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Abstract: Ms. Li, 43 years old, presented with vague pain in the lower abdomen after menstruation with no obvious cause 1 week ago, accompanied by a significant increase in leukorrhea and odor, which was not treated, and the abdominal pain worsened on March 9, so she visited our outpatient clinic. After abdominal ultrasound and routine leucorrhea examination, the diagnosis was made clearly: chronic pelvic inflammatory disease and bacterial vaginitis, and she was given western medicine treatment + Chinese herbal enema.
Basic information】Female, 43 years old
Disease Type】Chronic pelvic inflammatory disease, bacterial vaginitis
Hospital】Guangxi Zhuang Autonomous Region Jiangbin Hospital
Date of consultation】March 2021
【Treatment plan】Western medicine (doxycycline hydrochloride tablets, diazotide effervescent tablets) + Chinese medicine (pelvic inflammatory enema Ⅰ formula)
Treatment period】28 days of outpatient treatment (14 days of medication + 14 days of consolidation treatment with herbs and physical therapy)
Treatment effect] The condition was controlled, abdominal pain was relieved, and leucorrhea returned to normal
I. Initial Consultation
Ms. Li reported: she had two normal deliveries in the past, and two years ago, she had “acute appendicitis” treated by laparoscopy, and one year ago, she had acute pelvic inflammatory disease without systematic treatment, after which she had occasional vague pain in the lower abdomen, and one week ago, after her menstruation, she again had vague pain in the lower abdomen without any obvious cause, accompanied by a significant increase in leucorrhea and odor, which was not treated. On March 9, the abdominal pain worsened, so she went to our outpatient clinic.
Gynecological examination: large amount of yellow thick discharge was seen in the vagina, no painful lifting of the cervix, normal size of the uterus, obvious pressure pain, pressure pain in the right adnexal area, no obvious abnormality on the left side. The results of routine white belt examination showed: cleanliness ⅠV°, Gardnerella (+). Abdominal ultrasound suggested that no significant abnormalities were seen in the uterus and both adnexa. Routine blood leukocytes were normal and urine HCG was negative. Diagnosis: chronic pelvic inflammatory disease, bacterial vaginitis was established and outpatient treatment was given.
(Outpatient clinic visit history on March 9)
II. Treatment history
We explained to Ms. Li about the specific situation: based on the medical history, gynecological examination and outpatient examination results, the diagnosis of chronic pelvic inflammatory disease and bacterial vaginitis is clear and can be treated with outpatient medication without hospitalization. Ms. Li said she would actively cooperate with the treatment.
Since the course of chronic pelvic inflammatory disease is relatively long, the symptoms of infection are not as obvious as those of acute pelvic inflammatory disease. The blood test showed that the white blood cells were not elevated, so she took oral doxycycline hydrochloride tablets for 14 days for anti-inflammatory treatment. At the same time, as Ms. Li’s bacterial vaginitis was more severe, she was given topical treatment with diazotide vaginal plugs for 7 days. In order to enhance the effect of the treatment of chronic pelvic inflammatory disease, Ms. Li was asked to go to the Department of Traditional Chinese Medicine to prepare “pelvic inflammatory enema No. 1”, and then go to the clinic every day to perform Chinese herbal enemas and pelvic physical therapy with the physiotherapy instrument.
Treatment effect
After 14 days of treatment, Ms. Li’s body temperature was normal and she felt relief from abdominal pain. Gynecological examination showed that there was not much vaginal discharge, white color, no painful cervical lifting, no obvious pressure pain in the uterus, light pressure pain in the right adnexal area, and no obvious abnormality on the left side. The repeat blood test: normal white blood cells, white belt test results cleanliness ⅠⅠ°, Gardnerella (-), indicating that after treatment Ms. Li’s condition has been controlled. However, due to the long course of chronic pelvic inflammatory disease, in order to achieve complete cure, Ms. Li was advised to continue to perform Chinese herbal enema with physical therapy for 14 days. In summary, the treatment cycle was 28 days, including 14 days of western medicine anti-inflammatory treatment + 14 days of Chinese herbal enema and physical therapy, and the treatment effect was good, the condition was controlled, abdominal pain was relieved, and leucorrhea returned to normal.
IV. Notes
We are glad that Ms. Li’s condition gradually improved after the active treatment. In daily life, it is recommended that regular rest and rest, healthy diet and active exercise are recommended to enhance physical fitness and help the body recover. Because of the long course of chronic disease and the long treatment time, Ms. Li is physically and mentally stressed and prone to negative emotions, which may even lead to giving up the treatment halfway, so her family should encourage her more and help her actively complete the treatment and cure completely. In addition, it should be noted that if the first course of treatment is significantly better, you should adhere to the medical advice for consolidation treatment to avoid recurrence of the disease.
V. Personal insight
Chronic pelvic inflammatory disease mostly occurs after pelvic infections and pelvic surgical operations, as in this case of Ms. Li. The more the number of infections and surgical operations, the greater the chance of disease occurrence. Because the clinical manifestations of chronic pelvic inflammatory diseases are generally less serious than acute diseases, they are often not given enough attention by patients, who always consider them to be minor problems and delay treatment, leaving behind a series of pelvic disorders. After the diagnosis of chronic pelvic inflammatory disease, pay attention to follow the medical advice for treatment to promote recovery.