Pelvioperitonitis: what is dangerous, how to treat and restore reproductive function

Pain with pelvic peritonitis is often tolerable, despite the severity of the inflammatory process. This is due to a decrease in the number of pain receptors in the pelvis. The symptoms of intoxication come to the fore - temperature, confusion, lethargy. The code for ICD-10 is N73.3.

Forms of pathology

Depending on the cause of the development of the disease, two forms are distinguished.

• Primary. It develops due to the penetration of pathological agents into the pelvic cavity through the lymphatic and blood vessels. It can be E. coli, gonococcus, staphylococcus, mycoplasma, chlamydia. The focus of infection may be distant from the pelvic organs. Also, the disease can cause opportunistic bacteria, which are normally present on the peritoneum. Pelvioperitonitis develops in violation of the integrity of the vaginal fornix, with perforation of the uterine wall during gynecological procedures. For example, when installing an IUD (intrauterine device), diagnostic curettage, metrosalpingography, hydrotubation and tubal perturbation, surgical abortion.
• Secondary. Pathology occurs as a complication of another infectious disease of the pelvic organs and abdominal cavity. For example, purulent and serous salpingitis, acute adnexitis, tubo-ovarian formation, gonorrhea, genital tuberculosis, intestinal obstruction, appendicitis, sigmoiditis.

Pathologists always have an infectious etiology and an acute form. It occurs against a background of weakened immunity, stress loads, taking immunosuppressive drugs, after a cold, hypothermia.

It is more severe in women with chronic diseases of the liver, kidneys, and metabolic disorders. If the cause is not established, then the inflammation is considered cryptogenic.

The chronic diagnosis is a consequence of the transferred acute form in the form of an adhesive process in the small pelvis. Exacerbations of the infection and clinical signs of inflammation of the appendages periodically occur.

Development mechanism

The disease manifests itself as a local inflammatory reaction in the pelvic part of the peritoneum. Microcirculation is disturbed and capillary permeability increases, leukocytes, albumin, fibrinogen go beyond the boundaries of the vascular bed. This contributes to the accumulation of serous or purulent type fluid (effusion) around the pelvic organs. In the affected areas of the peritoneum, the concentration of serotonin, organic acids, histamine increases, which leads to degenerative changes and tissue edema. Subsequently, fibrin is deposited on the surface of organs. It provokes the adhesion process between the peritoneum, intestinal loops, pelvic organs, bladder, omentum, affecting the fallopian tubes.

Classification

In addition to dividing the disease into primary and secondary by the mechanism of occurrence, other criteria for classification are distinguished. They are presented in the table.

Table - Classification of pelvioperitonitis

Main symptoms

The defeat of the pelvic peritoneum is a process that is developing rapidly and makes itself felt with clearly defined signs.

• Lower abdominal pain. It occurs suddenly and is felt acutely. It is similar to manifestations with adnexitis. Often, the discomfort in the peritoneum increases at the time of bowel movement or urination.
• Body temperature. It always rises, often reaching 40 ° C. Chills are often felt.
• Nausea and vomiting. Concerned constantly and indicates intoxication. Vomiting does not bring relief; it can be one or several times the contents of the stomach without an impurity of blood. A white coating on the tongue is characteristic.
• Tachycardia. This is a response to fever, dehydration and an active inflammatory process.
• Peritoneal symptoms. There is a slight intestinal motility, the abdomen is swollen, painful in the lower sections. The symptom of Shchetkin-Blumberg is expressed.
• Purulent discharge. Often, pathology is accompanied by purulent and fetid discharge from the genital tract - the primary focus of infection can be localized here.

A woman’s condition worsens within literally several hours. It is impossible to diagnose the disease on your own, since the woman is in prostration due to pain and intoxication. Symptoms are similar to other pathologies:

• acute endometritis;
• ectopic pregnancy;
• the gap ovarian cysts;
• tubo-ovarian abscess;
• appendicitis;
• bowel obstruction.

Diagnostics

Pelvioperitonitis resembles many acute conditions in obstetrics, gynecology, and surgery. For differential diagnosis, the following methods are used.

• Medical history. If a woman is unconscious due to the severity of the condition, the doctor interviews her loved ones.
• General inspection. Body temperature, blood pressure are measured, the abdomen is examined, palpation is performed for the presence of peritoneal symptoms.
• Gynecological examination. Pain on palpation of the uterus and appendages is characteristic. Movement behind the neck is also sharply unpleasant. With the accumulation of pus or effusion in the back arch, its overhang is determined.
• Ultrasound procedure. It allows to identify pathological fluid behind the uterus, the presence of ovarian formations, and the accumulation of exudate in the fallopian tubes.
• Blood test. All signs of acute inflammation are detected - a decrease in hemoglobin level, elevated ESR and white blood cell count.

Treatment

If the pathology is confirmed, treatment should be started immediately. All variants of pelvioperitonitis require surgical intervention, with the exception of gonorrhea. The peculiarity of the latter is that the symptoms are similar to other forms, but after massive antibiotic therapy it passes.

Conservative

Conservative treatment is prescribed at the stage of preparation for the operation, as well as in the postoperative and rehabilitation periods. Clinical recommendations are as follows.

• Antibiotics. Initially, drugs are selected empirically, taking into account the severity of the woman's condition. Subsequently, therapy is adjusted based on the results of bacteriological culture from the vagina and abdominal cavity. Cephalosporins (Cefazolin, Cefoxitin, Ceftriaxone), carbapenems (Imipenem), natural and synthetic penicillins (Oxacillin, Amoxicillin), sulfanilamides (“Biseptol"), Fluoroquinolones (" Ciprofloxacin "). The list of effective medicines also includes representatives of the tetracycline group (“Tetracycline”, “Doxycycline"), Monobactams (" Aztreonam "), aminoglycosides (" Kanamycin "," Tobramycin "), macrolides ("Azithromycin"," Erythromycin ").
• Detoxification. Therapy involves the intravenous administration of solutions of glucose and insulin (5-10%), sodium chlorine (0.9%), a mixture of electrolytes. Blood plasma or its components, analogs (albumin, Stabizol, protein, Reftan, protein hydrolysates) are also used. With severe intoxication, 2-3 liters of fluid are administered in combination with non-specific diuretics (for example, Furosemide).
• Removal of edema and inflammation. Histamine receptor blockers are used. For example, Suprastin, Diphenhydramine.
• Painkillers and anti-inflammatory drugs. Apply Nimesulide, Ibuprofen, Ketones.
• Vitamin Complexes. Appointed to correct immunity, support systems and organs during rehabilitation. We need vitamins A, E, C, Group B.

Prompt

Access is chosen at the discretion of the surgeon:

• lower middle - from the navel to the pubis;
• transverse - in the suprapubic area.

It all depends on the severity of the condition of the woman and the experience of the surgeon. In exceptional cases, laparoscopy is possible - with a limited focus of inflammation.

During the intervention, the focus of infection and all organs that have undergone changes are removed. The following options are possible:

• removal of only the ovary (one or two);
• removal of the ovaries and fallopian tubes;
• amputation or hysterectomy with or without appendages.

Forecast

According to statistics, 10-15% of cases of pelvioperitonitis end fatally. Only correctly selected and timely treatment saves the patient's life. But after therapy, dubious predictions for reproductive function remain (even with ovarian preservation). High risks of such complications:

• ectopic pregnancy;
• infertility;
• miscarriage;
• pelvic pain syndrome.

Girls who have had the disease are often forced to perform IVF.

Prevention of pelvioperitonitis is sexual literacy, timely treatment of inflammatory gynecological diseases, the use of barrier methods of contraception, compliance with recommendations for the use of intrauterine devices.