Pelvioperitonitis is a local infectious and inflammatory lesion of the serous cover (peritoneum) of the pelvis. The development of pelvioperitonitis is manifested by high fever with chills, intoxication, severe abdominal pain, bloating and tension of the abdominal wall muscles. Diagnosis of pelvioperitonitis includes gynecological examination, ultrasound, laparoscopy, back examinations. Therapy of pelvioperitonitis requires the appointment of massive antimicrobial, infusion therapy, immune correction, performing therapeutic punctures. With purulent pelvioperitonitis, colpotomy, laparoscopy and drainage of the pelvic cavity are indicated.
General information
Pelvioperitonitis is characterized by a local reaction of inflammation in the pelvis: microcirculation disorders, increased vascular permeability, fibrinogen, albumin, leukocytes going beyond the vascular bed, the formation of serous or purulent effusion. In the affected focus, histamine, serotonin, organic acids accumulate, and the concentration of hydroxyl and hydrogen ions increases. The endothelium of the peritoneum undergoes dystrophic changes. Due to acute inflammation, adhesions form between the peritoneum, pelvic organs, intestinal loops, omentum, and bladder.
The course of pelvioperitonitis may be accompanied by an accumulation of exudate in the utero-rectal space with the formation of a douglas abscess, the breakthrough of which into the free abdominal cavity leads to the development of diffuse peritonitis. Pelvioperitonitis is caused by E. coli, Staphylococcus, gonococcus, chlamydia, mycoplasma, viruses, anaerobes, and more often by microbial associations – in the latter case, its course takes on a more severe character.
Classification
Clinical gynecology distinguishes between secondary pelvioperitonitis caused by inflammatory diseases and primary pelvioperitonitis, which develops with the direct penetration of infection into the pelvic cavity.
Taking into account the local prevalence, partial pelvioperitonitis is isolated with a limited area of inflammation near the source of infection and diffuse, involving the parietal and visceral peritoneum of the pelvis.
According to the type of predominant changes in the pelvis, pelvioperitonitis is divided into adhesive (adhesive, flowing with the formation of adhesions) and exudative (effusion).
By the nature of the inflammatory exudate, disease can be serous-fibrous, hemorrhagic or purulent. The nature of the exudate in pelvioperitonitis depends on the type of pathogens or their associations. Staphylococcal pelvioperitonitis is accompanied by serous-purulent or purulent effusion; with rod flora, the exudate is serous-purulent with a fetid fecal odor. With viral and chlamydial pelvioperitonitis, the inflammatory discharge is more often serous or serous-purulent; with gonorrheal etiology, purulent-hemorrhagic.
Causes
More often, the development of this disease is preceded by an infectious and inflammatory process in the pelvis. In this case, pelvioperitonitis is secondary and serves as a complication of acute adnexitis, serous or purulent salpingitis, purulent tubovarial formations (piovar, piosalpinx), suppurated uterine hematoma, genital tuberculosis, gonorrhea, metroendometritis, appendicitis, sigmoiditis, intestinal obstruction, etc.
Primary pelvioperitonitis occurs with direct penetration of microbial pathogens into the pelvic cavity due to perforation of the uterine wall during gynecological operations and manipulations (IUD installation, surgical abortion, diagnostic curettage), metrosalpingography, hydro- and pertubation of the fallopian tubes, introduction of chemicals into the uterine cavity to terminate pregnancy, damage to the vaginal arch during obstetric operations and Pelvioperitonitis often manifests against the background of a decrease in general resistance, stress, menstruation, hypothermia.
Symptoms
The development of pelvioperitonitis is acute: the disease begins with a sharp increase in temperature to 39-40 ° C, the appearance of intense pain in the lower abdomen, periodic chills, tachycardia (up to 100 or more beats. in min.), nausea, gas retention, painful urination, bloating. Objectively, with pelvioperitonitis, symptoms of intoxication, weakened peristalsis, dry, overlaid with a grayish coating of the tongue are revealed. Positive signs of peritoneal irritation are more pronounced in the lower abdomen and weaker in its upper half.
A somewhat more erased picture characterizes the course of chlamydial pelvioperitonitis. In this case, the symptoms increase gradually, but there is a tendency to the early formation of adhesions. During diagnosis, pelvioperitonitis is differentiated with peritonitis, parametritis, pyosalpinx, appendicitis, ectopic pregnancy, torsion of the leg of an ovarian tumor. Patients with suspected pelvioperitonitis require urgent hospitalization in a gynecological hospital.
Diagnostics
The assumption of the presence can be expressed by a gynecologist on the basis of the patient’s anamnesis. Analysis of peripheral blood in pelvioperitonitis reveals increased ESR, significant leukocytosis with a shift of the formula to the left, toxic anemia. A blood test for CRP gives a sharply positive reaction.
Palpation of the abdomen determines the tension of the abdominal muscles, the upper limit of the inflammatory infiltrate in the pelvis, positive peritoneal symptoms. Bimanual vaginal examination is accompanied by sharp soreness in the uterus and appendages; due to effusion, there is a protrusion of the posterior vaginal arch, displacement of the uterus anteriorly and upward. Ultrasound with a vaginal sensor allows you to clarify the prevalence of inflammation, to identify the presence of effusion in the pelvis. To exclude acute pathology in the abdominal cavity, an overview radiography is performed.
In order to identify microbial agents, a bacteriological examination of the separated vagina and cervical canal is carried out, and an ELISA diagnosis is carried out. However, since the vaginal microflora may not reflect the processes developing in the pelvis, pelvioperitonitis justifies diagnostic laparoscopy or puncture through the posterior vaginal arch to extract exudate.
Treatment
At the prehospital stage, before the diagnosis of pelvioperitonitis, the administration of painkillers is contraindicated; as a measure of relief, only applying ice to the lower abdomen is allowed. Pelvioperitonitis therapy is complex, aimed at suppressing the infectious process, relieving pain symptoms and intoxication. According to the indications, surgical intervention is performed.
In the acute period, bed rest, rest, position in a bed with a raised headboard, cold on the stomach is recommended. Taking into account the revealed microbial flora, the administration of antibiotics of the groups of semi-synthetic penicillins (amoxicillin, oxacillin), cephalosporins (cefazolin, cefotaxime), fluoroquinolones (ciprofloxacin), macrolides, aminoglycosides, tetracyclines, imidazoles (metronidazole), etc. is shown. Detoxification infusion therapy, the introduction of plasma and plasma substitutes, protein hydrolysates are carried out.
Antihistamines, painkillers and anti-inflammatory drugs, vitamins are included in the courses of drug therapy for pelvioperitonitis. Lacto- and bifidumpreparations are prescribed to restore the biocenosis of the vagina. A good effect in pelvioperitonitis is achieved by ultraviolet irradiation of blood. After the acute phenomena of pelvioperitonitis subside, physiotherapy is performed: ultrasound, electrophoresis, phonophoresis, microwave, UHF, laser therapy, physical therapy, massage.
Patients are shown therapeutic punctures through the posterior vaginal arch with evacuation of effusion, administration of antibiotics, antiseptics. When a purulent exudate is detected, a posterior colpotomy or laparoscopy with drainage of the pelvic cavity and intra-abdominal infusions is indicated for its evacuation.
If there is a suspicion of uterine perforation, necrosis of tumor nodes, pyosalpinx, piovar, tubovarial abscess, emergency glandular section is performed. The amount of surgical aid in this case is determined by the clinical situation. With a complicated course of pelvioperitonitis, adnexectomy, supravaginal amputation of the uterus with appendages, hysterectomy (complete removal of the uterus body), pangisterectomy (removal of the uterus with the neck and appendages) can be performed.
Prognosis and prevention
With competent and timely treatment of pelvioperitonitis, the disease ends in complete recovery. The best long–term results in the treatment of pelvioperitonitis are achieved with active tactics – punctures, laparoscopy, drainage. In this case, the percentage of subsequent pregnancies is higher than with conservative management. After undergoing pelvioperitonitis, the patient may suffer from infertility, miscarriage, development of ectopic pregnancy, recurrent inflammation, pelvic pain syndrome.
To exclude factors leading to the development of pelvioperitonitis, it is necessary to have a preventive examination by a gynecologist, timely treatment of genital infections, the use of barrier methods of contraception, timely extraction of IUD, preventive antimicrobial therapy after gynecological operations, prevention of complications associated with abortion, childbirth, intrauterine manipulations.
