Pelvic adhesions are connective tissue strands covering the surface of the pelvic organs and connecting them to each other. The adhesive process is manifested by constant or periodic pelvic pain, miscarriage or infertility, intestinal disorders in the form of constipation, frequent stools and flatulence. When making a diagnosis, bimanual examination, ultrasound and tomography of the pelvic organs, hysterosalpingography, diagnostic laparoscopy are used. Conservative therapy includes the appointment of antibacterial, anti-inflammatory, hormonal and fibrinolytic agents. Surgical treatment is based on laparoscopic dissection of adhesions.
Pelvic adhesions (plastic pelvioperitonitis) is one of the most common causes of chronic pelvic pain and disorders of the ovarian–menstrual cycle. Women suffer from this type of adhesive disease 2.6 times more often than men. At the same time, the incidence of acute intestinal obstruction due to adhesions in female patients is 1.6 times higher. Usually, the disease is detected in women who have undergone abdominal interventions or inflammatory processes. With repeated operations, the risk of formation of connective tissue splices increases significantly: if after the first intervention they are detected in 16% of the operated, then after the third — in almost 96% of patients.
Pelvic adhesions develops against the background of processes that provoke increased formation of connective tissue. The immediate causes of the formation of adhesions are:
- Inflammation of the pelvic organs. The disease is more often diagnosed in women who have undergone an acute inflammatory process, suffering from chronic colpitis, endometritis, adnexitis, parametritis, etc.
- Surgical interventions. The probability of adhesive disease is higher after laparotomy operations: appendectomy, cesarean section, removal of appendages, supravaginal amputation or extirpation of the uterus.
- Hemorrhages in the pelvis. The impetus for the beginning of the adhesive process can be ovarian apoplexy, bleeding due to rupture of the tube during ectopic pregnancy.
- Endometriosis. The spread of endometriodic growths to the organs and peritoneum of the pelvis stimulates the formation of fibrinous connective tissue strands.
- Pelvic injuries. Open and closed injuries received in an accident, when falling from a height, at work can lead to the development of the disease.
According to research, in more than half of cases, plastic pelvioperitonitis occurs with the combined action of two or more causes. Predisposing factors play an important role in the development of pathology: invasive gynecological interventions, promiscuous sex life, late seeking medical help.
With traumatic injuries, acute and chronic inflammation of the peritoneum covering the pelvic organs, mediators are released that stimulate the regeneration process. One of the links of this process is the activation of fibroblasts synthesizing fibrin. As a result, fibrin fibers “glue” adjacent organs and tissues. This reaction is protective in nature and is aimed at localizing the focus of inflammation. With massive lesions and chronic inflammatory processes, the reverse resorption of connective tissue is disrupted, which leads to the formation of dense adhesions between the serous membranes of the pelvic organs. At the same time, the leaves of the peritoneum are also compacted, the mobility of the uterus and appendages is limited. With the displacement of the organs, the adhesions are stretched, which is accompanied by irritation of the nerve endings and the appearance of a characteristic pain syndrome.
The clinical classification of plastic pelvioperitonitis is based on the features of its course. The following forms of pathology are distinguished:
- Spicy. The disease is manifested by pronounced clinical symptoms with pain syndrome, fever, pressure drop, nausea and other signs of increasing intoxication. In some cases, intestinal obstruction develops.
- Intermittent. The phase of the flow is noted. With exacerbation, characteristic pains occur, intestinal disorders may occur. During remission, the symptoms are minimal or absent.
- Chronic. The disease is asymptomatic or its manifestations are poorly expressed. The patient is periodically disturbed by constipation and pain in the lower abdomen. Usually, the reason for going to the doctor is the inability to get pregnant.
Since adhesions play an essential role in the development of infertility, it is important to take into account the peculiarities of the lesion of the uterine appendages. Specialists in the field of gynecology and reproductology distinguish the following stages of the process, determined laparoscopically:
- Stage I. Single thin splices are localized near the ovary, fallopian tube, uterus or other organs, but do not interfere with the movement of the egg.
- Stage II. The ovary is connected by dense accretions with the fallopian tube or other organs, while more than 50% of its surface remains free. Spikes interfere with the capture of the egg by fimbriae.
- Stage III. More than half of the ovary is covered with numerous dense adhesions. The fallopian tubes are impassable due to deformation and overlap of the lumen.
Symptoms of adhesive disease
With an uncomplicated course, the main clinical sign of the presence of adhesions between organs in the pelvis is pain syndrome. The patient almost constantly feels dull or aching pain of varying intensity in the lower abdomen, above the pubis, in the lumbar region, sacrum, rectum. Painful sensations increase with physical exertion (lifting weights, playing sports), stress, hypothermia, during ovulation and menstruation. Pain can occur during defecation, active sexual intercourse, an overflowing bladder or immediately after emptying it.
When the adhesions of the organs located in the pelvis are squeezed, there are signs of irritation or functional insufficiency. The patient is worried about intestinal disorders: frequent stools, constipation, moderate transient flatulence. Nausea occurs periodically, very rarely – vomiting. Symptoms worsen after eating legumes, garlic, beets, grapes and other products that contribute to increased gas formation. The defeat of the ovaries and fallopian tubes is manifested by a violation of reproductive function and complaints about the inability to get pregnant.
The most dangerous complication of the disease is acute intestinal obstruction. Due to compression by a spike, the intestinal lumen is partially or completely blocked, blood circulation in the intestinal wall is disrupted. With untimely treatment, a fatal outcome is possible. Infertility with pelvic adhesions occurs in 25% of patients. Due to the presence of connective tissue strands, innervation and blood flow in the uterine wall are disrupted, which causes its hyperactivity and provokes premature termination of pregnancy. Adhesions of the fallopian tubes and ovaries prevent the normal movement of the egg and its fertilization, increases the likelihood of ectopic pregnancy.
In making a diagnosis, an important role is played by collecting anamnestic information and identifying possible causes of pathology. To confirm the presence of pelvic adhesions, the examination plan includes:
- Examination in a gynecological chair. With bimanual palpation, heaviness and soreness are determined in the appendage area. The mobility of the uterus is limited. The vaginal arches are shortened.
- Diagnostic laparoscopy. Endoscopic examination is the most reliable diagnostic method that provides good visualization of adhesions between the pelvic organs.
- Gynecological ultrasound. During the study, the splices are revealed in the form of heterogeneous echoes of varying intensity connecting the walls of the pelvis and pelvic organs.
- Hysterosalpingography and ultrasound hysterosalpingoscopy. The methods are aimed at assessing the degree of involvement in the adhesive process of the fallopian tubes.
- MRI of the pelvic organs. In the resulting three-dimensional image, anechoic white strands are determined in the pelvic cavity.
To identify the causes of the disease, the patient is prescribed a smear on the flora, a bacposev with an antibioticogram, and a PCR diagnosis of STIs. Differential diagnosis is carried out with acute and chronic inflammatory processes, benign and malignant neoplasms in the pelvic organs. In acute course with signs of intestinal obstruction, it is necessary to exclude other surgical pathology. To clarify the diagnosis, consultations of an oncogynecologist, a urogynecologist, a surgeon can be appointed.
Therapeutic tactics are determined by the stage, the nature of the course, the clinical severity and the presence of complications. At the initial stage of treatment of chronic adhesive disease, complex conservative therapy is recommended, which includes:
- Antibacterial drugs. They are prescribed when confirming the leading role of infectious agents in the development of the adhesive process, taking into account the sensitivity of microorganisms.
- Nonsteroidal anti-inflammatory drugs. Effectively eliminate the pronounced pain syndrome. Relieve swelling and accelerate the resorption of adhesions in the initial stages of the disease.
- Hormonal drugs. Hormone therapy is indicated for the adhesive process that has arisen against the background of external genital or extragenital endometriosis.
- Fibrinolytic enzymes. Cleave glycopeptide bonds in connective tissue strands, which contributes to the complete or partial resorption of adhesions.
- Vitamins, immunocorrectors. They are used to improve general well-being and correct possible immune disorders.
- Physiotherapy, balneotherapy. They are used as auxiliary methods of treatment.
With the ineffectiveness of drug treatment of the chronic form of the disease, acute and intercurrent variants of pathology, surgical intervention is indicated. Endoscopic operations are usually used to dissect adhesions. Laparoscopy is often a therapeutic and diagnostic procedure, connective tissue splices are dissected directly during the examination. Depending on the instruments used, such interventions can be laser-surgical, electrosurgical and aquadissection. In the latter case, the spikes are destroyed by increased water pressure. With a common adhesive process, alternative laparoscopy options are performed: double with atypical trocar insertion points, open (minilaparotomic) with direct trocar insertion, with the creation of a high-pressure pneumoperitoneum. Operations with dissection of adhesions with a scalpel are rarely performed these days.
Prognosis and prevention
With adequate treatment in the early stages of the disease, the prognosis is favorable. Surgical dissection of adhesions makes it possible to eliminate or significantly reduce pain syndrome and restore reproductive function in 50-60% of cases in women with stage 1-2 adhesive disease. The use of an anti-adhesive gel barrier minimizes the risk of recurrence of the disease. Prevention of pelvic adhesions includes routine examinations by a gynecologist to detect and treat inflammatory processes, refusal of unjustified invasive interventions, pregnancy planning, use of contraceptives during sexual contact with casual partners. In order to reduce the likelihood of peritoneal pelvic adhesions, when performing operations in women, it is important to choose the most gentle type of intervention, treat inflammatory complications in a timely manner, and observe the motor regime in the postoperative period.