Laboratory and instrumental research methods
Primary diagnostics of inflammatory processes begins with assessing the state of the microflora. Smear bacterioscopy taken from the vagina and cervical canal allows the detection of signs of inflammation (leukocytosis), the presence of coccal flora, and the identification of specific pathogens such as gonococci and trichomonads. In addition, yeast-like fungus spores and pseudomycelia may be determined in smears.
It is important to note that standard bacteriological examination (culture) of the cervical canal discharge has low information value for establishing the true cause of adnexitis. The most accurate and reliable results are provided by microbiological examination of the abdominal cavity or fallopian tube contents. Material for such analysis is obtained invasively: during laparoscopy, laparotomy, or puncture.
Ultrasound examination (ultrasound) plays a key role in non-invasive diagnosis. The basic echographic signs of inflammation include:
- Widening of the fallopian tube lumen.
- Presence of inflammatory exudate (free fluid) in the pelvic cavity.
- Formation of tubo-ovarian masses, which appear on ultrasound as irregular structures with indistinct contours and heterogeneous echostructure.
If an abundant accumulation of free fluid is visualized on ultrasound, this is an alarming clinical sign, most often indicating the rupture of a purulent formation of the uterine appendages. Puncture of mass lesions can be used to confirm the purulent-inflammatory nature of the pathology. The manipulation is performed through the posterior vaginal fornix under strict ultrasound guidance and allows obtaining purulent contents for further analysis.
Laparoscopy: the "gold standard" of diagnosis
Laparoscopy is recognized as the most informative method for acute adnexitis. It allows not only assessing the severity and prevalence of uterine and appendage inflammation, but also conducting differential diagnosis with other causes of the "acute abdomen" syndrome, as well as determining further treatment tactics.
The endoscopic picture directly depends on the form of the pathology:
- Acute salpingitis: the fallopian tubes appear edematous and hyperemic. Seropurulent or purulent exudate is released from the ampullary (fimbrial) section and accumulates in the pouch of Douglas (rectovaginal recess). The ovaries are often secondarily involved in the process and enlarged in size.
- Pyosalpinx: visualized as a characteristic retort-shaped thickening of the tube, predominantly in its ampullary part. The walls of the tube are thickened and edematous, the fimbrial section is completely fused (obliterated), and pus accumulates inside the lumen.
- Pyoovarium (ovarian abscess): represents a mass lesion with a purulent cavity inside. It is distinguished by the presence of a dense capsule and fibrinous deposits on the surface.
- Tubo-ovarian abscess: characterized by an extensive adhesion process. The fallopian tube, ovary, uterus, pelvic wall, and intestinal loops fuse into a single inflammatory conglomerate. With a prolonged (chronic) course, a dense delimiting capsule forms around the purulent focus.
During intraoperative examination (both in laparoscopy and laparotomy), the rupture of a pyosalpinx looks like a perforation hole on the surface of a delimited purulent formation, from which pus pours freely into the abdominal cavity.
Chronic salpingo-oophoritis: pathogenesis and symptoms
Chronic adnexitis is a direct consequence of a previous acute or subacute inflammation. The disease acquires a protracted character with periodic exacerbations. Inadequate treatment of the acute phase, a decrease in the patient's general reactivity, and the specific properties of the pathogen itself contribute to the chronization of the process.
Morphological changes in the chronic course affect all pelvic structures:
- In the fallopian tubes, inflammatory infiltrates form, walls thicken due to connective tissue proliferation, and hydrosalpinges form.
- In the ovaries, pronounced dystrophic processes develop. The lumen of blood vessels narrows, leading to microcirculatory disorders and, consequently, to a decrease in the synthesis of sex steroid hormones.
- In the lesser pelvis, a massive adhesion process occurs, which may involve the uterus, appendages, bladder, greater omentum, pelvic walls, and intestines.
The clinical picture of chronic adnexitis is diverse. The main complaint is pain syndrome: dull and aching pains in the lower abdomen that radiate along the pelvic plexuses to the lower back, thigh, or rectum. Pain often intensifies with hypothermia, stress, or during menstruation.
Patients are also bothered by psychoemotional disorders (insomnia, nervousness, depressive states, irritability) and sexual disorders, including decreased libido and dyspareunia (painful intercourse). Menstrual function disorders manifest as premenstrual syndrome, menometrorrhagia, opsomenorrhea, or oligomenorrhea. Pathogenetically, these disruptions are caused by corpus luteum insufficiency or chronic anovulation.
Complications and exacerbation factors
Prolonged inflammation of the uterine appendages leads to serious reproductive complications. The most formidable of these is infertility, which develops under the influence of two key factors:
- Impaired normal steroidogenesis in ovarian tissues.
- Tuboperitoneal factor (fallopian tube obstruction and pronounced adhesions in the lesser pelvis).
In addition, the presence of adhesions in the appendages repeatedly increases the risk of ectopic pregnancy.
Exacerbation of chronic adnexitis can be provoked by reinfection, an increase in the pathogenic properties of an existing pathogen, or a decline in the macroorganism's immunobiological defense. Clinically, exacerbation manifests as a sharp increase in pain syndrome, a significant deterioration in general well-being, and a possible increase in body temperature.
To memorize the structures involved in the extensive adhesion process in tubo-ovarian abscess, use the "U-T-O-I-P" rule: Uterus, fallopian Tube, Ovary, Intestinal loops, pelvic Pall (wall).
Class and exam questions
Which method is most accurate for identifying the causative agent of appendage inflammation?
Maximum informative value is provided by microbiological examination of the fallopian tube or abdominal cavity contents obtained during laparoscopy or puncture. Conventional cervical culture is considered of low informative value.
How do pyosalpinx or tubo-ovarian formations appear on ultrasound?
They are visualized as irregular masses with indistinct contours and heterogeneous echostructure. Fallopian tube widening and the presence of inflammatory exudate in the pelvis are also frequently determined.
Why does the menstrual cycle become disrupted in chronic salpingo-oophoritis?
Inflammation causes ovarian tissue dystrophy and vascular narrowing. This disrupts microcirculatory perfusion and reduces the production of sex steroid hormones, leading to anovulation or corpus luteum insufficiency.
What else to study on this topic
- Differential diagnosis of "acute abdomen" syndrome in inflammation of the appendages.
- Mechanisms of hydrosalpinx formation during connective tissue proliferation in the fallopian tubes.
- The impact of the adhesion process on the pathogenesis of ectopic pregnancy development.
- Surgical management tactics for patients with rupture of purulent formations (pyosalpinx).
- The relationship between decreased macroorganism reactivity and the chronization of the inflammatory process.
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