Lecture inflammatory appendages

2021-03-22 12:00 AM

Depending on the bacteria that cause the disease, the clinical picture usually presents in an acute, acute and chronic form. The chronic form is often found by chance when the patient is examined for infertility.


Genital tract infections are one of the most common diseases in women, it is closely related to sexual intercourse, especially in cases where there are many sex partners, poor sexual hygiene. favorable conditions for the development of the disease. This means that the disease usually comes from the low genital tract. However, this is not always clear as the microbiological results are sometimes not quite the same between vaginal discharge and uterine tubes. In addition, it is also the result of complications in childbirth such as curettage, peeling vegetables after giving birth, insertion of a sterile uterine device, and especially in cases of unsafe abortion.

The appendages in a woman include ovaries, uterine tubes (oviduct), ligaments wide. Adnexitis for the most part usually starts with an inflammation of the uterus and then spreads around.

Genital inflammatory sites

  1. Cervicitis; 2. Endometritis; 3. Inflammation of the uterine tube;
  2. uterine tube stasis; 5. uterine hose abscess; 6.a Douglas abscess; 6.b Pelvic peritonitis

Harmful bacteria

Gonorrhea (Neisseria Gonorrhea), accounting for 20-40% of pelvic fossa infection, the direct test will detect coffee bean-shaped, gram-negative cocci.

Chlamydia trachomatis, the rate of 40-50% of pelvic inflammatory disease, is difficult to detect by direct test. Immunofluorescence is a good measure for detection.      


Other bacteria can be found in a number of conditions such as aerobic group (Colibacille, lactobacilli, protéus, staphylocoque), anaerobic group: (Bacteroides, fragilis, clostridium.)

In fact, the majority of genital infections are caused by a variety of bacteria (including both anaerobic and anaerobic bacteria), making treatment often difficult.


Depending on the bacteria that cause the disease, the clinical picture usually presents in an acute, acute, and chronic form. The chronic form is often found by chance when the patient is examined for infertility.

Acute morphology

Adnexitis usually occurs after childbirth, after miscarriage, or after surgical interventions in the subframe area such as aspiration curettage, insertion, removal of the ring ... and after acute vaginitis caused by gonorrhea bacteria.

The prominent clinical symptom is sudden lower abdominal pain in women, increased pain when walking, often pain on both sides (accounting for 90%).

Menstrual disorders, occurring in 50% of cases, are the signs of severe irritation in the lower abdomen such as pouring, loose bowel movements, difficulty urinating, urinary incontinence (accounting for 15-25% of cases).

Fever can be a symptom of these symptoms, up to a temperature of over 390C.

Possible vomiting or nausea.

Abdominal examination found lower abdominal resistance, but no abdominal wall spasticity, with signs of pressure drop- Blumberg (+).

Platypus: there are many damaged gases, sometimes pus, accounting for 39 - 65% of cases, we should get vaginal fluid for testing.

Examination with both hands in the vagina and on the abdomen, we find the uterus is soft, when the uterus is moved, it will cause pain, two appendages, pain. Sometimes a parenchymal mass is found, usually on the back of the uterus, which does not move.


Blood count has increased leukocytes, especially high neutrophils.

CRP increased.

Blood cultures can detect pathogenic bacteria. Cervical fluid test for gonorrhea and Chlamydia. In fact, the test is not always positive because adnexitis can occur due to bacteria. Ultrasound to detect inflammatory masses and appendages abscesses.

Semi-level form

This accounts for 30% of all cases. Clinical symptoms are usually milder with:

Dull pain in the lower back or lower back, sometimes throbbing pain.

Menorrhagia is common.

The vapors are not clear and nonspecific.

Low-grade fever, 37.50 - 380C.

Abdominal examination: often found soft, manipulated abdomen shows local resistance in the lower abdomen.

Vaginal examination: may see the pain on one or both sides of the appendages, with a blockage difficult to distinguish the boundary from the uterus. There are signs of pain when the cervix is ​​moved

Rectal examination: the patient was very painful during the examination  


Leukocytes increased with a moderate increase in neutrophils.

CRP increased.

Ultrasound identifies the appendage volume with mixed echoes (écho).

Laparoscopy, there may be combined lesions of adnexitis, peri-hepatic inflammation of the membrane between the liver and the diaphragm, or the upper surface of the liver and the anterior abdominal wall like violin strings (Fitz-Hugh syndrome -Curtis: peritonitis secondary to nonspecific genitalia. There are signs of fever, right lower rib pain spreading to the shoulder, there are signs in the subframe that reminds of adnexitis. , liver function tests and ultrasound are both normal).

Chronic morphology

Causes: due to acute adnexitis not being fully and promptly treated.



Pain: Pain in the hypotonic region or both sides of the pelvic fossa, usually with one dominant side Pain that changes in intensity, time, muscle, or continuity; Pain increases when walking a lot, while resting pain is less.

Damaged gas: not much, nonspecific.

Bleeding: abnormal bleeding may occur before and after menstruation or menstruation.


Abdominal manipulation combined vaginal exam can be found.

The uterus is limited, painful when moved.

There may be parenteral mass, painful compression, unknown boundary due to the uterine tube sticking to the ovary in a mass.

Differential diagnosis

Pain caused by diseases of the digestive tract and urinary tract

Acute appendicitis: inflammation of the appendix shows pain on both sides, the point of the appendix must be lower than the pain point of the inflamed appendix.



Pain caused by gynecological diseases

Ectopic pregnancy.

Delayed menstruation, abdominal pain on one side of the pelvic pit, hemorrhage.

HCG  ( + ).

Ultrasound: no amniotic sac in TC chamber.

Inflammation, stasis of uterine tap water due to tuberculosis.



When antibiotic is used early, the disease will go well with symptoms of fever elimination, abdominal pain relief, and subclinical tests will return to normal within a few days. Endoscopy may be ordered if a mass persists in the pelvic region after the appropriate antibiotic has been administered. 

Other developments

Peritonitis peritonitis:

This is a consequence when adnexitis is not properly treated, and can also become an abdominal emergency for serious infections. Peritonitis is localized in the perineum because the adjacent organs, especially the large connective membrane, the sigmoid colon, and the small intestinal loops next to the genitals cover, limit the spread of infection. When examining the abdomen, there is a localized reaction in the lower abdomen, sometimes signs of contraction of the abdominal wall, the abdomen above the navel is soft. Vaginal examination is very painful, the hypotension has a sticky mass, difficult to determine. uterus and the boundary between the uterus with adhesions

Abscess of an appendage:

Abscesses form from an inflamed tube of the uterus that goes undetected or untreated. On ultrasound, we show an image of a block of the uterus, oval, thick banks, mixed echo. Laparoscopy allows the pus to remove pus, to wash the abscess with physiological saline, to combine antibiotics with a broad antibacterial spectrum.

Ovarian abscess:

Rarely, the clinical picture resembles uterine tube stasis. When the surgery is found, the ovaries must be removed.

Inflammation spread to the perineum:

Infection can form an abscess under the peritoneum, which may spread higher in the broad ligament or downward toward the episiotomy. The treatment is usually surgery to drain the pus.

General peritonitis:

The infection spreads out of the pelvic fossa causing generalized peritonitis.

There are symptoms of serious infection: high fever, intoxication ...

There are signs of surgical abdominal surgery: peritoneal reaction, abdominal wall resistance ...

Long-term progression:

Severe or mild relapses may occur when there are genital or non-genital infections.


Common sequelae of pelvic inflammatory disease are:

Infertility is due to obstruction of the bilateral uterus, sticking to the speaker taps ...

Ectopic pregnancy.

Chronic pelvic pain.


Pelvic inflammatory disease due to many types of bacteria is often difficult to treat. There are many treatment regimens depending on the clinical form.

Acute inflammation caused by Chlamydia and gonorrhea

Primary line treatment:

Ofloxacin 400mg orally for 14 days or

Levofloxacin 500mg / day for 14 days.

Can be combined with Metronidazole 500mg orally for 14 days.

Can be combined with Doxycyclin 100mg x 2 tablets / day for 14 days.


Outpatient treatment if in 24 - 48 hours does not improve, hospitalization for treatment.

To avoid recurrence, you need to treat your partner.

Inpatient treatment:

Cephalosporin III 2g IV every 12 hours and Doxycycline 100mg IV every 12 hours until improvement.

Then, Doxycycline 100mg x 2 tablets orally / day for 14 days.

Abscess - adnexal abscess, perineal peritonitis

After using systemic antibiotics, a combination (Ceftriaxone + Aminozide + Metroni- dazone)

It can be treated with endoscopy with the release of sticky fibers, pus puncture, washing of the abscess, necessary to drain.

There are a few authors that recommend using a strong antibiotic followed by endoscopy remove the stick, remove the cap and drain the abdomen. There are anatomic effects associated with endoscopy due to inflammation and adhesion, and therefore special attention is required when performing surgical procedures.

Subacute peritonitis

Sticky peritonitis, it is necessary to prioritize treatment of Chlamydia trachomatis by combining cycline group (Doxycycline, Vibramycin) with Gentamycine or Metronidazole. The duration of treatment is about 21 days. In all cases, the treatment should be coordinated with a sexual partner

General peritonitis

Surgery: because the infection spreads out of the pelvic fossa, surgical intervention is required to resolve the cause, clean and drain the abdomen. Get the specimen for the bacteria test.

Internal Medicine: rehydration fluid, electrolytes, antibiotics before and after surgery.


Periodically organize gynecological examination at the grassroots level to detect and treat early, especially at-risk groups or those who have to work in a dirty water environment.

Early detection, active treatment of lower genital tract infections right after infection

Effective detection and treatment of urethritis in men and women.

Condom use in people at high risk of a sexually transmitted infection.

Respect the principle of sterility when performing obstetric and gynecological procedures.

Propagating and guiding menstrual hygiene, personal hygiene, and sexual intercourse.

Mobilize to give birth to a plan, to avoid unwanted pregnancy.

Promote a healthy lifestyle.