Treatment of purulent gynecologic diseases

The tactics of managing patients with purulent inflammatory diseases of the pelvic organs are largely determined by the timeliness and accuracy of diagnosis of the nature of the process, the extent of its spread and the assessment of the real risk of developing purulent complications, while the clinical approach and the ultimate goal are fundamentally important - timely and complete elimination of this process, as well as the prevention of complications and relapses.

That is why the importance of a correct, and most importantly, timely diagnosis in these patients is difficult to overestimate. The concept of diagnosing purulent lesions (clinically clearly thought out and instrumentally proven definition of the stages of localization of the process and the stage of suppuration) should be the foundation of successful treatment.

The main thing in this concept is the following:

1. Determination of the exact localization of the lesion, while it is important to identify not only the main "genital" but also extragenital foci. It is necessary to clarify whether there are foci of purulent destruction of cellular spaces, adjacent and distant organs and what is their depth and degree of prevalence.
2. Determining the extent of damage to an organ or organs (for example, purulent salpingitis or pyosalpinx; purulent endometritis, purulent endomyometritis or panmetritis), i.e. resolving the most important issue of the reversibility of the process and, accordingly, determining the adequate individual volume and optimal method of surgical intervention (drainage, laparoscopy or laparotomy), as well as predicting the immediate and distant prospects (life, health, reproduction) for each patient.
3. Determination of the form of purulent inflammation (acute, subacute, chronic) and the phase of the chronic purulent process (exacerbation, remission) to select the optimal moment for surgical intervention and determine the volume and nature of conservative therapy during preoperative preparation (inclusion of antibacterial therapy in the preparation complex or refusal to use it, for example, in patients with chronic purulent inflammation in the remission stage of the process).
4. Determination of the severity of intoxication and general disorders, since in patients with purulent diseases of the genitals, as in the case of a purulent process of any other localization, it is the degree of intoxication that directly correlates with the nature and severity of damage. Therefore, only by assessing the degree of metabolic disorders and intoxication, it is possible to carry out the necessary correction (up to extracorporeal detoxification methods) and prepare the patient for subsequent manipulations and interventions.

Thus, the attending physician must answer the basic questions: where is the lesion located, what organs and tissues and to what extent are involved in it, what is the stage of the inflammatory process and what is the degree of intoxication.

The choice of instrumental, laboratory and other diagnostic methods of research depends, of course, on the doctor himself - his experience, qualifications and knowledge. But he must do everything so that the answers to the above questions for such patients are exhaustive, because the outcome of the disease ultimately depends on this.

The successful outcome of treatment is based on surgical and medicinal components, and they should always be considered as a single whole. The medicinal component is a prologue to surgical treatment (even in emergency interventions in patients with purulent inflammation, short but vigorous correction of volemic and metabolic disorders is necessary), and, in addition, it always follows the surgical component, ensuring immediate and delayed rehabilitation.

The following is fundamentally important in the surgical component of treatment:

1. Complete removal of the focus of purulent destruction. This may be a "block" of organs, an organ, its part, cellulose, etc. The main condition for performing surgical reconstructive organ-preserving operations is the complete removal of pus, destructive necrotic tissues, pyogenic membrane, etc. The thesis "to preserve reproductive function at any cost" in a number of patients with purulent genital lesions is unacceptable, moreover, it is dangerous for their lives. However, there are and will always be situations and operations that we call "situations and operations of conscious risk." These are mainly surgical interventions in young patients with complicated, and sometimes septic forms of purulent infection, when, according to all surgical canons, it is necessary to perform a radical operation, which, undoubtedly, will have the most detrimental effect on the future fate of this girl. However, by consciously limiting the scope of the operation and giving such a patient a chance to realize her menstrual and, possibly, reproductive function in the future, on the other hand, the doctor risks progression or even generalization of the purulent process, i.e. severe and sometimes fatal complications. Taking full responsibility for the fate of the patient, the surgeon must decide in each specific case whether the risk is justified. Only a highly qualified specialist using optimal surgical technique, drainage, dynamic postoperative monitoring (in case of deterioration - timely relaparotomy and radical surgery) and intensive treatment (including antibiotics of the last resort) can perform "conscious risk" operations. It should be emphasized that in any situation, even when performing radical interventions, it is necessary to fight for the preservation of the patient's hormonal function at the slightest opportunity, i.e. to leave at least part of the ovarian tissue (at any age except menopause), since surgical castration, even with the availability of modern means of replacement therapy, is a mutilating intervention.
2. Adequate drainage of all surgical destruction zones. It should be remembered that the term "adequate" means aspiration drainage, which ensures constant evacuation of not only wound secretion, but also surgical substrate - liquid blood and clots, pus residues, necrotic masses. This is why evacuation must be constant and forced.
3. Refusal of local (intraoperative) use in patients with purulent lesions of the pelvic organs of various local sorbents, hemostatic sponges, and especially tampons, etc., because in these cases the main condition for a successful outcome is violated - free evacuation of wound discharge - and the prerequisites for the accumulation of microbes and toxins are created, i.e. a real basis for postoperative complications, and in particular abscess formation.
4. Categorical refusal from intraoperative use of electrocoagulators, coagulation scalpels and other devices for surgical coagulation in such patients. Any, even minimal, coagulation necrosis in conditions of purulent inflammation leads to its aggravation (an ideal environment for anaerobic microorganisms, the possibility of severe coagulation tissue damage even with the correct use of devices due to disruption of tissue trophism and changes in conductivity - increased hydrophilicity, tissue infiltration, changes in spatial relationships) and complicates the already difficult course of the postoperative period.

These conceptual principles do not at all mean the exclusion of a strictly individual surgical approach in each specific case: in the technique of approaching and isolating the site of destruction, in the technique of its removal and hemostasis, in the features and duration of drainage, etc.

The medicinal component is, in essence, intensive therapy for a patient with purulent genital lesions. Its volume and features, of course, should always be individual, but it is necessary to adhere to the following principles:

1. Adequate pain relief in the postoperative period (from non-narcotic analgesics to long-term epidural anesthesia). This component is extremely important, since only under pain relief conditions the course of reparative processes is not disrupted.
2. Antimicrobial therapy, the meaning, necessity and importance of which do not need explanation.
3. Detoxification therapy. The approach to this type of treatment is, of course, strictly individual, but it is important to remember that there is no purulent process without intoxication, the latter persists for a long time after the removal of pus and purulent focus, often its degree depends on the severity of concomitant extragenital diseases.

Of course, drug treatment of these patients is much broader, in each specific case it is individual in nature and often includes the use of immunomodulators, adaptogens, steroid hormones, heparin, symptomatic agents, etc.

Thus, in relation to patients with purulent diseases of the genital organs, an active approach in general and adherence to the basic fundamental conceptual provisions in particular are important, without which the outcome of the process may be called into question.

The currently existing different points of view on treatment methods are associated with the lack of a unified classification of purulent diseases of the pelvic organs and a single terminology in the interpretation of forms of purulent inflammation.

Regarding existing classifications, it is necessary to say that abroad they mainly use the classification of G. Monif, which divides acute inflammatory processes of the internal genital organs into:

1. acute endometritis and salpingitis without signs of inflammation of the pelvic peritoneum;
2. acute endometritis and salpingitis with signs of peritoneal inflammation;
3. acute salpingo-oophoritis with occlusion of the fallopian tubes and development of tubo-ovarian formations;
4. rupture of the tuboovarian formation.

Based on the clinical course of the disease and pathomorphological studies, our clinic considers it appropriate to distinguish two clinical forms of purulent inflammatory diseases of the genitals: uncomplicated and complicated, which ultimately determines the choice of management tactics. Uncomplicated forms practically include only acute purulent salpingitis, complicated forms include all encapsulated inflammatory appendage tumors - purulent tubo-ovarian formations.

Acute purulent salpingitis develops, as a rule, as a result of a specific infection - gonorrhea. With timely diagnosis and targeted therapy, the process can be limited to damage to the endosalpinx with subsequent regression of inflammatory changes and recovery.

In case of late or inadequate therapy, acute purulent salpingitis is complicated by pelvioperitonitis with partial delimitation of purulent exudate in the uterorectal pouch (abscess of Douglas's pouch) or becomes chronic - pyosalpinx or purulent tuboovarian formation. In these cases, changes in all layers of the fallopian tube and ovarian stroma are irreversible, which is confirmed by morphological studies.

If early and adequate complex treatment of purulent salpingitis makes it possible for patients to fully recover and for reproductive function to be realized, then with purulent tubo-ovarian formations the prospects for subsequent childbearing are sharply reduced or problematic, and the patient can only recover after surgical treatment. With delayed surgical intervention and further progression of the process, severe purulent complications develop that threaten the patient's life.

Further development of the purulent process follows the path of complications: simple and complex genital fistulas, microperforation of the abscess into the abdominal cavity with the formation of interintestinal and subdiaphragmatic abscesses, purulent-infiltrative omentitis. Mortality in such cases, according to literary data, reaches 15%. The final outcome of severe complications of the purulent process is peritonitis and sepsis.

Clinical manifestations of purulent inflammatory process of uterine appendages are diverse. They are caused by a number of factors: the nature of microbial pathogens, duration of the disease, stage of inflammation, depth of destructive process and nature of damage to organs and systems, as well as features of previous conservative treatment, dosage and nature of antibacterial drugs used.

Even with the possibility of using the most modern research methods, the main diagnostic method that demonstrates professional qualifications and the level of clinical thinking is clinical. According to our data, the coincidence of clinical (anamnesis and general and gynecological examination data) and intraoperative diagnosis was 87.2%. All purulent diseases have specific symptoms reflected in subjective complaints or objective examination data. The development of complications also goes through successive stages and is clearly traced in all patients when collecting information about the history of the disease (if, of course, the doctor is aware of the peculiarities of the course of the disease and asks targeted questions). For example, an episode in the anamnesis of frequent stools with the separation of mucus or pus through the rectum and subsequent improvement in the condition of a patient with a long-term purulent process may indirectly indicate the perforation of an abscess into the rectum. Periodic recurrence of such symptoms will most likely indicate the possibility of a functioning purulent appendicointestinal fistula, the nature of which can be clarified using ultrasound and additional contrast of the rectum, as well as invasive research methods, in particular colonoscopy or CT with fistulography.

Even if the diseases have a similar clinical picture to a certain extent (for example, purulent salpingitis, purulent tubo-ovarian formations in the acute stage), there are always clinical signs (initiation of the disease, its duration, degree of intoxication, etc., as well as microsymptomatology) that allow for a more precise primary clinical diagnosis.

All subsequent diagnostic measures should be aimed at determining the depth of purulent-destructive lesions of the uterus and appendages, pelvic tissue and adjacent pelvic organs (intestines, ureters, bladder).

The duration of preoperative preparation and the extent of the proposed surgical intervention must be clarified before the operation.

Sufficient information can be obtained by using non-invasive and invasive diagnostic methods.

In uncomplicated forms:

• Stage 1 - clinical examination, including bimanual, as well as bacteriological and laboratory tests;
• Stage 2 – transvaginal ultrasound of the pelvic organs;
• Stage 3 - laparoscopy.

In complicated forms:

• Stage 1 - clinical examination, including bimanual and rectovaginal examination, bacteriological and laboratory diagnostics;
• Stage 2 - transabdominal and transvaginal ultrasound of the pelvic organs, abdominal cavity, kidneys, liver and spleen; ultrasound with additional contrast of the rectum, if indicated - computed tomography (we have recently used it extremely rarely in a limited number of patients due to the high information content of modern ultrasound);
• Stage 3 - additional invasive examination methods: cystoscopy and colonoscopy, fistulography, X-ray examination of the intestine and urinary system.

Principles of treatment

The severity of general and local changes in patients with purulent formations of the uterine appendages, the morphologically proven irreversibility of destructive changes and, finally, the extreme danger of complications of varying nature and severity, would seem to provide every reason to believe that only surgical treatment is the best and, most importantly, the only way to recovery for these patients. Despite the obviousness of this truth, to this day some gynecologists advocate the tactics of conservative management of such patients, which consists of two manipulations:

1. puncture and evacuation of pus;
2. introduction of antibiotics and other medicinal substances into the lesion.

Recently, reports have appeared in the domestic and foreign press about successful results of therapeutic drainage of purulent inflammatory formations of the uterine appendages and pelvic abscesses under the control of transvaginal ultrasound or computed tomography.

However, there is no consensus on the indications, contraindications, and frequency of complications compared to open or laparoscopic surgical interventions in either domestic or foreign literature, and there is also no consensus on terminology.

As reported by A.N. Strizhakov (1996), “supporters of this method note its safety, believing that the evacuation of pus and the introduction of antibiotics directly into the site of inflammation improve treatment results and in many cases avoid traumatic surgical intervention.”

Although the authors believe that there are no absolute contraindications to the use of the method they propose, they nevertheless believe that its use is inappropriate “in the presence of purulent formations with numerous internal cavities (tubo-ovarian abscess of cystic-solid structure), as well as in the case of a high risk of injury to intestinal loops and main vessels.”

The works of foreign authors contain contradictory information. Thus, V. Caspi et al. (1996) performed drainage of tubo-ovarian abscesses under ultrasound control in combination with the introduction of an antibiotic into the abscess cavity in 10 patients. The average duration of the disease before drainage was 9.5 weeks. No severe complications were observed in the immediate postoperative period. However, a relapse of the purulent process was subsequently noted in three out of ten patients (30%).

It is believed that even multiple abscesses can be drained under ultrasound control. The authors consider the method of drainage under ultrasound control as a method of choice for the treatment of tubo-ovarian abscesses, which at the same time in some patients should only be a palliative preceding laparotomy.

There are reports of complications of this method and relapses of the disease: thus, T. Perez-Medina et al. (1996) noted a relapse of the purulent process in 5% of patients 4 weeks after discharge. According to G. Casola et al. (1992), after drainage of tubo-ovarian abscesses, complications were noted in 6 of 16 patients (38%) (sepsis developed in three of them, and one patient required radical surgery due to inadequate drainage and the development of extensive phlegmon). Two patients had relapses 3 and 4 months after drainage. Sonnenberg et al. (1991) performed transvaginal drainage of tubo-ovarian abscesses in 14 patients (in half with a needle, in the others - a catheter). The catheter was removed on average after 6-7 days. Two patients (14%) subsequently underwent surgery due to the development of extensive phlegmon.

The success rate of percutaneous drainage of intraperitoneal abscesses was 95%, while 5% died from septic shock.

FWShuler and CNNewman (1996) estimated the effectiveness of percutaneous drainage of abscesses in 67% of cases. One third of patients (33%) required surgical treatment due to inadequate drainage (22% due to clinical deterioration after drainage and 11% due to complications - perforation of the abscess and formation of a purulent intestinal fistula). There were also technical problems, including displacement or loss of drainage in 16.6% of cases and its blockage in 11.1% of patients. As a result, the authors concluded that the drainage method is unsuitable in one third of cases and proposed to immediately identify a group of patients in whom drainage is unlikely to be successful.

O.Goletti and P.V.Lippolis (1993) used the method of percutaneous drainage in 200 patients with single and multiple intra-abdominal abscesses. The percentage of successful attempts was 88.5% (94.7% for "simple" abscesses and 69% for "complex"). At the same time, a fatal outcome was noted in 5% of cases (1.3% for simple and 16% for complex abscesses). Hence, as the authors believe, drainage can be the initial procedure in patients with "simple" abdominal abscesses, while in case of multiple abscesses drainage is a risky manipulation.

TRMcLean and K. Simmons (1993) used percutaneous drainage of postoperative intra-abdominal abscesses as an alternative to the surgical method. Only 33% of attempts were successful. The authors concluded that the method is useful only in certain rare situations, while laparotomy is indicated for the majority.

Thus, on average, every third patient develops relapses or severe complications after drainage of abscesses, and in 5% of cases, patients die from the generalization of the purulent process.

The puncture method is possible in some patients with certain indications as a preoperative preparation. This method of treatment is contraindicated in patients with complicated forms of inflammation, since purulent formations of the uterine appendages are characterized by the presence, as a rule, of numerous purulent cavities - from microscopic to very large. In this regard, it is impossible to talk about complete evacuation of pus in these cases. In addition, as the purulent contents are removed from the main cavity, it decreases and several other chambers are formed, from which it is impossible to completely remove the pus. Finally, irreversible destructive processes not only in the abscess cavity, but also in the surrounding tissues create the prerequisites for the development of another relapse. Repeated use of the puncture method can contribute to the formation of appendovaginal fistulas. Similar information is provided by R. Feld (1994), who described drainage complications in 22% of patients, the most common of which was the formation of appendovaginal fistulas.

Particular attention should be paid to the recommendations of a number of domestic and foreign authors to introduce various antibiotics into the purulent cavity.

It is necessary to exclude from the arsenal the local use of antibiotics in purulent processes (administration of antibacterial drugs by puncture of a purulent formation, through drainage into the abdominal cavity, etc.), taking into account the fact that with local use of drugs, resistance to them develops faster than with any other route of administration. Such resistance also remains in the genetic apparatus of the cell. As a result of the transfer of the resistance factor, cells resistant to antibacterial drugs quickly multiply in the microbial population and constitute its majority, which leads to the ineffectiveness of subsequent treatment.

Local application of antibiotics causes a sharp increase in polyresistance of strains. By the 5th day of such treatment, pathogens sensitive to this drug practically disappear and only resistant forms remain, which is the result of direct continuous action of antibiotics on the microbial flora.

In view of the severity of general and local changes in patients with purulent diseases of the pelvic organs and the extreme risk of generalization of the process, the following fundamental provisions are important, in our opinion: for any form of purulent inflammation, treatment can only be complex, conservative-surgical, consisting of:

• pathogenetically directed preoperative preparation;
• timely and adequate volume of surgical intervention aimed at removing the source of destruction;
• rational management, including intensive treatment, of the postoperative period (the earlier surgical debridement of the lesion is performed, the better the outcome of the disease).

Tactics of managing patients with uncomplicated forms of purulent inflammation

The treatment of patients must be approached differentially, taking into account the form of purulent inflammation. As stated above, we classify purulent salpingitis as uncomplicated forms of purulent inflammation.

Preoperative preparation in patients with purulent salpingitis should be aimed at relieving acute manifestations of inflammation and suppressing the aggression of the microbial pathogen, therefore drug therapy for purulent salpingitis is a basic treatment measure, the “gold standard” of which is the correct choice of antibiotic.

Against the background of conservative treatment, it is necessary to evacuate purulent exudate in the first 2-3 days (surgical component of treatment).

The method of "minor" surgical intervention may vary, and its choice depends on a number of factors: the severity of the patient's condition, the presence of complications of the purulent process and the technical equipment of the hospital. The easiest and simplest method of removing purulent secretion is a puncture of the uterorectal cavity through the posterior vaginal fornix, the purpose of which is to reduce the degree of intoxication of the body as a result of the action of purulent decay products and to prevent the generalization of the process (peritonitis and other complications of pelvic abscess). Puncture has a greater effect if performed in the first three days.

The use of aspiration drainage increases the effectiveness of treatment. NJ Worthen et al. reported on percutaneous drainage of 35 pelvic abscesses in purulent salpingitis. The percentage of successful attempts with conventional drainage was 77%, while with aspiration drainage it increased to 94%.

However, the most effective method of surgical treatment of purulent salpingitis at the present stage should be considered laparoscopy, which is indicated for all patients with purulent salpingitis and certain forms of complicated inflammation (pyosalpinx, pyovar and purulent tubo-ovarian formation) when the disease has been going on for no more than 2-3 weeks, when there is no gross adhesive-infiltrative process in the small pelvis.

If purulent salpingitis is diagnosed in a timely manner and the patient is hospitalized in a timely manner, laparoscopy should be performed within the next 3-7 days when acute signs of inflammation are relieved. During laparoscopy, the pelvis is sanitized, the affected tissues are removed sparingly (if a tubo-ovarian formation has formed), and the pelvis is drained transvaginally through a colpotome wound. Insertion of drains through counter-openings on the anterior abdominal wall is less effective. The best results are achieved with active aspiration of purulent exudate. Laparoscopy is mandatory for young, especially nulliparous patients.

In purulent salpingitis, adequate intervention volume is adhesiolysis, sanation and transvaginal (through the colpotome opening) drainage of the small pelvis. In cases of purulent salpingo-oophoritis and pelvic peritonitis with the formation of an encapsulated abscess in the rectouterine pouch, adequate assistance is considered to be mobilization of the uterine appendages, according to indications, removal of the fallopian tube, emptying the abscess, sanation and active aspiration drainage through the colpotome opening. If pyosalpinx has formed, it is necessary to remove the fallopian tube or tubes. In case of small pyovarium (up to 6-8 cm in diameter) and preservation of intact ovarian tissue, it is advisable to enucleate the purulent formation. If there is an ovarian abscess, it is removed. An indication for removal of the uterine appendages is the presence of irreversible purulent-necrotic changes in them. In the postoperative period, for 2-3 days after the operation, it is advisable to perform aspiration-washing drainage using the OP-1 device.

In the postoperative period (up to 7 days), antibacterial, infusion therapy, and resorption therapy are continued, followed by rehabilitation for 6 months.

Rehabilitation of reproductive function is facilitated by conducting control laparoscopy to perform adhesiolysis after 3-6 months.

Tactics of managing patients with complicated forms of purulent diseases

It also consists of three main components, however, in the presence of an encapsulated purulent formation of the uterine appendages, the basic component that determines the outcome of the disease is surgical treatment.

Most often, all encapsulated pelvic abscesses are complications of an acute purulent process and, in fact, represent a form of chronic purulent-productive inflammation.

Unlike patients with acute purulent inflammation (purulent salpingitis, pelvic peritonitis), the use of antibiotics in patients with encapsulated abscesses in the preoperative period in the absence of an acute inflammatory reaction is inappropriate for the following reasons:

• due to a pronounced disruption or absence of blood circulation in purulent-necrotic tissues, an insufficient concentration of drugs is created;
• in patients with complicated forms of inflammation, with a process lasting many months, resistance to many drugs is acquired, since at different stages of the treatment process they receive at least 2-3 courses of antibiotic therapy;
• Most infectious agents are resistant to antibacterial drugs outside of an exacerbation, and carrying out “provocations” in such patients is absolutely contraindicated;
• The use of reserve antibiotics in the “cold” period that act on beta-lactamase strains excludes the possibility of their use in the intra- and postoperative periods, when this is truly vital.

Thus, in most cases, antibacterial therapy is not indicated for patients with complicated forms of purulent inflammation (chronic purulent-productive process). However, there are clinical situations that are an exception to this rule, namely:

• the presence of obvious clinical and laboratory signs of infection activation, including the presence of clinical, laboratory and instrumental symptoms of abscess pre-perforation or infection generalization;
• all generalized forms of infection (peritonitis, sepsis).

In these cases, empirical antibacterial therapy is prescribed immediately, continued intraoperatively (prevention of bacterial shock and postoperative complications) and in the postoperative period.

Thus, detoxification and detoxification therapy are of primary importance in preoperative preparation (detailed in Chapter 4 of this monograph).

The effect of detoxification and preparation of patients for surgery is significantly enhanced by the evacuation of purulent exudate.

Drainage, including laparoscopic, as an independent method of treatment can be safe and successful only in cases of purulent salpingitis and pelvic peritonitis with the formation of an abscess of the recto-uterine pouch, since in these cases there is no capsule of the formation and the removal of purulent exudate is performed from the abdominal cavity, which, due to the anatomical prerequisites, is well drained in any position of the patient.

In other cases, drainage should be considered as an element of complex preoperative preparation, allowing the operation to be performed under conditions of remission of the inflammatory process.

Indications for draining palliative operations (puncture or colpotomy) in patients with complicated forms of purulent inflammation are:

• the threat of perforation of an abscess into the abdominal cavity or a hollow organ (in order to prevent peritonitis or the formation of fistulas);
• the presence of acute pelvic peritonitis, against which background surgical treatment is least favorable;
• severe degree of intoxication. The conditions for performing a puncture are:
• accessibility of the lower pole of the abscess through the posterior vaginal fornix (the lower pole is softened, bulging, or easily identified upon examination);
• During examination and additional research, an abscess was detected, but not multiple abscesses (in the appendages and extragenital foci).

Colpotomy is advisable to perform only in cases where subsequent aspiration-washing drainage is assumed. With passive drainage, the outflow of purulent contents is quickly disrupted, while the introduction of any aseptic fluid for washing the abscess does not guarantee its complete removal and contributes to the dissemination of microbial flora. Puncture and drainage through the lateral and anterior vaginal fornices, as well as the anterior abdominal wall, is unacceptable. Repeated punctures of the posterior fornix and colpotomies in one patient are also inadvisable, since this contributes to the formation of severe pathology - appendovaginal fistulas.

The duration of preoperative preparation is determined individually. The optimal stage for surgery is considered to be the remission stage of the purulent process.

In the presence of an abscess in the small pelvis, intensive conservative treatment should last no more than 10 days, and if a picture of a threat of perforation develops, no more than 12-24 hours (if palliative intervention cannot be performed to eliminate it).

In case of emergency indications for surgery, preoperative preparation is carried out within 1.5-2 hours. It includes catheterization of the subclavian vein with transfusion therapy under the control of central venous pressure in a volume of at least 1200 ml of fluid (colloids, proteins and crystalloids in a ratio of 1:1:1).

Indications for emergency intervention are:

• perforation of an abscess into the abdominal cavity with the development of diffuse purulent peritonitis;
• perforation of an abscess into the bladder or the threat of it;
• septic shock.

In the development of septic shock, antibacterial therapy should be started only after stabilization of hemodynamic parameters; in other cases, immediately after diagnosis is established.

In uncomplicated forms, the nature of the surgical component also differs. In these cases, only laparotomy is indicated.

The extent of surgical intervention in patients with purulent diseases of the pelvic organs is individual and depends on the following main points: the nature of the process, concomitant pathology of the genitals and the age of the patients.

An idea of the scope of the operation should be formed before it, after receiving the examination data and determining the degree of damage to the uterus, appendages, identifying complications and extragenital foci.

Indications for performing reconstructive surgery with preservation of the uterus are primarily: absence of purulent endomyometritis or panmetritis, multiple extragenital purulent foci in the small pelvis and abdominal cavity, as well as other concomitant severe genital pathology (adenomyosis, myoma). In the presence of bilateral purulent tubo-ovarian abscesses complicated by genital fistulas, pronounced extensive purulent-destructive process in the small pelvis with multiple abscesses and infiltrates of pelvic and parametral tissue, confirmation of purulent endomyometritis or panmetritis, it is necessary to perform extirpation of the uterus with preservation, if possible, of at least part of the unchanged ovary.

In case of extensive purulent processes in the small pelvis, both complicated and not complicated by the formation of fistulas, it is inappropriate to perform supravaginal amputation of the uterus, since the progression of inflammation in the cervical stump creates a real threat of relapse of the purulent process after the operation and the formation of an abscess in it with the development of its failure and the formation of fistulas, especially in cases of using reactive suture material, such as silk and nylon. In addition, when performing supravaginal amputation of the uterus, it is difficult to create conditions for transvaginal drainage.

To prevent bacterial toxic shock, all patients are given antibiotics at the same time during surgery, with continued antibacterial therapy in the postoperative period.

The main principle of drainage is to install drains in the main places of fluid migration in the abdominal cavity and small pelvis, i.e. the main part of the drains should be in the lateral canals and retro-uterine space, which ensures complete removal of the pathological substrate. We use the following methods of inserting drainage tubes:

• transvaginal through the open vaginal dome after extirpation of the uterus (drainages with a diameter of 11 mm);
• by means of posterior colpotomy with the uterus preserved (it is advisable to use one drainage with a diameter of 11 mm or two drainage with a diameter of 8 mm);
• In addition to transvaginal, transabdominal introduction of drainage through counter-openings in the meso- or epigastric regions in the presence of subhepatic or interintestinal abscesses (drainages with a diameter of 8 mm). The optimal vacuum mode in the apparatus during drainage of the abdominal cavity is 30-40 cm H2O. The average duration of drainage in patients with peritonitis is 3 days. The criteria for stopping drainage are improvement in the patient's condition, restoration of bowel function, relief of the inflammatory process in the abdominal cavity, a tendency toward normalization of clinical blood tests and body temperature. Drainage can be stopped when the rinsing waters become completely transparent, light and have no sediment.

The principles of intensive therapy aimed at correcting multiple organ dysfunction (antibiotic therapy, adequate pain relief, infusion therapy, intestinal stimulation, use of protease inhibitors, heparin therapy, glucocorticoid treatment, administration of nonsteroidal anti-inflammatory drugs, drugs that accelerate reparative processes, use of extracorporeal detoxification methods) are described in detail in Chapter 4 of this monograph.

In conclusion of this chapter, we would like to emphasize that purulent gynecology is a special discipline, significantly different from purulent surgery due to the existing features in both the etiology, pathogenesis and course of the processes, as well as in their outcomes. In addition to the outcomes common to surgery and gynecology, such as peritonitis, sepsis, multiple organ failure, death, the latter is characterized by specific dysfunctions of the female body, in particular, reproductive function. The longer the course of the purulent process, the less chances there are to preserve the possibility of reproduction. This is why we are against long-term conservative treatment of patients with both uncomplicated and complicated forms of purulent inflammation and believe that treatment can only be conservative and surgical, allowing for more encouraging results.

The choice of method, access and volume of surgical intervention is always individual, but in any case its main principle is radical removal of the site of destruction, atraumatic intervention if possible, adequate sanitation and drainage of the abdominal cavity and pelvic cavity, correctly selected intensive therapy and subsequent rehabilitation.