Inflammation of the uterine appendages (salpingoophoritis) - Treatment

Treatment of acute inflammation of the uterine appendages should be performed only in a hospital setting. This rule also applies to patients with an acute course of the process without obvious clinical manifestations. The sooner the patient is hospitalized, the more timely adequate therapy will be started and the greater the chances for reducing the number of possible adverse effects characteristic of this type of disease. Attempts to treat patients in an outpatient setting, according to our observations, almost 3 times increase the percentage of such immediate and remote complications as the spread of the inflammatory process and the formation of purulent foci in the small pelvis, chronicity of the disease, disruption of menstrual and reproductive functions, and the development of ectopic pregnancy.

Patients need physical and mental rest. Depending on the characteristics of the disease, bed rest is prescribed for 3-5-7 days. Spicy dishes are excluded from the diet. Women with acute inflammatory diseases of the internal genital organs, especially with a recurrent course of the chronic process, are characterized by various psychoemotional disorders (sleep disorders, appetite, increased irritability, rapid fatigue, etc.). Therefore, it is advisable to involve a psychotherapist in the treatment of patients, prescribe sedatives, sleeping pills.

The leading method of treating acute inflammation of the uterine appendages is antibacterial therapy. It is carried out both independently and in combination with surgical methods of treatment. Antibacterial therapy should be started as early as possible, i.e. immediately after taking material for bacterioscopic, cytological and cultural studies. Determining the nature of the flora and its sensitivity to antibiotics requires a certain amount of time, and the appointment of antibacterial therapy, as already noted, is an emergency measure, so drugs must be selected empirically, guided by the following rules:

1. Take into account the clinical picture of the disease, which has its own characteristics for different pathogens.
2. Remember that in modern conditions the inflammatory process is often caused by a mixed infection.
3. Do not forget about the possible two-phase course of the disease due to the addition of an anaerobic infection.
4. Change the antibiotic regimen if there is no clinical effect after 3 days of treatment.

For example, acute inflammation of the appendages of gonorrheal etiology is characterized by the following signs: the onset of the disease is associated with menstruation; multiple lesions; involvement of the appendages on both sides; frequent spread of infection to the pelvic peritoneum; bloody or purulent discharge from the genital tract. Gonococci often coexist with trichomonads and chlamydia. The drug of choice in this situation is penicillin in combination with metronidazole or tinidazole in standard dosages. After confirming the presence of chlamydial infection, tetracycline antibiotics or macrolides are added.

Acute chlamydial salpingitis is characterized by a relatively mild but protracted course. The main complaints of patients are aching pain in the lower abdomen, radiating to the lower back, sacrum and inguinal areas. With the development of perihepatitis, pain in the right hypochondrium is added. Discharge from the genital tract is abundant, serous-purulent or purulent-serous. As a rule, all symptoms increase gradually. In half of patients with an objectively severe process, body temperature remains normal or subfebrile. Chlamydial infection rarely leads to the formation of tubo-ovarian formations, but due to the tendency to develop an adhesive process, it causes tubal infertility. Only early etiotropic treatment can preserve the health and reproductive function of a woman. Tetracyclines and macrolides have the most active effect against chlamydia, which must be prescribed in fairly high doses for a long time.

Tetracycline and oxytetracycline dihydrate are prescribed orally at 0.5 g (500,000 IU) every 6 hours for 2-3 weeks, tetracycline hydrochloride - intramuscularly at 0.05-0.1 g 2-3 times a day for 10 days. Doxycycline hydrochloride (vibramycin) can be used according to the following scheme: 3 days, 2 capsules (0.2 g) 3 times a day and (0 days, 1 capsule (0.1 g) 3 times a day.

Erythromycin is used orally at 0.5 g (500,000 IU) 4 times a day for 10-14 days. Erythromycin phosphate is administered intravenously at a dose of 0.2 g (200,000 IU) every 8 hours for 7-10 days; the drug is diluted in 20 ml of isotonic sodium chloride solution and administered slowly over 3-5 minutes.

The need for antibacterial therapy aimed at eliminating anaerobic infection is indicated by the following features of the clinical course of the inflammatory process in the appendages: acute onset of the disease after childbirth, abortions, other intrauterine interventions or against the background of IUD, characterized by high temperature, chills, severe pain syndrome. Contamination with anaerobes may be indicated by repeated deterioration of the patient's condition, despite the standard antibacterial therapy ("two-stage" process). An objective examination of anaerobic infection reveals pronounced tissue infiltration, abscess formation, and an unpleasant putrid odor of exudate. Relatively low leukocytosis is accompanied by a slight decrease in the hemoglobin level and a significant increase in ESR. In cases of suspected anaerobic infection, the drugs of choice are metronidazole (flagil, clion, trichopolum) and tinidazole (fazizhin, tricanix). Metronidazole and its analogues are prescribed orally at 0.5 g 3-5 times a day; thiidazole - 0.5 g 2 times a day; the course of treatment is 7-10 days. In severe cases - 100 ml of metragol (500 mg) is administered intravenously twice a day.

Clindamycin (dalacin C) is very effective against anaerobes, while lincomycin and chloramphenicol are somewhat less effective. Clindamycin can be administered intravenously at 0.6-0.9 g every 6-8 hours or orally at 0.45 g 3-4 times a day. Lincomycin hydrochloride is administered intramuscularly at 0.6 g every 8 hours or orally at 0.5 g 3 times a day. Levomycetin is taken orally at 0.5 g 3-4 times a day; chloramphenicol succinate is administered intramuscularly or intravenously at 0.5-1 g every 8-12 hours.

If there are no clear clinical signs characteristic of a particular type of infection, then before receiving the results of a laboratory study, it is advisable to prescribe a combination of antibiotics that cover the most common spectrum of pathogens: gonococcus, chlamydia, gram-positive and gram-negative aerobes and anaerobes. In addition, when choosing a drug, it is necessary to take into account the rate of penetration of antibiotics into the affected organ and the half-life of their decay in the inflammation focus. The following combinations meet such requirements:

• - penicillins with aminoglycosides;
• - cephalosporins with aminoglycosides;
• - cephalosporins with tetracyclines;
• - lincomycin or clindamycin with aminoglycosides.

It should not be forgotten that semisynthetic penicillins, cephalosporins and aminoglycosides have a broad spectrum of action on gram-positive and gram-negative aerobic microorganisms, but are not active enough against non-clostridial anaerobes, chlamydia and mycoplasma. However, the newest penicillins (piperacillin, aelocillin) and cephalosporins (cefotaxime, cefoxitin) are effective against many forms of anaerobes. Tetracycline antibiotics have a fairly wide range of antimicrobial action, including against chlamydia and mycoplasma, but do not affect anaerobic infection. Lincomycin and clindamycin are active against most gram-positive cocci, some gram-positive bacteria, many non-spore-forming anaerobes, mycoplasma. Aminoglycosides are broad-spectrum antibiotics; They are effective against gram-positive and especially gram-negative bacteria, but have no effect on chlamydia and anaerobes. Therefore, in patients with suspected anaerobic infection, it is advisable to supplement the antibiotic combination with metronidazole or tinidazole.

The doses of the drugs depend on the stage and extent of the inflammatory process. In acute catarrhal salpingitis and salpingo-oophoritis without signs of inflammation of the pelvic peritoneum, it is sufficient to prescribe intramuscular administration of medium doses of antibiotics for 7-10 days:

• 1-2 million units of penicillin sodium or potassium salt every 6 hours;
• 1 g of methicillin sodium salt also every 3 hours;
• 0.5 g oxacillin or ampicillin sodium salt 4-6 times a day;
• 1 g of ampiox 3-4 times a day;
• 0.5 g cephaloridine (ceporin) or cefazolin (cefzol) every 6 hours;
• 0.6 g of lincomycin hydrochloride after 8 hours, clindamycin phosphate (Dalacin C) in the same dosage;
• 0.5 g kanamycin sulfate 2-3 times a day;
• 0.04 g gentamicin sulfate 3 times a day.

Most tetracycline drugs are taken orally in tablets or capsules: tetracycline hydrochloride 0.2 g 4 times a day, metacycline hydrochloride 0.3 g 2 times a day, doxycycline hydrochloride 0.1 g also 2 times a day.

Acute adnexitis, pathogenetically associated with intrauterine manipulations, artificial abortions (especially out-of-hospital), intrauterine device, surgeries on internal genital organs, are suspicious for the possibility of developing an anaerobic infection, therefore, in such cases, it is recommended to supplement the complex of antibacterial agents with tinidazole or metronidazole preparations. Metronidazole (Flagyl, Trichopolum, Klion) is prescribed orally at 0.5 g 3 times a day, tinidazole (Fazizhin, Tricanix) - at 0.5 g 2 times a day.

In acute purulent salpingitis or adnexitis, the intensity of antibacterial therapy should be increased, for which purpose, by increasing the doses of antibiotics, it is advisable to administer one of them intravenously. The most rational combination, which provides a wide range of antibacterial action, speed and depth of penetration into the lesion, is considered to be the intramuscular use of aminoglycosides with intravenous infusion of clindamycin. A combination of intramuscular administration of aminoglycosides with intravenous infusion of penicillins or cephalosporins is quite effective. In this case, gentamicin sulfate is administered at 80 mg every 8-12 hours, kanamycin sulfate - at 0.5 g every 6 hours. Drip intravenous infusions of klindamycin phosphate are carried out at 600 mg every 6-8 hours, benzylpenicillin sodium salt is administered at 5-10 million IU every 12 hours, carbenicillin disodium salt at 2 g every 4-6 hours, ampicillin sodium salt at 1 g every 4-6 hours, cephaloridine or cefazolin - at 1 g every 6-8 hours. It is quite reasonable to supplement the combination of antibiotics with intravenous metronidazole (Metrogyl) at 500 mg 2-3 times a day, and in case of positive reactions to chlamydia - doxycycline (100 mg every 12 hours also intravenously).

In case of a favorable clinical effect, intravenous antibiotics should be administered for at least 4 days, and then intramuscular and enteral antibiotics can be used. Antibiotic therapy is stopped 2 days after the body temperature has returned to normal, but not earlier than the 10th day from the start of treatment. In the absence of positive dynamics, the patient's treatment plan should be reviewed in a timely manner, i.e. no later than 48 hours. The effectiveness of the therapy is monitored based on the assessment of clinical and laboratory manifestations: body temperature, pain, peritoneal signs, clinical and biochemical blood tests reflecting the acute phase of inflammation. If necessary, laparoscopy is used.

In order to increase the effectiveness of antibacterial therapy, in recent years we have successfully begun to use intrauterine injections of antibiotics according to the method of B. I. Medvedev et al. (1986). We use various broad-spectrum drugs, but most often aminoglycosides: kanamycin sulfate, gentamicin sulfate, tobramycin, amikacin. Transcervically, without dilating the cervical canal, a long needle in a guide is brought to the area of the tubular angle; the tip of the needle is extended by 1.5-2 mm; 2-3 ml of a solution containing a daily or single dose of an antibiotic is injected under the mucous membrane and partially into the muscle layer. A single dose injection was used only in cases where the course of the disease required the use of maximum quantities of the drug. Due to the impossibility of dissolving antibiotics in a limited volume of liquid (2-3 ml), only part of the daily dose was administered intrauterinely, replenishing the rest with conventional intramuscular injections. The course of treatment is 6-8 intrauterine injections once a day, alternately on the right and left sides.

Sulfanilamide drugs and nitrofuran derivatives currently do not occupy a leading place in the therapy of acute inflammation of the uterine appendages; they are used in cases where laboratory tests confirm the resistance of the pathogens to antibiotics. Usually, prolonged-release sulfonamides are prescribed, the use of which gives fewer side effects. Sulfapyridazine is taken orally once a day: 2 g on the first day of administration, 1 g - on subsequent days. The course of treatment is 7 days. Sulfamonomethoxine and sulfadimethoxine in cases of severe course of the disease are used in the same dosages; in mild and moderate course of the disease, the doses of the drugs are halved: 1 g on the first day of administration, 0.5 g - on subsequent days. The combined drug Bactrim (Biseptol) is used, 1 tablet or 1 ampoule (5 ml) of which contains 400 mg of sulfamethoxazole and 80 mg of trimethoprim. In mild to moderate cases of the inflammatory process, patients receive 2 tablets 2 times a day; in severe cases, 2 ampoules of Biseptol (10 ml) are diluted in 250 ml of isotonic sodium chloride solution or 5% glucose solution and administered intravenously by drip every 12 hours. The course of treatment is 5-7 days. Nitrofuran drugs (furagin, furadonin, furazolidone) are prescribed at 0.1 g 4 times a day. Furagin potassium salt (Solafur) can be administered intravenously by drip as a 0.1% solution at 300-500 ml per day. The course of treatment with nitrofurans lasts 7-10 days.

The duration of antibiotic therapy, especially in weakened patients, requires prophylactic use of antifungal agents. For this purpose, nystatin tablets of 1 million units and levorin of 500 thousand units are prescribed orally 3-4 times a day.

It is rational to include pyrazolone derivatives in the complex of therapeutic agents, which have analgesic, antipyretic and anti-inflammatory properties. These include antipyrine and amidopyrine, which are prescribed in tablets of 0.25 g 2-3 times a day, butadion - 0.05 g 4 times a day, analgin - in tablets of 0.5 g or in injections of 1-2 ml of a 50% solution.

The use of antihistamines producing an anti-inflammatory effect is pathogenetically justified. 2-3 times a day, patients receive diphenhydramine in tablets of 0.05 g or intramuscularly 1-2 ml of a 1% solution, diprazine (pipolfen) in tablets of 0.025 g or intramuscularly 1 ml of a 2.5% solution, suprastin in tablets of 0.025 g or 1 ml of a 2% solution intramuscularly, tavegil in tablets (0.001 g) or in injections (2 ml containing 0.002 g of the substance). The effect of antihistamines is enhanced by calcium chloride and gluconate, 5-10 ml of a 10% solution of which are administered intravenously. G. M. Savelyeva and L. V. Antonova (1987) strongly recommend using histaglobulin, which is a combination of histamine chloride and y-globulin, which increases the body's ability to inactivate free gnetamine and increases the protective properties of the blood. Histaglobulin is administered subcutaneously every 2-4 days at 1-2-3 ml, the course of treatment is 3-6 injections.

It is desirable to include sedatives in the complex of therapeutic agents that regulate the functions of the central nervous system, enhance the effect of analgesics, and have antispasmodic properties. Infusion and tincture of valerian root, infusions and tincture of motherwort herb, and tincture of peony are widely used.

Inflammatory diseases of the uterine appendages often develop in women with a marked decrease in specific immune reactivity and weakening of the body's nonspecific defenses. Etiotropic antibiotic therapy leads to further disruption of the processes that ensure the macroorganism's tolerance to the effects of infection. Consequently, increasing the patient's resistance to infection is an important component of complex treatment. A fairly wide range of drugs can be used for this purpose:

• antistaphylococcal immunoglobulin: 5 ml intramuscularly every 1-2 days, for a course of 3-5 injections;
• normal human immunoglobulin, or polyglobulin: 3 ml intramuscularly every 1-2 days, for a course of 3-5 injections;
• adsorbed staphylococcal anatoxin 0.5-1 ml subcutaneously in the area of the lower angle of the scapula every 3-4 days, for a course of 3 injections; The following scheme for administering concentrated purified staphylococcal anatoxin is also recommended: under the skin of the inguinal fold of the thigh once every 3 days in increasing doses (0.1, 0.3, 0.5, 0.7, 0.9, and 1.2 ml), the drug is used after the acute symptoms of adnexitis have subsided;
• if the staphylococcal genesis of the disease is confirmed, intravenous drip administration of 200 ml of hyperimmune antistaphylococcal plasma gives an excellent effect, which, depending on the severity of the disease, is repeated after 1-2-3 days;
• pyrimidine and purine derivatives that increase the effectiveness of antibiotics, stimulate phagocytosis and antibody production, and have pronounced anti-inflammatory and anabolic properties: of the pyrimidine derivatives, the most widely used are pentoxyl in tablets of 0.4 g 3 times a day and methyluracil in tablets of 0.5 g 3 times a day, and among the purine derivatives, potassium orotate at 0.5 g 2 times a day;
• the protein enzyme lysozyme, which, along with the ability to stimulate the body's non-specific reactivity, has antibacterial and anti-inflammatory properties, is administered intramuscularly at 100 mg 2-3 times a day, for a course of 7-10 days;
• vitamins B12, C and folic acid, which enhance the effect of adjuvants, i.e. agents that increase the body's non-specific defenses;
• lipopolysaccharides of bacterial origin, of which the most studied is prodigiosan, which activates cellular immunity, increases the level of gamma globulins, and has an adjuvant effect in the synthesis of antibodies: a 0.005% solution of prodigiosan in the amount of 0.5-1 ml is administered intramuscularly at intervals of 4 days, the course of treatment is 3-4 injections;
• other drugs that stimulate immunological processes, in particular levamisole (decaris), thymalin, taktivin.

Levamisole acts mainly on cellular immunity factors, normalizing the functions of T-lymphocytes and phagocytes. There are many schemes for administering the drug. The following schemes are used:

• 50 mg once a day for 3 days in a row with a 4-day break, 450 mg per course;
• 150 mg once a week, also 450 mg per course.

Levamisole is contraindicated in case of unfavorable allergic history, severe liver and kidney diseases, and leukocyte content in peripheral blood below 4 • 10 ⁹ /l.

Thymalin regulates the number and ratio of T- and B-lymphocytes, stimulates cellular immune responses, enhances phagocytosis, and accelerates regeneration processes. It is prescribed intramuscularly at 10 mg 2-3 times a day for 7-10 days.

Taktivin normalizes quantitative and functional indicators of the T-system of immunity. It is used subcutaneously at 1 ml once a day for 7-14 days.

Stimulation of non-specific defense and immunity factors can be achieved by autotransfusion of ultraviolet-irradiated blood (AUFOK). Along with activation of complement and phagocytic activity of neutrophils, normalization of lysozyme, increase in quantitative and functional characteristics of T- and B-lymphocytes, AUFOK has a variety of effects on the patient's body. Strong bactericidal and oxygenating effect, stimulating effect on the processes of hematopoiesis and regeneration, favorable effect on the rheological properties of blood and microcirculation are the basis for the widespread use of AUFOK for the purpose of stopping acute inflammatory diseases of the female genital organs. The volume of irradiated blood is determined at the rate of 1-2 ml per 1 kg of the patient's body weight. The rate of exfusion and infusion is 20 ml / min. The course of treatment is 5-10 sessions.

In case of severe intoxication accompanying the development of acute inflammatory processes, infusion therapy is indicated with strict control of the ratio of the amount of solutions introduced into the body and the excreted fluid (urine, sweat, excretion of liquid vapor by the lungs). If the excretory function of the kidneys is not impaired, then the maximum amount of solutions is administered at the rate of 30 ml / (kg • day). With an increase in body temperature by 1 C, the amount of infused fluid increases by 5 ml / (kg • day). With an average patient body weight of 60-70 kg, about 2000 ml of fluid is administered intravenously during the day.

It should be noted that the detoxifying effect can be achieved using 3 principles:

• blood dilution, which reduces the concentration of toxins; any plasma substitutes can be used for this purpose, including saline solutions and glucose;
• attraction of toxins from the blood and interstitial space and their binding through the formation of complexes (hemodes, neohemodes, polydes, neocompensan) or adsorption on the surface of molecules (reololiglucin, gelatinol, albumin);
• elimination of toxins in the urine by increasing diuresis (mannitol, lasix).

In order for complex therapy of acute adnexitis to be successful, it is necessary to follow the rule of an individual approach in each specific case of the disease. This concerns not only rational antibiotic therapy, as discussed above. All components of treatment must be individualized.

In 60% of cases, for example, exacerbation of chronic inflammation of the appendages is not associated with activation of the infectious agent or reinfection. It is provoked by non-specific factors: overfatigue, hypothermia, stressful situations and extragenital diseases against the background of decreased immunological reactivity of the woman's body. In the pathogenesis of relapse of chronic adnexitis, a significant role is played by the processes of autosensitization and autoallergization, dysfunction of the nervous system; hemodynamic disorder in the vascular basin of the small pelvis, impaired synthesis of steroid hormones by the ovaries. All this determines the individual choice of complex therapy. In such cases, there is no need for long-term and massive antibiotic therapy. The emphasis is on the use of desensitizing, rheologically active, non-specific anti-inflammatory agents with simultaneous immunocorrection and intake of adaptogens. It is rational to prescribe minimal doses of sex hormones, vitamins and early introduction of physiotherapy taking into account the phase of the menstrual cycle.

In acute catarrhal salpingitis or salpingo-oophoritis with mild clinical manifestations, in addition to appropriate antibacterial therapy, it is sufficient to prescribe sedatives and antihistamines, pyrimidine or purine derivatives, and vitamins. If the inflammatory process has a moderate clinical course, then, against the background of adequate antibiotic therapy, it is necessary to resort to parenteral administration of antihistamines and enhance immunocorrection. Conducting sessions of AUFO and detoxifying infusions is justified.

An objectively severe course of acute or exacerbation of chronic inflammation in the uterine appendages requires maximum use of all therapeutic agents. Intensive antibacterial, detoxifying, desensitizing, immunocorrective therapy is carried out under careful clinical observation under the control of laboratory tests. The choice of further treatment depends on which of the three options the pathological process will develop:

1. positive dynamics of clinical and laboratory manifestations;
2. further progression of the disease;
3. absence of significant changes in the patient's condition within 48 hours.

In the first case, the therapy started should be continued, since it turned out to be adequate.

In the second case, the deterioration of the patient's condition indicates a threat or an already occurred perforation of the pyosalpinx, pyovar or tubo-ovarian formation. Evidence of this complication is: a sharp increase in pain in the lower abdomen, accompanied by vomiting; hectic body temperature with chills; the appearance of peritoneal symptoms; progressive enlargement of the appendages with loss of clarity of boundaries; a sharp deterioration in the leukocyte formula of peripheral blood; an increase in ESR. In such a situation, urgent surgical intervention is indicated.

In the 3rd case, there is a need to clarify the condition of the appendages to correct further therapy. In modern conditions, in such a situation, the method of choice is therapeutic and diagnostic laparoscopy. If acute catarrhal or purulent salpingitis is confirmed, drainage of the appendage area is performed with subsequent administration of antibiotics for 3-5 days.

If a developing pyosalpinx, pyovar or tubo-ovarian abscess is detected during laparoscopy, then the patient's age, her desire to preserve reproductive function, and concomitant pathology of the female genital organs (uterine fibroids, endometriosis of the appendages, ovarian cysts, etc.) should be taken into account when choosing the treatment tactics. In women over 35 years old, as well as in patients of any age with concomitant pathology of the genital organs, it is possible to limit oneself to bringing drainage to the inflammation site for further antibiotic therapy. Without reducing the intensity of general anti-inflammatory treatment, it is necessary to carefully monitor the dynamics of the process. If the patient's condition worsens, the question of urgent surgical intervention may arise. If the active inflammatory process can be eliminated, but the appendage formation remains, then the patient becomes a candidate for planned surgical intervention. In young women who do not have concomitant pathology of the genital organs and who wish to preserve reproductive function, it is advisable to perform a puncture of the purulent formation during laparoscopy, evacuate the exudate, wash and drain the cavity, thereby providing the opportunity to administer antibacterial drugs directly to the lesion for 3-5 days. The optimal option for such therapy is to carry it out under the control of dynamic laparoscopy.

Puncture of inflammatory formations can be performed through the posterior vaginal fornix under the control of ultrasound (preferably transvaginal) examination or computed tomography. After aspiration of purulent exudate, either drainage of the cavity is performed with a special catheter, or antibiotics are administered. In the latter case, puncture of the purulent formation can be performed 2-3 times with an interval of 2-3 days. Some authors insist on the inappropriateness of such a treatment method, referring to the extensiveness of destructive changes in the uterine appendages with their purulent lesion. It seems to us that this opinion is reasonable only in cases of recurrent chronic inflammatory process with the formation of bilateral pyosalpinx or tubo-ovarian abscesses: However, if acute inflammation of the appendages with the formation of a unilateral abscess in the fallopian tube or ovary occurs for the first time, if it is not a consequence of endomyometritis and is not combined with pelvic peritonitis, then a positive effect can be expected. Modern diagnostic methods (laparoscopy, transvaginal echography, computed tomography) provide accurate diagnostics and gentle puncture, and the latest antibacterial agents successfully eliminate infection. Some authors report the preservation of fallopian tube patency in 41.8% of women who underwent complex therapy using dynamic therapeutic and diagnostic laparoscopy, transabdominal or transvaginal drainage.

In the vast majority of cases, acute inflammatory processes in the uterine appendages can be eliminated by conservative treatment methods: according to our data, in 96.5%. Indications for laparotomy can be formulated as follows:

• suspected perforation of a purulent formation in the appendages;
• the presence of pyosalpinx, pyovarium or tubo-ovarian abscess against the background of IUD;
• complication of acute inflammation of the uterine appendages with purulent parametritis;
• ineffectiveness of complex treatment using laparoscopic drainage, carried out over 2-3 days.

Operations performed for inflammation of the uterine appendages are not standard either in volume or in technique. The nature of the surgical intervention depends on:

• prevalence of the process in the appendages (pyosalpinx, pyovar, tubo-ovarian formation; unilateral, bilateral lesion; involvement of parametrium tissue);
• severity of the adhesion process in the abdominal cavity;
• connections of the disease with childbirth, abortions, intrauterine menstruation;
• the presence of concomitant diseases of the reproductive system;
• age of the patient.

In young women, it is necessary to use the slightest opportunity to preserve reproductive function. The operation is limited to the removal of the altered organs: the fallopian tube or appendages on the affected side. However, if the operation for purulent inflammation of the appendages is performed in young women with postpartum, postabortion endomyometritis or against the background of IUD, then its scope should be expanded to extirpation of the uterus with both tubes. The ovary is removed only if there are pathological changes in it. Severe infiltration of parametric tissues allows, instead of extirpation of the uterus, to limit itself to its amputation, although this opinion is not shared by everyone. Tumor lesions of the ovaries, body and cervix of the uterus require adequate expansion of the operation.

The radicality of surgical intervention increases with the woman's age. In women over 35 years of age, with unilateral appendage damage, it is reasonable to remove the second fallopian tube. In women over 45 years of age, if surgical treatment of acute inflammatory diseases of the appendages is necessary, it makes sense to perform a panhysterectomy.

To prevent postoperative complications, mandatory drainage of the pelvis or abdominal cavity is performed, during which the principle of an individual approach remains relevant. If there is no significant adhesion process, if there is no infiltration of tissues of adjacent organs, if reliable hemostasis is achieved, then it is enough to insert a thin drainage tube for antibiotics into the pelvis, the latter is usually removed on the 4th day of the postoperative period.

In case of pronounced adhesions, extensive infiltration and increased tissue bleeding, adequate drainage is necessary to ensure the outflow of wound secretions. A good effect can be achieved by draining the small pelvis through the posterior vaginal fornix (posterior colpotomy during supravaginal amputation of the uterus) or through an opening in the vaginal dome (during extirpation of the uterus). At the same time, thin tubes are inserted through counter-openings in the hypogastric regions to administer antibiotics and, if necessary, an analyte solution.

It is recommended to use the method of continuous aspiration-washing drainage, which consists of the forced evacuation of liquefied wound exudate, pus and fibrin through double-lumen silicone tubes in the postoperative period. The narrow lumen of the tube is intended for the introduction of Analytical solutions, the wide one is for the evacuation of liquefied exudate. Aspiration is carried out automatically by means of the OP-1 device for 5-7 days. Drainage tubes can be brought to the bed of the removed abscess through the vaginal fornix or through the abdominal wall.

In the presence of extensive tissue infiltration surrounding the purulent formation of the uterine appendages, drainage is successfully performed using gauze pads placed in a rubber glove. In a regular surgical glove, the fingers are cut off almost at their bases, several holes about 1 cm in diameter are cut on the palm and back of the glove. Several gauze strips 2-3 cm wide and one thin silicone tube are placed inside the glove. The gauze strips are brought to each base of the finger, without going beyond it; the tube is pulled out of the glove at a distance of 5-6 cm. The prepared glove-gauze drainage through a counter-opening in the hypogastric region of the abdominal wall is brought to the bed of the abscess and carefully straightened over its entire area. The cuff of the glove, the ends of the gauze strips and the silicone tube intended for the introduction of antibiotics remain on the surface of the abdominal wall. Gauze drains enclosed in a rubber glove function well without becoming slimy for 7 days or more, do not cause pressure sores on the intestinal wall, and are easily removed along with the glove. The tube for administering antibiotics usually functions for 4 days and is then removed.

In the postoperative period, it is necessary to continue intensive therapy in the following main areas:

• fight against infection taking into account the results of bacteriological studies and antibiograms;
• infusion-transfusion therapy aimed at detoxification, normalization of protein and electrolyte balance, improvement of rheological properties of blood;
• implementation of non-specific anti-inflammatory therapy, use of desensitizing agents;
• impact on the patient's immune status;
• vitamin therapy and the use of anabolic agents;
• adequate stimulation of bowel function.

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