Displacement of cervix causes strong pain. Uterus is of normal size, and pain is determined in ovaries region from one side. There is enlarged, cystically changed ovary.
Frequently at apoplexy a diagnosis of ectopic pregnancy is made, because there are no symptoms, typical for apoplexy.
Differential diagnostics is made with ectopic pregnancy and appendicitis. It is necessary because at ectopic pregnancy operative intervention is obligatory, while a apoplexy — not always.
During differential diagnostics of ovary apoplexy with ectopic pregnancy one must pay attention to the fact that at apoplexy there are not signs of pregnancy. More frequently ectopic pregnancy appears after menses delay (not always!). Pain in both cases appears abruptly, irradiates into the same areas. In ectopic pregnancy frenicus-symptom is expressed, while apoplexy it happens rarely.
In apoplexy the peritoneal irritation phenomena and symptoms of internal bleeding are not so clearly expressed. However there are no clear criterions, for which one can distinguish ovarian apoplexy from interrupted ectopic pregnancy, especially if it interrupts by tubal rupture type. That’s why management has to be determined by patient’s general state.
As for differential diagnostics with acute appendicitis, one must remember, that in appendicitis more frequently pain initiate at the epigastric region, there are nausea and vomiting and no signs of internal bleeding. At abdominal examination muscular defancel and positive Schotkin-Blumberg’s symptom are observed.
Treatment. At absence of expressed signs of internal bleeding a conservative cure can be applied. We put a cold thind on abdomen, hold haemostatics. After fading of acute phenomena physiotherapy is prescribed.
In case of expressed internal bleeding an operative intervention is indicated. Its volume depends upon the changes which take place in ovaries. If there is a big haematoma, and ovarian tissue is completely blasted by effusions of blood, it should be removed. In case of small haematoma an ovary resection is made.
During hospitalization of the woman into statinary with suspicion on ovary apoplexy one should define blood type, rhesus-factor, measure arterial blood pressure, make a clinical blood test immediately. During conservative cure, woman is to be held under permanent careful surveillance of medical personnel and a nurse or midwife must report about the changes in woman’s health to the doctor.
An abscess rupture takes place spontaneously or in the result of physical trauma.
Clinic. Before abscess perforation there is always patient’s health change to the worse — pain reinforces, temperature rises, peritoneum irritation symptoms are intensifying. Just after rupture there appears an acute pain which has a cutting character through the abdomen, collapse, nausea, vomiting, stomach is strained and strongly painful. General patient’s state becomes worse, the face features sharpen, breathing becomes frequent and superficial. In the result of bowels paresis abdomen becomes flatulent, peristalsis disappears and meteorism develops.
Diagnosis. During stomach percussion one can find blunting of sound in lateral departments because of exudate presence in abdominal cavity.
During bimanual examination uterus and ovaries palpation is impossible because of acute pain and tension of front abdominal wall and vaginal fornixes bulgeng. Pelvic peritonitis may develop in the result of pyosalpinx rupture. Specification of the diagnosis can be made by means of ultrasonic research and culdocentesis.
Treatment. Cure of patients with purulent process in abdominal cavity is a complicated problem, successful solving of which needs fast and decisive actions. Operative cure with ablating of altered ovaries and following drainage of abdominal cavity is necessary. Laparotomy should be made by lower-middle incision, because this access gives a possibility to make a revision of abdominal cavity organs and its wide drainage, and if it is necessary — peritoneal dialysis. During the operation it is necessary examine appendix because its frequent involving in pathological process. If pathological changes are found appendectomy is done. Removal of purulent mass is technically difficult and needs caution and carefulness, but ablating of purulent formation is obligatory, because drainage, without ablating causes formation of purulent fistulas, those do not heal for a long time. A conservative care of such patients (antibiotics, vitamin therapy, cold on umbilicus) can give a temporary state improvement, but not a convalescence. Disease acquires chronic recidivate character with frequent acutenings. Operative intervention is inevitable anyways, however before operation it is necessary to make out suitable patient’s preparation with stimulation of immune system and detoxicaton.
Torsion of tumor crus
Cystoma crus torsion can happen more often, but sometimes the crus of subserous fibrous myoma can also happen. Quick motions, pregnancy, labor, stormy bowel peristalsis can cause torsion. In the result of torsion trophies of tumor tissue disturb, degenerative changes and necrosis with wall rupture appear in it.
Clinic. complete and incomplete crus torsion may occur. Clinically at crus torsion the symptoms of “acute abdomen” appear. Muscles of anterior abdominal wall tension is expressed on the part of process localization. In case of a big tumor its contours are available for palpation through abdominal wall, and during bimanual examination one can reach a lower tumor pole. Examination is very painful. In incomplete torsion the clinical picture is poor less and all phenomena can temporally vanish if blood supply of the tumor will be renewed.
Treatment. Torsion of tumor crus needs immediate operation. Protraction with laparotomy gives rise to tumor necrosis, infection, beginning of adhesion’s process and accretion of tumor to adjacent organs, that will create additional complications during the operation. An operation volume depends on ovarian tumor type: at benign tumor it is removed; in suspicion of malignization total hysterectomy with omentum resection is indicated.
There is a peculiarity in the operation: clench is laid more proximally from the place of torsion and the tumor is cut off without twisting its crus. It is forbidden to twist the crus because the thrombs those are in crus and also substances of necrotic destruction of the tumor can get into woman’s blood.
Causes of uterine bleeding are extraordinarily various, they can be manifestations of general changes in organism, endocrine violations in ovaries (dysfunctional uterine bleeding), changes in the part of uterus (submucous fibromatous nodes, polyps), interrupting of pregnancy.
Dysfunctional uterine bleeding
The dysfunctional uterine bleeding appears in the result of various violations of neurohumoral and hormonal regulation of menstrual cycle. Structural changes in women’s genital organs are absent. Inflammatory processes or pregnancy are also absent. These bleedings can be both cyclic and acyclic. They happen in different phases of menstrual cycle.
Juvenile bleeding, bleeding of reproductive and menopause period are distinguished, that’s why the approach to taking of diagnostic manipulations, treatment and emergency help in each case must be different. Emergency help includes hemostasis and prevention of bleeding relapse, and also anemia or hemorrhagic shock treatment which can appear when the bleeding is massive.
The juvenile bleedings appear in the period of puberty, usually on the background of general and gynecological diseases (angina, glomerulonephritis, anemia, hypovitaminosis, diseases of blood and so on).
the girls with hypoplastic constitution and vegetodystonia suffer from this pathology more frequently. Sometimes a hyperplasia of thyroid gland is found in them. In winter-spring period bleeding appears more frequently, than in summer-autumn one. As a rule, such girls have menarche at the age of 12 or13 years, but then menses last with long interruption and following bleeding.
The long acyclic bleedings cause anemia of the patient, lead to her exhaustion that into its turn causes states which contribute to beginnings of these bleeding. Ordinarily the bleeding becomes severe at once causes state of the patient.
Treatment of juvenile bleeding begins with using remedies for uterine contraction (oxytocin, methylergometrine), hemostatic preparations (vicasol, ЕАCA, nettle, watery pepper tincture, Dicinon). A bottle with ice can be put down on the lower abdomen. These methods give a possibility to decrease bleeding. For further treatment patient has to be directed to gynecologist, in case of severe bleeding she must be transported by sanitary carriage into stationary. In majority of cases treatment is conservative. Only on condition of absence of effect from treatment defloration is held and uterine curretage with parents’ consent. Hormonal therapy with the aim of hemostasis can be used only after detailed examination.
Treatment of dysfunctional uterine bleeding in women in reproductive and climacteric age begins from uterine curretage with the following hormonal correction (combination of estrogens with gestagens, progestins). Symptomatic therapy at this pathology includes application of haemostatics (Vicasol 1% 1 ml, Dycinon, Calcium chloride 10% 10 ml, ЕАCA 0,1 three times a day), retractive preparations (Oxytocin, Methylergometrin), a bottle with ice may be put down on abdomen. If bleeding causes considerable anaemia, that is followed by lowering of circulatory blood volume, lowering of arterial pressure, pulse acceleration, one should make a transfusion of the blood substitutes immediately. One should define a patient’s blood type, rhesus-factor and transfuse the same group blood according to the volume of hemorrhage.
Interrupting of pregnancy
Initial abortion. Bloody excretions from vagina on this stage of pregnancy violation are nonsignificant, because embryo exfoliates on small area. Cervical canal is closed or slightly opened.
On this stage of pregnancy violation one should employ arrangements, directed to save of pregnancy (spasmolitics, analgetics, vitamin E, Progesterone). It is necessary to note that abortion may go into the following stage — inevitable abortion. Strong bleeding appears. During bimanual examination cervical canal is opened, normally we can palpate the embryo in it.
There appears considerable bleeding in case of incomplete abortion. When part of an embryo is localized in uterine cavity. In this case cervical canal and internal os lets a finger in.
In such cases (inevitable abortion and incomplete abortion) patient has to be transported into the hospital. In case of severe bleeding the transfusion of blood substitutes can be adjusted on stage of unspecialized help. Taking into account the possibility of hemotransfusion need, a blood type and rhesus-factor should be defined. Treatment is a removal of the embryo or its remainders with instrumental methods. antibacterial therapy, haemostatics retractives are prescribed after curretage. If it is necessary anemia treatment should be continued.
Bleeding because of uterine fibromyoma
Bleeding can happen in presence of the submucous fibrous myoma. Sometimes a patient knows about the presence of fibromyoma, however in some cases diagnosis is made only after bleeding.
Its intensity can be different, but long repeating bleeding causes anemia in women, exhaustion of their protective forces.
Bimanual examination reveals enlarged uterus and rather frequently, ovaries are enlarged (cystic changed) too. US diagnosis is helpful.
The patient should be given hemostatics (Vikasol, ЕАCA, Calcium chloride). Blood substitutes and hemotransfusion, according to blood loss are used. The contractile remedies are not used in that case. The woman must be hospitalized. Submucous fibromyoma of the uterus must be operated.
Bleeding appearing due to uterine cervix cancer, cervical pregnancy must be treated by tight tamponade of the vagina. The tampon can include ЕАCA. It is possible to use intravenous introduction of blood substitutes, inhalation of Oxygen. Giving emergency help, a patient should be transported into hospital.
TRAUMAS OF FEMALE GENITALS
Damages of external genitals can be as contusion, haematoma, hypodermic effusions of blood, that ordinary are accompained by damage of skin. More often these damages appear as a result of trauma such as falls and blows. In the village hornblows of domestic animals are observed. These traumas can be followed by lacerated wounds which ordinary penetrating deeply into tissues, sometimes vagina and even rectum can be damaged. In case of heavy traumas of urethra, urinary bladder, and also pelvis bone can be damaged. In case of damage of vagina trauma can penetrate into abdominal cavity. Ruptures of lateral walls of vagina are very dangerous because vaginal branches of uterine arteries pass in this area.
Clinically trauma is characterised by pain and haematoma of blue to purple colour in damaged place. In case of severe internal bleeding a picture of hemorrhagic shock develops. Bleeding can be followed by anaemia. In case of clitoris rupture bleeding can be especially massive. Sometimes inserting of foreign objects into genital organs can happen. Especially frequently it happens in girls before 10 years. Adult women can introduce catheters, sounds and other objects into uterus with aim of pregnancy interruption. In such cases frequently uterus perforation, bleeding can appear, that’s why the woman applies for medical care. If there is no damage of genital organs, presence of foreign body causes inflammatory process. Purulent excretions from vagina, sometimes with blood admixtures appear. Foreign body in adults can be found due to speculum examination. For children one should use cautious rectal research and vaginoscopy.
Diagnosis is based on examination. If there is suspicion on trauma of adjacent organs catheterization of urinary bladder, cystoscopy is made. US can be useful for diagnostics of foreign bodies in vagina.
Treatment. Traumatized tissues are sutured. In case of haematoma it is incised, bleeding vessels are knitted and drained. If it is necessary hemotransfusion is performed. Uterine cervix, vaginal, uterine ruptures, associated with labor act, are described in obstetrics course.
State, associated with acute blood loss, which is in abrupt lowering of circulatory blood volume (CBV), cardiac outflow and tissual perfusion in the result of adaptation mechanisms decompensation is the so-called “hemorrhagic shock”. In gynecology hemorrhagic shock often appears as a result of internal bleeding in case of ectopic pregnancy, ovarian rupture or external bleeding in case of artificial and spontaneous abortion, stand still pregnancy, hydatiform mole, dysfunctional uterine bleeding, traumas.
Shock appears at hemorrhage, which exceeds more than 20% of CBV or
15 ml per kg of body mass. Practically blood loss over 1000 ml causes shock development, blood loss over 1500 ml is considered to be massive and it is very dangerous for woman’s life.
The main part in pathogenesis of hemorrhagic shock is a disproportion between diminished CBV and volume of vascular system.
At blood loss, that does not exceed 10% of circulatory blood volume (compensated hemorrhage), compensation for rise of venous vessels tone, receptors of which are most sensible to hypovolemia takes place. Due to this tissual perfusion does not change, frequency of cardiac beats and BP remain normal. Due to blood loss, which exceeds these indexes, expressed hypovolemia can appear. As a reaction on stress situation, the tone of sympato-adrenal system rises, release of catecholamines, aldosterone, glucocorticoids, activates renin-angiotensive system activation. Due to these factors increasing of cardiac contractions intensity, liquid excretion delay, spasm of peripheral vessels, opening of arteriovenosus shunts take place. This causes centralization of blood circulation, owing to which minute heart volume and BP are supported for a while. However blood circulation centralization can’t support organism’s vital functions for a long time, that is why during this violation of peripheral blood flow and oxygenation in tissues is available. Hypoxia and metabolic acidosis can appear. In this case microelements redistribution takes place - Sodium and Hydrogen ions go inside the cells, and Magnesium and Potassium go into intercellular space. This causes hydrataion and their damage. Poor perfusion in tissues is followed by stasis, formation of thrombs, blood secvestration, in the result of which CBV continues to fall down. As an effect of CBV deficiency there is violation of vitally important organs blood perfusion, cardiac blood flow falls down, coronal insufficiency develops. Time factor plays a very important role in the expression of pathophysiologycal hemorrhage effects. The faster hemorrhage is, the more severe are hemodynamic violations. Whereas slow blood loss, even more massive, can cause less expressed violations, but there exists the danger of inconvertible changes initiation.
Ectopic pregnancy presents a major health problem for women of childbearing age. It is the result of a flaw in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in death of the fetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation.
Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimester in the United States, accounting for 9% of all pregnancy-related deaths. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well.
History of the Procedure: Ectopic pregnancy was first described in the 11th century, and, until the middle of the 18th century, it was usually fatal. John Bard reported the first successful surgical intervention to treat an ectopic pregnancy in New York City in 1759.
The survival rate in the early 19th century was dismal. One report demonstrated only 5 patients of 30 surviving the abdominal operation. Interestingly, the survival rate in patients who were left untreated was 1 of 3.
In the beginning of the 20th century, great improvements in anesthesia, antibiotics, and blood transfusion contributed to the decrease in the maternal mortality rate. In the early half of the 20th century, 200-400 deaths per 10,000 cases were attributed to ectopic pregnancy.
Problem: Ectopic pregnancy is derived from the Greek word ektopos, meaning out of place, and it refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, cornual region of the uterus, and the abdominal cavity. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death.
Frequency: Since 1970, the frequency of ectopic pregnancy has increased 6-fold, and it now occurs in 2% of all pregnancies. An estimated 108,800 ectopic pregnancies in 1992 resulted in 58,200 hospitalizations with an estimated cost of $1.1 billion.
Etiology: Multiple factors contribute to the relative risk of ectopic pregnancy. In theory, anything that hampers the migration of the embryo to the endometrial cavity could predispose women to ectopic gestation. The most logical explanation for the increasing frequency of ectopic pregnancy is previous pelvic infection; however, most patients presenting with an ectopic pregnancy have no identifiable risk factor. The following risk factors have been linked with ectopic pregnancy:
ABDOMINAL GYNECOLOGICAL OPERATIONS
For performing of abdominal gynecological operations most frequently lower midline laparotomy and incision by Pfannenshtiel are used.
Midline vertical laparotomy
Midline vertical laparotomy provides a sufficient access to organs of small pelvis, gives a possibility to have a view of other organs of abdominal cavity by widening the dissection up, one can carry out the revision of all the organs of abdominal cavity and to conduct necessary interventions. That’s why this access is used when during operation there are foreseen technical difficulties (in case of peritonitis, internal bleeding, big tumors etc).
Technique (fig. 183). Along the middle abdominal line (linea alba) the skin and hypodermic fat is dissected with scalpel from pubis towards umbilicus. An incision size depends on the volume of surgical intervention, in case of tumor removal — from its size.
The aponeurosis is dissected. At first a small cut with scalpel is made, then it continues with scissors.
The muscles are disconnected. The peritoneum is grasped with two anatomic pincers and is cutted between them with scalpel, then incision is continued up and down with scissors.
While continuing the incision towards pubic tubercle, one must be careful for preventing damaging of urinary bladder. To prevent it, only area, that is translucent, under the sight control is dissected.
Stitches on abdominal wall layer-by-layer in reverse order are putted.
Laparotomy by Pfannenshtiel
Advantages of this kind of incision is absence of cosmetic defect, especially in case of stitching with subcuticular (сosmetic) suture, better healing of the wound, there never happen such complications as eventration because wound layers are dissected in different directions.
Techniques(fig. 184). Skin and subcutaneous fat are cut along the suprapubic fold on distance 2-3 cm from pubic symphysis.
In inguinal regions from both sides of incision there pass the superficial epigastric arteries, damaging of which should be avoided, and if they dissect them, it is necessary ligate them immediately.
Aponeurosis is cutted slightly with scalpel from both sides from the white line, then the incision is continued with scissors into both sides of wound. The upper edge of aponeurosis in the wound center is clenched with Kocher’s forceps and pulling it up they snip it off with scissors from the white line towards umbilicus, as far as skin dissection allows. Muscles of anterior abdominal wall are not dissected, they are separated in longitudinal direction, as at midline vertical laparotomy. Peritoneum is clenched with two pincers and cutted in longitudinal direction at first with scalpel, and then with scissors.
Taking into consideration the indisputable advantages of this approach, it is necessary to note, that in case of Pfannenshtiel incision appearing of subfascial haematoma, difficult access to organs of small pelvis are observed frequently. if during the operation some problems such as the necessity of abdominal cavity revision, big size of the tumor are appeared, it is impossible to extent of this incision.