Parametritis is a diffuse infectious-inflammatory process in the surrounding uterus. The term "parameter" is not always understood unambiguously. Sometimes it is used when talking about the cellulose located under the serous cover of the uterus (adventitial vagina), but in the clinical sense this term is understood much wider. In order not to get confused in such terminological subtleties, it is necessary to get acquainted with the anatomy of the organs of the pelvic cavity, namely, the uterus.
The structure, location and functioning of the uterus meets its main function - procreation. Outwardly it resembles a hollow, outstretched bottom pear, consists of a body and a neck. The uterine cavity communicates with the fallopian tubes (their mouths are localized in the uterine corners) and the vagina (through the cervical canal), so the infectious process that first arises in any part of the genitals can migrate along the genital tract in any direction.
The uterine wall is formed by three layers. From the inside, the uterine cavity lining the mucous membrane (endometrium). The outer, functional, endometrial layer is closely related to cyclic hormonal oscillations (especially estrogens) and is constantly updated. Deep, basal, endometrial layer from estrogens practically does not depend and serves as a source of replenishment of cells of the functional layer, tearing away during menstruation. In the mucous layer of the uterine wall, there are many secreting glands and blood vessels.
The most powerful and voluminous layer of the uterine wall is the myometrium. It is formed by numerous interwoven smooth muscle fibers, located in different directions. The muscular framework of the myometrium is strengthened by elements of connective tissue and elastic fibers.
The outermost layer of the uterus (perimetry) is a strong serous tissue (transformed peritoneum), which protects the organ from negative external influences.
Constant position in the pelvic cavity of the uterus retains with the help of a retaining ligamentous apparatus, the ligaments are fixed, suspended and provide the necessary mobility of the organ. The most important are the wide ligament of the uterus, which, like wide sheets of dense and elastic tissue, connect and fix together the fallopian tubes, ovaries and uterus. In fact, these ligaments are peritoneum.
Between the sheets of broad ligaments and localized parameter - okolomatoe cellulose, and in it - a lot of venous and lymphatic vessels. When the infection enters this zone of the pelvic region, local inflammation develops - parametritis.
It should be noted that not only the space between the sheets of broad ligaments is filled with cellulose, so sometimes any parotiditis inflammation is called a parametrite. Diagnostic nuances do not influence the diagnosis and methods of therapy.
Parametrite always provokes an infection that has got into the cellulose by means of lymphatic pathways from any organs surrounding the uterus. Postpartum parametritis is more common than others.
Like any infectious-inflammatory process, parametrite can proceed with a pronounced clinical picture. Chronic parametery is characterized by scant symptoms and alternation of periods of exacerbation and remission.
With the parameter, the inflammatory process often has a diffuse character. However, since the infectious process is localized in a space bounded by anatomical structures (ligaments), a delimited purulent parametritis in the form of an abscess can form at the site of inflammation.
Treatment parametrita is consistent with the rules for the therapy of acute infectious processes and is largely determined by the clinic and the nature of the infection. Antibacterial therapy is in the lead.
Reasons for the parameter
Parametrit provokes an infection: staphylococci, streptococci, anaerobes, pneumococci, E. coli (less often). Often, the culprits of inflammation are microbial associations. Therefore, predisposing conditions for its development include conditions that facilitate the penetration of pathogenic microflora into the circumba - mechanical damage and a decrease in the natural mechanisms of immune defense. Inflammation is predominantly serous, less often a purulent process occurs.
More often parametritis is a complication of endometritis or develops against the background of traumatic births. Postnatal parametritis is usually associated with lateral ruptures of the cervical tissue, they open the access of microbes to the peritoneal tissue, so the infection through the injured areas is able to penetrate the interconnected space.
Out of pregnancy predisposing to the formation of parametritis are:
- mechanical injuries of the mucous (abortion, diagnostic instrumental manipulation, hysteroscopy and the like) of the cervix and / or uterus.
- infectious processes in the uterine cavity, fallopian tubes, ovaries;
- extragenital infections, localized in the intestine or bladder.
Since the pelvic region, and especially cellulose, is well supplied with blood and lymphatic vessels, it is possible to penetrate into it infections from distant foci ( angina , tuberculosis and others) in weakened patients.
Symptoms and signs of the parameter
As a rule, the first symptoms of the parametrite appear after 7-10 days after the effect of the provoking factor - severe labor, scraping of the uterine cavity with a diagnostic purpose or for abortion, gynecological surgery and other intra-uterine interventions.
The clinical course of inflammation is determined not only by its stage (acute or chronic parametritis), but also by the localization of the pathological process.
According to the localization of infectious inflammation, the parameter is classified into:
- Front parameter. All available pathological processes are localized in front of the uterus. Inflammation forms a dense infiltrate, which smooths the anterior arch, can spread to the surrounding bladder tissue and even the anterior abdominal wall.
- Rear parameter. Diagnosed by the localization of an inflammatory infiltrate behind the uterus. The inflammatory process can tightly surround the rectum, so often the rear parameter leads to a narrowing of its lumen.
- Side (right or left) parameter. Smoothes the vaginal vault on the side of the localization.
In the development of the parametrite, the staging is traced. At the beginning (infiltration stage) the inflammation penetrates into the cellulose and provokes local edema, local vasodilation and local tissue infiltration.
With further progression of the pathological process (stage of exudation), the affected tissues in response to microbial aggression are trying to get rid of the infection by increasing exudation. Depending on the nature of the infection, the exudate can be serous, purulent or mixed (serous-purulent).
Parametrism always accompanies pelvic pain, more often it radiates into the lumbar region. Depending on the location of the infiltrate, pain can be accompanied by a change in the function of adjacent organs. Also, patients note fever and deterioration of well-being.
In the uncomplicated course of the parametrix, all active symptoms subsided no later than two weeks. If the inflammation becomes purulent, the symptoms increase. Purulent parameterisation is infrequent (12-14%).
Diagnostics of the parametrite
To diagnose parametrists, with rare exceptions, is not difficult. It should be noted that the complaints of patients with most inflammatory processes (including parametrization) with localization in the pelvic cavity are very similar, therefore they can only indicate the presence of infectious inflammation. To clarify the diagnosis, gynecological examination and ultrasound scanning with a vaginal sensor help.
The uterus is always painful when viewed. The degree of soreness in palpation is determined by the stage and form of the parametrite. With suppuration of periarticular tissue, the pain is very sharp.
Also, with palpation, the shortening of the vaginal vaults, the displacement of the uterus in the "healthy" side or upwards are well expressed. The uterus becomes immobile, and the boundaries of the exudate-filled area are well palpated and felt as a dense, bounded uterus with no clear palpation borders. At the stage of infiltration, the inflammatory conglomerate upon palpation resembles a subserous myoma.
Ultrasonic scanning allows you to see infiltrates of irregular shape without clear boundaries. With an abscess, the infiltrate looks like a capsule-shaped formation filled with a thick heterogeneous content.
Laboratory diagnostics can detect inflammatory changes: leukocytosis , neutrophilia, increased ESR.
A purulent parameter is fraught with serious complications. Sometimes the formed abscess opens itself and breaks into adjacent areas with the formation of fistulas. In similar situations, adjacent specialists diagnose the presence of pus in the urine or in the feces.
Serous parameters, proceeding without complications, do not threaten the health of the patient, do not provoke menstrual and reproductive dysfunction. With a favorable course, the inflammatory process is eliminated six weeks or earlier. More often uncomplicated parametrit leaves after itself a slight disruption of uterine mobility (due to local sclerotic changes).
With a purulent parameter, the prognosis always worsens, especially if the abscess breaks into the surrounding organs or peritoneum.
Treatment of parametrite
Parametrite therapy is consistent with that in the treatment of inflammatory processes in the uterus and appendages and depends on the stage of the disease.
In the acute stage, the patient is hospitalized. To reduce inflammation, a cold is placed on the anterior abdominal wall. Anesthetics and antipyretic drugs are used.
The basis for the treatment of acute parametritis is antibacterial therapy. For the therapy to be successful, a causative agent is identified with the help of a laboratory test. Antibiotics (aminoglycosides, cephalosporins, penicillins, tetracyclines) and sulfanilamide preparations are used, since the majority of cases of acute parametrite is provoked by a mixed microflora in the composition of microbial associations, it is advisable to use them together.
In the treatment of acute gynecological infections of any localization it is extremely important to begin antibiotic therapy as early as possible in order to prevent further spread of the infection and to avoid aggravation of the disease, and laboratory identification of the pathogen always requires a certain amount of time. Therefore, the most common antibiotics, which are capable of destroying most pathogens of the disease, are initially appointed, and if necessary, the preparations change after receiving the results of the examination.
Infusion (intravenous) therapy is suitable for severe parametrite. As a rule, parallel intramuscular and intravenous administration of antibacterial agents is carried out. If the patient's condition can be regarded as satisfactory, they are limited to tableted antibiotics.
After the infection is eliminated with antibiotics, the inflammatory infiltrate in the parameter begins to dissolve. At this therapeutic stage, drugs from the group of non-steroidal anti-inflammatory drugs, biostimulators, vitamins are used. A good effect is physiotherapy.
If the treatment does not improve the clinical situation, or if the symptoms of the parametrite continue to increase, you should think about starting the process of suppuration in the infiltration area. To prevent a spontaneous dissection of the abscess, it must be opened. More often this procedure is carried out through the vagina. Through a small incision, the contents of the abscess are evacuated, a drainage tube is inserted into the resulting cavity, the cavity is constantly washed through it, and then antibiotics are introduced.