Chronic salpingo-oophoritis (adnexitis)
Chronic inflammation of the uterine appendages is often accompanied by purulent discharge and pelvic pain. Diagnosis is difficult due to the nonspecificity of the pain syndrome, requiring differentiation from endometriosis, ovarian tumors, and colitis.
- Bimanual examination: reveals limited mobility of the uterus (due to adhesions) and elongated masses in the adnexa region (hydrosalpinx).
- Instrumental diagnostics: Ultrasound is effective for detecting mass lesions. X-ray hysterosalpingography shows contrast accumulation in closed cavities, but is currently rarely used due to frequent errors in image interpretation.
- Laparoscopy: indicated for prolonged pain and ineffectiveness of antibiotics. It allows visualization of adhesions, hydrosalpinges, and Fitz-Hugh–Curtis syndrome (adhesions between the liver surface and the diaphragm).
Acute inflammation and pelviculitis
Pelviculitis is secondary inflammation of the pelvic peritoneum (serofibrinous or purulent) that occurs when flora from the uterus and appendages penetrates into it.
The disease manifests acutely: fever up to 39–40 °C, chills, nausea, vomiting, diarrhea. Objectively, a coated wet tongue, abdominal distension, and sharp tenderness in the lower abdomen with a positive peritoneal irritation sign (Shchetkin–Blumberg sign) are noted.
During gynecological examination, palpation is sharply painful, and the posterior vaginal fornix is smoothed out due to the accumulation of exudate in the rectouterine pouch. For accurate diagnosis, the following are used:
- Transvaginal ultrasound (looking for free pus in the pelvis).
- Culdocentesis (puncture through the posterior fornix to collect exudate for bacteriological analysis).
- Laparoscopy (the most informative method, revealing peritoneal hyperemia and purulent contents).
As acute symptoms subside, adhesions of the pelvic organs with the omentum, intestines, and bladder are formed.
Parametritis
Inflammation of the parametrium (parametrial tissue) develops with lymphogenous spread of infection from the uterus. This often occurs after childbirth, abortions, diagnostic curettage, intrauterine device (IUD) use, or cervical surgery.
The process begins with the formation of an infiltrate and serous exudate. Possible outcomes:
- Favorable: complete resolution.
- Fibrosis: development of dense connective tissue displacing the uterus toward the affected side.
- Suppuration: purulent parametritis with hectic fever, which can spontaneously rupture into the rectum (more frequently) or the urinary bladder.
Clinically, parametritis presents with intoxication and lower abdominal pain radiating to the lower back or leg. A dangerous complication is compression of the ureter by the infiltrate, leading to impaired urine flow and the development of hydronephrosis.
A key role in diagnosis is played by bimanual and rectovaginal examination: a dense, immobile, slightly painful infiltrate is palpated, and the lateral vaginal fornix is smoothed out. A specific physical sign is Genter's sign (dullness of percussion sound over the anterior superior iliac spine on the affected side).
Gynecological peritonitis
Along with sepsis, this is the most severe form of PID, characterized by diffuse peritoneal damage, systemic inflammatory response syndrome (SIRS), and multiple organ dysfunction syndrome. It proceeds in three stages:
- Reactive stage (about 1 day): edema and hyperemia of the peritoneum, exudation with fibrin formation. The patient is agitated, complains of diffuse pain aggravated by movement. Skin is pale gray, tachycardia, dry tongue. Abdomen is sharply tender in all parts, peristalsis is slowed.
- Toxic stage (about 2 days): local symptoms of peritonitis subside, but intoxication rapidly increases. The patient becomes lethargic, adynamic. Repeated vomiting and pronounced intestinal paresis lead to severe disorders of water-electrolyte balance, acid-base balance, and dysproteinemia.
- Terminal stage (after 2–3 days): profound CNS damage. Facies Hippocratica is formed (Hippocratic facies: sharpened features, pale gray cyanotic skin covered with sweat. Hypotension, bradycardia, oliguria, vomiting of stagnant contents, impaired consciousness are noted).
Principles of PID treatment
Therapy for acute inflammatory processes of internal genital organs is carried out strictly in a hospital setting. The patient is provided with physical and mental rest, prescribed a diet with easily digestible proteins and vitamins, and an ice pack is applied locally to the hypogastric region.
The central place is occupied by antibacterial therapy. Due to the polymicrobial nature of the inflammation, drugs or their combinations effective against most potential pathogens are selected, with mandatory consideration of their pharmacokinetics and side effects.
To remember the stages of peritonitis: RTT — Reactive (painful and agitated), Toxic (lethargic, intestinal paresis), Terminal (Hippocratic facies, multiple organ failure).
Class and exam questions
Why is X-ray hysterosalpingography rarely used now for adnexitis?
Due to a large number of diagnostic errors in the interpretation of X-ray images.
What is Fitz-Hugh-Curtis syndrome?
This is the formation of adhesions between the liver surface and the diaphragm, which is a consequence of suffered acute salpingo-oophoritis (predominantly gonococcal or chlamydial etiology).
How to distinguish parametritis on physical examination?
Key signs are smoothing of the lateral vaginal fornix, palpation of a dense immobile infiltrate, and Genter's sign (dullness of percussion sound over the iliac spine).
Where does pus most often rupture during suppuration of parametrial tissue?
Most often, purulent exudate spontaneously ruptures into the rectum, much less often into the urinary bladder or abdominal cavity.
What else to study on this topic
- Differential diagnosis of chronic pelvic pain (endometriosis, ovarian tumors, colitis, pelvic plexitis).
- Technique of culdocentesis (puncture of the abdominal cavity through the posterior vaginal fornix).
- Pathogenesis of systemic inflammatory response syndrome (SIRS) in gynecological peritonitis.
- Impact of adhesive disease on the development of tubal-peritoneal infertility factor.
- Complications of parametritis: mechanisms of ureteral compression and hydronephrosis development.
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