Surgical tactics and purulent complications
In combined lesions, when a purulent-destructive process affects adjacent organs, surgery requires a strict sequence. Restoration of bowel integrity is performed before the gynecological stage. The main goal of this approach is to prevent contamination of the pelvis with intestinal microflora. The scope of surgery ranges from removal of a tubo-ovarian mass to total hysterectomy with adnexectomy. The choice of tactics depends on the patient's age, the cause of inflammation, and the degree of tissue involvement.
A severe consequence of purulent processes is the development of vesicogenital fistulae of inflammatory origin. Unlike traumatic fistulae (in which general well-being is usually unaffected), inflammatory fistulae are accompanied by marked intoxication, chills, and fever. Patients complain of suprapubic pain radiating to the lower back and thigh, dysuria, pyuria, and purulent discharge. In rare cases, menouria — the presence of blood in the urine during menstruation — is observed.
Diagnosis and treatment of urogenital fistulae
The detection of fistulae is based on gynecological examination, ultrasound, endoscopy (cystoscopy, hysteroscopy), and imaging modalities (CT, MRI, urography). Particular difficulties arise when the fistula is located high and opens into a scarred vaginal vault.
For differential diagnosis, the three-tampon test is used. It is indicated for urinary leakage with preserved spontaneous urination. Methodology: the vagina is tightly packed with three gauze tampons, and a methylene blue solution is instilled into the urinary bladder via a catheter. Interpretation of results:
- Staining of the upper and middle tampons blue indicates a vesicovaginal fistula.
- If all tampons are soaked with clear urine without blue dye, it is a ureterovaginal fistula.
- Staining of only the lower tampon indicates urinary incontinence.
At the initial stage of treatment for vesicovaginal fistulae, conservative management is applied: placement of an indwelling urinary catheter for 8–10 days, bladder irrigation with antiseptics, antibiotic therapy, and insertion of ointment-soaked tampons into the vagina.
Impact of inflammation on female infertility
Previous infections (chlamydia, gonorrhea, tuberculosis) and inflammation directly impair reproductive function, causing several forms of infertility:
- Tubal and peritoneal: inflammation leads to organic damage to the fallopian tubes (obstruction) and the formation of severe adhesions in the adnexal region.
- Endocrine: luteal phase defect (LPD) may develop against the background of inflammatory processes. Hypofunction of the corpus luteum prevents normal secretory transformation of the endometrium, leading to implantation failure or early miscarriage.
- Uterine factor: intrauterine synechiae and endometrial polyps, which frequently occur after inflammation, mechanically hinder embryo implantation.
Intrauterine contraception (IUC) in PID
The presence of acute or subacute pelvic inflammatory disease, as well as chronic forms with frequent exacerbations, is an absolute contraindication to the insertion of any IUC. Severe extragenital infections are considered relative contraindications.
To prevent inflammatory complications, IUC is recommended for parous women without risk of sexually transmitted infections (STIs). In nulliparous patients, the risk of complications is significantly higher, so the use of an IUD is permitted only if there is a single partner and a history of abortions. It is worth noting that hormone-releasing systems (e.g., levonorgestrel-releasing intrauterine systems) have a therapeutic effect and can be used for concurrent endometrial hyperplastic processes or cycle disorders.
How to read the three-tampon test: Upper blue — Vesicovaginal fistula; Lower blue — Incontinence; Clear (no dye) — Ureteric fistula.
Class and exam questions
Why are combined surgeries performed by repairing the bowel first rather than the uterus?
This strict rule is necessary to prevent infection of the pelvic organs by aggressive intestinal microflora before the start of the gynecological stage.
How to clinically distinguish a fistula of inflammatory origin from a traumatic one?
In inflammatory fistulae, the patient's condition is severely impaired due to intoxication and a purulent-destructive process in the pelvis, whereas in traumatic fistulae, general well-being usually remains satisfactory.
Is it permissible to insert an intrauterine device in nulliparous women?
This is a relative contraindication due to the high risk of complications. Insertion is permitted only with a history of abortions and strictly a single permanent sexual partner.
What else to study on this topic
- Etiology and classification of urogenital fistulae of traumatic origin.
- Psychogenic factors of infertility and the mechanism of functional tubal obstruction.
- Anovulatory infertility and luteinized unruptured follicle syndrome (LUF syndrome).
- Advantages, disadvantages, and therapeutic effects of hormonal intrauterine systems.
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