Obstetrics and Gynecology - A.M. Gromova 2000

"Acute Abdomen" in Gynecology
"Acute Abdomen" in Purulent Inflammatory Diseases of Female Reproductive Organs

Among Inflammatory Diseases of the female pelvic Organs, symptoms of an "acute abdomen" most frequently arise As a result of purulent inflammation of the adnexa.

Etiology AND Pathogenesis

The formation of an abscess in the adnexa may occur during the primary inflammatory process. Contributing factors include the Specific characteristics of the microflora—namely, the causative pathogen of the inflammation—concomitant genital and extragenital pathology, the presence of an intrauterine device (IUD) in the uterine cavity, and inadequate Treatment. However, purulent complications are most commonly the result of long-standing, recurrent salpingo-oophoritis.

The causative agents of adnexitis can include aerobes (gonococci, staphylococci, Proteus, Escherichia coli, enterococci), anaerobes (pneumococci, streptococci, bacteroids), chlamydia, Mycoplasmas, and ureaplasmas. The primary route of infection is ascending (sexually transmitted).

Endosalpingitis develops initially, after which the process extends to the submucosal, muscular, and serous layers. Serous exudate accumulates within the lumen of the fallopian tube. When the distal ends undergo adhesion, hydrosalpinx develops; if the tubular contents become suppurative, pyosalpinx occurs.

The Ovary is typically involved in the inflammatory process secondary to the tube. Following ovulation, an abscess may form within the corpus luteum; if the ovarian tissue completely melts down, a pyovar develops. Due to tissue destruction, the pyovar merges with the pyosalpinx to form a tubo-ovarian abscess.

Clinical presentation and Diagnosis

In the presence of a purulent inflammatory process in the adnexa (pyosalpinx, pyovar, tubo-ovarian abscess), the patient's general condition is usually moderate to severe. Distinct signs of intoxication are present: pale Skin with a grayish or cyanotic tint, body Temperature reaching 38°C and above, rapid pulse, and a somewhat lowered Blood pressure. Blood tests reveal generalized leukocytosis, a left shift in the leukocyte differential, and an accelerated ESR. The Tongue is moist at the onset of the disease, but becomes dry and coated if the abscess perforates. The abdomen is moderately distended and tender in the lower regions. Perforation of a purulent formation is marked by guarding of the anterior abdominal wall Muscles and the appearance of peritoneal irritation signs. A mass originating from the lesser pelvis can be palpated in the Abdominal cavity. The palpable level of this mass is higher than the percussive border, owing to the Isolation of the tubo-ovarian abscess from the general peritoneal cavity by adherent omentum and bowel.

Gynecological examination reveals purulent vaginal discharge. Bimanual examination demonstrates a slightly enlarged Uterus that is tender upon displacement. The adnexa are exquisitely tender, retort-shaped, or lack distinct contours due to adhesions to surrounding Tissues. Occasionally, the uterus and adnexa form a single, immobile conglomerate with indistinct borders.

When perforation of a purulent focus has occurred, the vaginal fornices are tender and flattened.

For diagnostic purposes, a culdocentesis (puncture of the abdominal cavity through the posterior vaginal fornix) is performed. Obtaining pus confirms the presence of a perforated pyosalpinx or pyovar and serves as an indication for surgical intervention. If no fluid is aspirated, a targeted puncture of the tubo-ovarian mass is performed. The retrieval of pus confirms the diagnosis of purulent inflammation of the uterine adnexa, but, because the process is localized, it allows for conservative management in young women.

Additional Diagnostic Methods used for Purulent inflammatory diseases of the uterine adnexa include ultrasound and laparoscopy. Identification of the microbial agent responsible for the acute inflammatory process and determination of its antibiotic sensitivity are mandatory. Bacteriological studies are performed on discharges from the Vagina, cervical canal, Urethra, and peritoneal fluid, as well as on the Contents of the purulent focus in cases of surgical intervention.

Treatment

Treatment is conducted in an inpatient Setting. In the presence of a non-perforated pyosalpinx without clinical signs of an "acute abdomen," aspiration puncture, removal of pus, and drainage of the focus may be performed, followed by aggressive antibacterial, anti-inflammatory, detoxifying, immunomodulatory, and desensitizing therapy, alongside dynamic clinical monitoring under laboratory control. However, this approach is not entirely justified because, despite the evacuation of pus, the pyogenic capsule remains, frequently leading to disease recurrence and the spread of the inflammation. Therefore, once a diagnosis of pyosalpinx—or, particularly, pyovar—is established, surgical intervention is necessary, which entails removal of the fallopian tube or adnexa and drainage of the peritoneal cavity. If the surgery is performed in women with postpartum or post-abortion endometritis in the presence of an IUD, Hysterectomy with salpingectomy is indicated. If the patient is older than 35, it is advisable to remove the contralateral fallopian tube In addition to the purulent focus. For women over 45, extending The Scope of surgery to panhysterectomy is recommended.