Adnexitis (salpingo-oophoritis): Causes, Symptoms, Diagnosis, and Treatment
- What is adnexitis?
- Adnexitis: The mechanism of development
- Diagnostics of adnexitis
- Acute adnexitis
- Chronic adnexitis
- Diet with adnexitis
- Prophylaxis of adnexitis and doctor’s advice
What is adnexitis?
Adnexitis or salpingo-oophoritis is a one- or two-sided, combined inflammation of the ovaries and fallopian (uterine) tubes forming the appendages of the uterus. In the structure of inflammatory diseases of the female sexual apparatus, the inflammation of the appendages (adnexitis) occupies one of the first places.
Inflammation of the appendages can be caused by streptococci, enterococci, staphylococci, gonococci, fungi, viruses, mycobacteria tuberculosis, escherichia, chlamydia and other microorganisms. Often the cause of adnexitis are microbial associations (usually E. coli and staphylococci). As a rule, the causative agents of adnexitis are resistant to many antibiotics.
Tuberculosis bacillus, gonococcus usually cause bilateral inflammation of the appendages, streptococcus, staphylococcus and E. coli – one-sided. Predisposing to the development of inflammation of the appendages or its recurrence is hypothermia, infection with STIs, non-compliance with hygiene norms, stresses, promiscuous sexual intercourse.
Adnexitis: The mechanism of development
The development of the inflammatory process with adnexitis begins with the introduction of an infectious agent into the mucous membrane of the uterine tube with a gradual involvement of the muscular and serous layers.
Further, the inflammation spreads to the surrounding tissues: the ovarian integument epithelium and the pelvic peritoneum. Immediately after ovulation, the infection enters the bursted follicle or yellow body, developing further in the ovary. With adnexitis, the ovary and tube are welded together to form a single inflammatory conglomerate, and then a tubo-ovarian abscess. The outcome of inflammation of the appendages is the development of numerous adhesions, limiting the patency of the fallopian tubes.
The causative agents of the pathological process with adnexitis can fall into the fallopian tubes in the following ways:
- hematogenous (with blood flow);
- lymphogenous (with a current of lymph);
- downward (from sigmoid or cecum peritoneum);
- ascending (from the vagina to the cervical canal, then into the uterine cavity, fallopian tubes and ovaries).
Hematogenous infection of appendages with adnexitis occurs in cases of tuberculous lesions of the genitals, lymphogenous and descending – with diseases of the rectum, sigmoid colon and appendix of the cecum. For the E. coli, streptococci, staphylococci, the entrance gates are the ascending anatomical channels of the genital tract. Chlamydia and gonococci are able to penetrate intact tissue of the genital tract. Often the infection gets into the appendages in several ways at the same time. The course of adnexitis can be acute, subacute, chronic (without relapse and recurrent).
Diagnostics of adnexitis
The basis for the diagnosis of adnexitis is the history (introduction of an intrauterine device, abortion, diagnostic scraping, complicated births, factors that aggravated inflammation of the appendages, etc.), complaints and results of objective research. With a two-hand gynecological examination with adnexitis, one-or two-sided painful enlargement of the uterine appendages is determined. To establish a microbial pathogen of adnexitis allows bacteroscopy and examination of the smears of the urethra, vagina and cervix.
Ultrasound diagnostics with adnexitis reveals inflammatory formations (hydrosalpinks, pyosalpinks) of appendages. As a diagnostic method for the detection of purulent formations and inspection of the fallopian tubes with simultaneous conducting intracavitary treatment procedures for inflammation of the appendages, laparoscopy is used.
To determine the patency of the fallopian tubes and the degree of manifestation of pathological changes in them in chronic adnexitis, hysterosalpingography is carried out-X-ray examination of the uterus and appendages with the introduction of a contrast agent. In cases of violation of the menstrual cycle with inflammation of the appendages, functional tests are performed to assess the function of the ovaries: measurement of rectal temperature, determination of the pupil symptom, tension of cervical mucus.
Symptoms of acute adnexitis
The acute form of adnexitis occurs with a characteristic clinical picture: intense, sharp pains in the lower abdomen that give back, sacrum and more pronounced on the side of inflammation, elevated temperature, often accompanied by chills, the appearance of unusual mucous or purulent discharge, weakness, weakness, dysuric disorders, bloating. When palpating the abdomen, the symptoms of muscle protection (irritation of the peritoneum) are noted. In the blood formula, leukocytosis is observed with a shift to the left, acceleration of the ESR.
Often develop bilateral inflammation of the appendages, combined with inflammation of the uterus. Adnexitis can be accompanied by algomenorrhea and menorrhagia. With the growth of inflammatory changes, a purulent saccular tumor develops in the appendages area – the tubo-ovarian abscess. With abscessing, there is a risk of rupture of the fallopian tube and the entry of purulent contents into the abdominal cavity with the development of pelvioperitonitis.
With severe intoxication in the acute phase of adnexitis, there may be changes in the nervous and vascular systems.
Expressed symptoms with uncomplicated form of acute adnexitis persist for 7-10 days, then gradually weaken pain, blood and body temperature normalize. The outcome of acute inflammation of the appendages is complete clinical recovery (with adequate and timely treatment) or a chronic process with a prolonged course.
Stages of acute adnexitis
In the development of acute adnexitis four consecutive stages are noted:
- stage acute endometritis and salpingitis without symptoms of irritation of the pelvic peritoneum;
- stage acute endometritis and salpingitis with symptoms of irritation of the pelvic peritoneum;
- stage acute adnexitis, accompanied by the development of an inflammatory conglomerate and abscess formation;
- rupture of a tubo-ovarian abscess.
The course of acute adnexitis passes through two phases:
- Toxic – with a predominance of aerobic flora and symptoms of intoxication.
- Septic – with the addition of anaerobic flora, weighting symptoms of adnexitis and the development of complications. In the septic phase of adnexitis, a purulent tubo-thoracic formation is formed with the threat of perforation.
Treatment of acute adnexitis
The acute stage of inflammation of the appendages is subject to inpatient treatment with the creation of conditions for the patient’s physical and mental rest, the appointment of an easily assimilated diet, adequate amounts of liquid (alkaline drink, mors, tea), observation of excretory function. With acute adnexitis, antibacterial treatment with broad-spectrum drugs, analgesic, anti-inflammatory, desensitizing treatment is prescribed.
The main means of therapy for adnexitis are antibiotics, taking into account the sensitivity of the pathogen to the drug. The dose of antibacterial drug should ensure its maximum concentration in the inflammatory focus. In the treatment of inflammation of the appendages, antibiotics of the following groups are widely used:
- penicillins (ampicillin, oxacillin);
- tetracyclines (doxacyclin and tetracycline);
- fluoroquinolones (ofloxacin, etc.);
- macrolides (azithromycin, erythromycin, roxithromycin);
- aminoglycosides (kanamycin, gentamicin);
- nitroimidazoles (metronidazole);
- lincosamides (clindamycin).
Antibiotic therapy of adnexitis prefers antibiotics for a long period of half-life and elimination (ampicillin – 5 hours, amoxicillin – 8 hours, etc.). In severe clinical course of inflammation of the appendages, the risk of septic complications, mixed or anaerobic flora, antibiotics are prescribed in various combinations (gentamicin + levomycetin, clindamycin + chloramphenicol, lincomycin + clindamycin, penicillins + aminoglycosides).
Bactericidal effect on anaerobic flora is metronidazole (given intravenously or orally). To relieve symptoms of intoxication with adnexitis, infusion therapy is prescribed: intravenous administration of solutions of glucose, dextran, protein preparations, water-salt solutions (total liquid volume up to 2-2.5 l / day).
With the development of purulent forms of inflammation, operative treatment of adnexitis is indicated. Today surgical gynecology widely uses low-traumatic methods of conducting operations, including in the treatment of adnexitis. So, with acute purulent adnexitis, laparoscopy is performed, during which pus is removed and irrigation is carried out with antiseptics and antibiotics of the inflammatory focus.
Successfully used evacuation of the contents of the saccate tumor by puncture of vault arches and subsequent local administration of antibiotics. In a number of cases, with the development of purulent melting of the appendages (the increase in renal failure, the threat of opening the abscess, the generalization of the septic process), their operative removal (adnexectomy) is shown.
After removing acute symptoms of adnexitis, physiotherapy (ultrasound, electrophoresis with magnesium, potassium, zinc on the lower abdomen, vibromassage) and biostimulants are prescribed in the subacute phase. In the absence of timely medical measures, acute adnexitis passes into chronic inflammation of the appendages, which proceeds with periodic exacerbations.
Symptoms of chronic adnexitis
Chronic adnexitis is most often the result of an incomplete acute process and occurs with relapses resulting from the influence of nonspecific factors (stressful situations, hypothermia, overwork, etc.). Periods of exacerbation of chronic inflammation of the appendages occur with deterioration of the general well-being of the woman, weakness, the appearance or intensification of pain in the lower abdomen, an increase in body temperature to 37-38 °, the appearance of mucopurulent discharge from the genital tract. After 5-7 days, the symptoms of adnexitis gradually subside, only a mild aching or dull pain in the abdomen remains.
In 50% of patients with chronic adnexitis short-term or persistent irregularities of the menstrual cycle are observed according to the type of menorrhagia, metrorrhagia, algomenorrhea, and rarely oligomenorrhoea. In 35-40% of women with chronic adnexitis, there is a disorder of sexual function (soreness in sexual intercourse, a decrease or absence of sexual desire, etc.). With chronic inflammation of the appendages, the function of the digestive organs (colitis, etc.) and urination (cystitis, bacteriuria, pyelonephritis) is impaired.
Frequent relapses of adnexitis lead to the development of neuroses, a decrease in a woman’s working capacity, the emergence of conflict situations in the family.
Variants of chronic adnexitis
Exacerbation of chronic adnexitis can occur in two ways:
- infectious-toxic – with an increase in pathological secretion, exudative processes in the appendages of the uterus, increasing their soreness, changes in the blood formula;
- neuro-vegetative – with deterioration of state of health, decrease in ability to work, mood instability, vascular and endocrine disorders.
Complications of chronic adnexitis
Chronic recurrent inflammation of the appendages often leads to the development of pathological outcomes of pregnancy (ectopic pregnancy, spontaneous abortion), secondary infertility. Infertility in chronic adnexitis can be not only a consequence of anatomical and functional changes in the fallopian tubes, but also disorders of the ovary function (menstrual cycle disorder, anovulation, etc.). Such mixed forms of infertility arising from inflammation of the appendages are extremely difficult to treat.
With chronic adnexitis, the formation of infiltrates, the development of sclerotic processes in the fallopian tubes and their obstruction, the formation of adhesions around the ovaries. From the chronic foci with adnexitis infection can spread to other organs and cause chronic colitis, cholecystitis, pyelonephritis.
Treatment of chronic adnexitis
In the stage of exacerbation of chronic adnexitis, therapeutic measures corresponding to the acute process (hospitalization, antibacterial, infusion, desensitizing therapy, vitamins) are carried out.
After the aggravation of the inflammation of the appendages subsiding, autohemotherapy, aloe injection, physiotherapy (UV irradiation, electrophoresis with drugs (lidase, potassium, iodine, magnesium, zinc), UHF therapy, ultrasound, vibromassage) are recommended under the control of laboratory and clinical indicators.
Physiotherapeutic procedures used for inflammation of the appendages reduce the exudation of tissues, have a resolving and analgesic effect, contribute to a decrease in the formation of adhesions.
Effective in chronic inflammation of the appendages are therapeutic mud (ozocerite), paraffin treatment, therapeutic baths and vaginal irrigation with chloride sodium, sulfide mineral waters. In the stage of stable remission of adnexitis, spa treatment is indicated.
Diet with adnexitis
Compliance with diet with inflammation of the appendages strengthens the body’s resistance to infectious agents, improves metabolic processes in the inflammatory focus. During the acute and subacute stage of adnexitis, a hypoallergic diet is prescribed, excluding egg proteins, fungi, chocolate, sweets, etc., and limiting the amount of table salt and carbohydrates. The total calorie content of a daily diet includes 100 g of proteins, 70 g of fats, 270-300 g of carbohydrates (2300 kcal per day). Recommended for adnexitis, the thermal treatment of food – cooking or quenching.
Without exacerbating adnexitis, strict adherence to diet is not necessary, but nutrition should be balanced and rational with sufficient intake of protein and vitamins.
Prophylaxis of adnexitis and doctor’s advice
The risk group for the development of adnexitis includes women who have sexually transmitted infections using intrauterine contraceptives that have undergone reproductive surgery and after pregnancies that have ended with artificial or spontaneous abortions. The threat of the development of the effects of adnexitis points to the need for taking care of one’s health and taking timely preventive measures:
- exclusion of factors provoking the development of acute adnexitis and relapses of chronic inflammation of appendages (hypothermia, stress, sexual infections, alcohol abuse, spicy food, etc.);
- the use of rational contraception, the prevention of abortion;
- if necessary, drug abortion or mini-abortions;
- conducting timely, rational and complete complex therapy of inflammatory diseases of the pelvic organs, including inflammation of the appendages, taking the pathogen into account;
- systematic consultations of the gynecologist every 6-12 months.