When inflammation occurs in the female internal genitalia and surrounding connective tissue and pelvic peritoneum, it is called pelvic inflammatory disease. There are two types of pelvic inflammatory disease: acute and chronic. The pathogens that cause pelvic inflammatory disease can be simple aerobic bacteria, simple anaerobic bacteria, or a mixture of aerobic and anaerobic bacteria, with or without sexually transmitted disease pathogens. Common pathogens include: Streptococcus, Staphylococcus, Escherichia coli, anaerobic bacteria, Neisseria gonorrhoeae, Chlamydia, Mycoplasma, and Mycobacterium tuberculosis.
Etiology]
The main causes of pelvic inflammatory disease are as follows.
(1) Infection after childbirth or abortion.
(2) Lack of hygiene during menstruation, use of unclean menstrual pads, sexual intercourse during menstruation, etc.
(3) Infection with sexually transmitted diseases, history of unclean sexual life, early marriage, multiple sexual partners, and too frequent sexual intercourse can lead to pathogenic invasion and cause pelvic inflammatory disease.
(4) Inflammation of organs adjacent to the uterus spreads directly and causes pelvic inflammatory disease, such as appendicitis, peritonitis, etc.
(5) Infection after surgical operations in the uterine cavity, such as curettage, tubal lavage, hysterosalpingography, etc.
(6) Acute attack of chronic pelvic inflammatory disease.
(7) Intrauterine device (contraceptive ring) placement.
Infection route
Pelvic inflammatory disease is contracted through the following routes.
(1) spread through the lymphatic system: bacteria invade the pelvic connective tissue and other parts of the internal reproductive organs through the lymphatic vessels of the vulva, vagina, cervix and uterine body, which is the main route of infection during the puerperium (during the month) and after the placement of the intrauterine device (IUD).
(2) Upstream spread along the genital mucosa. The pathogen invades the vulva and vagina and then travels along the mucosal surface through the cervix, endometrium and fallopian tube mucosa to the ovaries and peritoneum.
(3) Transmission via blood circulation: The pathogen invades other systems of the body and then infects the genitalia via blood circulation, which is the main way of tuberculosis bacilli infection.
(4) Direct spread: Infection of other organs in the abdominal cavity spreads directly to the internal genitalia, such as appendicitis can cause right-sided tuberculitis.
The dangers of pelvic inflammatory disease]
Acute pelvic inflammatory disease can cause acute endometritis, acute myometritis, acute tubal inflammation, tubal pus, tubo-ovarian abscess, acute pelvic connective tissue inflammation, acute pelvic peritonitis, sepsis and septicemia if not treated in time. If the treatment is not complete, the inflammation can become chronic, and chronic pelvic inflammatory disease is more stubborn and more difficult to cure completely.
Chronic pelvic inflammatory disease can cause chronic tubal inflammation, hydrosalpinx, tubo-ovarian inflammation, tubo-ovarian cysts, and chronic pelvic connective tissue inflammation. Chronic pelvic inflammatory disease is often caused by the incomplete treatment of acute pelvic inflammatory disease or by the poor physical condition of the patient and the long duration of the disease. The inflammation in chronic pelvic inflammatory disease can diffuse throughout the pelvis, so the inflammatory lesions adhere to the surrounding tissues and form fibrous strips, causing impaired blood circulation and malnutrition in the local tissues. It is difficult to completely cure chronic pelvic inflammatory disease because it is not easy to reach the inflammatory lesions with antibiotic drugs alone, so that it is not easy to eliminate the germs.
Clinical manifestations
(1) Acute pelvic inflammatory disease: there are different clinical manifestations depending on the severity of the inflammation and the extent of the inflammation. The patient feels pain in the lower abdomen with fever, if the condition is severe there are chills, high fever, headache, loss of appetite. The onset of menstruation may be characterized by increased menstrual flow and prolonged menstrual periods, and non-menstrual onset by increased leucorrhea. If there is peritonitis, there are gastrointestinal symptoms such as nausea, vomiting, abdominal distension, diarrhea, etc. If there is abscess formation, there are lower abdominal masses and local pressure irritation. If the abscess or inflammatory mass is located in the front of the uterus, bladder irritation symptoms such as difficulty in urination, urinary frequency, urinary urgency, and painful urination may occur; if the abscess or inflammatory mass is located in the back of the uterus, it may cause rectal symptoms such as diarrhea with shortness of breath or difficulty in defecation.
The patient has an acute appearance, elevated body temperature, rapid heartbeat, abdominal distension, pressure pain, rebound pain and abdominal muscle tension in the lower abdomen, and diminished or absent bowel sounds. Gynecological examination: vaginal congestion with large amount of purulent discharge, marked tenderness in the vaginal vault, cervical congestion and edema, painful cervical lifting, slightly large uterine body with pressure pain, rebound pain, restricted movement, marked pressure pain on both sides of the uterus, thickened fallopian tubes or inflammatory masses can be palpated, and there is marked pressure pain.
(2) The scar adhesions and pelvic congestion formed by chronic pelvic inflammatory disease often cause lower abdominal swelling, pain and lumbosacral aches and pains, especially after exertion, sexual intercourse and before and after menstruation. Chronic pelvic inflammatory disease causing tubal adhesions and obstruction can lead to infertility or ectopic pregnancy. Pelvic stasis can lead to increased menstrual flow; ovarian damage can lead to menstrual disorders; endometritis is often associated with irregular menstruation; and senile endometritis can lead to pus and blood discharge. The systemic symptoms of chronic pelvic inflammatory disease are not obvious, sometimes there may be hypothermia, fatigue, neurological symptoms such as mental discomfort, insomnia, peripheral discomfort, etc. When the patient’s resistance is poor, it is easy to have acute or subacute attacks. Gynecological examination: there is an enlarged uterus, pressure pain, thickened fallopian tubes in strips can be palpated on one or both sides of the uterus, and there is mild pressure pain; there are sheets of thickened tissue with pressure pain on one or both sides of the pelvis; the uterosacral ligament is often thickened, hardened, and has tenderness.
(3) The clinical manifestations of tuberculous pelvic inflammatory disease are very inconsistent, and many patients can be asymptomatic, while some patients have more severe symptoms. Common clinical manifestations include.
(1) Infertility: genital tuberculosis is often one of the main causes in patients with primary infertility.
②Menstrual disorders: there may be excessive menstruation, scanty menstruation or amenorrhea.
(iii) Lower abdominal pain.
(iv) Systemic symptoms: lower abdominal cramps, fever, night sweats, fatigue, loss of appetite, weight loss, etc.
⑤ Physical signs and gynecological examination: in more serious patients with peritoneal tuberculosis, there is tenderness or ascites sign in the abdomen during examination. If the tuberculosis forms an encapsulated effusion, a cystic mass with unclear and inactive borders may be palpable. The uterus is generally less developed and less mobile. A mass of variable size and irregular shape, hard, with an uneven surface and nodular or papillary prominence, may be palpated on both sides of the uterus.
Diagnosis and differential diagnosis
The initial diagnosis can be made based on the medical history, symptoms and signs. Since there is no specificity in the clinical manifestations of acute pelvic inflammatory disease and chronic pelvic inflammatory disease, the accuracy of clinical diagnosis is not high. Necessary auxiliary examinations, such as routine blood, routine urine, ultrasound, cervical canal secretions and posterior vaginal fornix aspiration fluid, are required.
After the diagnosis of pelvic inflammatory disease is made, the pathogen needs to be further clarified and bacterial culture and drug sensitivity test should be done on the smear of cervical canal secretion and posterior vaginal fornix; antibiotic treatment should be selected according to the bacterial culture and drug sensitivity test.
In some patients with chronic pelvic inflammatory disease, due to atypical clinical symptoms, they need to be differentiated from pelvic vein stasis and endometriosis; in the case of hydrocele or tubal abscess, they need to be differentiated from ovarian cysts. When the diagnosis is difficult, laparoscopy should be done.
Most patients with tuberculous pelvic inflammatory disease have no obvious symptoms and few positive signs, which can easily be overlooked. The possibility of genital tuberculosis should be considered if the patient has primary infertility, scanty menstruation or amenorrhea with hypothermia, night sweats or ascites, a history of previous exposure to tuberculosis, or if he or she has had pulmonary tuberculosis, pleurisy, or intestinal tuberculosis. Endometrial pathological examination is the most reliable basis for the diagnosis of endometrial tuberculosis. Since the endometrium is thicker before menstruation, if there is tuberculosis bacilli, the positive rate is high at this time, so scraping should be done 1 week before menstruation or within 6 hours of menstruation. Chest X-ray may reveal the primary lesion, and pelvic X-ray may reveal isolated calcified spots, suggesting a previous pelvic lymph node tuberculosis lesion. Iodine oil imaging of the uterine tubes with contrast entering the venous plexus on one or both sides of the uterus should be considered for endometrial tuberculosis. Laparoscopy shows corn nodules in the plasma membrane of the uterus and fallopian tubes, and culture of tuberculosis can clarify the pathogenic bacteria.
Treatment
1. The principles of management of acute pelvic inflammatory disease are.
(1) Patients with acute pelvic inflammatory disease should be treated actively and thoroughly to prevent the inflammation from turning into chronic pelvic inflammatory disease. Even if the temperature has returned to normal and the symptoms have disappeared, it is still necessary to continue to apply antibiotics for several days to avoid any residual problems. The thoroughness of treatment can be based on the return of normal erythrocyte sedimentation rate as one of the important indicators. If the self-conscious symptoms disappear and the body temperature is normal, but the sedimentation rate is still high, it means that the inflammation has not been completely controlled and treatment still needs to be continued.
(2) Treatment for pathogens. Pelvic inflammatory disease is mostly a mixed infection, and if the bacterial culture is positive, the most effective antibiotic treatment can be selected according to the drug sensitivity test. The choice of antibiotics should be based on the drug sensitivity test, but before the laboratory results are available, it should be based on the medical history, the characteristics of clinical symptoms to speculate which pathogen and refer to the onset of which antibiotics have been used to select the medication. As most of the pathogens of acute pelvic inflammatory disease are aerobic bacteria, anaerobic bacteria and chlamydia mixed infection, therefore, in the selection of antibiotics are mostly used in combination, the commonly used drugs are.
① Penicillins: these drugs have strong antibacterial effect on Gram-staining positive cocci and antibacterial effect on Gram-staining negative bacilli, but they are prone to resistance.
② Cephalosporins: the first generation of cephalosporins have strong effect on Gram-staining positive cocci, although they have antibacterial effect on Gram-staining negative bacilli, but the resistance to the endocannase of Gram-staining negative bacteria is weak and easy to be resistant. The second generation of cephalosporins, with strong anti-enzyme performance, broad antibacterial spectrum, and enhanced effect on Gram-staining negative bacteria. The antibacterial spectrum and anti-enzyme performance of the third generation cephalosporins are better than the second generation cephalosporins, and the effect on Gram-staining negative bacteria is stronger than the second generation.
③Aminoglycosides: antibacterial spectrum for Gram-staining negative bacilli.
④Macrolides: sensitive bacteria are mainly Gram-staining positive cocci and mycoplasma and chlamydia.
⑤ Tetracyclines: mainly used for chlamydia, mycoplasma and rickettsia infections.
⑥Nitroimidazoles: mainly used for anaerobic bacterial infections.
⑦Other drugs: such as clindamycin, lincomycin, etc.
(8) Patients with tuberculous pelvic inflammatory disease can be treated with a combination of anti-tuberculosis drugs such as rifampin, isoniazid, ethambutol and bisacodylamide.
(3) For patients with inflammatory masses, if the effect of antibiotics is not significant, surgical treatment should be considered. In acute pelvic inflammatory disease after miscarriage, full-term delivery, intrauterine operation or acute attack of chronic pelvic inflammatory disease, treatment with high doses of sensitive antibiotics is usually the mainstay, and surgery should be considered promptly in a few patients for whom conservative treatment is ineffective. Prompt surgery should be performed for pelvic inflammatory disease with.
①Ineffective drug treatment: pelvic abscess formation by drug treatment for 48 to 72 hours, the temperature continues not to drop, and the patient’s toxic symptoms worsen or the mass increases should be operated in a timely manner.
② tubal abscess or tubo-ovarian cyst: the condition has improved by drug treatment, continue to control the inflammation for several days, the mass still does not disappear, but the inflammation has been limited, surgical excision should be done to avoid future acute attacks again still need to do surgery.
③ Abscess rupture: sudden increase in abdominal pain, chills, high fever, nausea, vomiting, abdominal distension, examination of the abdomen refuses to press or has toxic shock performance, should be suspected of abscess rupture, must be immediately dissected and explored.
2. The following should be done to control recurrent episodes of chronic pelvic inflammatory disease.
(1) Exercise: actively participate in physical exercise to enhance physical fitness and improve the body’s resistance.
(2) Chinese medicine to activate blood circulation and remove blood stasis: you can visit a Chinese medicine practitioner, ask him for dialectical treatment, take Chinese medicine to promote local blood circulation, accelerate the absorption and cure of pelvic inflammatory disease.
(3) Physiotherapy: Through physiotherapy, local blood circulation in the pelvic cavity is promoted to improve the nutritional status of tissues and increase metabolism to facilitate the complete elimination of inflammation.
(4) Pharmacotherapy: While applying anti-inflammatory drugs, α-chymotrypsin or hyaluronidase can be used to facilitate the decomposition of adhesions and absorption of inflammation.
(5) Surgical treatment: inflammatory masses, such as hydrocele or tubo-ovarian cyst can be treated surgically, and the operation is based on the principle of complete cure to avoid the recurrence of the remaining lesions.
Prevention
1, prevention of acute and chronic pelvic inflammatory disease to pay attention to the following matters.
(1) Pay attention to the hygiene during menstruation, pregnancy and puerperium. The sanitary pads used should be purchased from regular manufacturers; the vulva should be washed every day to keep it clean and hygienic; the basin with water should be used exclusively for this purpose.
(2) After suffering from acute pelvic inflammatory disease, treatment should be promptly and completely cured to prevent acute pelvic inflammatory disease from turning into chronic pelvic inflammatory disease.
(3) Pay attention to the hygiene of sexual life, reduce sexually transmitted diseases, and prohibit sexual intercourse during menstruation.
(4) Pay attention to contraception, do not do or less abortion. You should go to a regular hospital to have an abortion.
2, prevention of tuberculosis pelvic inflammatory disease should actively participate in physical exercise to enhance physical fitness. Do BCG vaccination and actively prevent tuberculosis, lymphatic tuberculosis and intestinal tuberculosis and other diseases.