ADNEXITIS (adnexitis; lat. adnexa — appendages + itis; synonym salpingo-oophoritis) — inflammation of appendages of a uterus (ovaries and pipes). One of the most often found gynecologic diseases.
Etiology and pathogeny. The disease develops at a combination of a contagium to the certain contributing moments reducing protective forces of an organism: the overfatigue, overcooling, disturbance of food increased by menstrual blood losses, intercurrent diseases, psychological shocks, etc. And. various pathogenic microorganisms, most often staphylococcus, streptococci, gonokokk, colibacillus, mycobacteria of tuberculosis, etc. cause. Rather seldom And. it can be connected with influence of noninfectious factors, e.g. the chemical substances (alcohol, iodine, etc.) entered into a cavity of the uterus.
A certain way of spread of an infection is characteristic of each type of the activator. Gonorrheal And. develops in the ascending way. The activator gets through the unimpaired mucous membrane of a genital tract. Distribution of the activator at And., caused by stafilokokka, streptococci, colibacillus, in most cases occurs in also ascending way.
Pathogenic microbes get into generative organs of the woman at bruises of fabrics during abortions, especially criminal, childbirth, diagnostic vyskablivaniye, etc. Tubercular defeat of appendages of a uterus arises owing to spread of an infection in the hematogenous way from lungs, in a lymphogenous way from bronchial and mezenterialny limf. nodes, from a peritoneum. For some microorganisms (colibacillus) ways of infection from a worm-shaped shoot, a sigmoid gut are possible.
Gonokokki and mycobacteria of tuberculosis usually cause a bilateral inflammation of appendages of a uterus, streptococci, staphylococcus and colibacillus — is more often unilateral.
The inflammation of uterine tubes — a salpingitis — usually begins with an inflammation of a mucous membrane (endosalpingitis). In the beginning process has catarral character and is shown by a hyperemia, hypostasis and infiltration of a mucous membrane. Rather quickly acute inflammation extends to a muscular wall of uterine tubes and a peritoneal cover (salpingitis). Inflammatory process is followed by desquamation of an epithelium owing to what there is a pasting of folds of a mucous membrane to formation of pockets, unions that can result in impassability of pipes and infertility (see). The inflammatory exudate accumulating in a gleam of a uterine tube follows through its belly opening, causing inflammatory reaction from a peritoneum (perisalpingitis). At an obliteration of uterine and ampullar departments of a pipe accumulation of inflammatory exudate leads to emergence of meshotchaty education — a sactosalpinx. Exudate can be transparent, watery — a hydrosalpinx, purulent — a pyosalpinx. Availability of pus in a uterine tube usually is followed by formation of the piogenic capsule and involvement in pathological process of an ovary.
Destruction of tissues of uterine tube can lead to break of an abscess in a peritoneal cavity with development of purulent peritonitis.
At tubercular And. in a wall of uterine tubes there are typical granulomas consisting of epithelial and colossal cells. At distribution of process on all pipe wall the expressed destruction of fabrics, adhesion of folds of a mucous membrane with the subsequent disturbance of passability of uterine tubes and development of persistent infertility is observed. Inflammatory process at tuberculosis always chronic.
The inflammation of ovaries — an oophoritis — in most cases develops for the second time at spread of an infection from uterine tubes. Much less often pathogenic microorganisms are brought in ovaries by a blood flow and a lymph. Around vospalitelno the changed uterine tubes and ovaries numerous commissures are formed (perisalpingooforit, a periadnexitis). The purulent salpingitis often is followed by development of a purulent oophoritis (pyoovarium). Quite often purulent fusion of fabrics so changes anatomic relationship between a uterine tube and an ovary that these educations represent the uniform inflammatory conglomerate surrounded with the general piogenic capsule and numerous commissures with intestines and an epiploon. At the considerable amount of «tubo-ovarian» education it is incorrectly called sometimes «adneks-tumor», however this name is conditional since in such inflammatory education there are no symptoms of a true tumor. Inflammatory changes of ovaries quite often are followed by disturbances of processes of maturing of follicles and ovulations that can lead to developing of dysfunctional uterine bleedings of preferential anovulatory character.
At tubercular And. pipes are surprised first of all; damage of ovaries meets seldom.
Clinical picture depends on a species of a microbe activator and features of reactivity of a macroorganism.
At the ascending infection in an acute stage of a disease patients complain of severe pains in the bottom of a stomach and in the field of a sacrum, inog yes symptoms of irritation of a peritoneum of a basin are noted (see the Pelviperitonitis). Temperature is increased, sometimes to high figures, pulse is speeded up according to temperature. Menstrual function usually is not broken, but there can sometimes be meno-also metrorrhagias owing to disturbance function of ovaries. The delay of a chair and gases, dysuric frustration is observed. The general condition of patients if there are no phenomena of a pelviperitonitis, is usually broken a little. In blood the leukocytosis, a deviation to the left and the accelerated ROE is observed.
Acute And. it is characterized by gektichesky fever, tachycardia, the phenomena of intoxication, severe pains in the bottom of a stomach, oznoba and it is frequent the phenomena of pelvic peritonitis (see the Pelviperitonitis). The rupture of the piogenic capsule is followed by development of purulent peritonitis. Quite often the pus following from a belly ostium tubae uterinae can accumulate in rectouterine deepening, causing formation of pozadimatochny abscess. The abscess is most often opened in a direct, sigmoid gut or a bladder therefore it can be formed is long not healing fistula.
At an acute salpingo-oophoritis the rough phenomena of an inflammation usually abate in 1 — 2 week, process passes into a subacute stage, and then into chronic.
It is more often observed chronic And. with the erased clinical symptoms.
Emergence of primary chronic forms A. it is caused by changes of properties of microbes activators, in particular decrease in their antigenic properties owing to broad and quite often irrational use of antibiotics, and also changes of reactivity of an organism of the patient. Thereof even at gonorrheal And., earlier almost always proceeding sharply, the erased forms of a disease began to prevail. Quite often only clinical manifestation And. persistent tube infertility and detection in appendages of a uterus of commissural process is.
At chronic And. exacerbations of a disease are often observed. A recurrence, as a rule, arises under the influence of nonspecific factors (overcooling, overfatigue, periods etc.); the infectious agent at the same time does not play usually leading pathogenetic role. On a clinical picture similar aggravations differ from the course of the disease which is directly caused by a microbic factor a little: more short-term course of a disease and rather bystry decrease in temperature under the influence of nonspecific methods of medical influence, without prescription of antibiotics is noted; moderate changes from peripheral blood. It is characteristic that inflammatory exudate at recurrent And. at many patients it is sterile.
Tubercular And. differs long, hron, in a current with periodic aggravations. Main symptom tubercular And. — infertility, is more often primary. Disturbances of menstrual function like meno-or metrorrhagias are quite often observed.
The diagnosis usually does not cause big difficulties: typical localization of pains; temperature increase, morbidity and increase in appendages of a uterus and other characteristic symptoms allow to make the correct diagnosis timely.
Happens much more difficultly to reveal an etiology of inflammatory process, especially when before inspection and specification of the diagnosis of a disease the patient accepted the antibiotics changing properties of a microbe activator. Therefore along with data of bacteriological inspection the great value is attached to the anamnesis and clinic of a disease.
Existence of signs of damage of a lower part of urinogenital system soon after infection is characteristic of a gonorrheal infection: urethritis, paraurethritis, cervicitis; quite often the proctitis joins. Serological tests (Borde — Zhangu, Feygel — Lisovskoy) almost completely lost the diagnostic value.
For And. a septic etiology developing of a disease after abortions, childbirth and various intrauterine interventions is characteristic. Diagnosis tubercular And. is based on data of the anamnesis, hron, the course of a disease, persistent infertility, typical changes of the uterine tubes revealed at a gisterosalpingografiya (rigid, gyrose pipes), and results of a tuberculinodiagnosis (especially Koch's reactions).
And. most often it is necessary to differentiate with the broken pipe pregnancy, a parametritis, a pelviperitonitis and appendicitis (see). The broken pipe pregnancy is characterized by colicy pains in the bottom of a stomach, an unconscious condition, a delay of periods, emergence of dark and bloody allocations from a genital tract after the previous delay, increase and a softening of a uterus and existence of the appendages of a uterus of a pasty consistence increased on the one hand. Biological and immunological reactions to pregnancy are positive, at a puncture of a back vault of the vagina usually receive dark blood.
At a parametritis the pain syndrome is less expressed, than at A. Infiltrat more often happens unilateral and passes from a uterus to walls of a small pelvis; the mucous membrane of a vagina under infiltrate loses the mobility. Infiltrate sticks out a back vault of the vagina. The pelviperitonitis (see) is characterized by an acute clinical picture with the peritoneal phenomena. The Palpatorny border of infiltrate does not match percussion; the first is wider than the second.
Forecast. And. does not pose hazard to life and its forecast is, as a rule, favorable. Timely diagnosis, etio-and pathogenetic the caused treatment contribute to recovery and normalization of functions of female generative organs.
To number of the most frequent adverse effects And. persistent infertility, ectopic pregnancy, disturbances of menstrual function belong.
Treatment is defined by an etiology of a disease and a stage of development of inflammatory process. In an acute stage nonspecific And. and at the expressed aggravation the patient needs to be hospitalized. Appoint rest, mechanically and chemically sparing diet, ice to a bottom of a stomach, anesthetics, drugs of calcium. Topical treatment in acute cases and at aggravations is contraindicated.
It is necessary to administer antibiotics and the sulfanamide drugs only after capture of smears from the channel of a neck of uterus on microbic flora and definitions of its sensitivity to antibiotics.
In an acute stage it is reasonable to apply antibiotics with a wide antibacterial range of action: a combination of penicillin (on 200 000 — 300 000 PIECES 3 — 4 times a day intramusculary) with streptomycin (0,5 g 2 times a day intramusculary), tetracycline (on 100 000 PIECES in 6 — 8 times a day), Oletetrinum (on 0,25 g 4 times a day), etc. Antibiotics combine with streptocides (up to 20 g on a course of treatment). Course doses of antibiotics are defined by disease severity and efficiency of treatment.
Treatment of aggravations And. nonspecific character carry usually out without prescription of antibiotics and streptocides. In a subacute stage apply an autohemotherapy (10 — 12 procedures), drugs of calcium (10% solution of a gluconate of calcium on 10 ml intravenously or intramuscular — 8 injections once a day), general uv irradiation (4 — 5 procedures) and local (10 — 12 procedures). In hron. stages of a disease use various physiotherapeutic procedures: galvanoforez, UVCh, diathermy, mud cure, ultrasound, medical hydrotubations, etc.
Prescription of antibiotics and streptocides at chronic And. it is justified only against the background of the focal reaction caused by physical therapy, provocation, introduction of Prodigiosanum (on 25 — 50 mkg intramusculary).
Antibacterial treatment And. a tubercular etiology carry out in 2 steps.
The first stage — continuous administration of drugs within 6 — 10 months. During this period (the first 2 — 3 months) apply streptomycin (1 g a day), PASK (8 — 10 g a day), Ftivazidum (0,9 g a day). Streptomycin is entered as intramusculary, and through the back vulval arch. In 2 — 3 months after an initiation of treatment appoint two drugs — PASK and Ftivazidum. After the first stage of treatment stabilization of pathological process is observed.
The second stage — discontinuous therapy within 1,5 — 2 years. Drugs accept every other day or 2 — 3 times a week. Considering bent of tubercular process of genitalias to an aggravation, especially in the spring and in the fall, treatment is carried surely out to these periods of year, and also at an aggravation of process. After treatment by the patient appoint resorptional physical therapy (ultrasound with lidazy, a diathermy, an electrophoresis), mud cure.
Surgical treatment And. make at a frequent recurrence of a disease and existence of considerable anatomic changes in area of appendages of a uterus, prolonged unsuccessful conservative treatment; in the presence of a pyosalpinx and a pyoovarium; in the presence of caseous process (at tuberculosis).
Prevention comes down to the prevention of entering of contagiums in a genital tract of the woman at abortions, childbirth and intrauterine interventions. Prevention gonorrheal and tubercular And. is based on the general principles of fight against these infections.
Bibliography: Bodyazhina V. I. Questions of a pathogeny and general principles of treatment of inflammatory diseases of a reproductive system of women, Works of the 12th Vsesoyuz. congress akush. - ginek., page 288, M., 1971; The Multivolume guide to obstetrics and gynecology, under the editorship of L. S. Persianinov, t. 4, book 1, page 473, 516, 569, m, 1963; Thomsen K. u. Humke W. Entzttndungen der Uterus und Adnexe, in book: Gynfikologie u. Geburtshilfe * hrsg. v. O. Kfiser, Bd 3, S. 1, Stuttgart, 1971: V 1 b erg L. Acute inflammatory conditions of the uterine adnexa, Stockholm, 1964, bibllogr.
And P. Kiryushchenkov.