Vaginitis

Etiology and routes of infection spread

The inflammatory process in the area of the uterine adnexa rarely occurs in isolation. Infectious agents penetrate tissues via three main routes. The most common is ascending infection, in which microorganisms migrate from the uterine cavity directly into the lumen of the Fallopian tubes. A contact route of transmission is also possible, for example, in acute appendicitis, when the inflamed appendix comes into contact with the adnexa. The hematogenous route (via the bloodstream) is significantly less common.

Specific microflora—gonococcal and chlamydial infections—plays a leading role in the development of the disease. The main risk group consists of female patients of early reproductive age who lead an active sex life.

Depending on the localization of the pathological process, several forms of the disease are distinguished:

• Salpingitis—isolated inflammation of the Fallopian tube, involving absolutely all layers of its wall.
• Oophoritis—inflammatory lesion of the ovarian tissue. According to statistics, the spread of infection to the ovary is registered in half of patients with salpingitis.
• Adnexitis (salpingo-oophoritis)—combined lesion encompassing the Fallopian tube, ovary, and supporting ligamentous apparatus.

Destructive changes and tubo-ovarian formations

The progression of infection leads to pronounced anatomical changes. The accumulation of inflammatory exudate inside the Fallopian tube provokes an adhesive process. The fimbrial end of the tube closes, which leads to the formation of saccular structures—sactosalpinx. If serous fluid accumulates inside, a hydrosalpinx forms, and when purulent masses accumulate, a pyosalpinx forms.

Concurrently, pathogens penetrate into the ovarian tissue, where isolated purulent cavities—ovarian abscesses—initially form. Over time, these cavities merge, causing total purulent melting of the tissue. The end result is pyovarium—the transformation of the ovary into a single saccular formation filled with pus.

The most formidable stage is the formation of a tubo-ovarian abscess. This inflammatory conglomerate arises as a result of purulent melting of the contacting walls of the already formed pyovarium and pyosalpinx.

Clinical presentation and types of course

Acute salpingo-oophoritis is characterized by a prominent symptom complex, the severity of which directly depends on two factors: the degree of microbial virulence and the immune reactivity of the patient (host).

The main manifestations include:

1. Pain syndrome: pain is localized in the lower abdomen and can vary in intensity.
2. Intoxication: a sharp rise in temperature to febrile or pyretic values (38–40 °C), accompanied by severe chills.
3. Dyspepsia: patients are troubled by nausea, and in some cases vomiting joins.
4. Local symptoms: the appearance of pathological purulent discharge from the genital tract.
5. Dysuria: urination disorders occur due to the secondary involvement of the urethra and urinary bladder.

It is important to remember the insidious nature of the disease: sometimes a mild or masked clinical picture is observed. In such situations, sparse symptoms completely fail to correspond to the severity of the morphological destructive changes that have already developed in the lesser pelvis.

Complications and generalization of infection

If the purulent process is not halted, the infection extends beyond the adnexa and penetrates the abdominal cavity. This occurs either through the open fimbrial end of the Fallopian tube or as a result of perforation and rupture of purulent tubo-ovarian formations (pyosalpinx, ovarian abscess, or tubo-ovarian abscess).

Stages of infection spread:

• Pelvioperitonitis—local inflammation of the peritoneum within the lesser pelvis.
• Generalized peritonitis—generalization of the process with further spread to other floors of the abdominal cavity.
• Formation of secondary localized pus pockets: interintestinal abscesses and abscesses of the rectovaginal pouch (pouch of Douglas) arise.

Objective and laboratory diagnostics

During general examination, the physician notes a moist tongue coated with white plaque, and abdominal palpation reveals tenderness in the hypogastric region.

Gynecological examination (Status localis) detects purulent or serosanguineous-purulent discharge from the cervical canal. The uterine adnexa are palpated as edematous, thickened, and sharply tender. In the presence of purulent processes, the palpation picture changes: volumetric, immobile, painful structures without clear contours and with uneven consistency are determined in the adnexal region or posterior to the uterus. A specific sign is that these formations often merge with the uterine body into a single inflammatory conglomerate.

Laboratory markers confirm the acute inflammatory process:

• Blood: leukocytosis with a left shift, a significant increase in the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, as well as dysproteinemia, are recorded.
• Urine: proteinuria (protein), leukocyturia, and bacteriuria are detected, confirming secondary involvement of the urinary tract.

Class and exam questions

What else to study on this topic

• Mechanisms of formation of tubo-ovarian abscess and purulent tissue melting
• Differential diagnosis of mild/masked forms of acute adnexitis
• Laparoscopic picture of pelvioperitonitis and generalized peritonitis
• Influence of host immune reactivity on symptom severity

Other topics in the "Gynecology" section

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