Pelvic inflammatory disease

Pelvic inflammatory disease is a spectrum of inflammatory conditions in the upper reproductive tract in women and may include any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

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Causes pelvic inflammatory disease

In most cases, sexually transmitted organisms, especially N. gonorrhoeae and C. trachomatis, are involved; however, pelvic inflammatory disease may be caused by organisms that are part of the vaginal flora, such as anaerobes, G. vaginalis, H. influenzae, gram-negative enterobacteria, and Streptococcus agalactiae. Some experts also believe that M. hominis and U. urealyticum may be the etiologic agent of pelvic inflammatory disease.

These diseases are caused by gonococci, chlamydia, streptococci, staphylococci, mycoplasmas, E. coli, enterococci, and proteus. Anaerobic pathogens (bacteroids) play a major role in their occurrence. As a rule, inflammatory processes are caused by mixed microflora.

Pathogens of inflammatory diseases are most often brought in from outside (exogenous infection); less common are processes whose origin is associated with the penetration of microbes from the intestines or other foci of infection in the woman's body (endogenous infection). Inflammatory diseases of septic etiology occur when the integrity of tissues is compromised (entry gate of infection).

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Forms

Inflammatory diseases of the upper genital organs or inflammatory diseases of the pelvic organs include inflammation of the endometrium (myometrium), fallopian tubes, ovaries and pelvic peritoneum. Isolated inflammation of these organs of the genital tract is rare in clinical practice, since they all represent a single functional system.

Based on the clinical course of the disease and on the basis of pathomorphological studies, two clinical forms of purulent inflammatory diseases of the internal genital organs are distinguished: uncomplicated and complicated, which ultimately determines the choice of management tactics.

Uncomplicated forms include:

• endometritis,
• acute purulent salpingitis,
• pelvioperitonitis,

Complicated ones include all encapsulated inflammatory tumors of the appendages - purulent tubo-ovarian formations.

Complications and consequences

Any form of inflammatory disease of the upper female genital organs can be complicated by the development of an acute purulent process.

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Diagnostics pelvic inflammatory disease

The diagnosis is established based on the patient's complaints, life and disease history data, general examination and gynecological examination results. The nature of morphological changes in the internal genital organs (salpingo-oophoritis, endometritis, endomyometritis, tubo-ovarian abscess, pyosalpinx, inflammatory tubo-ovarian formation, pelvioperitonitis, peritonitis), and the course of the inflammatory process (acute, subacute, chronic) are taken into account. The diagnosis must reflect the presence of concomitant gynecological and extragenital diseases.

All patients must undergo examination of discharge from the urethra, vagina, cervical canal (if necessary, washings from the rectum) in order to determine the flora and sensitivity of the isolated pathogen to antibiotics, as well as discharge from the fallopian tubes, contents of the abdominal cavity (effusion), obtained during laparoscopy or laparotomy.

To determine the degree of microcirculation disorders, it is advisable to determine the number of erythrocytes, erythrocyte aggregation, hematocrit, the number of platelets and their aggregation. From the indicators of non-specific protection, the phagocytic activity of leukocytes should be determined.

Serological and immunoenzyme methods are used to establish the specific etiology of the disease. If tuberculosis is suspected, tuberculin reactions must be performed.

Additional instrumental methods include ultrasound examination, computed tomography of small organs, and laparoscopy. If laparoscopy is not possible, a puncture of the abdominal cavity is performed through the posterior vaginal fornix.

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Diagnostic Notes

Due to the wide range of symptoms and signs, the diagnosis of acute pelvic inflammatory disease in women presents significant difficulties. Many women with pelvic inflammatory disease have mild to moderate symptoms that are not always recognized as pelvic inflammatory disease. Consequently, delay in diagnosis and appropriate treatment leads to inflammatory complications in the upper reproductive tract. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and for a more complete bacteriological diagnosis. However, this diagnostic technique is often unavailable in acute cases or in milder cases where symptoms are mild or vague. Moreover, laparoscopy is not suitable for the detection of endometritis and mild inflammation of the fallopian tubes. Therefore, as a rule, the diagnosis of pelvic inflammatory disease is made on the basis of clinical features.

Clinical diagnosis of acute pelvic inflammatory disease is also poorly defined. Data show that clinical diagnosis of symptomatic pelvic inflammatory disease has positive predictive values (PPVs) for salpingitis of 65% to 90% compared with laparoscopy as the standard. PPVs for clinical diagnosis of acute pelvic inflammatory disease vary by epidemiologic characteristics and type of health care setting; they are higher in sexually active young women (especially adolescents), in patients presenting to STD clinics, or in areas with a high prevalence of gonorrhea and chlamydia. However, no single history, physical, or laboratory criterion has equal sensitivity and specificity for diagnosing an acute episode of pelvic inflammatory disease (i.e., a criterion that can be used to identify all cases of PID and to exclude all women without pelvic inflammatory disease). When diagnostic techniques are combined that improve either sensitivity (identify more women with PID) or specificity (exclude more women who do not have PID), they do so at the expense of one another. For example, requiring two or more criteria excludes more women without PID, but also reduces the number of women with PID identified.

A large number of episodes of pelvic inflammatory disease remain unrecognized. Although some women with PID are asymptomatic, others remain undiagnosed because the health care provider fails to correctly interpret subtle or nonspecific symptoms and signs, such as unusual bleeding, dyspareunia, or vaginal discharge ("atypical PID"). Because of the diagnostic challenges and the potential for reproductive harm in women with even mild or atypical PID, experts recommend that health care providers use a "low threshold" for diagnosis of PID. Even under these circumstances, the impact of early treatment on clinical outcome in women with asymptomatic or atypical PID is unknown. These guidelines for the diagnosis of PID are intended to help health care providers consider the possibility of PID and to have additional information to make the correct diagnosis. These recommendations are based in part on the fact that the diagnosis and management of other common causes of lower abdominal pain (eg, ectopic pregnancy, acute appendicitis, and functional pain) are unlikely to be impaired if a health care provider initiates empirical antimicrobial treatment for pelvic inflammatory disease.

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Minimum criteria

Empirical treatment for pelvic inflammatory disease should be considered in sexually active young women and others at risk for STDs when all of the following criteria are met and there is no other cause for the patient's illness:

• Pain on palpation in the lower abdomen,
• Pain in the appendages, and
• Painful cervical traction.

Additional criteria

Diagnostic overestimation is often justified because incorrect diagnosis and treatment can lead to serious consequences. These additional criteria can be used to increase diagnostic specificity.

Below are additional criteria that support the diagnosis of pelvic inflammatory disease:

• Temperature above 38.3°C,
• Abnormal discharge from the cervix or vagina,
• Increased ESR,
• Elevated C-reactive protein levels,
• Laboratory confirmation of cervical infection caused by N. gonorrhoeae or C. trachomatis.

Below are the defining criteria for the diagnosis of pelvic inflammatory diseases, which are evidenced by selected cases of diseases:

• Histopathological finding of endometritis on endometrial biopsy,
• Transvaginal ultrasound (or other technology) showing thickened, fluid-filled fallopian tubes with or without free fluid in the abdominal cavity or the presence of a tubo-ovarian mass,
• Abnormalities found at laparoscopy consistent with PID.

Although the decision to initiate treatment may be made before a bacteriologic diagnosis of N. gonorrhoeae or C. trachomatis infections has been made, confirmation of the diagnosis emphasizes the need to treat sexual partners.

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Treatment pelvic inflammatory disease

If acute inflammation is detected, the patient should be hospitalized, where she is provided with a therapeutic and protective regimen with strict adherence to physical and emotional rest. Bed rest, ice on the hypogastric region (2 hours with breaks of 30 minutes - 1 hour for 1-2 days), a gentle diet are prescribed. Intestinal activity is carefully monitored, warm cleansing enemas are prescribed if necessary. Bromine, valerian, and sedatives are useful for patients.

Etiopathogenetic treatment of patients with inflammatory diseases of the pelvic organs involves the use of both conservative therapy and timely surgical treatment.

Conservative treatment of acute inflammatory diseases of the upper genital organs is carried out in a comprehensive manner and includes:

• antibacterial therapy;
• detoxification therapy and correction of metabolic disorders;
• anticoagulant therapy;
• immunotherapy;
• symptomatic therapy.

Antibacterial therapy

Since the microbial factor plays a decisive role in the acute stage of inflammation, antibacterial therapy is decisive in this period of the disease. During the first day of the patient's stay in the hospital, when there is still no laboratory data on the nature of the pathogen and its sensitivity to a certain antibiotic, the presumptive etiology of the disease is taken into account when prescribing drugs.

In recent years, the effectiveness of treating severe forms of purulent-inflammatory complications has increased with the use of beta-lactam antibiotics (augmentin, meronem, tienam). The "gold" standard is the use of clindamycin with gentamicin. It is recommended to change antibiotics after 7-10 days with repeated determination of antibiograms. Due to the possible development of local and generalized candidiasis during antibiotic therapy, it is necessary to study hemo- and urocultures, as well as prescribe antifungal drugs.

If oliguria occurs, an immediate revision of the doses of antibiotics used is indicated, taking into account their half-life.

Treatment regimens for pelvic inflammatory disease should empirically eliminate a broad spectrum of potential pathogens, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci. Although some antimicrobial regimens have been shown to be effective in achieving clinical and microbiologic cure in a randomized clinical trial with short-term follow-up, there are few studies assessing and comparing the elimination of endometrial and fallopian tube infection or the incidence of long-term complications such as tubal infertility and ectopic pregnancy.

All treatment regimens should be effective against N. gonorrhoeae and C. trachomatis, since negative endocervical tests for these infections do not exclude infection in the upper reproductive tract. Although the need to eradicate anaerobes in women with PID is still controversial, there is evidence that it may be important. Anaerobic bacteria isolated from the upper reproductive tract of women with PID and in vitro data clearly indicate that anaerobes such as B. fragilis can cause tubal and epithelial destruction. In addition, many women with PID also have bacterial vaginosis. To prevent complications, recommended regimens should include drugs that are active against anaerobes. Treatment should be initiated as soon as the preliminary diagnosis is made, since the prevention of late sequelae is closely related to the timing of appropriate antibiotic administration. When choosing a treatment regimen, the physician must consider its availability, cost, patient acceptability, and the sensitivity of pathogens to antibiotics.

In the past, many experts recommended that all women with PID be hospitalized so that parenteral antibiotics could be administered under bed rest and supervision. However, hospitalization is no longer synonymous with parenteral therapy. There are currently no data available to compare the effectiveness of parenteral versus oral treatment, or inpatient versus outpatient treatment. Until the results of ongoing trials comparing parenteral inpatient versus oral outpatient treatment in women with PID become available, observational data should be considered. The decision to hospitalize should be based on the following observational and theoretical recommendations:

• Conditions requiring urgent surgical intervention, such as appendicitis, cannot be ruled out.
• The patient is pregnant,
• Unsuccessful treatment with oral antimicrobials,
• Inability to adhere to or tolerate outpatient oral regimen,
• Severe illness, nausea and vomiting, or high fever.
• Tuboovarian abscess,
• Presence of immunodeficiency (HIV infection with low CD4 count, immunosuppressive therapy or other diseases).

Most clinicians provide at least 24 hours of direct observation in the hospital for patients with tubo-ovarian abscesses, after which adequate parenteral treatment should be instituted at home.

There are no convincing data comparing parenteral and oral regimens. There is considerable experience with the following regimens. There are also multiple randomized trials demonstrating the efficacy of each regimen. Although most studies have used parenteral therapy for at least 48 hours after the patient has shown significant clinical improvement, this regimen has been assigned arbitrarily. Clinical experience should guide the decision to switch to oral therapy, which can be made within 24 hours of the onset of clinical improvement.

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Regimen A for parenteral treatment

• Cefotetan 2 g IV every 12 hours,
• or Cefoxitin 2 g IV every 6 hours
• plus Doxycycline 100 mg IV or orally every 12 hours.

NOTE: Because intravenous infusions are associated with pain, doxycycline should be given orally whenever possible, even if the patient is hospitalized. Oral and intravenous doxycycline have similar bioavailability. When intravenous administration is necessary, the use of lidocaine or other rapidly acting local anesthetics, heparin, or steroids or prolongation of the infusion time may reduce infusion complications. Parenteral therapy can be discontinued 24 hours after the patient has shown clinical improvement, and oral doxycycline 100 mg twice daily should be continued for 14 days. In the presence of a tubo-ovarian abscess, many clinicians use clindamycin or metronidazole with doxycycline for continuation therapy rather than doxycycline alone because it provides better coverage of the entire spectrum of pathogens, including anaerobes.

Clinical data on second- or third-generation cephalosporins (eg, ceftizoxime, cefotaxime, or ceftriaxone), which can replace cefoxitin or cefotetan, are limited, although many authors believe that they are also effective in PID. However, they are less active against anaerobic bacteria than cefoxitin or cefotetan.

Regimen B for parenteral treatment

• Clindamycin 900 mg IV every 8 hours
• plus Gentamicin - loading dose intravenously or intramuscularly (2 mg/kg body weight), then a maintenance dose (1.5 mg/kg) every 8 hours.

NOTE: Although the use of single-dose gentamicin has not been studied in the treatment of pelvic inflammatory disease, its efficacy in other similar situations is well established. Parenteral therapy may be discontinued 24 hours after the patient has shown clinical improvement and then switched to oral doxycycline 100 mg twice daily or clindamycin 450 mg orally 4 times daily. The total duration of treatment should be 14 days.

For tubo-ovarian abscess, many health care providers use clindamycin rather than doxycycline for continuation treatment because it is more effective against anaerobic organisms.

Alternative parenteral treatment regimens

There are limited data using other parenteral regimens, but the following three regimens have each been tested in at least one clinical trial and have shown efficacy against a broad spectrum of microorganisms.

• Ofloxacin 400 mg IV every 12 hours,
• plus Metronidazole 500 mg IV every 8 hours.
• or Ampicillin/sulbactam 3 g IV every 6 hours,
• plus Doxycycline 100 mg orally or IV every 12 hours.
• or Ciprofloxacin 200 mg IV every 12 hours
• plus Doxycycline 100 mg orally or IV every 12 hours.
• plus Metronidazole 500 mg IV every 8 hours.

The regimen of ampicillin/sulbactam with doxycycline was effective against N. gonorrhoeae, C. trachomatis, and anaerobes and was effective in patients with tubo-ovarian abscess. Both intravenous drugs, ofloxacin and ciprofloxacin, have been studied as monotherapy. Given the data on the low effectiveness of ciprofloxacin against C. trachomatis, it is recommended to routinely add doxycycline to the treatment. Since these quinolones are active only against some anaerobes, metronidazole should be added to each regimen.

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Oral treatment

There are few data on the immediate and long-term outcome of treatment, either with parenteral or outpatient regimens. The following regimens provide antimicrobial coverage against the most common etiologic agents of PID, but clinical trial data on their use are limited. Patients who do not improve within 72 hours with oral therapy should be re-evaluated to confirm the diagnosis and treated with parenteral therapy in an outpatient or inpatient setting.

Scheme A

• Ofloxacin 400 mg 2 times a day for 14 days,
• plus Metronidazole 500 mg orally twice daily for 14 days

Oral ofloxacin used as monotherapy has been studied in two well-designed clinical trials and was effective against N. gonorrhoeae and C. trachomatis. However, given that ofloxacin is still not effective enough against anaerobes, the addition of metronidazole is necessary.

Scheme B

• Ceftriaxone 250 mg intramuscularly once,
• or Cefoxitin 2 g IM plus Probenecid, 1 g orally once simultaneously,
• or Another third-generation parenteral cephalosporin (eg, ceftizoxime, cefotaxime),
• plus Doxycycline 100 mg orally twice daily for 14 days. (Use this regimen with one of the above regimens)

The optimal choice of cephalosporin for this regimen is unclear; while cefoxitin is active against a wider range of anaerobes, ceftriaxone has greater efficacy against N. gonorrhoeae. Clinical trials have shown that a single dose of cefoxitin is effective in producing rapid clinical response in women with PID, but theoretical data suggest the addition of metronidazole. Metronidazole will also be effective in treating bacterial vaginosis, which is often associated with PID. There are no published data on the use of oral cephalosporins for the treatment of PID.

Alternative outpatient regimens

Information on the use of other outpatient regimens is limited, but one regimen has been tested in at least one clinical trial and shown to be effective against a broad spectrum of pelvic inflammatory disease pathogens. The combination of amoxicillin/clavulanic acid with doxycycline has produced rapid clinical response, but many patients have had to discontinue treatment because of gastrointestinal symptoms. Several studies have evaluated azithromycin in the treatment of upper reproductive tract infections, but the data are insufficient to recommend this drug for the treatment of pelvic inflammatory disease.

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Detoxification therapy and correction of metabolic disorders

This is one of the most important components of treatment aimed at breaking the pathological circle of cause-and-effect relationships that arise in purulent-inflammatory diseases. It is known that these diseases are accompanied by a violation of all types of metabolism, the removal of a large amount of fluid; an imbalance of electrolytes, metabolic acidosis, renal and hepatic failure occur. Adequate correction of the identified disorders is carried out jointly with resuscitation doctors. When carrying out detoxification and correction of water-electrolyte metabolism, two extreme conditions should be avoided: insufficient fluid intake and hyperhydration of the body.

In order to eliminate the above errors, it is necessary to control the amount of fluid introduced from the outside (drinks, food, medicinal solutions) and excreted with urine and other ways. The calculation of the introduced fluid should be individual, taking into account the above parameters and the patient's condition. Correct infusion therapy in the treatment of acute inflammatory and purulent-inflammatory diseases is no less important than the prescription of antibiotics. Clinical experience shows that a patient with stable hemodynamics with adequate replenishment of the BCC is less susceptible to the development of circulatory disorders and the occurrence of septic shock.

The main clinical signs of restoration of the circulating blood volume and elimination of hypovolemia are the central venous pressure (60-100 mm H2O), diuresis (more than 30 ml/h without the use of diuretics), and improvement of microcirculation (skin color, etc.).

Pelvioperitonitis is observed quite often in the development of inflammatory diseases of the pelvic organs. Since inflammation of the peritoneum is accompanied by an increase in extrarenal fluid and electrolyte losses, it is necessary to take into account the basic principles of fluid and protein replenishment. According to modern concepts, both colloidal solutions (plasma, albumin, low-molecular dextrans) and crystalloid solutions (0.9% sodium chloride solution) should be administered per 1 kg of the patient's body weight.

Crystalloid solutions include isotonic sodium chloride solution, 10% and 5% glucose solution, Ringer-Locke solution, and polyionic solutions. Colloid solutions include low-molecular dextrans. It should be emphasized that the total amount of dextrans should not exceed 800-1200 ml/day, since their excessive administration can contribute to the development of hemorrhagic diathesis.

Patients with septic complications of extra-hospital abortion lose a significant amount of electrolytes along with the fluid. During treatment, it becomes necessary to quantitatively calculate the introduction of the main electrolytes - sodium, potassium, calcium and chlorine. When introducing corrective doses of electrolyte solutions, it is necessary to adhere to the following:

1. Electrolyte deficiency should be replenished slowly, drop by drop, avoiding the use of concentrated solutions.
2. Periodic monitoring of the acid-base balance and serum electrolytes is indicated, since the corrective doses are calculated only for the extracellular fluid.
3. There is no need to strive to bring their indicators to the absolute norm.
4. After achieving stable normal serum electrolyte levels, only a maintenance dose is administered.
5. If kidney function deteriorates, it is necessary to reduce the volume of administered fluid, reduce the amount of administered sodium and completely eliminate the administration of potassium. To conduct detoxification therapy, the method of fractional forced diuresis is widely used, obtaining 3000-4000 ml of urine per day.

Since hypoproteinemia is always observed in septic conditions due to a disruption of protein synthesis, as well as due to increased protein breakdown and previous blood loss, the administration of protein preparations is mandatory (plasma, albumin, protein).

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Anticoagulant therapy

In widespread inflammatory processes, pelvic peritoneum, peritonitis, patients may experience thromboembolic complications, as well as the development of disseminated intravascular coagulation syndrome (DIC).

Currently, one of the first signs of DIC is thrombocytopenia. A decrease in the platelet count to 150 x 10 ³ /l is the minimum that does not lead to hypocoagulation bleeding.

In practice, determination of the prothrombin index, platelet count, fibrinogen level, fibrin monomers and blood clotting time is sufficient for timely diagnosis of DIC. For the prevention of DIC and with minor changes in the above tests, heparin is prescribed at 5000 U every 6 hours under the control of blood clotting time within 8-12 minutes (according to Lee-White). The duration of heparin therapy depends on the speed of improvement of laboratory data and is usually 3-5 days. Heparin should be prescribed before the blood clotting factors decrease significantly. Treatment of DIC syndrome, especially in severe cases, is extremely difficult.

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Immunotherapy

Along with antibacterial therapy, in conditions of low sensitivity of pathogens to antibiotics, agents that increase the general and specific reactivity of the patient's body are of particular importance, since generalization of the infection is accompanied by a decrease in cellular and humoral immunity. Based on this, substances that increase immunological reactivity are included in the complex therapy: antistaphylococcal gamma globulin and hyperimmune antistaphylococcal plasma. Gamma globulin is used to increase non-specific reactivity. Such drugs as levamisole, taktivin, timogen, cycloferon contribute to an increase in cellular immunity. Efferent therapy methods (plasmapheresis, ultraviolet and laser irradiation of blood) are also used to stimulate immunity.

Symptomatic treatment

An essential condition for the treatment of patients with inflammatory diseases of the upper genital organs is effective pain relief using both analgesics and antispasmodics, as well as prostaglandin synthesis inhibitors.

It is mandatory to introduce vitamins based on the daily requirement: thiamine bromide - 10 mg, riboflavin - 10 mg, pyridoxine - 50 mg, nicotinic acid - 100 mg, cyanocobalamin - 4 mg, ascorbic acid - 300 mg, retinol acetate - 5000 U.

The prescription of antihistamines (suprastin, tavegil, diphenhydramine, etc.) is indicated.

Rehabilitation of patients with inflammatory diseases of the upper genital organs

Treatment of inflammatory diseases of the female genital organs necessarily includes a set of rehabilitation measures aimed at restoring the specific functions of the female body.

To normalize menstrual function after acute inflammation, medications are prescribed that are aimed at preventing the development of algomenorrhea (antispasmodics, nonsteroidal anti-inflammatory drugs). The most acceptable form of administration of these medications are rectal suppositories. Restoration of the ovarian cycle is carried out by prescribing combined oral contraceptives.

Physiotherapeutic methods in the treatment of pelvic inflammatory diseases are prescribed differentially, depending on the stage of the process, duration of the disease and effectiveness of previous treatment, presence of concomitant extragenital pathology, state of the central and autonomic nervous system and age characteristics of the patient. The use of hormonal contraception is recommended.

In the acute stage of the disease, with a body temperature below 38° C, UHF is prescribed to the hypogastric region and lumbosacral plexus using a transverse technique in a non-thermal dosage. With a pronounced edematous component, combined exposure to ultraviolet light is prescribed to the panty area in 4 fields.

In the case of a subacute onset of the disease, it is preferable to prescribe a microwave electromagnetic field.

When the disease passes into the stage of residual phenomena, the task of physiotherapy is to normalize the trophism of the affected organs by changing the vascular tone, the final relief of edematous phenomena and pain syndrome. For this purpose, reflex methods of exposure to supersonic frequency currents are used. D'Arsonval, ultrasound therapy.

When the disease goes into remission, heat and mud therapy (paraffin, ozokerite) procedures are prescribed for the panty area, balneotherapy, aerotherapy, heliotherapy and thalassotherapy.

In the presence of chronic inflammation of the uterus and its appendages in the period of remission, it is necessary to prescribe resorption therapy using biogenic stimulants and proteolytic enzymes. The duration of rehabilitation measures after acute inflammation of the internal genital organs is usually 2-3 menstrual cycles. A pronounced positive effect and a decrease in the number of exacerbations of chronic inflammatory processes are noted after spa treatment.

Surgical treatment of purulent-inflammatory diseases of the internal genital organs

Indications for surgical treatment of purulent-inflammatory diseases of the female genital organs are currently:

1. Lack of effect when conservative complex therapy is carried out within 24-48 hours.
2. Deterioration of the patient's condition during conservative treatment, which may be caused by perforation of a purulent formation into the abdominal cavity with the development of diffuse peritonitis.
3. Development of symptoms of bacterial toxic shock. The extent of surgical intervention in patients with inflammatory diseases of the uterine appendages depends on the following main points:
   1. nature of the process;
   2. concomitant pathology of the genital organs;
   3. age of patients.

It is the young age of patients that is one of the main factors determining the commitment of gynecologists to sparing operations. In the presence of concomitant acute pelvic peritonitis In case of purulent lesions of the uterine appendages, extirpation of the uterus is performed, since only such an operation can ensure complete elimination of the infection and good drainage. One of the important moments of surgical treatment of purulent inflammatory diseases of the uterine appendages is the complete restoration of normal anatomical relationships between the pelvic organs, abdominal cavity and surrounding tissues. It is necessary to perform a revision of the abdominal cavity, determine the condition of the vermiform appendix and exclude interintestinal abscesses in the case of a purulent nature of the inflammatory process in the uterine appendages.

In all cases, when performing surgery for inflammatory diseases of the uterine appendages, especially in the case of a purulent process, one of the main principles should be the mandatory complete removal of the site of destruction, i.e. the inflammatory formation. No matter how gentle the operation is, it is always necessary to completely remove all tissues of the inflammatory formation. Preservation of even a small section of the capsule often leads to severe complications in the postoperative period, relapses of the inflammatory process, and the formation of fistulas. Drainage of the abdominal cavity (colyutomy) is mandatory during surgical intervention.

The condition for reconstructive surgery with preservation of the uterus is, first of all, the absence of purulent endomyometritis or panmetritis, multiple extragenital purulent foci in the small pelvis and abdominal cavity, as well as concomitant severe genital pathology (adenomyosis, myoma), established before or during surgery.

In women of reproductive age, if conditions are present, it is necessary to perform an extirpation of the uterus with preservation, if possible, of at least part of the unchanged ovary.

In the postoperative period, complex conservative therapy continues.

Follow-up observation

In patients receiving oral or parenteral therapy, significant clinical improvement (e.g., decreased temperature, decreased abdominal wall muscle tension, decreased tenderness on palpation during examination of the uterus, appendages, and cervix) should be observed within 3 days of starting treatment. Patients who do not experience such improvement require clarification of the diagnosis or surgical intervention.

If the physician has chosen outpatient oral or parenteral therapy, follow-up and testing of the patient should be performed within 72 hours, using the above criteria for clinical improvement. Some experts also recommend repeat screening for C. trachomatis and N. gonorrhoeae 4 to 6 weeks after completion of therapy. If PCR or LCR is used to monitor cure, repeat testing should be performed one month after completion of therapy.

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Management of sexual partners

Examination and treatment of sexual partners (in contact in the previous 60 days before the onset of symptoms) of women with PID is necessary because of the risk of reinfection and the high probability of gonococcal or chlamydial urethritis. Male sexual partners of women with PID caused by gonococci or chlamydia are often asymptomatic.

Sexual partners should be treated empirically according to the treatment regimen for both infections, regardless of whether the etiologic agent of pelvic inflammatory disease is identified.

Even in clinics that see only women, health care providers should ensure that male sexual partners of women with PID are treated. If this is not possible, the health care provider treating the woman with PID should ensure that her partners are treated appropriately.

Special Notes

Pregnancy: Given the high risk of adverse pregnancy outcome, pregnant women with suspected PID should be hospitalized and treated with parenteral antibiotics.

HIV infection. Differences in the clinical presentation of PID between HIV-infected and uninfected women have not been described in detail. Early observational data suggested that HIV-infected women with PID were more likely to require surgical intervention. Subsequent, more comprehensive reviews of HIV-infected women with PID noted that even though symptoms were more severe than in HIV-negative women, parenteral antibiotic treatment was successful. In another trial, microbiologic findings were similar in HIV-infected and uninfected women, except for higher rates of concomitant chlamydial and HPV infection and HPV-associated cellular changes. Immunocompromised HIV-infected women with PID require more aggressive therapy using one of the parenteral antimicrobial regimens described in this guideline.