Parametritis symptoms and treatment. Parametritis: how and why inflammation develops, principles of treatment

Parametritis - inflammation of the parauterine tissue.

Diagnosis is not difficult. Treatment depends on the stage of the disease: in acute - antibiotic therapy, in the stage of suppuration - surgical treatment. The prognosis, excluding the septic form, is favorable.

ICD-10 code

N73.0 Acute parametritis and pelvic cellulitis

N73.1 Chronic parametritis and pelvic cellulitis

Causes of parametritis

It often occurs as a complication of abortion (mainly community-acquired) and childbirth. Parametritis can occur with inflammation of organs adjacent to the uterus (rectum, appendix, etc.). Pathogens in this case penetrate into the periuterine tissue, as a rule, by the lymphogenous route. With hematogenous infection of the parauterine tissue, parametritis can be a complication of common infectious diseases (flu, tonsillitis, etc.).

Risk factors

The development of the disease can be facilitated by surgical interventions (both vaginal - the introduction of an intrauterine contraceptive, expansion of the cervical canal, diagnostic curettage, and abdominal wall - removal of interligamentally located tumors of the internal genitalia, suppurating tumors).

Pathogenesis

In most cases, parametritis develops against the background of a purulent lesion of the uterine appendages due to the involvement of parametric fiber in the inflammatory process. The route of infection is predominantly per continuitatem. Postpartum and post-abortion parametritis is currently extremely rare. The way of infection of cellulose is lymphogenous. The inflammatory process in the fiber spreads further along the lymphatic vessels, as well as along the veins.

Symptoms of parametritis

Symptoms of parametritis in most cases correspond to a severe inflammatory process. An early symptom is severe persistent pain in the lower abdomen, radiating to the sacrum and lower back. With the progression of the disease, the condition of patients worsens. Body temperature rises to 38-39 ° C; weakness, thirst, headaches are noted. Patients take a forced position - bend and bring the leg to the stomach on the side of the lesion.

The pulse corresponds to the temperature. Urination and defecation may be difficult.

During vaginal examination, a dense, motionless, painful infiltrate is determined on the side of the uterus, starting from the uterus and reaching the pelvic wall. The uterus is deviated to the healthy side.

stages

The development and progression of parametritis goes through several stages.

1. The stage of exudation corresponds to the initial period of parametritis.
2. The stage of infiltration (compaction of exudate) is the gradual replacement of exudate with a dense (sometimes extremely dense) infiltrate. This is due to the loss of fibrin. As a rule, the undertaken treatment stops acute inflammation in the adnexal formation and contributes to the subsidence of the phenomena of concomitant parametritis. The course of parametritis in these patients is limited to the stage of infiltration. The infiltrate in the parametrial region gradually decreases in size, but always leaves behind areas of residual infiltration.
3. The stage of suppuration is characterized more often by the presence of many microabscesses in the structure of the infiltrate. In some rare cases (in 3.1%), total purulent fusion of parametric fiber occurs.

During parametritis, the stages of infiltration, exudation and compaction (scarring) are distinguished. At the stage of exudation, the infiltrate can suppurate with the development of purulent parametritis.

Forms

There are anterior, posterior and lateral parameters. The latter are especially common (about 90%).

Complications and consequences

With suppuration of the parametric infiltrate, the condition of the patients worsens, the pain increases sharply, the temperature becomes hectic, chills appear, a shift of the leukocyte formula to the left and an increase in LII are noted, and dysuric phenomena increase. Vaginal examination reveals softening and fluctuation of the infiltrate, overhanging of the vaginal vault. A short-term improvement in the patient's condition, the appearance of pus in the vagina (in the urine or feces) testifies to the breakthrough of the abscess.

Abscess formation always sharply aggravates the course of the underlying disease and can develop in different directions.

• Most often, purulent fusion captures the lower sections of the parametrium and the retinaculum uteri region. The wall of the bladder is involved in the process, pain during urination, pyuria appear, which serves as a harbinger of the impending perforation of the abscess into the bladder.
• Less commonly, abscess formation and spread of pus goes up and anteriorly towards the round ligament, then in the form of a wide infiltrate along the side wall of the pelvis and above the inguinal (pupart) ligament. This localization of the abscess is called "Dupuytren's abscess". Above the inguinal ligament in these patients, a dense, sharply painful infiltrate is always determined, creating an asymmetry of the anterior abdominal wall visible to the eye, skin hyperemia appears.
• The most dangerous variant of suppuration of parametric fiber in patients with purulent diseases of the uterine appendages, of course, is the development of an abscess in the region of the plexus limphaticus spermaticus - the so-called upper lateral parametritis. This is due to the fact that effusion and pus spread along the back of the parametric tissue to the walls of the small, and then the large pelvis, and from here, heading behind the blind or sigmoid colon, they can “tongue” up the perirenal tissue to the kidney, forming paranephrotic, and sometimes subdiaphragmatic abscess. Clinical manifestations of such parametritis usually begin with the development of periphlebitis of the external iliac vein, while the development of severe forms of thrombosis is possible. The thigh on the side of the lesion increases in size, starting from the area of ​​the inguinal ligament, pronounced cyanosis appears, increasing towards the periphery, arching pains in the leg. Swelling and pain decrease somewhat after 2-3 days, which coincides with the development of collateral outflow. The severity of these symptoms depends on the prevalence of thrombosis and the depth of occlusion of the vessel. It should be noted that with such complications, there is practically no complete obstruction of the external iliac vein, but there is always a risk of thromboembolism. In this regard, the treatment of such women is of particular difficulty and should include the whole range of measures aimed at stopping phlebitis and phlebothrombosis, preventing embolism.
• Another no less formidable complication is the spread of the purulent process to the perirenal tissue. At first, paranephritis proceeds as a limited process, but then it quickly captures the entire fatty capsule, resulting in the development of phlegmon. Clinically, in the early stages, paranephritis is manifested by symptoms of psoitis. The leg on the side of the lesion is bent at the knee and hip joint and slightly brought to the stomach. When you try to unbend it, sharp pains in the iliac region increase. At the same time, body temperature rises more and more (up to 39-40 ° C), a rapid hourly increase in the number of leukocytes begins, a neutrophilic shift is also noted, and the severity of intoxication increases. Behind in the region of the kidney, a swelling appears without sharp boundaries, the contours of the waist are smoothed out.

Diagnosis of parametritis

During vaginal examination in patients, the main gynecological pathology is determined, i.e. inflammatory conglomerate of formations (uterus, appendages and adjacent organs) without a clear identification of organs. In the presence of a bilateral process, the uterus is generally poorly contoured. In the study of parametria, infiltrates of different consistency depending on the stage of the process are determined - from woody density in the stage of infiltration to uneven with areas of softening during suppuration; infiltrates can have different sizes depending on the severity of the process or its phase. So, in the initial stages or in the stage of resorption, infiltrates in the form of a sleeve "envelop" the neck and uterus, in the stage of infiltration during severe processes, they can reach the side walls of the pelvis, sacrum and womb. The mucous vault (vaults) of the vagina in the area of ​​fiber infiltration is motionless, the vaults are shortened.

In operated patients, the infiltrate is located in the center of the pelvis above the stump of the cervix or occupies one half of the small pelvis. The complete immobility of the entire formation and the absence of clear contours are determined.

Signs of parametric fiber abscess formation are bursting or pulsating pains, hyperthermia, and often chills.

Parametrial abscesses (especially those resulting from postoperative complications) can perforate into adjacent hollow organs (distal intestines or bladder), in such cases, symptoms of pre-perforation appear, and in case of untimely treatment, symptoms of perforation of the abscess into the corresponding organs appear.

During vaginal examination in the pelvic cavity, a conglomerate of organs is also determined, which includes the affected appendages, uterus, omentum, intestinal loops. infiltrated bladder Palpation fails to determine the relative position of the organs included in this conglomerate, but it is always possible to identify signs characteristic of the developed complication:

1. the affected parametrium is infiltrated, sharply painful, the infiltrate can reach the pelvic bones and spread towards the anterior abdominal wall;
2. the lateral arch is sharply shortened;
3. the cervix is ​​located asymmetrically relative to the midline and is displaced to the side opposite to the parametrium lesion and abscess formation;
4. it is practically impossible to displace the pelvic organs (conglomerate).

It is imperative to conduct a rectovaginal examination, in which it is necessary to identify the prolapse of an infiltrate or abscess towards the rectum and determine the condition of the mucosa above it (mobile, limited mobility, immobile), which reflects the fact and degree of involvement in the inflammatory process of the anterior or lateral walls of the rectum.

The main additional diagnostic method is echography.

In addition to the ultrasonic criteria for damage to the uterus and appendages described above, in patients with parametritis, the following echographic signs of damage to the cellular spaces of the small pelvis are observed in parallel:

• inflammatory infiltrates of the small pelvis are determined on the echogram in the form of an irregular shape of echopositive formations without a clear capsule and precise contours and boundaries; their sizes are different, in some cases the infiltrates reach the pelvic bones;
• infiltrates are characterized by reduced echogenicity in relation to surrounding tissues and, when suppurated, contain in their structure one or many cystic formations with a clear capsule and dense heterogeneous contents.

The informativeness of the method of computed tomography in the diagnosis of parametrial abscesses, according to our data, was 80%, in the detection of panmetritis and pancellulitis - 68.88%.

On the radiograph, in addition to the main pathology, a reduced echogenicity of the parametric fiber is determined, the latter may contain cavities with a reduced density (purulent contents).

The development of infiltrative parametritis sometimes leads to significant deformities, compression of the ureter and the development of a pronounced hydroureter and hydronephrosis, which requires catheterization of the ureter and placement of a urethral stent. Infiltrative parametritis causes the formation of urethropyeloectasias not only as a result of the formation of a mechanical obstacle to the outflow of urine, but also because in these cases there is a violation of the function of the neuromuscular apparatus of the ureter under the influence of the inflammatory process. It should be emphasized that in the process of examination by additional methods, we detected pyelonephritis in 78% of patients, which does not have classical clinical manifestations.

The severity of secondary renal disorders is directly dependent on the duration of the underlying disease, its severity, frequency and duration of relapses. It is important to emphasize that in all cases of a progressive purulent process, the functional ability of the kidneys continues to progressively deteriorate until the development of such a formidable disease as chronic renal failure.

Therefore, all patients with complicated forms of purulent inflammation in the presence of parametrial infiltrates are indicated for renal echography.

With the development of hydronephrosis as a result of inflammatory stricture of the ureter or pyelonephritis, the diameter of the renal pelvis, as a rule, exceeds the norm (3 cm), while the ratio of the thickness of the parenchyma and the pyelocaliceal system is shifted towards the latter and is 1.5:1 or 1:1 (at a rate of 2:1). A hydroureter is diagnosed if the ureter diameter is 1 cm or more.

Conducting excretory urography is necessary for patients with hydronephrotic transformation of the kidneys of varying degrees or hydroureter, identified by ultrasound examination of the kidneys. Signs of stricture of the ureter in excretory urography is a clearly limited narrowing of the latter in the pelvic region.

To study the function of the kidneys, all patients with severe purulent-septic diseases of the internal genital organs, both before and after surgery, are shown to undergo radioisotope renosraphy. In severe purulent lesions, the isostenuric or afunctional type of the renographic curve predominates.

Carrying out cystoscopy is indicated for patients with the presence of parametritis and clinical symptoms of the threat of perforation into the bladder. In this case, bullous edema of the bladder mucosa is detected, corresponding to the inflammatory infiltrate and prolapsing towards the bladder, vasodilation.

Differential Diagnosis

Differential diagnosis in patients with pelvic infiltrates is carried out primarily with malignant neoplasms of the uterus and appendages. The rapid progression of the disease, a causal relationship with risk factors (especially with the use of IUDs), the prevailing laboratory criteria for purulent inflammation, a pronounced regression of palpable pathological structures and laboratory parameters under the influence of complex anti-inflammatory and infusion therapy suggest an inflammatory genesis of the disease, otherwise timely consultation with an oncogynecologist is necessary , as well as the complete exclusion of physiotherapeutic methods of treatment until the diagnosis is clarified.

It's important to know!

There are monopolar and bipolar electrosurgery. In monopolar electrosurgery, the entire body of the patient is a conductor. Electric current passes through it from the surgeon's electrode to the patient's electrode. Previously, they were called active and passive (return) electrodes, respectively. However, we are dealing with alternating current, where there is no constant movement of charged particles from one pole to another, but their rapid oscillations occur.

Parametritis is an inflammatory process localized in the region of the periuterine tissue. Periuterine fiber (parametria) is located between the uterus, bladder and rectum. Given the large number of neurovascular bundles, as well as a pronounced lymphatic network of vessels, in the case of a primary focus of infection, favorable conditions are created for the penetration of an infectious agent into the specified area.

It is a complication of inflammatory diseases of the pelvic organs: endometritis, metroendometritis, adnexitis, salpingoophoritis. In addition, parametritis can occur against the background of acute appendicitis, sigmoiditis, paraproctitis, iatrogenic damage to the uterus during surgical interventions, during childbirth and miscarriages. The causative agent of infection can be nonspecific pyogenic microbes (staphylococci, streptococci, E. coli, Proteus, Klebsiella), as well as sexually transmitted infections (gonococci). The inflammatory process in the parauterine tissue can acquire a purulent course and is a potentially dangerous condition for a woman's body.

The parametritis can be anterior and posterior (depending on the location of the inflammation), as well as lateral (right or left). Sometimes there is a total lesion of the periuterine tissue.

Clinic and diagnosis of parametritis

During the course of the disease, several stages can be distinguished:

• At the initial stage, the symptoms of the underlying disease predominate, which led to the development of parametritis. There may be common signs of inflammation: fever, general weakness and malaise. Of the local symptoms, pastosity of the parametrium during vaginal examination can be noted.
• Next comes the infiltration phase. Growing general signs of inflammation. Of the local signs, there are pains in the lower abdomen, symptoms of irritation of the peritoneum. Palpation can determine a dense, painful infiltrate that displaces the uterus in the opposite direction. There may be dysuric phenomena, as well as violations of the act of defecation.
• Then comes the phase of compaction of the exudate. In this period, a dense capsule is formed around the focus of inflammation. Periuterine tissue is impregnated with inflammatory exudate, which leads to a change in the structure of tissues. She becomes dense.
• If suppuration does not occur, the disease gradually regresses: the infiltrate resolves with the formation of fibrous tissue, which leads to a change in the anatomical and topographic relationships of the pelvic organs. In cases of parametrial suppuration, the process spreads to the entire pelvic tissue, or the abscess opens into the rectum, bladder or vagina. Rarely, spontaneous opening of purulent parametritis on the skin can occur. The general condition of the patients is extremely severe, there are all signs of sepsis.

Opened purulent cavities decrease in size, the general condition of patients improves. However, fistulas are formed through which incomplete drainage of abscesses occurs. In this case, they speak of chronic parametritis.

Treatment of parametritis

In the initial period, conservative therapy is possible, which is aimed at eliminating the infection and reducing inflammation. Along with the treatment of the underlying disease, symptomatic therapy is carried out: rest, cold on the lower abdomen, infusion and detoxification therapy.

When an abscess is formed, treatment is only surgical. It is necessary to open the cavity of the abscess. This is done by transvaginal access. The cavity is emptied of pus and drained. Further management of the patient - in accordance with the rules and principles of management of patients with purulent lesions. After the subsidence of acute inflammatory phenomena, procedures are carried out aimed at resorption of the infiltrate: physiotherapeutic methods, enzymes, autohemotherapy, pyrogenal therapy, mud therapy.

Parametritis is an inflammation of the parauterine tissue (parametria). It occurs as a result of penetration into it (usually through the lymphatic tract), and other microorganisms. Parametritis is observed mostly after childbirth and abortion (especially community-acquired).

Parametritis can develop with appendicitis, diseases of the uterine appendages, common infectious diseases, as well as after intrauterine manipulations and operations on the internal genital organs.

There are parameters: anterior, when inflammation spreads towards the bladder, posterior - to the side, lateral - inflammation is localized in one of the lateral sections of the pelvic tissue.

Parametritis is always accompanied by an increase in body temperature, sometimes with chills. Depending on the localization and distribution of the process, the activity of neighboring organs is disrupted.

The diagnosis of parametritis is based on anamnestic data and the results of a two-handed vaginal examination (the infiltrate is easily palpable, dense and homogeneous).

A frequent complication of parametritis is the formation of abscesses in the pelvic tissue. An abscess can open into the rectum, bladder and lead to the formation of a fistula, less often -.

Treatment of parametritis is conservative. In the acute period - bed rest, ice on the stomach, antibiotics (as prescribed by a doctor) and symptomatic treatment; resort treatment is also used in the subacute and chronic stages; with the formation of an abscess, surgical intervention is indicated.

Parametritis (parametritis; from the Greek para - about and metra - uterus) - diffuse inflammation of the periuterine tissue (phlegmon), located between the serous sheets of the wide ligaments of the uterus. Inflammation of the entire fiber of the small pelvis should be called pelvic cellulitis.

Etiology and pathogenesis. Parametritis is caused by an infection, usually spreading through the lymphatic vessels from the primary focus. Pathogens: pyogenic staphylo- and streptococci, much less often Escherichia coli, pneumococci and anaerobes. Gonococci cause parametritis only in exceptional cases - with mixed or secondary infection. Parametritis is observed mostly after childbirth and abortion (especially community-acquired). Often parametritis develops in diseases of the uterine appendages (secondary parametritis), more often it is observed after surgical interventions (probing the uterus, cervical dilatation, curettage, biopsy, etc.) performed without proper asepsis. Sometimes the source of infection is the intestines (appendicitis, sigmoiditis, paraproctitis), pelvic bones. Parametritis can also develop during the treatment of cervical cancer with radiant energy.

Clinical picture(signs and symptoms). There are the following stages of parametritis development. The initial stage is characterized by hyperemia, expansion of blood and lymphatic vessels, the appearance and growth of edema. There is an increase in temperature to 39 ° or more, sometimes with a single chill, increased heart rate in full accordance with the temperature, minor pain, pain during the study. When examined through the vagina, the affected tissue appears to be testy, pasty, and resistant.

Stage of infiltration and exudation: the temperature is kept and the pulse is quickened. In the blood, leukocytosis, the blood is sterile, slight pain in the lower abdomen (with movement, pressure) and pain on palpation. During a vaginal examination (a rectal examination is mandatory!) In the area of ​​the affected tissue, a dense exudate is felt, resp. infiltrate, displacing the uterus in the opposite direction and up. Large infiltrates compress the bladder and rectum. Around the inflammatory focus, a granulation shaft is formed, blocking the path of infection. Localization, ways of distribution of inflammatory exudate depend on the anatomical ratios (see Parametrium) and on the entrance gate through which the infectious agents have penetrated. The mobility of the mucous membrane in the area of ​​contact with inflamed tissue is limited, its folds are smoothed out.

Stage of compaction of the exudate: the resulting inflammatory effusion is rich in fibrin, which soon falls out. In place of the granulation shaft, a powerful capsule protrudes, firmly delimiting the inflammatory process. The consistency of the exudate resembles a fibroid. When squeezing the infiltrate of the bladder, frequent urination, tenesmus are observed, when squeezing the rectum, the act of defecation is difficult.

Final stage. In most cases, the exudate resolves; only a slight seal may remain (residual infiltration), but there are cases when the exudate is purulent. These cases are accompanied by remitting fever (suppurative fever), increased heart rate, chills, and neutrophilic leukocytosis is noted in the blood. Lymphatic vessels are filled with pus, individual abscesses, merging, form a parametric abscess. Sometimes such an abscess turns into diffuse phlegmonous inflammation of the entire pelvic tissue. In other cases, the abscess breaks into the rectum (most often), into the bladder, into the vagina, into the abdominal cavity (rarely), into the buttocks (through the ischial opening), into the femoral triangle.

With a breakthrough of pus into the rectum, tenesmus, discharge of mucus and spotting are noted. Perforation of the abscess into the bladder is accompanied by symptoms of cystitis.

If pus makes its way through the outer integument, redness, protrusion and swell are observed at the site.

After the breakthrough of the abscess, the process usually flows favorably. A breakthrough into the bladder is prognostically more severe (the threat of pyelonephritis).

In some cases, the purulent process after a breakthrough continues for a long time, fistulas, streaks form, the general condition of the patient worsens, exhaustion increases, and if appropriate prompt assistance is not provided in a timely manner, amyloid degeneration of parenchymal organs may develop with all the ensuing consequences.

There are the following forms of parametritis. Acute septic parametritis (septic phlegmon) is characterized by formidable signs of general sepsis. On the 3-4th day after childbirth or miscarriage, a picture of a serious illness quickly develops (t ° up to 40 °, frequent pulse, often an alarming crossover of the temperature curve with the pulse curve, insomnia, prostration, tongue dry, coated). In these cases, there is little exudate in the parametrium. The prognosis is poor; therapy - see Sepsis.

Anterior parametritis - inflammation of the tissue within the anterior part of the retinaculum uteri - is rare. Entrance gates of infection - damage to the anterior wall of the cervix and the mucous membrane of the bladder, accidental damage in the anterior vaginal fornix. This form of parametritis can develop after some surgical interventions (vaginal and retrovesical caesarean section). The effusion can pass into the non-vesical space and from there into the tissue of the anterior abdominal wall, forming a flat seal. Pus can break (rarely) into the bladder, vagina, peritoneal cavity (peritonitis) and, as an exception, into the pubic symphysis.

Lateral parametritis - inflammation of the tissue of the wide uterine ligaments - is more common than other forms (70-80%). If the infection enters from the anterior-lateral wall of the cervix from the corresponding vaginal fornix, the inflammatory exudate goes sideways, up and forward in a wide strip, towards the round uterine ligament, then spreading in the form of a wide infiltrate along the side wall of the pelvis and above the inguinal ligament (the so-called Dupuytren's abscess). With the primary localization of infection in the posterolateral parts of the cervix or in the lateral fornix of the vagina, the exudate usually spreads along the back of the parametric retina, reaching the walls of the small, and then the large pelvis, from where, heading behind the rectum (resp. sigmoid), rises up to the kidney, forming here paranephrotic or even subdiaphragmatic abscess (see). With the involvement of the psoas major muscle, psoitis may develop. (see) with the formation of a contracture of the lower limb (Fig.).

Right-sided purulent parametritis. m is involved in the process. psoas with the formation of contracture of the lower limb.

Lateral parametritis is divided into upper and lower; ways of distribution of pus and the place of its exit to the outside, see Parametrium.

Posterior postpartum parametritis is extremely rare; some authors generally deny its existence as an independent form. Entrance gates for infection are inflammatory processes of the posterior wall of the cervix, rectum and Douglas pocket (purulent erosion, catarrh of the cervix, accidental damage during obstetric and gynecological operations).

In most cases, the disease from the very beginning takes on a sluggish torpid character without high fever and the formation of an inflammatory effusion.

More often, posterior parametritis occurs in combination with chronic intraperitoneal inflammation in the region of the Douglas pocket. As a result of such inflammation, wrinkling, compaction and shortening of the sacro-uterine ligaments occur. In the clinical picture of the disease, excruciating pains in the sacrum and lower back, painful coitus, algodysmenorrhoea, and painful defecation come to the fore.

The clinical syndrome of the posterior parametritis type is considered as a particular manifestation of autonomic dystonia.

Clinical symptoms of chronic posterior parametritis may be similar to those of endometriosis (see).

Given the localization of the pathological process, inflammation of the parametria is divided into several types:

• Front parameter. Formed extremely rarely. The inflammatory process is localized in the area of ​​the bladder mucosa and the anterior wall of the cervix. Usually formed after surgery and surgical interventions. Purulent accumulations can penetrate into the pubic joint, abdominal cavity, vagina and bladder.
• Lateral parameter. It is diagnosed in 85% of cases. The inflammatory process covers the vagina, inguinal ligament, the walls of the large and small pelvis. Depending on the pathways of distribution and exit of purulent contents, the lateral parametritis is divided into lower and upper.
• Rear parameter. Childbirth is considered the cause of this form of pathology. Inflammation extends to the area between the rectum and the uterus. The posterior form of parametritis can lead to problems with bowel movements and narrowing of the rectum.

Depending on the severity and nature of the inflammation, the parametritis is divided into several stages:

• stage of infiltration - characterized by intercellular infiltration, swelling and dilation of the vessels of the periuterine tissue;
• stage of exudation - accompanied by the penetration of blood particles into the fiber. The exudate may be purulent, serous, or mixed;
• the stage of compaction and resorption of the infiltrate.

With purulent parametritis, an abscess is formed, which periodically opens to the outside or nearby organs. When the abscess is not completely emptied, the inflammation often recurs, leading to constant abscess ruptures and fistula formation that support the course of the pathology.

Reasons for the development of parametritis

Inflammation of the parametrium can occur in acute and chronic form. The entry of pyogenic microflora into the periuterine tissue and the subsequent development of acute parametritis can occur for the following reasons:

• the presence of inflammatory pathologies of the uterus, its cervix and appendages, as well as the vaginal cavity and tissue around the pelvic organs;
• installation of an intrauterine contraceptive (IUD) with damage to the uterine cervix;
• traumatization of the genital organs;
• the presence of systemic bacterial pathologies (pneumonia, tonsillitis, typhus, appendicitis, tuberculosis, enteritis).

Pathogenic microorganisms can penetrate into the parameters through the instruments used for abortions, operations on the cervix, uterus and inside the uterine ligaments (removal of tumor neoplasms, diagnostic curettage).

The most common cause of periuterine tissue inflammation is postpartum parametritis, since after delivery, the uterus for 4-6 weeks is an open wound, into which various bacteria and infections easily penetrate. In such a case, the occurrence of parametritis is facilitated by:

• childbirth that occurred in the presence of inflammation in the appendages, cervix or uterus;
• ruptures of the walls of the uterine cervix, which were sewn incorrectly or went completely unnoticed;
• accumulation of blood between the anterior and posterior leaf of the broad ligament due to delivery;
• the formation of postpartum endometritis (inflammation of the mucous membranes of the uterus);
• purulent fusion of blood clots that have arisen in the veins of the fiber during childbirth.

Chronic parametritis is characterized by a change in periods of exacerbations and remissions (the absence of manifestations of inflammation). The chronic course of inflammation of the periuterine tissue can develop with an untreated acute form of the disease (self-treatment, withdrawal of antibiotics, change in dosage or drug regimen).

The following factors can contribute to the chronicity of the inflammatory process:

• self-installation or untimely change of the intrauterine device;
• the presence of a constant source of infection in the body (tonsils, teeth);
• frequent change of partners (more than once every 2-3 months).

Symptoms of parametritis

Signs of inflammation of the periuterine tissue occur 8-12 days after an abortion, labor, curettage, celiac or gynecological intervention. If the parametritis is formed against the background of diseases of the internal organs, there are no clear terms for the onset of symptoms of the pathological process.

It is possible to suspect the presence of inflammation of the parametrium by the occurrence of stabbing and cutting pains in the lower abdomen, radiating to the lower back and sacrum. Chills, general malaise and fever are also noted. If appropriate measures are not taken, the fluid in the periuterine tissue begins to suppurate, which leads to a significant increase in temperature and the onset of symptoms such as nausea, headaches, constant thirst, severe weakness. Interruptions in cardiac activity and palpitations are possible.

With anterior parametritis, signs of cystitis can be observed - painful urination, the presence of blood impurities in the urine, constant urge to urinate. Posterior parametritis is accompanied by frequent urge to defecate. When a fistulous tract is formed (one of the complications of parametritis), pus inclusions appear in the urine or feces.

Diagnosis of parametritis

To detect inflammation of the periuterine tissue, the following clinical studies are carried out:

• Gynecological examination. With parametritis during palpation, compaction, displacement of periuterine tissue and soreness of the uterus are determined.
• Transabdominal or intravaginal ultrasound. It is performed to detect echopositive formations (infiltrates) around the uterus.
• Computed tomography of the pelvic organs. Allows visualization of parametric seals of any size.
• Cystoscopy. It is prescribed to detect a breakthrough of the abscess into the bladder.
• excretory urography. It is carried out with suspicion of narrowing of the ureter, paranephritis or other complications of parametritis, the signs of which were identified during ultrasound diagnostics.
• Sigmoidoscopy. Allows you to determine the breakthrough of the abscess into the rectum.

Given the nature of the clinical picture, the severity of the pathological process and the state of health of the patient, the list of diagnostic studies may vary. The expediency of carrying out this or that procedure is determined by the doctor individually on the basis of complaints and anamnestic information.

Treatment of parametritis

Therapy of parametria inflammation is carried out permanently. Since the disease is inflammatory in nature, antihistamines and broad-spectrum antibacterial drugs are prescribed (fluoroquinolone antibiotics are more often used). According to the indications, other drugs are additionally used. To strengthen the immune system, the intake of vitamins and minerals is indicated. During the therapeutic course, the patient must adhere to bed rest and apply cold compresses to the lower abdomen.

Usually, parametritis therapy begins with a puncture of the infiltrate, which makes it possible to detect the presence of pus and avoid the breakthrough of the abscess into the abdominal cavity. When an abscess is formed, surgery is indicated. In such a case, the treatment process is conditionally divided into several stages: the elimination of suppuration and the stage of resorption. Suppuration is removed through the posterior vaginal fornix or abdominal cavity, followed by the installation of a drainage system into the purulent cavity. At the end of the procedure, the cavity is washed with a disinfectant solution. Then antibacterial drugs are introduced into it.

At the stage of resorption of the infiltrate, therapeutic exercises, gynecological massage, the use of immunostimulating drugs, biostimulants, vitamins and enzymes are indicated. Good results in the treatment of parametritis are shown by physiotherapeutic procedures:

• diadynamic therapy;
• electrophoresis with zinc, iodine, copper and magnesium;
• phototherapy;
• inductothermy;
• magnetotherapy.

If inflammation of the parauterine tissue is accompanied by endogenous intoxication, plasmapheresis procedures are prescribed.

Therapy for chronic parametritis includes the use of hormonal drugs, the use of indomethacin suppositories, and ultrasound treatment.

Rehabilitation and recovery after parametritis

After 6-7 months after the end of complex inpatient therapy, it is recommended to undergo a course of sanatorium treatment. Mud therapy procedures and hydrogen sulfide baths have a good effect on health. Rest on the sea will be useful.

To prevent recurrence of the disease, injuries and damage to the vagina should be avoided. It is not recommended to install an intrauterine device after inflammation of the periuterine tissue, since potentially possible consequences can lead to the return of parametritis. Moderate physical activity (yoga, Pilates, fitness), a proper, balanced diet and daily walks will help improve health and recover faster after treatment.

For the timely detection and elimination of possible pathological abnormalities, you should be regularly examined by a gynecologist (at least 2 times a year) and, if the first signs of parametritis occur, consult a doctor. This will allow for effective treatment and avoid the formation of adverse complications.

Parametritis is a diffuse inflammation of the parauterine tissue in combination with lymphangitis and perivascular edema.

The sacro-uterine, pubic-vesical and vesico-uterine ligaments form partitions between different sections of the pelvic tissue. In these departments pass the ureters, blood and lymphatic vessels, nerve trunks and plexuses, lymph nodes are located.

There are anterior, posterior and two lateral parameters, therefore, anterior, posterior and lateral parameters are distinguished.

The spread of a purulent inflammatory process in the cellular spaces of the small pelvis (according to P.P. Makarov, A.A. Gabelov):
a - lateral parametritis, spreading along the side wall of the pelvis: 1 - purulent cavity; b - anterior parametritis: 1 - purulent cavity, 2 - pus outlet to the anterior abdominal wall; c, d — distribution of exudate in the small pelvis with parametritis (transverse and sagittal sections)

The causative agents of parametritis are most often streptococci, staphylococci; less often - bacteroids, anaerobic streptococcus Escherichia coli. Exudate in the fiber can be serous-purulent or purulent.

Clinical picture and diagnosis

In the initial stage of the inflammatory process, the tongue is moist, slightly lined; palpation of the abdomen is almost painless. When the process goes to the peritoneum, the pain intensifies, becomes sharp. Vaginal and rectal examination is sharply painful; on the side, less often in front or posterior to the uterus, an infiltrate is palpated. First, the infiltrate is located in the upper or lower part of the fiber of the broad ligament of the uterus, then spreads to the sides up to the walls of the pelvis, up and down to the inguinal and pubic regions, smoothing or even protruding the vaginal vault.

With a posterior parameter, the infiltrate is well defined through the rectum, closely covering it in front and from the sides. Palpation of the infiltrate is not painful. The duration of the acute stage of the inflammatory process is from 7 to 14 days, sometimes longer. With a favorable course of the process, the infiltrate resolves, the body temperature decreases, and the general condition improves.

The disease becomes longer with the development of purulent parametritis. They note a deterioration in the general condition, increased pain, impaired function of neighboring organs, relapsing fever appears. Repeated chills indicate a purulent process. Suppuration and approach of the infiltrate to the bladder causes dysuric phenomena.

A breakthrough of pus into the rectum or bladder is accompanied by the appearance of pus in the urine and discharge from the rectum. The approach of the infiltrate to the wall of the rectum is accompanied by an admixture of mucus in the feces and tenesmus. With the spread of the process, thrombophlebitis of the uterine and internal iliac veins occurs.

Palpation of the abdomen with suppuration becomes painful, there are no signs of peritoneal irritation. When spreading to the walls of the pelvis, the upper limit of the infiltrate is determined in some cases at the level of the inguinal ligaments, along the midline wedge-shaped towards the navel. In a bimanual vaginal examination, the uterus is not completely contoured due to its complete or partial inclusion in the infiltrate, the vaginal vaults are smoothed and shortened.

The smoothness of the arches helps in determining the localization of the process in the parauterine tissue: a more pronounced smoothness of the anterior, posterior or lateral arch corresponds to the defeat of the parauterine tissue; with a total lesion, all the vaults are smoothed or bulge into the vagina. Signs of suppuration are the deterioration of the general condition of the patient and the appearance of softening areas in the infiltrate.

Differential diagnosis is carried out between pelvioperitonitis, acute inflammation of the uterine appendages, torsion of the legs of the ovarian cyst, uterine tumor, necrosis of myomatous nodes and uterine fibroids. Intraligamentous fibroids and cystomas have a smooth surface and a rounded shape, do not cause an increase in body temperature and signs of intoxication; the cervix and vagina are involved in the cancerous infiltrate (take into account the history data). A complication of purulent parametritis is the breakthrough of the abscess into the rectum, bladder. The most formidable complication is the breakthrough of the abscess into the free abdominal cavity.

Treatment

If an abscess is found that occupies the entire anterior surface of the lower abdomen, it is necessary to make additional incisions - counter-openings - on the opposite side, defining the boundaries of the abscess using a forceps or other blunt instrument inserted into the abscess cavity, as well as using a digital examination. The cavity of the abscess is drained through the main incision and through the counter-opening.

With extensive abscesses that have not only spread into the iliac fossa, but also descended downward to the cervix and vaginal vault, capturing the posterior and lateral parameters, it is not enough to drain the abscess through the abdominal wall. Additional drainage through the colpotomy incision is required.

Opening (a) and drainage (b) of the lateral parametrium with a purulent process that has spread into the iliac fossa:
1 - localization of the abscess; 2 - incision line of the abdominal wall; 3 - drainage with a drainage tube

In the postoperative period, when the discharge of pus stops, the end of the tube brought to the abdominal wall is cut off at the edge of the wound, and the vaginal end is pulled up as the fistula closes. If purulent fusion of the partitions between individual inflammatory foci occurs and the process spreads towards any organ (intestine, vagina, bladder), pus may break into these organs with the formation of a fistula. Fistulas can also form in the area of ​​the main incision.

At vaginal access most often, a posterior colpotomy is used to open the posterior and lateral phlegmon of the periuterine space.

Opening of the posterior parametrium (a) and drainage of the posterior parauterine abscess (b)

Fixation of the vault ensures the correct holding of the needle during puncture and the scalpel when opening the abscess. A long needle is used to puncture the fornix. Having received pus and making sure that the needle is in the right direction in relation to the infiltrate, the actual colpotomy is performed. In the intended area, the vault and the dense capsule of the abscess are pierced with a scalpel, directing it parallel to the cervix. Pus is removed through the hole made, a drainage tube is inserted.

A crossbar (cross) is installed at the inner end of the tube in order to prevent the drainage from slipping out of the abscess cavity. The drainage tube is removed after the final elimination of the symptoms of inflammation: the normalization of blood counts, pulse, temperature, the general condition of the patient and the cessation of purulent discharge from the wound.

The anterior abscess of the parauterine tissue is opened through the anterior colpotomy incision. The cervix is ​​fixed behind the anterior lip with forceps, the anterior wall of the vagina is dissected directly at the anterior surface of the cervix, the fiber is bluntly stratified and the abscess is opened.

Lateral colpotomy is used extremely rarely, only when the abscess is located only in the lateral parameter. Its implementation requires special care. If with a posterior colpotomy there is a risk of injury to the rectum, then with a lateral colpotomy, damage to the ureters and uterine vessels is possible. In order to prevent these complications, lateral colpotomy must begin with an incision in the posterior fornix.

Having captured the posterior lip of the cervix, it is taken towards the pubis, the mucous membrane of the posterior fornix of the vagina is dissected and through the resulting hole in a blunt way (preferably with a forceps or a grooved probe) gradually and very carefully penetrate to the lower part of the infiltrate, exfoliating the tissue tissue until a dense abscess capsule is felt. Under the control of the finger, the abscess is punctured. Having received pus, the abscess capsule is opened with a scalpel (a grooved probe is used). The hole is expanded with forceps and the abscess is drained.