Causes of purulent gynecologic diseases

The development and formation of inflammatory diseases is based on many interconnected processes, ranging from acute inflammation to complex destructive tissue changes.

The main trigger for the development of inflammation is, of course, microbial invasion (microbial factor).

On the other hand, in the etiology of the purulent process, the so-called provoking factors play a significant and sometimes decisive role. This concept includes physiological (menstruation, childbirth) or iatrogenic (abortions, IUD, hysteroscopy, hysterosalpingography, operations, IVF) weakening or damage to barrier mechanisms, which contributes to the formation of entry gates for pathogenic microflora and its further spread.

In addition, it is necessary to emphasize the role of background diseases and other risk factors (extragenital diseases, some bad habits, certain sexual inclinations, socially conditioned conditions).

An analysis of the results of numerous bacteriological studies in gynecology conducted over the past 50 years has revealed a change in the microbes that cause such diseases over these years.

Thus, in the 30-40s, one of the main pathogens of inflammatory processes in the fallopian tubes was gonococcus. Leading gynecologists of that time cite data on the isolation of gonococcus in more than 80% of patients with inflammatory diseases of the genitals.

In 1946, V.A. Polubinsky noted that the frequency of detection of gonococcus decreased to 30% and associations of staphylococcus and streptococcus began to be detected more and more often (23%).

In subsequent years, gonococcus gradually began to lose its leading position among the leading pyogenic pathogens, and in the 40-60s this place was taken by streptococcus (31.4%), while staphylococcus was detected in only 9.6% of patients. Even then, the importance of E. coli as one of the pathogens of the inflammatory process of the uterine appendages was noted.

In the late 1960s and early 1970s, the role of staphylococcus as a causative agent of various human infectious diseases increased, especially after childbirth and abortions. According to I.R. Zak (1968) and Yu.I. Novikov (1960), staphylococcus was found in 65.9% of women when culturing vaginal discharge (in pure culture it was isolated in only 7.9%, in the rest its associations with streptococcus and E. coli predominated). As noted by T.V. Borim et al. (1972), staphylococcus was the causative agent of the disease in 54.5% of patients with acute and subacute inflammation of the internal genital organs.

In the 1970s, staphylococcus continued to play an important role, while the importance of gram-negative flora, in particular E. coli, and anaerobic flora also increased.

In the 70-80s, gonococcus was the causative agent in 21-30% of patients with GERD, and the disease often became chronic with the formation of tubo-ovarian abscesses requiring surgical treatment. Similar data on the frequency of gonorrhea in patients with inflammatory processes of the uterine appendages - 19.4%.

Since the 1980s, most researchers have been almost unanimous in their opinion that the leading initiators of purulent diseases of the internal genital organs are associations of non-spore-forming gram-negative and gram-positive anaerobic microorganisms, aerobic gram-negative and, less often, gram-positive aerobic microbial flora.

Causes of purulent inflammatory diseases of the internal genital organs

Probable pathogens
Facultative (aerobes)			Anaerobes
Gram +	Gram -	Sexually transmitted infections	Gram +	Gram-
Streptococcus (group B) Enterococcus Staph, aureus Staph.epidermidis	E. coli, Klebsiella, Proteus, Etiterobacter, Pseudomonas	N. gonorrhoeae, Chlamydia trachomatis, M. hominis, U. urealyticum, Gardnerella vaginalis	Clostridium Peptococcus	Bacteroides fragilis, Prevotella species, Prevotella bivia, Prevotella disiens, Prevotella melanogenica, Fusobacterium

Associations of pathogenic agents of the purulent process include:

• Gram-negative non-spore-forming anaerobic bacteria such as the Bacteroides fragilis group, Prevotella species, Prevotella bivia, Prevotella disiens and Prevotella melaninogenica;
• gram-positive anaerobic streptococci Peptostreptococcus spp. and gram-positive anaerobic spore-forming rods of the genus Clostridium, with the specific gravity not exceeding 5%;
• aerobic gram-negative bacteria of the Enterobacteriacea family, such as E. coli, Proteus;
• aerobic gram-positive cocci (entero-, strepto- and staphylococci).

A frequent component in the structure of pathogens causing inflammatory diseases of the internal genital organs is also a transmissible infection, primarily gonococci, chlamydia and viruses, and the role of chlamydia and viruses in abscess formation has not been sufficiently assessed to date.

Scientists who studied the microflora of patients with acute inflammation of the pelvic organs obtained the following results: Peptostreptococcus sp. was isolated in 33.1% of cases, Prevotella sp. - 29.1%, Prevotella melaninogenica - 12.7%, B. Fragilis - 11.1%, Enterococcus - 21.4%, group B streptococcus - 8.7%, Escherichia coli - 10.4%, Neisseria gonorrhoeae - 16.4%, and Chlamydia trachomatis - 6.4%.

The bacteriology of inflammatory diseases is complex and polymicrobial, with the most commonly isolated microorganisms being gram-negative facultative aerobes, anaerobes, Chlamydia trachomatis and Neisseria gonorrhoeae in combination with opportunistic bacteria that commonly colonize the vagina and cervix.

M.D. Walter et al. (1990) isolated aerobic bacteria or their associations from 95% of patients with purulent inflammation, anaerobic microorganisms from 38%, N. gonorrhoeae from 35%, and C. trachomatis from 16%. Only 2% of women had sterile cultures.

R.Chaudhry and R.Thakur (1996) studied the microbial spectrum of abdominal aspirate in female patients with acute purulent inflammation of the pelvic organs. Polymicrobial flora predominated. On average, 2.3 aerobic and 0.23 anaerobic microorganisms were isolated from one patient. Aerobic microflora included coagulase-negative staphylococci (isolated in 65.1% of cases), Escherichia coli (in 53.5%), Streptococcus faecalis (in 32.6%). Among the anaerobic flora, microorganisms of the Peptostreptococci type and Basteroides species prevailed. Symbiosis of anaerobic and aerobic bacteria was noted only in 11.6% of patients.

It is claimed that the etiology of pelvic inflammatory diseases is undoubtedly polymicrobial, but the specific pathogen in some cases is difficult to differentiate due to the peculiarities of cultivation even during laparoscopy. All scientists are unanimous in the opinion that Chlamydia trachomatis, Neisseria gonorrhoeae, aerobic and facultative anaerobic bacteria should be covered by the spectrum of antibacterial therapy according to the clinical and bacteriological manifestations of each individual case.

It is believed that in the occurrence of acute respiratory viral infections in modern conditions, associations of microorganisms (anaerobes, staphylococci, streptococci, influenza viruses, chlamydia, gonococci) are of greater importance (67.4%) than monocultures.

According to research data, aerobes, gram-negative and gram-positive microorganisms are more often determined in the form of microbial associations of various compositions and much less often - monocultures; facultative and obligate anaerobes are present in isolation or in combination with aerobic pathogens.

According to some doctors, 96.7% of patients with acute myelitis were found to have predominantly polymicrobial associations, in which the dominant role (73.3%) belonged to opportunistic microorganisms (E. coli, enterococcus, epidermal staphylococcus) and anaerobes-bacteroids. Among other microorganisms (26.7%) were chlamydia (12.1%), mycoplasma (9.2%), ureaplasma (11.6%), gardnerella (19.3%), HSV (6%). Bacterial-like microorganisms and viruses play a certain role in the persistence and chronization of the process. Thus, the following pathogens were identified in patients with chronic inflammation: staphylococcus - in 15%, staphylococcus in association with E. coli - 11.7%, enterococci - 7.2%, HSV - 20.5%, chlamydia - 15%, mycoplasma - 6.1%, ureaplasma - 6.6%, gardnerella - 12.2%.

The development of acute purulent salpingitis is usually associated with the presence of a sexually transmitted infection, primarily Neisseria gonorrhoeae.

F. Plummer et al. (1994) consider acute salpingitis to be a complication of cervical gonococcal infection and the main cause of infertility.

DESoper et al. (1992) attempted to determine the microbiological characteristics of acute salpingitis: Neisseria gonorrhoeae was isolated in 69.4%, Chlamydia trachomatis was obtained from the endocervix and/or endometrium in 16.7% of cases. In 11.1% there was a combination of Neisseria gonorrhoeae and Chlamydia trachomatis. Polymicrobial infection was determined in only one case.

SEThompson et al. (1980), when studying the microflora of the cervical canal and exudate obtained from the recto-uterine cavity of 34 women with acute adnexitis, found gonococcus in the cervical canal in 24 of them and in the abdominal cavity in 10.

RLPleasant et al. (1995) isolated anaerobic and aerobic bacteria in 78% of patients with inflammatory diseases of the internal genital organs, with C. trachomatis isolated in 10% and N. gonorrhoeae in 71% of cases.

Currently, the incidence of gonococcal infection has increased, but most researchers note that Neisseria gonorrhoeae is often found not in isolation, but in combination with another transmissible infection (Chlamydia trachomatis, Mycoplasma hominis).

C. Stacey et al. (1993) found Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum or a combination of these microorganisms most often in the cervical canal, less often in the endometrium and least often in the tubes, but C. trachomatis was isolated mainly from the tubes. There was clear evidence that N. gonorrhoeae and C. trachomatis are pathogens.

Of interest are the data of J. Henry-Suehet et al. (1980), who, during laparoscopy in 27 women with acute adnexitis, examined the microbial flora obtained from the distal part of the tube. In 20 patients, the pathogen was gonococcus in monoculture, in the rest - aerobic-anaerobic flora.

Acute inflammation of the pelvic organs is associated with gonococcal, chlamydial and anaerobic bacterial infections.

In patients with acute pelvic inflammatory disease, Neisseria gonorrhoeae was isolated more frequently (33%) than Chlamydia trachomatis (12%), but neither microorganism was predominant in cases with complicated disease.

M. G. Dodson (1990) believes that Neisseria gonorrhoeae is responsible for 1/2-1/3 of all cases of acute ascending infection in women, while he does not underestimate the role of Chlamydia trachomatis, which is also an important etiologic agent. The author concludes that acute inflammation is still polymicrobial, since along with N. gonorrhoeae and/or C. trachomatis, anaerobes such as Bacteroides fragilis, Peptococcus and Peptostreptococcus and aerobes, especially of the Enterobacteriaceae family such as E. coli, are often isolated. Bacterial synergism, co-infection and the presence of antibiotic-resistant strains make adequate therapy difficult.

There is a natural resistance that protects the upper genital tract in women.

T. Aral, JNNesserheit (1998) believe that two leading factors contribute to the development of acute ascending infection in women: chronic chlamydial infection of the cervical canal and critical delays in determining the nature and treatment of cervical infection.

If the development of acute purulent salpingitis is usually associated with the presence of a sexually transmitted infection, primarily with Neisseria gonorrhoeae, then the development of purulent-destructive processes in the appendages (complicated forms of purulent inflammation) is associated by most researchers with associations of gram-negative anaerobic and aerobic bacteria. In such patients, the use of antibiotics is practically ineffective, and progressive inflammation, deep tissue destruction and the development of purulent infection lead to the formation of inflammatory tumors of the appendages.

Existing observations indicate that 2/3 of anaerobic bacterial strains, in particular Prevotella, produce beta-lactamases, which makes them extremely resistant to therapy.

The pathogenesis of purulent inflammatory diseases allowed us to understand the Weinstein model of intra-abdominal sepsis. In the experimental model of Weinstein's intra-abdominal sepsis, the main role of pathogens was played not by transmissible infections, but by gram-negative bacteria, and above all E. coli, which are one of the main causes of high mortality.

Anaerobes play an important role in the association of bacteria, and therefore the prescribed therapy must have high anti-anaerobic activity.

Among anaerobic bacteria, the most common pathogens are B.fragilis, P.bivia, P.disiens and peptostreptococci. B.fragilis, like other anaerobes, is responsible for the formation of abscesses and is practically a universal etiological cause of abscess formation.

A unilateral tubo-ovarian abscess in a 15-year-old girl, caused by Morganella morganii and requiring adnexectomy, was described by A. Pomeranz, Z. Korzets (1997).

The most severe forms of inflammation are caused by Enterobacteriaceae (gram-negative aerobic rods) and B. fragilis (gram-negative anaerobic non-spore-forming rods).

Anaerobes can not only cause inflammation of the uterine appendages in isolation, but also superinfect the pelvic organs.

Aerobic streptococci, such as group B streptococci, are also a common etiologic cause of gynecologic infections.

Analyzing the role of other pathogens of purulent inflammation, it can be noted that Streptococcus pneumoniae was considered the only causative agent of purulent inflammation back in the early 19th century. It is known that it was often the cause of pneumonia, sepsis, meningitis and otitis in children. There are 3 known cases of peritonitis with the formation of tubo-ovarian abscesses in three girls, from whom S. pneumoniae was subsequently isolated.

Enterococci are isolated from 5-10% of women with purulent-inflammatory diseases of the genital organs. The question of the participation of enterococci (gram-positive aerobic streptococci of the E. Faecalis type) in the development of mixed anaerobic-aerobic infection of purulent-inflammatory diseases of the genital organs is still controversial.

Recent data indicate a possible role of enterococci in maintaining mixed aerobic-anaerobic inflammation, which increases the likelihood of bacteremia. There are facts confirming the synergistic effect between Efaecalis and B. fragilis. Experimental data also indicate that enterococci participate in the inflammatory process as a copathogen with E. coli.

Some authors associate the development of enterococcal infection with preoperative antibacterial prophylaxis or a long course of cephalosporin therapy.

Other studies conducted in patients with intra-abdominal infection indicate that the detection of enterococci in isolate cultures can be considered as a factor indicating the lack of effectiveness of antibacterial therapy.

As already mentioned above, the role of these bacteria is still controversial, although 5-10 years ago they began to talk about this pathogen as an impending serious problem. However, if today some authors believe that enterococci are not the initiating cause and have no independent significance in mixed infections, then according to others, the role of enterococci remains underestimated: if these microorganisms were easily ignored 10 years ago, now they should be considered as one of the main pathogens of purulent inflammation.

In modern conditions, opportunistic flora with weak immunogenicity and a tendency to persist in the body plays an equally important role as an etiological factor.

The overwhelming majority of purulent inflammatory diseases of the uterine appendages are caused by the body's own opportunistic microflora, among which obligate anaerobic microorganisms predominate to a significant extent.

When analyzing the role of individual participants in the purulent process, one cannot help but dwell once again on chlamydial infection.

While many developed countries are currently seeing a decrease in the incidence of gonorrheal infection, the level of inflammatory diseases of the pelvic organs of chlamydial etiology, according to numerous authors, remains high.

In the United States, at least 4 million people are infected with Chlamydia trachomatis each year, and in Europe, at least 3 million. Since 50-70% of these infected women have no clinical manifestations, the disease represents an exceptional challenge for public health programs, and women with cervical chlamydial infection are at risk of developing pelvic inflammatory disease.

Chlamydia is a microorganism pathogenic for humans, which has an intracellular life cycle. Like many obligate intracellular parasites, chlamydia are able to change the normal defense mechanisms of the host cell. Persistence is a long-term association of chlamydia with the host cell, when chlamydia are in it in a viable state, but are not detected by culture. The term "persistent infection" means the absence of obvious growth of chlamydia, suggesting their existence in an altered state, different from their typical intracellular morphological forms. A parallel can be drawn between persistence, concerning chlamydial infection, and the latent state of the virus.

Evidence of persistence is provided by the following facts: approximately 20% of women with cervical infection caused by Ch. trachomatis have only minor signs of the disease or none at all. So-called "silent infections" are the most common cause of tubal infertility, and only 1/3 of infertile women have a history of pelvic inflammatory disease.

Asymptomatic persistence of bacteria may serve as a source of antigen stimulation and lead to immunopathological changes in the tubes and ovaries. It is possible that during prolonged or repeated chlamydial infection, antigens of persistent altered chlamydia "trigger" the body's immune response with a delayed hypersensitivity reaction even in cases where the pathogen is not detected by cultural methods.

Currently, the vast majority of foreign researchers consider Chlamydia trachomatis to be a pathogen and a major participant in the development of inflammation of the internal genital organs.

A clear direct correlation has been established between chlamydia, inflammatory diseases of the pelvic organs and infertility.

C. trachomatis has weak intrinsic cytotoxicity and more often causes diseases with more benign clinical signs that appear at later stages of the disease.

L.Westxom (1995) reports that in developed countries Chlamydia trachomatis is currently the most common pathogen of sexually transmitted diseases in young women. It is the cause of approximately 60% of pelvic inflammatory diseases in women under 25 years of age. The consequences of Chlamydia trachomatis infection, confirmed by laparoscopic examinations in 1282 patients, were:

• infertility due to tubal occlusion - 12.1% (versus 0.9% in the control group);
• ectopic pregnancy - 7.8% (versus 1.3% in the control group).

Research indicates that the main locus of chlamydial infection - the fallopian tube - is the most vulnerable among other (cervical canal, endometrium) parts of the genitals.

APLea, HMLamb (1997) found that even with asymptomatic chlamydia, 10 to 40% of patients with urethral and cervical canal lesions subsequently have acute inflammatory diseases of the pelvic organs. Chlamydia increases the risk of ectopic pregnancy by 3.2 times and is accompanied by infertility in 17% of patients.

However, when studying world literature, we were unable to find any indication that chlamydia can directly lead to abscess formation.

Experiments on rats have demonstrated that N. gonorrhoeae and C. trachomatis cause abscess formation only in synergy with facultative or anaerobic bacteria. Indirect evidence of the secondary role of chlamydia in abscess formation is the fact that the inclusion or non-inclusion of antichlamydial drugs in treatment regimens does not affect the recovery of patients, while regimens that include the use of drugs that affect anaerobic flora have significant advantages.

The role of Mycoplasma genitalium in the development of the inflammatory process has not been determined. Mycoplasmas are opportunistic pathogens of the urogenital tract. They differ from both bacteria and viruses, although they are close to the latter in size. Mycoplasmas are found among representatives of normal microflora, but more often - with changes in the biocenosis.

D. Taylor-Robinson and P. M. Furr (1997) described six varieties of mycoplasmas with tropism for the urogenital tract (Mycoplasma hominis, M. fermentans, M. pivum, M. primatum, M. penetrans, M. spermatophilum). Some varieties of mycoplasmas colonize the oropharynx, others - the respiratory tract (M. Pneumoniae). Due to orogenital contacts, mycoplasma strains can mix and enhance pathogenic properties.

There is ample evidence of the etiologic role of Ureaplasma urealyticum in the development of acute and especially chronic non-gonococcal urethritis. The ability of ureaplasmas to cause specific arthritis and decreased immunity (hypogammaglobulinemia) is also undoubted. These conditions can also be attributed to complications of STIs.

There is a clear tendency among doctors to consider mycoplasmas as pathogens of a number of diseases, such as vaginitis, cervicitis, endometritis, salpingitis, infertility, chorioamnionitis, spontaneous abortions and pelvic inflammatory diseases, in which mycoplasmas are isolated significantly more often than in healthy women. Such a model, when the results of microbiological studies are interpreted unambiguously (gonococci are isolated - therefore, the patient has gonorrhea, mycoplasmas - therefore, there is mycoplasmosis), does not take into account the complex transitions from colonization to infection. These same researchers believe that only a massive growth of mycoplasma colonies (more than 10-10 CFU/ml) or at least a fourfold increase in the antibody titer in the dynamics of the disease should be considered evidence of a specific infectious process. This is actually what happens with postpartum bacteremia, sepsis, and complications after abortions, which was documented back in the 60s and 70s by blood culture studies.

Most practitioners, despite the dubious etiological role of mycoplasmas and the obscurity of their pathogenetic action, recommend using antibiotics that act on mycoplasmas and ureaplasmas in cases where these microorganisms are detected in the discharge from the cervical canal. It must be acknowledged that in some cases such therapy is successful, since it is possible that when using broad-spectrum antibiotics, foci of infection caused by other pathogens are sanitized.

JTNunez-Troconis (1999) did not reveal any direct influence of mycoplasmas on infertility, spontaneous abortion and development of intraepithelial cancer of the cervix, but at the same time he established a direct correlative connection between this infection and acute inflammatory diseases of the pelvic organs. A final conclusion about the role of Mycoplasma genitalium in the development of acute inflammatory diseases of the pelvic organs can be made only after its detection by polymerase chain reaction in the upper genital tract.

Genital herpes is a common disease. According to L.N. Khakhalin (1999), 20-50% of adult patients who visit venereal disease clinics have antibodies to the virus. The genital tract lesions are caused by the herpes simplex virus of the second type, less often the first (during orogenital contacts). Most often, the external genitalia and perianal area are affected, but in 70-90% of cases, cervicitis is diagnosed.

The role of viruses in purulent inflammation of the internal genital organs is indirect. Their action is still not clear enough and is associated mainly with immunodeficiency, and specifically with interferon deficiency.

At the same time, A.A. Evseev et al. (1998) believe that the leading role in the development of interferon system deficiency in combined lesions is played by bacterial flora.

L.N.Khakhalin (1999) believes that all people who suffer from recurrent herpes virus diseases have an isolated or combined defect in the components of specific antiherpetic immunity - a specific immunodeficiency, which limits the immunostimulating effects of all immunomodulators. The author believes that it is inappropriate to stimulate the defective immune system of patients with recurrent herpes virus diseases.

Due to the widespread use of antibiotics and long-term wearing of the IUD, an increase in the role of fungi in the development of the purulent process has been noted. Actinomycetes are anaerobic radiant fungi that cause chronic infectious lesions of various organs and tissues (thoracic and abdominal actinomycosis, actinomycosis of the genitourinary organs). Actinomycetes cause the most severe course of the process with the formation of fistulas and perforations of various localizations.

Fungi are very difficult to culture and are usually associated with other aerobic and anaerobic microorganisms, and the exact role of actinomycetes in abscess formation remains unclear.

O. Bannura (1994) believes that actinomycosis affects abdominal organs in 51% of cases, pelvic organs in 25.5%, and lungs in 18.5%. The author describes two cases of complex purulent abdominal tumors of gigantic size (tubo-ovarian abscesses with perforation, infiltrative lesions, stricture of the large intestine, and fistula formation).

J. Jensovsky et al. (1992) describe a case of abdominal actinomycosis in a 40-year-old female patient who had been experiencing an unexplained febrile condition for a long period of time and who had repeatedly undergone laparotomy due to the formation of abdominal abscesses.

N. Sukcharoen et al. (1992) report a case of actinomycosis at 40 weeks of pregnancy in a woman who had had an intrauterine cyst for 2 years. During surgery, a right-sided purulent tubo-ovarian formation measuring 10x4x4 cm was found, growing into the posterior fornix.

The deterioration of the quality of life for the majority of the Ukrainian population in recent years (poor nutrition, malnutrition, stress) has led to a virtual epidemic of tuberculosis. In this regard, clinicians, including gynecologists, must constantly remember the possibility of tuberculosis of the internal genitalia.

Thus, Y. Yang et al. (1996) examined a large group (1120) of infertile patients. Among patients with tubal infertility, tuberculosis was found in 63.6% of cases, while nonspecific inflammation occurred only in 36.4%. The authors described four types of tuberculous lesions: miliary tuberculosis in 9.4%, tubo-ovarian formation in 35.8%, adhesions and petrifications in 43.1%, and nodular sclerosis in 11.7%. Complete occlusion of the tubes was observed in 81.2% of patients with genital tuberculosis and in 70.7% with nonspecific inflammation.

J. Goldiszewicz, W. Skrzypczak (1998) describe a tubo-ovarian abscess of tuberculous genesis with damage to regional lymph nodes in a 37-year-old patient who had “mild” pulmonary tuberculosis in the past.

One of the main moments in the pathogenesis of the inflammatory process is the symbiosis of pathogens. Previously, it was believed that the relationship of anaerobes with aerobes is based on the principles of antagonism. Today, there is a diametrically opposed point of view, namely: bacterial synergism is the leading etiological form of non-clostridial anaerobic infection. Numerous studies and literature analysis allow us to conclude that synergism is not random mechanical, but physiologically conditioned combinations of bacteria.

Thus, the identification of pathogens is extremely important for the choice of antibacterial therapy, but the results of bacteriological studies are influenced by various factors, namely:

• duration of the disease;
• features of material collection: technique, thoroughness, collection time (before antibacterial therapy for a fresh process, during or after it, during an exacerbation or remission);
• duration and nature of antibacterial therapy;
• laboratory equipment.

Only cultures isolated from the abdominal cavity fluid or from the abscess contents should be examined, these are the only reliable microbiological indicators of infection. Therefore, during preoperative preparation, we used material for bacteriological studies not only from the cervical canal, vagina, urethra, but also directly from the abscess by a single puncture through the posterior vaginal fornix or during laparoscopy.

When comparing the microflora, we found some interesting data: pathogens obtained from the purulent focus and the uterus were identical in 60% of patients, while similar microflora was observed in only 7-12% of the purulent focus, cervical canal and urethra. This once again confirms that the initiation of the hyoid process of the appendages occurs from the uterus, and also indicates the unreliability of the bacteriological picture when taking material from typical places.

According to the data, in 80.1% of patients with purulent-inflammatory diseases of the internal genital organs complicated by the formation of genital fistulas, various associations of microbial flora were identified, with 36% of them having aerobic-anaerobic flora with a predominance of gram-negative.

Purulent diseases, regardless of etiology, are accompanied by pronounced dysbacteriosis, which is aggravated by the use of antibacterial drugs, and every second patient develops an allergic reaction, which limits the use of antibacterial drugs.

In addition to the microbial factor, provoking factors play a major role in the development of the inflammatory process and the severity of its clinical manifestations. They are the main mechanism of invasion or activation of the infectious agent.

The first place among the factors that provoke purulent inflammation is occupied by intrauterine device (IUD) and abortions

Numerous studies indicate the negative impact of a certain method of contraception, especially the IUD, on the development of the inflammatory process of the internal genitalia.

Only a small group of authors believe that with careful selection of patients for IUD insertion, the risk of pelvic inflammatory disease is low.

The frequency of inflammatory complications when using intrauterine contraception, according to various authors, varies significantly - from 0.2 to 29.9% of cases.

According to some doctors, inflammatory diseases of the uterus and appendages occur in 29.9% of IUD carriers, menstrual dysfunction - in 15%, expulsions - in 8%, pregnancy - in 3% of women, while the author considers inflammatory diseases to be the most dangerous complication of IUD use, both at the time of their occurrence and development, and in connection with the long-term consequences for the reproductive function of a woman.

In the structure of inflammatory complications against the background of IUD, endomyometritis (31.8%) and combined lesions of the uterus and appendages (30.9%) predominate.

The risk of developing a pelvic infection for a woman who is a carrier of an IUD increases threefold, and for women who have not given birth, sevenfold.

The contraceptive effect of the IUD is to change the nature of the intrauterine environment, which negatively affects the passage of sperm through the uterus - the formation of "biological foam" in the uterine cavity, containing fibrin threads, phagocytes and protein-splitting enzymes. IUDs stimulate the formation of prostaglandins in the uterine cavity, which causes inflammation and constant contraction of the uterus. Electron microscopy of the endometrium in IUD carriers reveals inflammatory changes in its superficial sections.

The “wick” effect of IUD threads is also known – it facilitates the persistent spread of microorganisms from the vagina and cervix to the upper parts.

Some authors believe that the occurrence of inflammatory diseases in IUD carriers is associated with an exacerbation of an already existing chronic inflammatory process in the uterus and appendages.

According to the International Planned Parenthood Federation, the risk group for the development of inflammatory complications against the background of IUD should include women with a history of chronic inflammatory diseases of the uterine appendages, as well as patients in whom persistent microorganisms are isolated during bacterioscopic examination.

It is believed that pelvic inflammatory disease associated with IUD use is associated with gonorrheal or chlamydial infection, and therefore IUDs should not be used in women with signs of endocervicitis. According to these authors, 5.8% of IUD wearers were diagnosed with chlamydia, and 0.6% of them subsequently developed ascending infection.

Different types of IUDs differ in the degree of possible risk of developing pelvic inflammatory diseases. Thus, the most dangerous in this regard are the Dalkon type IUDs, which are no longer in production. For progesterone-containing IUDs, the risk of pelvic inflammatory diseases increases by 2.2 times, for copper-containing IUDs - by 1.9 times, for Saf-T-Coil - by 1.3 times, and for the Lippes loop - by 1.2 times.

It is believed that IUDs increase the risk of PID by an average of three times, with inert plastic models increasing it by 3.3 times and copper-containing IUDs by 1.8 times.

It has not been proven that periodic replacement of the contraceptive reduces the risk of purulent complications.

According to some doctors, the greatest number of inflammatory complications is observed in the first three months from the moment of introduction of the contraceptive, namely in the first 20 days.

The incidence of PID decreases from 9.66 per 1000 women during the first 20 days after introduction to 1.38 per 1000 women later.

A clear correlation was noted between the severity of inflammation and the duration of wearing the IUD. Thus, in the structure of inflammatory diseases during the first year of wearing the contraceptive, salpingo-oophoritis accounted for 38.5% of cases, patients with tubo-ovarian diseases were not identified. With a duration of wearing the IUD from one to three years, salpingo-oophoritis was observed in 21.8% of patients, tubo-ovarian diseases developed in 16.3%. With a duration of wearing the contraceptive from 5 to 7 years, salpingo-oophoritis and tubo-ovarian diseases accounted for 14.3 and 37.1%, respectively.

There are numerous reports of the development of inflammation, the formation of tubo-ovarian tumors and abscess formation of the appendages when using intrauterine devices.

Scientists point out that IUDs are capable of colonizing various microbes, of which E. coli, anaerobes, and sometimes actinomycetes pose a particular danger for abscess formation. The use of intrauterine contraceptives has resulted in the development of severe forms of pelvic infection, including sepsis.

Thus, Smith (1983) described a series of fatal outcomes in the UK associated with the use of IUDs, where the cause of death was pelvic sepsis.

Long-term wearing of the IUD can lead to the development of tubo-ovarian and, in some cases, multiple extragenital abscesses caused by Actinomycetis Israeli and anaerobes, with an extremely unfavorable clinical course.

Six cases of pelvic actinomycosis directly associated with IUD are described. Due to the severity of the lesion, hysterectomy with bilateral or unilateral salpingo-oophorectomy was performed in all cases. The authors did not find a relationship between the occurrence of pelvic actinomycosis and the type of IUD, but noted a direct correlation between the disease and the duration of wearing the contraceptive.

It is known that severe purulent inflammation of the internal genital organs often develops after spontaneous and especially criminal abortions. Despite the fact that the frequency of extra-hospital abortions has decreased at present, the most severe complications of the purulent process, such as tubo-ovarian abscesses, parametritis and sepsis, are the cause of maternal mortality and account for up to 30% of its structure.

It is believed that inflammatory diseases of the internal genital organs are common complications of artificial termination of pregnancy, and the presence of STIs increases the risk of complications during termination of pregnancy.

Spontaneous and artificial termination of pregnancy, requiring curettage of the uterine cavity, are often the initial stage of severe infectious complications: salpingo-oophoritis, parametritis, peritonitis.

It was established that the development of PID in 30% of patients is preceded by intrauterine interventions, 15% of patients previously had episodes of inflammatory diseases of the pelvic organs.

The second most common (20.3%) cause of purulent inflammation in the pelvis is complications of previous surgeries. In this case, any abdominal or laparoscopic gynecological interventions and especially palliative and non-radical surgical operations for purulent diseases of the uterine appendages can be a provoking factor. The development of purulent complications is undoubtedly facilitated by errors in the course of surgical interventions (napkins, drains or their fragments left in the abdominal cavity), as well as poor technical performance of sometimes the most routine operations (insufficient hemostasis and hematoma formation, repeated ad mass ligation with long silk or nylon ligatures left on the stumps in the form of "balls", as well as long operations with significant blood loss.

When analyzing the possible causes of suppuration in the pelvis after gynecological surgeries, the use of inadequate suture material and excessive diathermocoagulation of tissues are highlighted, while Crohn's disease and tuberculosis are considered risk factors.

According to the researchers, “pelvic cavity infection” – infiltrates and abscesses of the paravaginal tissue and urinary tract infection – complicated the course of the postoperative period in 25% of patients who underwent hysterectomy.

It is reported that the frequency of infectious complications after hysterectomy (analysis of 1060 cases) is 23%. Of these, 9.4% are wound infections and infections in the surgical area, 13% are urinary tract infections, and 4% are infections not associated with the surgical area (thrombophlebitis of the lower extremities, etc.). An increased risk of postoperative complications is reliably associated with the Wertheim procedure, blood loss exceeding 1000 ml, and the presence of bacterial vaginosis.

According to some doctors in developing countries, particularly in Uganda, the rate of postoperative purulent infectious complications is significantly higher:

• 10.7% - after surgery for ectopic pregnancy;
• 20.0% - after hysterectomy;
• 38.2% - after cesarean section.

A special place is currently occupied by inflammatory complications of laparoscopic operations. The introduction of endoscopic treatment methods into wide clinical practice with liberalization of indications for them, often inadequate examination of patients with chronic inflammatory processes and infertility (for example, lack of tests for STIs), the use of chromohydrotubation during laparoscopy and often massive diathermocoagulation for hemostasis have led to an increase in mild to moderate inflammatory diseases, for which patients undergo outpatient treatment, including powerful antibacterial agents, as well as severe purulent diseases leading to hospitalization and repeated surgery.

The nature of these complications is extremely diverse - from the exacerbation of existing chronic inflammatory diseases or the development of ascending infection as a result of damage to the cervical barrier (chromohydrotubation or hysteroscopy) to suppuration of extensive hematomas in the pelvic cavity (hemostasis defects) and the development of fecal or urinary peritonitis due to unrecognized injury to the intestine, bladder or ureters due to a violation of the technique or technology of the operation (coagulation necrosis or tissue damage during separation of adhesions).

The use of massive coagulation during hysteroresectoscopy and the entry of reactive necrotic emboli into the uterine vascular bed can lead to the development of acute septic shock with all the ensuing consequences.

Unfortunately, at present there is no reliable accounting of these complications, many of them are simply hushed up; a number of patients are transferred or after discharge are admitted to surgical, gynecological or urological hospitals. The absence of statistical data leads to the lack of due alertness regarding possible purulent-septic complications in patients who have undergone endoscopic treatment methods, and their late diagnosis.

In recent decades, in vitro fertilization (IVF) methods have been widely developed and distributed worldwide. The expansion of indications for this method without adequate examination of patients and sanitation (in particular, transmissible infections) has recently led to the emergence of severe purulent complications.

Thus, AJ Peter et al. (1993), having reported a case of pyosalpinx confirmed by laparoscopy after IVF-ET, list the possible causes of abscess formation:

• activation of persistent infection in patients with subacute or chronic salpingitis;
• puncture of the intestine during surgery;
• introduction of cervicovaginal flora into this area.

The authors believe that the risk of infection after IVF-ET requires prophylactic administration of antibiotics.

SJ Bennett et al. (1995), having analyzed the consequences of 2670 punctures of the posterior fornix for the purpose of collecting oocytes for IVF, noted that every tenth woman had rather severe complications: 9% of patients developed hematomas in the ovary or small pelvis, which in two cases required emergency laparotomy (a case of the formation of a pelvic hematoma as a result of damage to the iliac vessels was also noted), 18 patients (0.6% of cases) developed an infection, half of them developed pelvic abscesses. The most likely route of infection, according to the authors, is the introduction of vaginal flora during puncture.

S.D. Marlowe et al. (1996) concluded that all physicians involved in infertility treatment should be aware of the possibility of tubo-ovarian abscess formation after transvaginal hysterectomy for oocyte retrieval in an IVF program. Rare causes of abscess formation after invasive procedures include potential complications after insemination. Thus, S. Friedler et al. (1996) believe that a serious inflammatory process, including tubo-ovarian abscess, should be considered as a potential complication after insemination even without transvaginal oocyte retrieval.

Purulent complications occur after cesarean section. Moreover, as a result of these operations they occur 8-10 times more often than after spontaneous birth, occupying one of the first places in the structure of maternal morbidity and mortality. Mortality directly related to the operation is 0.05% (Scheller A., Terinde R., 1992). D.B. Petitti (1985) believes that the level of maternal mortality after the operation is currently very low, but still cesarean section is 5.5 times more dangerous than vaginal delivery. F. Borruto (1989) speaks of the frequency of infectious complications after cesarean section in 25% of cases.

Similar data are provided by SA Rasmussen (1990). According to his data, 29.3% of women had one or more complications after CS (8.5% intraoperative and 23.1% postoperative). The most common complications were infectious (22.3%).

P. Litta and P. Vita (1995) report that 13.2% of patients had infectious complications after cesarean section (1.3% - wound infection, 0.6% - endometritis, 7.2% - fever of unknown etiology, 4.1% - urinary tract infection). Scientists consider the age of the mother, duration of labor, premature rupture of the membranes and anemia (but below 9 g/l) to be risk factors for the development of infectious complications, and especially endometritis.

A. Scheller and R. Terinde (1992) noted serious intraoperative complications with damage to adjacent organs in 3799 cases of planned, emergency and "critical" cesarean sections (in 1.6% of cases in planned and emergency cesarean sections and in 4.7% of cases in "critical" cesarean sections). Infectious complications amounted to 8.6; 11.5 and 9.9%, respectively, which could be explained by the more frequent prophylactic use of antibiotics in the "critical" group.

The most common intraoperative complication is considered to be damage to the bladder (7.27% of patients), postoperative complications are wound infection (20.0%), urinary tract infection (5.45%) and peritonitis (1.82%).

The third place among provoking factors is occupied by spontaneous births. A significant decrease in the number of spontaneous births, as well as the appearance of effective antibacterial drugs, did not lead to a significant decrease in postpartum purulent complications, since unfavorable social factors have sharply increased.

In addition to the above microbial and provoking factors ("entry gates for infection"), there are currently a significant number of risk factors for the development of inflammatory diseases of the internal genital organs, which can be a kind of collector of persistent infection. Among them, it is necessary to highlight: genital, extragenital, social and behavioral factors (habits).

Genital factors include the presence of the following gynecological diseases:

• chronic diseases of the uterus and appendages: 70.4% of patients with acute inflammatory diseases of the uterine appendages suffered from chronic inflammation. 58% of patients with purulent inflammatory diseases of the pelvic organs had previously been treated for inflammation of the uterus and appendages;
• sexually transmitted infections: up to 60% of confirmed cases of pelvic inflammatory disease are associated with the presence of STIs;
• bacterial vaginosis: complications of bacterial vaginosis include premature birth, postpartum endometritis, inflammatory diseases of the pelvic organs and postoperative infectious complications in gynecology; they consider the presence of anaerobic facultative bacteria in the vaginal flora of patients with bacterial vaginosis to be an important cause of inflammation;
• the presence of urogenital diseases in the husband (partner);
• a history of complications of an inflammatory nature after childbirth, abortions or any intrauterine manipulations, as well as miscarriage and the birth of children with signs of intrauterine infection.

Extragenital factors imply the presence of the following diseases and conditions: diabetes mellitus, lipid metabolism disorders, anemia, inflammatory diseases of the kidneys and urinary system, immunodeficiency states (AIDS, cancer, prolonged treatment with antibacterial and cytostatic drugs), dysbacteriosis, as well as diseases requiring the use of antacids and glucocorticoids. In the case of non-specific etiology of the disease, there is a connection with the presence of extragenital inflammatory foci.

Social factors include:

• chronic stressful situations;
• low standard of living, including insufficient and unhealthy nutrition;
• chronic alcoholism and drug addiction.

Behavioral factors (habits) include some features of sexual life:

• early onset of sexual activity;
• high frequency of sexual intercourse;
• a large number of sexual partners;
• non-traditional forms of sexual intercourse - orogenital, anal;
• sexual intercourse during menstruation, and the use of hormonal rather than barrier contraception. Women who have used barrier methods of contraception for two or more years have a 23% lower incidence of pelvic inflammatory disease.

It is believed that the use of oral contraceptives leads to a latent course of endometritis.

It is believed that when using oral contraceptives, the mild or moderate nature of inflammation is explained by the erasure of clinical manifestations.

It is assumed that douching for contraception and hygiene purposes may be a risk factor for the development of acute inflammatory diseases of the pelvic organs. It has been established that anal sex contributes to the development of genital herpes, condylomas, hepatitis and gonorrhea; douching for hygiene purposes increases the risk of inflammatory diseases. It is believed that frequent douching increases the risk of inflammatory diseases of the pelvic organs by 73%, the risk of ectopic pregnancy by 76% and may contribute to the development of cervical cancer.

Of course, the listed factors not only create the background against which the inflammatory process occurs, but also determine the characteristics of its development and course as a result of changes in the body's defenses.

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