Metritis is an inflammatory process in the muscular layer of the uterus (myometrium), occurring in an acute or chronic form. The course of metritis is accompanied by discharge from the genital tract (mucous, purulent, bloody), pain in the lower abdomen, uterine bleeding and menstrual irregularities, general infectious symptoms. When diagnosing the etiology and form of metritis, the data of bimanual examination and gynecological ultrasound, the results of blood tests and vaginal smears are taken into account. In the acute phase of metritis, rest, cold on the lower abdomen, antibiotics, uterotonics, painkillers are prescribed; in case of chronic course – physiotherapy, hirudotherapy, intrauterine irrigation.
Metritis (myometritis, mesometritis) is an inflammatory disease of the uterus that occurs with a lesion of its muscular membrane. Metritis may have an infectious or aseptic origin. In an isolated form, it is rare, more often occurs in the form of metroendometritis with simultaneous involvement in the inflammatory process of the mucous membrane – the endometrium. With a complicated course, the development of perimetritis, pelvioperitonitis, pyometra, abscess and gangrene of the uterus is possible. In some patients, metritis can cause uterine infertility in women. Given the seriousness of the prognosis and the high risk of potential complications, finding ways to prevent and effectively treat metritis are priorities for practical gynecology.
Classification of metrite
There are three clinical variants of metritis – acute, subacute and chronic. The inflammatory process in metritis can occur in several forms: catarrhal, purulent-catarrhal, necrotic and gangrenous, which differ in clinical manifestations and prognosis.
Acute puerperal (postpartum) metritis is distinguished as an independent form. Taking into account pathoanatomic changes, postpartum metritis is divided into phlegmonous (with diffuse infiltration of the entire intermuscular space), thrombophlebitic (metrothrombophlebitis, inflammation and thrombosis of the uterine veins) and lymphangoitic (inflammation of the lymphatic vessels of the uterus).
In the uncomplicated course of metritis, inflammation is limited to the muscle membrane. Complicated forms develop in the case of the transition of inflammation to the serous or mucous membranes or the spread of infection outside the uterus (septic metritis).
The etiology of infectious metritis in most cases is associated with bacterial flora. The primary role in the development of pathology is played by nonspecific microbial pathogens: Streptococcus, Staphylococcus, E. coli, proteus, anaerobic bacteria. In addition, pathogens of specific infections can act as etioagents: Mycobacterium tuberculosis, Gonococcus, mycoplasma. Acute metritis can be observed in measles, diphtheria, typhus, cholera, etc. Quite often, during the bacteriological examination of smears from the genital tract, microbial associations are sown.
The introduction of pathogens into the uterine cavity usually occurs in an ascending way during menstruation, the introduction of an intrauterine contraceptive, abortion, therapeutic and diagnostic curettage. The development of infectious metritis is often preceded by colpitis, cervicitis, endometritis. Possible hematogenic spread of infection to the uterus (for example, with pyelonephritis, angina and other extragenital diseases), as well as direct (contact) transfer of infection from a number of located organs (appendicitis, tuberculosis of the fallopian tubes, etc.).
Postpartum metritis usually develops against the background of weakness of labor, a long anhydrous period, bleeding, retention of parts of the placenta in the uterine cavity. Aseptic metritis occurs without the participation of infectious agents; most often it is preceded by a bruise of the uterus or the introduction of irritating chemicals into its cavity.
Acute metritis is accompanied by an increase in the uterus (thickening of its walls, expansion of the cavity) and softening of the consistency. On the incision, the myometrium is swollen, loosened, has a pink-red color, permeated with a network of dilated lymphatic and blood vessels. Microscopic examination of the tissue determines its leukocyte infiltration, dystrophy of the endometrial glands.
Symptoms of metritis
The clinical symptom complex of acute metritis consists of general infectious and local symptoms. The disease usually manifests violently, 3-4 days after intrauterine intervention. Signs of an infectious and inflammatory process in the body are increased body temperature, apathy, weakness, lack of appetite, headaches.
Characteristic local symptoms are genital tract whiteness, bleeding, pain syndrome. The nature of the discharge makes it possible to differentiate various forms of acute metritis. With catarrhal metritis, the whites are abundant, mucous, odorless. Purulent-catarrhal inflammation is accompanied by mucopurulent secretions with an admixture of blood, which also do not have a specific smell. For necrotic metritis, the appearance of brown secretions containing small fragments of tissue is typical; the secretions have an unpleasant, repulsive odor. With the most severe – gangrenous form of metritis, vaginal discharge has a red-brown color with gas bubbles and an extremely fetid odor.
At rest, the patient is disturbed by pain in the lower abdomen, in the projection of the sacrum and in the depth of the pelvis. On palpation, the uterus is enlarged in size and sharply painful. Acyclic uterine bleeding often develops against the background of acute metritis. The disease may be accompanied by oophoritis and adnexitis.
With chronic metritis, all signs of inflammation are expressed moderately, Vaginal discharge is not abundant, more often serous. The uterus is slightly enlarged in size, dense, but painless. The pain syndrome is expressed intermittently, periodically there are pulling pains over the pubis or in the sacrum. With this form of metritis, symptoms and menstrual function disorders come to the fore more often: irregular menstruation, menorrhagia, hypomenorrhea, anovulatory cycle, intermenstrual bleeding.
Postpartum metritis develops 3-7 days after delivery. The disease begins with chills and a high rise in temperature (38.5-40 ° C), a significant deterioration in the general condition. Lochia have a dark red color, contain an admixture of pus, their number is reduced. There may be intestinal atony, stool and gas retention, soreness during urination. During vaginal examination, an enlarged, poorly contracted, painful uterus is determined, the cervix is open and the finger passes through even 9 days after delivery. After 2-2.5 weeks, the temperature decreases to subfebrility, the volume of lochia first increases, then decreases, the discharge becomes serous-purulent or purulent. The duration of postpartum metritis is 3-4 weeks.
Severe complications of metritis, threatening not only reproductive health, but also the patient’s life, can be uterine abscess, uterine gangrene, pelvioperitonitis, peritonitis, sepsis.
Diagnosis and treatment
The algorithm for diagnosing metritis involves an assessment of anamnesis and complaints, gynecological examination, ultrasound of the pelvic organs, general clinical and microbiological analyses. When collecting information, the gynecologist pays attention to recently transferred intrauterine manipulations, childbirth, the connection of inflammation of the uterus with sexual and extragenital infections. The data of the vaginal examination vary depending on the severity of the process and the form of metritis. Common signs of inflammation are an increase in the size of the uterus and the presence of pathological secretions from the cervical canal. It is possible to obtain an objective assessment of the thickness and structure of the muscle layer during gynecological ultrasound. Of the laboratory diagnostic tests for metritis, the most important are general clinical blood and urine tests, a smear on flora, bacteriological sowing of vaginal secretions, PCR examination.
Treatment of acute and postpartum metritis is inpatient. Bed rest and cold are prescribed for the lower abdomen. Active systemic antibiotic therapy with semi-synthetic penicillins, cephalosporins and other drugs is carried out, taking into account the sensitivity of isolated microorganisms; detoxification measures are carried out, adequate anesthesia is applied. Uterotonic means are used to stimulate the contractility of the uterus. Under medical supervision, the uterine cavity is washed with antiseptic solutions.
If the remains of the fetal egg or parts of the placenta are found in the uterine cavity, they are removed by vacuum aspiration or curettage of the uterine mucosa. In the most severe forms of metritis, surgical removal of the uterus – supravaginal amputation of the uterus or hysterectomy is performed to prevent septic complications and profuse bleeding.
In the treatment of chronic metritis, an important role is assigned to physiotherapy (ultrasound, electrophoresis, diathermy, ozokeritotherapy, mud therapy), spa treatment. In order to normalize menstrual function, the issue of prescribing hormone therapy is being resolved. Prevention of acute and chronic metritis – prevention of penetration of pathogenic microorganisms into the uterine cavity during intrauterine manipulations, protection against STIs, rational management of childbirth, timely sanitation of infectious foci. The prognosis regarding reproductive function in patients who have undergone metritis is very cautious. It is possible to develop secondary infertility against the background of endometrial atrophy, anovulation, adhesions in the fallopian tubes.