Acute pelvic inflammatory disease

Introduction to acute pelvic inflammatory disease Acute pelvic inflammatory disease is more common in women with menstruation and sexual activity. Inflammation can be limited to one site, but can also involve several sites at the same time. The most common are salpingitis and tubal oophoritis. Simple endometritis or oophoritis is rare. Pelvic inflammatory disease is divided into acute and chronic. Acute pelvic inflammatory disease mainly includes acute endometritis, acute salpingitis, acute fallopian tube ovarian abscess, acute pelvic peritonitis, and acute pelvic connective tissue inflammation. The development of acute pelvic inflammatory disease can cause diffuse peritonitis, sepsis, septic shock, and severe cases can be life-threatening. If it is not completely cured in the acute phase, it will turn into chronic pelvic inflammatory disease, often prolonged unhealed, and can be repeated, leading to infertility, tubal pregnancy, chronic pelvic pain, not only seriously affecting women's health, life and work, but also The burden of family and society. basic knowledge Proportion of the disease: the prevalence of married women is about 10% Susceptible people: women Mode of infection: non-infectious Complications: infertility peritonitis sepsis septic shock

Cause of acute pelvic inflammatory disease

1. The natural defense function of the female reproductive tract:

The anatomical and physiological characteristics of the female genital tract are characterized by a relatively complete natural defense function, which enhances the defense ability against infection. Although some pathogens exist in the vagina of healthy women, they do not cause inflammation.

The reason is:

(1) The labia majora on both sides are naturally closed to cover the vaginal opening and the urethra.

(2) Due to the action of the pelvic floor muscles, the vaginal opening is closed, and the anterior and posterior vaginal walls are closely attached to prevent external contamination. This defensive function is poor after maternal vaginal relaxation.

(3) vaginal self-cleaning effect.

(4) The internal cervix is tightly closed, the cervical mucosa is covered by a high columnar epithelium secreting mucus, the mucosa forms wrinkles, condyles or lacuna, thereby increasing the surface area of the mucosa; the cervical canal secretes a large amount of mucus to form a mucus plug, which contains lysobacteria Enzymes and topical antibodies are important for maintaining visceral genital sterility.

(5) The periodic exfoliation of the endometrium of women of gestational age is also a favorable condition for eliminating intrauterine infection.

(6) The cilia of the oviduct mucosal epithelial cells oscillate in the direction of the uterine cavity and the peristalsis of the fallopian tubes are all beneficial to prevent the invasion of pathogens.

When natural defense function is destroyed, or the body's immune function declines, endocrine changes or exogenous pathogens invade, inflammation can occur.

2, the induced factors of acute pelvic inflammatory disease:

(1) Postpartum or post-abortion infection: maternal physique is weak after delivery, uterine cervix is not completely closed, such as birth caused by birth canal damage or placenta, residual membrane, etc., pathogens invade the uterine cavity, easy to cause infection; vaginal bleeding time during abortion Acute pelvic inflammatory disease can occur if it is too long, or if tissue remains in the uterine cavity, or if the surgical aseptic operation is not strict.

(2) infection after intrauterine surgery: such as curettage, tubal sputum, hysterosalpingography, hysteroscopy and water sac induction, etc., because the surgical disinfection is not strict, causing infection or improper selection of preoperative indications, Such as the original chronic inflammation of the genitals, caused by surgery and caused by acute attacks and spread.

(3) poor hygiene during menstruation: the use of unclean menstrual pads, menstrual sexual intercourse, etc., can cause pathogens to invade and cause inflammation. The pathogens of the above-mentioned infections are mainly pathogens of endogenous flora of the reproductive tract, such as staphylococcus, streptococcus, Escherichia coli, anaerobic bacteria, etc.

(4) Infectious sexually transmitted diseases: unclean sexual life history, premature sexual life, multiple sexual partners, sexual intercourse can cause pathogens of sexually transmitted diseases, causing pelvic inflammation, common pathogens are Neisseria gonorrhoeae, Chlamydia trachomatis Or combined with aerobic bacteria, anaerobic infection.

(5) direct spread of inflammation of adjacent organs: for example, appendicitis, peritonitis, etc., mainly Escherichia coli.

(6) Acute exacerbation of chronic pelvic inflammatory disease.

(7) Intrauterine device: First, the intrauterine device can cause acute pelvic inflammatory disease within 10 days. The infection is mainly aerobic and anaerobic bacteria; the second is the second time after placing the intrauterine device. Infection forms chronic inflammation and can sometimes be acute.

3. Pathogens and their pathogenic characteristics:

There are two sources of pathogens causing pelvic inflammatory disease: 1 endogenous pathogens, from the original colonies in the vagina including aerobic and anaerobic bacteria; 2 exogenous pathogens, pathogens from the outside, mainly sexually transmitted diseases Pathogens such as Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma, others with Mycobacterium tuberculosis, Pseudomonas aeruginosa, etc., causing pelvic inflammatory pathogens can be simply aerobic bacteria, simple anaerobic or aerobic and anaerobic bacteria Mixed infection; pathogens with or without sexually transmitted diseases, pelvic inflammatory disease is often a mixed infection of aerobic and anaerobic bacteria, about 2 / 3 cases combined with anaerobic infection, in the United States, 40% ~50% of pelvic inflammatory disease is caused by Neisseria gonorrhoeae, 10% to 40% of pelvic inflammatory disease can be isolated from Chlamydia trachomatis; in China, Neisseria gonorrhoeae, Chlamydia trachomatis caused by pelvic inflammatory disease is also increasing, has attracted people's attention, Different pathogens have different routes of transmission and pathogenic characteristics. Understanding these characteristics can determine pathogenic bacteria and thus help to select antibiotics during treatment.

(1) Aerobic bacteria:

1 Streptococcus: There are many types of Gram-positive streptococci. B-type hemolytic streptococcus has strong pathogenicity, can produce hemolysin and a variety of enzymes, making infection easy to spread, and causing sepsis, pus is relatively thin, reddish The amount is more, but generally there is no metastatic abscess, which is sensitive to penicillin.

2 Staphylococcus: Gram-positive cocci, is a common pathogen of postpartum genital inflammation and wound infection after surgery, often along the vagina, uterus, fallopian tube mucosal ascending infection, sub-epidermal, saprophytic and Staphylococcus aureus, epidermal staphylococcal Can cause disease, Staphylococcus aureus usually does not cause disease, Staphylococcus aureus has the strongest pathogenicity, its pus is yellow, thick, not odorous, often accompanied by metastatic abscess, easy to produce common antibiotics Drug resistance, according to the drug sensitivity test is ideal, commonly used effective drugs are oxacillin sodium, cloxacillin sodium and so on.

3 Escherichia coli: Gram-negative bacilli, normal parasites in the intestines and vagina, generally do not cause disease, but when the body is extremely weak, it can cause serious infections, even endotoxin, often mixed with other pathogens. Infected, Escherichia coli infected pus is not stinky, when mixed infection, it produces thick pus and fecal odor, ampicillin, amoxicillin is effective, but easy to produce resistant strains, it is best to do drug susceptibility test, Choose sensitive drugs.

(2) Anaerobic bacteria: It is one of the important bacteria in pelvic infection. These bacteria are mainly from colon, rectum, vaginal and oral mucosa. The infection is characterized by easy formation of pelvic abscess, infectious thrombophlebitis, pus Fecal odor and bubbles, this type of bacteria are sensitive to clindamycin (clopidogrel), cephalosporin I in cephalosporin, chloramphenicol, metronidazole, etc., in anaerobic infection, The pathogenicity of Bacteroides fragilis is the strongest, often accompanied by severe infections and the formation of abscesses.

1 Digestive Streptococcus: Gram-positive bacteria, easy to breed in the decidual fragments or residual placenta of postpartum endometrial necrosis, the endotoxin toxicity is higher, Escherichia coli is low, -lactam may destroy penicillin Enzyme, resistant to penicillin, also produces heparinase, dissolves heparin, promotes blood clotting, causes thrombophlebitis, gram-positive cocci in light-mirror, in the smear of pelvic infection It is helpful for diagnosis.

2 Bacteroides fragilis: Gram-negative bacteria, the main anaerobic bacteria in severe pelvic infections are Bacteroides fragilis, the recovery period of this infection is very long, accompanied by malodor, resistance to penicillin, in the presence of fecal odor In the pus smear of the taste, pleomorphic bacteria were observed under the light microscope, and Gram-negative bacteria with uneven coloration were found in white blood cells, suggesting the possibility of infection by Bacteroides fragilis.

3 Clostridium perfringens: Gram-negative bacteria, more common in wound infections and illegal abortion infections, secretions stench, gas in tissues, prone to toxic shock.

(3) Sexually transmitted pathogens:

1 Neisseria gonorrhoeae: Gram-negative diplococcus, Neisseria gonorrhoeae is characterized by invasive reproduction, columnar epithelium and transitional epithelium of urinary system mucosa, Neisseria gonorrhoeae mainly infects the lower genital tract, 10% to 17% of patients Can occur in the upper genital tract infection, causing Neisseria gonorrhoeae pelvic inflammatory disease, more than menstrual period or 7 days after menstruation, acute onset, may have high fever, body temperature above 38 ° C, often cause tubal empyema, treatment Sensitive to the reaction, Neisseria gonorrhoeae is sensitive to penicillin, second or third generation cephalosporins, aminoglycosides.

2 Chlamydia: Commonly known as Chlamydia trachomatis, its characteristics is the same as Neisseria gonorrhoeae, only infected with columnar epithelium and transitional epithelium, not deep invasion, Chlamydia trachomatis infection symptoms are not obvious, may have mild lower abdominal pain, but often lead to severe fallopian tubes Mucosal structure and function destruction, and can cause extensive adhesion of the pelvic cavity.

Three mycoplasma: Mycoplasma is a kind of prokaryotic microbial cell without cell wall. It is morphologically pleomorphic and is a kind of normal vaginal flora. Mycoplasma mycoplasma isolated from the reproductive tract, ureaplasma urealyticum, genital mycoplasma, Mycoplasma can cause inflammation of the genital tract under certain conditions.

(4) Viral infection: For example, cytomegalovirus is a group of viruses belonging to the herpes virus. Infected cells have inclusion bodies, which are enlarged in volume, and are often infected in patients with extremely weak body and low immune function. Pregnant women suffer from this disease. The disease can cause stillbirth, miscarriage and premature birth.

4, pathogenesis

1, acute endometritis and acute myositis

More common in abortion, after childbirth.

2, acute salpingitis, fallopian tube empyema, fallopian tube ovarian abscess

Acute salpingitis is mainly caused by pyogenic bacteria. It has different pathological characteristics according to different transmission routes. If the pathogen spreads to the paracanceal connective tissue through the lymph of the cervix, it first invades the serosal layer, inflammation around the fallopian tube occurs, and then the muscle is involved. Layer, and the oviduct mucosa layer can be unaffected or involved extremely light, the light fallopian tube only slightly congested, swollen, slightly thicker; severely the fallopian tube is obviously thickened, curved, more fibrous purulent exudate, causing adhesion to the surrounding If the inflammation spreads through the endometrium, it first causes tubal mucositis, tubal mucosal swelling, interstitial edema, congestion and a large number of neutrophil infiltration, severe degeneration of the fallopian tube epithelium or flaking, causing adhesion of the tubal mucosa It causes the tubal lumen and the umbrella end to be locked. If pus accumulates in the lumen, it forms a fallopian tube.

The ovary is rarely inflamed alone. The tunica albuginea is a good defense barrier. The ovary often adheres to the inflamed oviduct umbrella end and occurs around the ovarian inflammation. It is called oviduct oophoritis. It is called annex inflammation. Inflammation can invade the ovarian parenchyma through the ovarian ovulation. Form ovarian abscess, abscess wall and fallopian tube empyema adhesion and perforation, the formation of fallopian tube ovarian abscess, fallopian tube ovarian abscess can occur after the initial onset of acute attachment inflammation, but often formed on the basis of repeated acute episodes of chronic annexitis, abscess The posterior uterus or the uterus, the posterior lobe of the broad ligament and the adhesion between the intestines can be broken into the rectum or vagina. If it breaks into the abdominal cavity, it will cause diffuse peritonitis.

3, acute pelvic connective tissue inflammation

When the genital tract is acutely inflammatory, or when the vagina or the cervix is traumatized, the pathogen enters the pelvic connective tissue through the lymphatic vessels and causes connective tissue congestion, edema and neutrophil infiltration, and the most common uterine connective tissue inflammation begins local thickening. The texture is soft, the boundary is unclear, and then the fan wall is infiltrated into the pelvic wall on both sides. If the tissue is suppurated, a pelvic extraperitoneal abscess is formed, which can spontaneously break into the rectum or vagina.

4, acute pelvic peritonitis

When the pelvic organs are severely infected, they often spread to the pelvic peritoneum, inflamed peritoneal congestion, edema, and a small amount of cellulose-containing exudate, forming pelvic organ adhesions, when a large amount of purulent exudate accumulates in the adhesion. In the gap, scattered small abscess can be formed; accumulation in the rectum uterus depression forms a pelvic abscess, more common, abscess can break into the rectum and suddenly relieve symptoms, can also break into the abdominal cavity caused by diffuse peritonitis.

5, sepsis and sepsis

When the pathogen is highly toxic, the number is large, and the patient's resistance is reduced, sepsis often occurs. It is more common in severe puerperal infections and infections. If not controlled in time, patients often develop septic shock or even death. After infection, If multiple inflammatory lesions or abscesses are found in other parts of the body, sepsis should be considered, but it should be confirmed by blood culture.

6, Fitz-Hugh-Curtis syndrome

It refers to perihepatitis of the liver capsule without inflammation of the liver parenchyma. Neisseria gonorrhoeae and chlamydia infection can be caused. Due to hepatic edema, right upper quadrant pain during inhalation, purulent or fibrous infiltration on the liver capsule. In the early stage, a soft adhesion was formed between the liver capsule and the anterior abdominal wall peritoneum, and a string-like adhesion was formed in the late stage. This syndrome may occur in 5% to 10% of salpingitis, and the clinical manifestation is right upper abdominal pain after lower abdominal pain, or Lower abdominal pain and right upper quadrant pain occur simultaneously.

Acute pelvic inflammatory disease prevention

1. Do a good job in health promotion during menstruation, pregnancy and puerperium.

2, strict control of obstetrics, indications for gynecological surgery, good preparation before surgery; pay attention to aseptic operation during surgery; postoperative care, prevent infection.

3, treatment of acute pelvic inflammatory disease, should be treated in a timely manner, completely cured, to prevent the conversion to chronic pelvic inflammatory disease.

4, pay attention to sexual health, reduce sexually transmitted diseases, sexual intercourse is prohibited.

Acute pelvic inflammatory disease Complications infertility peritonitis sepsis septic shock

Infertility, diffuse peritonitis, sepsis, septic shock, severe can be life-threatening.

Acute pelvic inflammatory symptoms Common symptoms Lower abdominal pain, increased vaginal discharge, fever, chills, menstrual flow, multiple purulent secretions, chills, urinary frequency, bladder irritation, abdominal distension, abscess

Can be due to the severity and extent of inflammation and different clinical manifestations, lower abdominal pain with fever at the time of onset, if the condition is serious, there may be chills, high fever, headache, loss of appetite, menstrual period can occur increased menstrual flow, prolonged menstruation, non-menstrual period There may be an increase in vaginal discharge. If there is peritonitis, digestive symptoms such as nausea, vomiting, abdominal distension, diarrhea, etc., if there is abscess formation, there may be lower abdominal mass and local compression stimulation symptoms, and the cyst may be located in front of the bladder to cause irritation. Such as dysuria, frequent urination, if the bladder myositis can also have dysuria, etc.; the mass may be rectal irritations in the posterior uterus, if it can cause diarrhea in the peritoneal, sensation and difficulty in defecation, depending on the pathogen of the infection, clinical There were also differences in performance. Neisseria gonorrhoeae infection was onset, and hyperthermia, peritoneal irritation and vaginal purulent discharge were observed within 48 hours. Non-gonococcal pelvic inflammatory disease was slower onset, and hyperthermia and peritoneal irritation were not obvious. It is often accompanied by abscess formation. If it is an anaerobic infection, it is easy to have multiple recurrences, abscess formation, and Chlamydia trachomatis infection. Long, high fever is not obvious, long-term sustained low fever, mainly manifested as mild lower abdominal pain, long-term cure, irregular vaginal bleeding.

The patient has acute disease, elevated body temperature, increased heart rate, abdominal distension, tenderness in the lower abdomen, rebound tenderness and muscle tension, weakened or disappeared bowel sounds, pelvic examination: the vagina may be congested, and there is a large amount of purulent discharge, the cervix The secretion of the surface is wiped off. If the purulent discharge is seen from the cervix, it indicates that the cervical mucosa or the uterine cavity has acute inflammation. The vaginal fistula has obvious tenderness. It must be noted whether it is full; cervical congestion, edema, and painfulness; The body is slightly larger, has tenderness, and has limited activity; the tenderness on both sides of the uterus is obvious. If it is simple salpingitis, it can touch the thickened fallopian tube and has obvious tenderness; if it is empyema or fallopian tube ovarian abscess, it can touch the mass and The tenderness is obvious; when the connective tissue of the uterus is adjacent to the uterus, there may be a flaky thickening on one side or both sides of the uterus, or a high degree of edema of the uterine ligament on both sides, thickening and tenderness; if the abscess is formed and the position is low It can be used to treat the posterior iliac crest or the lateral iliac crest with a lump and a sense of volatility. The triad diagnosis can often help to further understand the pelvic condition.

Acute pelvic inflammatory disease

Blood routine, urine routine, erythrocyte sedimentation rate, C-reactive protein, cervical secretions and posterior iliac puncture examination.

Blood routine white blood cell examination is meaningful for the diagnosis of inflammation, trichomonas vaginitis, mucopurulent cervicitis, pelvic inflammatory disease, more white blood cells, and bacterial vaginosis and vulvovaginal candidiasis leukocytes less.

B-mode ultrasound, laparoscopy, etc. can assist in the diagnosis of pelvic inflammatory disease.

Diagnosis and differentiation of acute pelvic inflammatory disease

Diagnostic criteria

According to the history, symptoms and signs, the auxiliary examination can make a definite diagnosis.

The clinical diagnostic criteria for acute pelvic inflammatory disease must have the following three items:

1. Lower abdominal tenderness with or without rebound tenderness;

2, cervical or palace body pain or swing pain;

3. The tenderness in the attachment area.

The following criteria may increase the specificity of the diagnosis: cervical secretion culture or Gram stain smear positive for Neisseria gonorrhoeae or Chlamydia trachomatis; body temperature over 38 ° C (mouth); total blood WBC > 10 × 109 / L; Puncture and drainage of purulent fluid; double or B-mode ultrasound findings of pelvic abscess or inflammatory mass, due to clinical diagnosis of acute salpingitis has a certain rate of misdiagnosis, laparoscopic examination can improve the diagnosis rate.

The diagnostic criteria for laparoscopic eyes are:

1. The surface of the fallopian tube is obviously congested;

2, tubal wall edema;

3. There is purulent exudate on the umbrella end or serosal surface of the fallopian tube.

After the diagnosis of acute pelvic inflammatory disease, the pathogen of the infection should be clearly identified, and the secretion culture of the infected part should be directly taken by laparotomy or laparoscopic, and the drug sensitivity and drug sensitivity result can be the most accurate. The smear of cervical secretion and posterior Qianlong puncture fluid Although the culture and immunofluorescence assays are not as good as the secretion culture of the infected site and the drug sensitivity is accurate, it is helpful for clear pathogens. The smear can be stained with Gram. If Neisseria gonorrhoeae is found, the diagnosis can be confirmed. In addition to bacteria, it can provide clues for the selection of antibiotics according to bacterial morphology and Gram stain; the culture positive rate is high, and the pathogen can be identified; immunofluorescence is mainly used for chlamydia examination, in addition to pathogen examination, according to medical history, clinical symptoms and The characteristics of the signs make a preliminary judgment of the pathogen.

Differential diagnosis

Acute pelvic inflammatory disease should be differentiated from acute appendicitis, abortion or rupture of tubal pregnancy, and acute abdomen such as rupture or rupture of ovarian cyst.

1, acute appendicitis

Acute right fallopian tube ovarian inflammation is easy to be confused with acute appendicitis. Acute appendicitis often has gastrointestinal symptoms before the onset, such as nausea, vomiting, diarrhea, etc. Abdominal pain occurs mostly around the umbilicus, and then gradually fixes to the right lower abdomen. Only Mai's point has tenderness, body temperature and white blood cell increase is not as good as acute tubal oophoritis, right side of acute tubal oophoritis, often tenderness below the Mai's point, gynecological examination of the cervix often has tenderness, both sides have tenderness.

2, ovarian tumor pedicle twist

More often after the active mass, after the stool, etc., severe abdominal pain occurs. After the ovarian mass is twisted, there is often bleeding in the cystic cavity, and the mass is enlarged, accompanied by fever. The medical history and B-ultrasound examination are helpful for diagnosis. .

3, ectopic pregnancy or rupture of ovarian corpus luteum cyst

Acute lower abdominal pain can occur, intra-abdominal hemorrhage, patients with pale, acute disease, and even shock, do vaginal puncture, can extract dark red non-coagulated blood, ectopic pregnancy can also have menopause history and vaginal bleeding, urine HCG often Positive, laparoscopic examination can confirm the diagnosis.

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