Parametritis is a purulent-infiltrative inflammation of the parametrium – connective tissue tissue surrounding the uterus in the cervical region and the leaves of the broad ligament. Parametrite manifests after complicated abortions, childbirth, gynecological operations, purulent-inflammatory diseases of the uterus. Parametritis is manifested by febrile fever, malaise, chills, pain in the lower abdomen. In the diagnosis of parametritis, it is important to collect anamnesis, gynecological examination data, ultrasound. Treatment of parametritis requires active antimicrobial, infusion, desensitizing, immunocorrective therapy. During the formation of the parametric abscess, the opening and drainage of the abscess is shown.
The macroscopic picture in parametritis is characterized by an expanded network of lymphatic and venous vessels, the development of perivascular edema and exudation. Initially, the infiltrate is formed near the entrance gate – in the uterine space, then by lymphogenic and venous pathway, the inflammation diffusely spreads downward, anteriorly and posteriorly – to the paarvaginal, paravesical and pararectal tissue. In the case of purulent melting of the fascia that delimit these departments, diffuse inflammation of the fiber of the entire pelvic floor occurs – pelviocellulitis. With ascending infection, the tubes and ovaries, retroperitoneal tissue (paratyphlitis, paranephritis) may also be involved in the process. In rare situations, parametritis is complicated by phlegmon of the abdominal wall and external genitals.
In most (70-75%) cases, inflammation with parametritis does not go beyond the fiber of the pelvis. At the current stage of the development of gynecology, due to the early recognition of parametritis and the use of antibiotics, the course of the disease is more erased, light, and the infiltrate usually resolves before reaching the stage of abscess formation.
Microbial flora in parametritis is more often mixed, with a predominance of E. coli, klebsiella, proteus, non-spore-forming anaerobes, streptococci and staphylococci. Infection of the parametrium can occur through the cervical canal during complicated or community-acquired abortions, operations on the cervix; through postpartum unrecognized and unshaped lateral ruptures of the cervix.
Possible lymphogenic spread of infection from appendages (with adnexitis) or uterine cavity with endometritis, metrothrombophlebitis, diagnostic curettage, IUD administration, complicated by damage to the walls of the uterus. Sometimes parametritis develops against the background of bacterial extragenital processes by hematogenic introduction of pathogens in osteomyelitis of the pelvic bones, paraproctitis, cystitis, appendicitis, angina, tuberculosis, typhus, etc.
According to the topography of inflammation of the parotid tissue, anterior, posterior and lateral parametrites are distinguished. With anterior parametritis, the infiltrate is located anteriorly from the uterus, leading to smoothing of the anterior vaginal arch; often infiltration affects the pre-bubble tissue, as well as the anterior abdominal wall. In the case of posterior parametritis, inflammation spreads to the utero-rectal space; infiltration of pararectal fiber can lead to narrowing of the rectal lumen. With lateral parametrites, inflammation is limited at the top by a wide ligament, at the bottom by cardinal ligaments; in front – by the wall of the pelvis; infiltrate is formed on the side of the uterus, smoothing the lateral arches of the vagina.
Taking into account the pathogenesis, a primary parametrite or a secondary one is distinguished, acting as a complication of genital or extragenital inflammation. The clinical course of parametritis can be chronic, subacute or acute.
In its development, the parametrite goes through three stages – infiltrative, exudative, the stage of compaction and resorption of the exudate. The stage of infiltration in parametritis is characterized by dilation and partial thrombosis of blood vessels, the development of perivascular edema. At the stage of exudative changes, leukocytes and other blood elements leave the vascular bed into the parametral fiber; diffuse, fan-shaped infiltrate spreading to the pelvic walls is observed. In the compaction phase, the infiltrate is organized as a result of the loss of fibrin from the exudate; formation of a granulation shaft separating the infiltrate from healthy tissues.
A favorable outcome of the parametrite is the resorption of the infiltrate. When the exudate suppurates, an abscess forms, which can open into hollow organs (bladder, rectum, vagina) or out through the anterior abdominal wall. With incomplete emptying of the abscess, purulent inflammation will recur with repeated breakthroughs into neighboring organs and the formation of fistulas that support the course of parametritis.
The clinic of acute parametritis usually appears 7-10 days after childbirth, surgical termination of pregnancy, intrauterine interventions, gynecological operations. The first and early manifestations of parametritis include febrility (body temperature 38-39 ° C), constant, often stabbing or cutting abdominal pain, radiating into the sacrum and lower back. With suppuration of the parametrium, the patient’s condition worsens: the temperature rises even more, assuming a hectic character; tachycardia, chills, thirst, headaches are noted.
When the infiltrate of the bladder or rectum is involved in the ring, a clinic of cystitis or proctitis with tenesmus is observed. In the case of the spread of parametritis to the lumbosacral muscle, its inflammation develops – psoitis, which is characterized by a typical flexor contracture of the hip on the side of the lesion. With chronic parametritis, pain weakens and increases only during sexual intercourse; functional changes in the cardiovascular and nervous systems may be noted; menstrual function disorders.
Parametritis is diagnosed by a combination of anamnesis data, gynecological examination (vaginal and rectovaginal), ultrasound. Vaginal examination with parametritis determines the sharp soreness of the parametrium, shortening of the vaginal arches, displacement of the uterus upward or to the healthy side, solidity into a single conglomerate with a fixed dense infiltrate. Rectovaginal examination evaluates the position of the infiltrate (abscess) relative to the rectum and the degree of mobility of the mucosa over the inflammatory seal.
In the general blood test with parametritis, an increase in ESR to 30-60 mm / h, leukocytosis, neutrophilosis is noted. The echoscopic picture of the parametrite allows you to visualize infiltrates – echopositive formations without clear contours, having an irregular shape. When suppuration occurs, a clear capsule is determined in the structure of infiltrates, inside which thick heterogeneous contents are located.
When the infiltrate of parametria is abscessed with a breakthrough of the abscess into the bladder or rectum, urologists and proctologists are involved in the diagnosis. The opening of a parametral abscess in the bladder is detected by cystoscopy, a study of general urine analysis, bacteriological urine culture; the breakthrough of the abscess into the rectum is confirmed by a study of the coprogram, macroscopic presence of pus in the stool and rectoscopy data. With a persistent course of parametritis, the exclusion of actinomycosis is required. In the process of diagnosis, parametrite is differentiated with tubal-ovarian abscess, tumors, pelvioperitonitis.
Treatment of parametritis
In the infiltrative stage of parametritis, treatment is carried out, as in acute salpingoophoritis: bed rest, cold on the stomach is prescribed; antibiotics, taking into account the type of pathogen or microbial associations and their sensitivity to drugs; infusion therapy, desensitizing, immunomodulatory treatment.
In the stage of resorption of the infiltrate, NSAIDs, biostimulants, vitamins and enzymes are used. In this phase of the parametrite, physical therapy, gynecological massage, electroprocedures (electrophoresis with magnesium, copper, iodine, zinc; diadinotherapy, UHF), light therapy (UFO, UFOC, VLOC), magnetotherapy, inductothermy are widely practiced.
Prolonged course of parametritis, accompanied by endogenous intoxication syndrome, requires plasmapheresis. Rehabilitation of patients with parametritis includes an active physiotherapy campaign: the appointment of oxygenobarotherapy, microwave therapy, ultrasound therapy, ultraphonophoresis, mud applications; spa treatment (hydrogen sulfide baths and vaginal irrigation, massage, mud tampons, etc.).
During the formation of a parametral abscess, its puncture through the vaginal arch is shown. When receiving pus, an opening of the abscess by the vaginal or abdominal route and drainage of the parametrium is required. After installing drainage into the purulent cavity, sanitizing measures are carried out: washing with desalves, administration of antibiotics.
Prognosis and prevention
The unfavorable outcomes of parametritis include the formation of fistulas, adhesions and scarring in the pelvis, and the development of sepsis. When opening ulcers during colpotomy, injury to the ureters, bladder or uterine vessels may occur. With the timely initiation of treatment of parametritis, a gradual reverse development of inflammatory changes occurs.
Measures for the prevention of parametritis include rational management of childbirth, prevention of abortions (especially criminal ones), strict adherence to asepsis when performing intrauterine manipulations, timely sanitation of infectious foci.