Endometritis

Pathogenesis and routes of spread

The mechanism of injury begins with the attachment of the pathogen (e.g., gonococcus) to the epithelium using pili. Bacteria penetrate inside cells, into intercellular spaces, and into the subepithelial space, causing tissue destruction and inflammation.

The primary route of infection spread into the uterine cavity is canalicular (by extension from the lower sections of the urogenital tract). Microorganism ascent is promoted by:

• Adhesion of bacteria to spermatozoa.
• Presence of Trichomonas, inside which the pathogen can hide and act as an active vector of infection.

Hematogenous route is rare, as many bacteria are destroyed by the bactericidal properties of blood serum.

Risk factors for ascending infection

Penetration of infection beyond the internal os of the cervix and the development of acute endometritis rarely occur spontaneously. Certain triggers contribute to this:

1. Artificial interventions: artificial abortions, diagnostic fractional curettage (DFC), sounding of the uterine cavity, endometrial aspiration, and cervical biopsy. Insertion of an intrauterine contraceptive device (IUD) poses a particular danger.
2. Physiological states: menstruation and childbirth often immediately precede the manifestation of the acute inflammatory process.

Clinical presentation

With the development of endomyometritis, the uterus becomes enlarged, painful upon palpation, and acquires a somewhat soft consistency. The ascending infection is accompanied by a marked deterioration in the patient's general condition:

• Fever (up to 39 °C) and severe chills.
• Severe lower abdominal pain.
• Nausea, vomiting, diarrhea.
• Frequent and painful urination (dysuria).
• Menstrual irregularities.

Upon objective gynecological examination, abundant purulent or mucopurulent discharge is visualized from the cervical canal.

Features of the modern course and complications

Currently, the classic acute presentation is not always observed. The modern course of inflammatory diseases is characterized by the absence of typical clinical signs and the predominance of mixed infections (mixed flora). This leads to a prolonged incubation period, frequent relapses, and significantly complicates diagnosis.

If acute endometritis transitions into a chronic form, prolonged inflammation causes pelvic adhesion disease. The consequences of chronic progression are extremely severe:

• Infertility and miscarriage.
• High risk of ectopic pregnancy.
• Chronic pelvic pain syndrome.
• Spread of infection to the appendages (salpingo-oophoritis) with the risk of forming tubo-ovarian inflammatory masses up to abscesses.

Diagnostics and principles of therapy

To identify the pathogen, material is collected from the urethra, vagina, and cervical canal. Bacterioscopy (e.g., searching for Gram-negative intracellular diplococci) and bacteriological culture on selective media with antibiotic susceptibility testing are used.

Treatment of acute forms of ascending infection (including endometritis) requires prescribing antibiotics for at least 7 days. Drugs from various groups (ceftriaxone, azithromycin, ciprofloxacin, amoxicillin/clavulanate, etc.) are used, taking into account the isolated microflora.

During therapy, complete abstinence from sexual intercourse and alcohol is mandatory, along with simultaneous examination and treatment of sexual partners. After the course of antibiotics, prescribing eubiotics to restore the vaginal microflora is advisable.

Class and exam questions

What else to study on this topic

• Cure criteria and provocation methods in specific pelvic infections.
• Differential diagnosis of endometrial and cervical polyps based on ultrasound data.
• Background diseases of the cervix (ectopia, ectropion) against the background of chronic inflammation.
• The role of human papillomavirus (HPV) infection in the development of cervical intraepithelial neoplasia (CIN).
• The problem of antibiotic resistance: bacterial L-forms and beta-lactamase production.

Other topics in the "Gynecology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.