Tuboovarialny abscess — an acute purulent infectious and inflammatory disease of appendages of a uterus at which there is their fusion to formation of osumkovanny education. It is shown by acute unilateral pain in the bottom of a stomach, nausea, vomiting, a hyperthermia, dizurichesky frustration. For diagnostics use a vaginal research, transvaginal ultrasonography, KT of a small pelvis, laboratory methods. Schemes of drug treatment assume prescription of antibiotics, NPVS, immunomodulators, infusional therapy. At the heavy course and inefficiency of conservative therapy abscess is deleted surgically.
Tuboovarialny abscess (tuboovarialny purulent education, inflammatory adnekstumor) — the most severe form of gynecologic inflammations. In structure of infectious and inflammatory diseases of pelvic bodies at women its share, according to different authors, reaches 6-15%. Pathology is revealed mainly at young patients aged up to 20 years with the low social and economic status that, most likely, is connected with their high sexual activity. In the last decade of more often there are erased inflammation forms: almost at a third of patients the sharp clinical picture develops against the background of chronically current inflammatory and destructive process.
Reasons of tuboovarialny abscess
Formation of volume pyoinflammatory education in the field of uterus appendages often becomes possible at a combination of several factors and is a complication of already existing gynecologic diseases. Primary abscesses of tuboovarialny area are observed extremely seldom. According to experts in the sphere of gynecology, developing of a disease usually requires a combination of two or three conditions:
- Existence of aggressive associative flora. At crops from the abscess center usually there are several microorganisms. At 25-50% of patients gonokokk, at 25-30% — trichomonads, at 25-60% aerobic and anaerobic associations , bakteroid, peptostreptokokk, streptococci, enterobakteriya, mobilunkus, other opportunistic infectious agents are defined.
- Solderings in a small basin. Suppuration of appendages is revealed more often at patients with it is long the current chronic ooforita, salpingita, adneksita, external genital endometriosis complicated by adhesive process. Existence of interorgan sinekhiya simplifies and accelerates formation of a piogenny membrane which limits outside tuboovarialny education.
- Immunity easing. Activization of microflora usually happens at decrease in protective forces of an organism. The exacerbation of genital and ekstragenitalny pathology, a serious catarrhal illness, stresses, physical activities, long reception of corticosteroids, derivatives of acetilsalicylic acid, tsitostatik, etc. become the reasons of immunosupression.
The risk of development of abscess in tuboovarialny area is increased at the patients who are often changing the sexual partners who had a bacterial vaginosis or diseases, sexually transmitted. The probability of developing of pathology increases after performance of intrauterine manipulations (abortions, separate diagnostic vyskablivaniye, installations filched, extracorporal fertilization, a gisterosalpingografiya, removal of polyps of endometrium, etc.).
Penetration of an infection into appendages usually happens in the ascending (intrakanalikulyarny) way from a vagina, a neck and a cavity of a uterus. In rare instances the inflammation begins due to contact infection with a serous cover of a pipe. Before final formation of tuboovarialny purulent education pathological process takes place several stages. At first in a fallopian pipe under the influence of infectious agents the mucous membrane inflames, in the subsequent the inflammation extends to other layers of a wall ‒ the picture of a sharp purulent salpingit develops. The obliteration of a gleam of a pipe comes to the end with formation of a piosalpinks.
From uterine tubes microorganisms get on the surface of an ovary and get into its fabrics that leads to development of a sharp purulent ooforit with formation of multiple purulent cavities which walls are presented by granulations and connecting fabric. Merge of abscesses is resulted by meshotchaty education — . Formation of tuboovarialny abscess comes to the end with partial destruction of walls of a piosalpinks and piovar with merge in the general piogenny soyedinitelnotkanny membrane. The disease can chronically proceed with increase in a pathological conglomerate during an aggravation, fibrosis and a sclerosis of fabrics in remission.
Symptoms of tuboovarialny abscess
The clinical symptomatology usually develops sharply. The patient has severe pristupoobrazny pains at the left or on the right in the lower part of a stomach. Painful feelings can irradiate to the lumbar area, a rectum, the internal surface of a hip from the relevant party. The woman is disturbed by fever, a fever, nausea and vomiting are possible. Temperature is usually increased to 38 °C and more. Are typical whitish, yellowish, flavovirent purulent vaginal bleach, morbidity at an urination, irritation of intestines in the form of a frequent liquid chair. At the expense of the general intoxication there are an emotional lability, weakness, bystry fatigue, appetite loss, the general block.
The most terrible consequence of tuboovarialny abscess — a rupture of an adnekstumor with emergence of clinic of a sharp stomach, development of peritonitis, septic shock, polyorgan insufficiency, formation of interintestinal, pryamokishechno-vaginal, uretro-vaginal, puzyrno-vaginal fistulas in the remote period. Almost at two thirds of patients functional violations of an urinary system come to light, and distribution of an inflammation on predpuzyrny and pelvic cellulose causes development of a gidroureter and gidronefroz in a half. Involvement in infectious process of adjacent bodies is followed by developing of a secondary parametritis, appendicitis, a sigmoidit, rektit, omentit, pelvic abscesses, etc. In the future at such women disgormonalny states, extra-uterine pregnancy, infertility meet more often, chronic pelvioperitonit, chronic pelvic pains, pelvic thrombophlebitis, an ovary vein thrombosis.
The symptomatology of tuboovarialny abscess is similar to manifestations of other states at which signs of "a sharp stomach" are observed. Therefore taking into account high probability of the complicated course of infectious and inflammatory process diagnostic search is directed to bystry confirmation or an exception of pathology. The most informative methods are:
- Survey on a chair. It is difficult to execute the Bimanualny palpation because of intensive pains and the peritonealny phenomena. A typical sign is strengthening of morbidity at a research side and the back arches of a vagina, attempts of shift of a neck of a uterus. From the tservikalny channel slime and pus are emitted. Sometimes it is possible to propalpirovat the painful conglomerate located on the right or to the left of a uterus.
- Transvaginal ultrasonography. On the party of defeat multichamber education decides on signs of inflammatory process by the sizes of 5-18 cm of the irregular ovoidny shape. Walls of a pipe are thickened to 5 mm and more. Unlike a piosalpinks of a congestion of pus are located outside a fallopian pipe. Adhesive process in a cavity of a small pelvis is expressed. There are symptoms of an endometritis. The ovary is not visualized.
- KT of pelvic bodies. Tomographic purulent tuboovarialny education has an appearance of the oval or roundish volume pathological structure adjoining a uterus and displacing it. The illegibility of contours, heterogeneity of structure of a conglomerate with existence of cavities of the lowered density are characteristic. The capsule can be both is thickened, and thinned. Informational content of a method reaches 99-100%.
Invasive methods (puncture of the back arch of a vagina, laparoscopy) apply is limited because of widespread adhesive process and risk to damage the capsule of tuboovarialny abscess. As indirect confirmation of sharp inflammatory process serve characteristic changes of the general blood test: increase in quantity of leukocytes, acceleration of SOE, shift of a leykotsitarny formula to the left. Test for pregnancy, a microbiological research of dab for gonorrhea and clamidiosis is recommended. A disease differentiate with salpingoofority, a rupture of a cyst of an ovary or reabrupt her legs, extra-uterine pregnancy, septic abortion, appendicitis, sharp cholecystitis, divertikulity, pyelonephritis, an attack of an urolithic disease, peritonitis, intestinal impassability, other sharp surgical pathology. Involve the surgeon, the urologist, the oncologist, the infectiologist, the intensivist in diagnosis.
Treatment of tuboovarialny abscess
At suspicion on purulent fusion of uterine appendages the emergency hospitalization, ensuring rest and a bed rest is shown. At stable indicators of pulse and pressure, the conglomerate sizes to 9 cm, presence at the patient of reproductive plans the conservative therapy allowing to refuse in 75% of cases carrying out operation is shown. For treatment of tuboovarialny purulent educations are recommended:
- Antibiotic treatment. At the choice of medicine it is desirable to consider sensitivity of the activator. But as the disease is usually caused by polymicrobic association, even before obtaining results of bacteriological crops of dab with antibiotikogrammy appoint combinations of tsefalosporin, semi-synthetic tetratsiklin, penicillin, linkozamid, aminoglycosides, etc.
- Nonsteroid resolvents. NPVS at the expense of inhibition of isoforms of enzyme of a tsiklooksigenaza reduce production of prostaglandins, a tromboksan and other mediators of an inflammation. Along with it medicines render analgeziruyushchy effect due to increase in a pain threshold of peripheral receptors. Are especially effective in the form of rectal candles.
Taking into account a clinical picture and for decrease in possible complications of the main medicamentous therapy also use other pathogenetic and symptomatic means — eubiotik, immunomodulators, diuretics, infusion solutions, sedative medicines, vitamins. In the absence of effect of antibacterial treatment within 48-72 hours (further deterioration in a condition of the patient, increase of temperature and a leykotsitoz) surgical intervention for drainage of abscess is recommended.
At the choice of a method of expeditious treatment consider prevalence and dynamics of tuboovarialny inflammatory process, weight of a condition of the woman. In more mild cases the abscess is drained through a puncture of a belly wall, a rectum or vagina with the subsequent washing of a cavity antimicrobic means. In cases of widespread abscesses and the heavy course of a disease operation on removal of a tuboovarialny inflammatory conglomerate and excision of the struck appendages is carried out. Laparoscopic approach is justified at prescription of a disease no more than 3 weeks and lack of the expressed adhesive process. Existence of osumkovanny thick-walled abscess and the chronic course of frustration are indications for a laparotomy. The extirpation of a uterus and appendages is carried out in the most difficult cases — at identification of multiple abscesses, fistulas, sepsis, the poured peritonitis. In the postoperative period are shown antibacterial and dezintoksikatsionny therapy.
Forecast and prevention
Early diagnosis and adequate therapy of tuboovarialny abscess allows to keep reproductive function at 70-90% of patients. Primary prevention of a disease assumes refusal of the unprotected sex with casual partners, reasonable purpose and technically exact performance of invasive gynecologic manipulations, regular observation at the gynecologist, timely treatment of genital infections. For strengthening of immunity sufficient physical activity, a balanced diet, observance of the mode of a dream and rest, an exception of excessive psychological and physical activities, the termination of smoking and abuse of alcoholic drinks are recommended.