RU2485504C2 - Diagnostic technique for inflammatory pelvic diseases in females - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method includes physical examination, detection of a febrile or hyperpyretic fever in a patient, abnormal cervical or vaginal discharge, peripheral blood leukocytosis, increased erythrocyte sedimentation rate, positive C-reactive protein, and sexually transmitted infections (STIs). While endometrial and/or cervical polyps are additionally detected in the absence of mucosal hyperplasia, transient anechoic ovarian formations with preserved menstrual rate, keratosis or an atypical area of cervical epithelium transformation, condylomatosis of vaginal mucosa and/or vulva, or comorbid STIs. Then, adequate points are assigned to these criteria. Thus, if observing a febrile or hyperpyretic fever in the patient, 10 points are assigned, 5 points for abnormal cervical or vaginal discharge, 10 points for peripheral blood leukocytosis and increased erythrocyte sedimentation rate, 5 points for positive C-reactive protein, 3 points for the presence of STIs, 7 points for the presence of endometrial and/or cervical polyps in the absence of mucosal hyperplasia, 7 points for transient anechoic ovarian formations with preserved menstrual rate, 8 points for keratosis or an atypical area of cervical epithelium transformation, condylomatosis of vaginal mucosa and/or vulva, and 7 points for comorbid STIs, and if total score is more than 15, the presence of inflammatory pelvic diseases is stated.

EFFECT: improved diagnosis of chronic inflammatory pelvic diseases, and increased proportion of patients showing the improvement when discharged from hospital, normalised specific functions of the female body, and the onset and the physiological course of a pregnancy.

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Description

The present invention relates to medicine, namely to gynecology, and can be used to improve the quality and specificity of the diagnosis of inflammatory diseases of the pelvic organs (PID) by expanding the set of additional criteria in order to increase the effectiveness of therapeutic measures and attract at the earlier stages of the development of the process rational methods of therapy.

The frequency of inflammatory diseases of the female genital organs does not tend to decrease, as does the infertility of tubal-peritoneal genesis caused by them, which occupies a leading position among the causes of infertility in women and has the lowest reversibility rates. The probability of losing the ability to realize reproductive function is directly dependent on the duration of PID and the woman's age. In uncomplicated situations, the success of treatment of the inflammatory process of the genitals is determined by adequate antimicrobial therapy, with the chronicity of the process, etiotropic treatment loses its paramount importance, pathogenetic therapy is considered priority, all of which are met by hardware methods of treatment and methods based on the use of natural factors. Timely initiated and adequately selected therapy of this kind can stop the course of the disease and prevent the onset of irreversible changes in the reproductive system. The clinical course of inflammatory diseases of the pelvic organs in modern conditions is “rejuvenation”, a latent, primarily chronic course of the process with minimal clinical manifestations. Obtaining indisputable criteria for chronic PID with clear indications for an adequate set of therapeutic measures is associated with invasive measures, which in most cases are forced, and, since they are themselves associated with the likelihood of worsening the course of the pathology, cannot be recommended for routine general examination in order to diagnosis of the disease; non-invasive methods are able to give an affirmative answer to this question only in advanced cases when conservative treatment is ineffective. Therefore, the expansion of non-invasive methods for the diagnosis of VZOMT is indisputably important to facilitate the diagnostic search and timely selection of the right therapeutic direction.

There is a known method for the diagnosis of VZOMT, which consists in determining the minimum, additional and determining criteria (Outpatient care in obstetrics and gynecology: a practical guide / Edited by I.S. Sidorova, T.V. Ovsyannikova, I.O. Makarova. - M .: MEDpress-inform, 2009. - S.402-403), which is taken as the closest analogue.

Diagnostic criteria for PID.

Minimum criteria:

- Pain on palpation in the lower abdomen;

- soreness in the uterus;

- painful traction of the cervix.

Additional criteria:

- febrile or hyperpyretic fever;

- pathological discharge from the cervix or vagina;

- leukocytosis, increased ESR;

- positive CRP;

- laboratory confirmation of infection.

Evidence-Based Criteria:

- ultrasound data using transvaginal scanning;

- changes detected by laparoscopy, corresponding to PID;

- histopathological diagnosis of endometritis with endometrial biopsy.

To date, the evidence-based criteria of PID, developed by WHO, are histopathological confirmation of endometritis during endometrial biopsy, ultrasound detection (using transvaginal scanning) of thickened, fluid-filled fallopian tubes (with or without free fluid in the abdominal cavity), the presence of tubo-ovarian formation, as well as deviations found during laparoscopy, the corresponding PID. At the same time, direct visual diagnosis of VZOMT is not always available: it requires general anesthesia and is expensive, invasive interventions taken against the background of pathology contribute to upward infection and aggravation of the process, accepted ultrasound criteria appear in distant cases and when conservative therapy is ineffective.

Among the additional VZOMT criteria listed in modern literature, such signs as peripheral blood leukocytosis, a left shift of the leukocyte formula, an increase in ESR, hyperthermia are extremely rare, as is the acute onset of the process, exacerbation of chronic inflammation with a predominance of an infectious toxic component. Positive CRP is not specific. In the absence of evidence-based criteria, in the presence of minimal criteria, additional signs of PID are of decisive importance, the most constant of which in modern conditions is chronic vaginitis. There are no clear criteria for chronic vaginitis in the modern literature. The narrowness of the criteria that contribute to the diagnosis contributes to such phenomena in practical medicine as inadequate screening without proper screening methods, antibiotic monotherapy for STIs, symptomatic therapy, the absence of the pathogenetic orientation of therapy as such, unreasonable surgical interventions. Meanwhile, the ongoing development of pathology contributes to the development of irreversible changes in the reproductive system, repeated hospitalizations, complex, expensive and not always effective treatment. Expanding the list of PID criteria is necessary for the speedy diagnosis of pathology, increasing its accuracy and targeted use of the most effective methods of therapy, which, ultimately, cannot but affect the improvement of the quality of life of patients while minimizing the costs of treating complications.

The expansion of the PID criteria is designed to increase the reliability of diagnosis, ensure the timely detection and correction of treatment tactics for serious violations of women's health, and reduce the time of medical and social rehabilitation.

The technical result of the method is to increase the reliability of diagnosis by obtaining a complex of additional indicators confirming the detected pathology. The specificity of the criteria used for the first time allows diagnosing PID at an earlier stage with an accuracy of p <0.05 and selecting adequate therapy in a timely manner. Testing the method on 250 women showed that the differentiated use of modern technologies of restorative medicine provides high therapeutic and prophylactic effectiveness of medical rehabilitation of patients, as evidenced by an increase in the proportion of patients discharged from the clinic with improvement, up to 92.5% of cases, by normalizing their specific functions of the female body in 75% of cases, the onset and physiological course of pregnancy in 86.4% of cases.

The essence of the invention lies in the fact that additionally detect the presence of polyps of the endometrium and / or cervical canal in the absence of mucosal hyperplasia, transient anechogenic ovarian masses with a preserved rhythm of menstruation, keratosis or atypical zone of transformation of the cervical epithelium, condylomatosis of the vaginal mucosa and / or vulva, combined STIs, these signs are assigned appropriate points, so if a patient has febrile or hyperpyretic fever, 10 points are assigned, patolo uterine cervical or vaginal discharge - 5 points, peripheral blood leukocytosis, increased erythrocyte sedimentation rate - 10 points, positive C-reactive protein - 5 points, with an STI, 3 points are determined, the presence of endometrial polyps and / or cervical canal in the absence of hyperplasia mucous membrane - 7 points, transient anechogenic formations of the ovaries with a preserved rhythm of menstruation - 7 points, with existing keratosis or atypical zone of transformation of the cervical epithelium, condylomatosis of the mucous membrane vaginal and / or vulvar - 8, combined STD - 7 points, and, provided their sum values over 15 determine the presence of inflammatory diseases of the pelvic organs.

An expanded set of criteria for assessing the presence of PID is assigned points depending on specificity and their significance.

Table Signs of VZOMT Points Yes no Febrile or hyperpyretic fever 10 0 Pathological discharge from the cervix or vagina 5 0 Leukocytosis, increased ESR 10 0 Positive CRP 5 0 Laboratory confirmation of infection 3 0 Polyp of the endometrium and / or cervical canal in the absence of mucosal hyperplasia 7 0 Transient anechogenic formations of the ovaries with a preserved rhythm of menstruation 7 0 Keratosis or atypical transformation zone, 8 0 condylomatosis of the mucous membrane of the vagina and / or vulva Combined STIs 7 0

With a total score of 15 or more, the diagnosis of PID is most likely, requires the patient to carry out a full range of therapeutic measures in order to prevent irreversible disorders of the reproductive system.

The method is as follows: when the patient is treated with pain in the lower abdomen and a secretory function is impaired, body thermometry is performed, while the history is taken, the presence of polyps of the endometrium and / or cervical canal, transient anechogenic formations of the ovaries in the absence of irregular menstruation, marked by pathological changes in the mucosa sheaths of the vagina and cervix, for which treatment was carried out in the office of pathology of the cervix (requests for extract from the medical cumentation), with a vaginal examination, determine the presence and severity of the minimum criteria for PID, carry out laboratory diagnosis of vaginitis (microscopy of vaginal smears) and an oncocytological study when visualizing the pathology of exocervix. Further examination includes a general analysis of blood, urine, a biochemical blood test with the determination of CRP, the determination of the presence of STIs (PCR, PIF, bacterioscopy and bacteriological examination), in the presence of combined STIs, laboratory confirmation of infection is not taken into account, extended colposcopy, ultrasound examination of the pelvic organs . Empirical antimicrobial therapy is prescribed when the total score at the diagnostic stage is more than 15 according to the criteria: if a patient has febrile or hyperpyretic fever, 10 points are assigned, pathological discharge from the cervix or vagina - 5 points, peripheral blood leukocytosis, increased erythrocyte sedimentation rate - 10 points, positive C-reactive protein - 5 points; in the presence of STIs, 3 points are determined; presence of endometrial polyps and / or cervical canal in the absence of mucosal hyperplasia - 7 points in, transient anehogennoe formations when stored ovarian menstrual rhythm - 7 points, with the available keratosis conversion zone or atypical cervical epithelium condylomatosis vaginal mucosa and / or vulva - 8, combined STD - 7 points. With continued indications for surgical treatment (tumor of the appendages, pathology of the endometrium, mucous membrane of the cervix and vagina), appropriate treatment is carried out, the results of visual and histological diagnostics are used to diagnose and determine further management tactics.

EXAMPLES: 1. Patient K., 19 years old, came to the Clinic with complaints of moderate pulling pain in the lower abdomen, discharge from the genital tract yellowish, with an unpleasant odor. These complaints bothered at least 3 months. Objectively: body temperature 36.7 ° C, with a vaginal examination revealed signs of vaginitis, cervical erosion, pain on palpation of the uterus and appendages, the severity of the latter. Echographically - indirect signs of ovarian inflammation, anechogenic formation with a diameter of 35 mm in the right ovary, colposcopically - genital warts and vulva condylomas, keratosis of the stratified squamous epithelium of the cervix against the background of the incomplete transformation zone, focal vaginitis; laboratory - in the general analysis of blood and urine there are no deviations, in the biochemical analysis of blood CRP ++, bacterioscopic - vaginitis, M. hominis, U. urealyticum were found during examination for STIs (PCR). Based on the presented algorithm, the scoring of the criteria obtained, among which the patient revealed pathological discharge (leucorrhoea) (5b.), Positive CRP (5b.), Anechogenic ovarian formation with a preserved menstrual rhythm (7b.), Cervical keratosis and vaginal condyloma and vulva (8b.), combined STIs (7b.), i.e. the amount amounted to more than 15b.

Σ = 5 + 5 + 8 + 7 (b.) Σ = 25 (b.)

Empirical antimicrobial therapy was the basis of the patient’s subsequent treatment, taking into account the identified STIs when choosing drugs. The full clinical effectiveness of the therapy was confirmed by vaginal examination. A control ultrasound examination was carried out after the next menstruation - no focal pathology was revealed, i.e. this education was transient, which served as a reason to increase the amount of calculated points to Σ = 32 b. After receiving negative results of a bacteriological study on treated STIs, a cervical biopsy was performed, the result was histologically confirmed, treatment in the CPSM was successfully completed. Surgical treatment of tumor-like formation of the ovary was avoided. Further treatment of the patient was carried out in a planned manner, in the absence of active complaints and initial pathological deviations for 1 year, included the use of individually selected natural and transformed therapeutic factors.

2. Patient B., 28 years old, came to the Clinic with complaints of a lack of pregnancy during regular sexual life without contraception during the year, moderate inconsistent aching pains in the lower abdomen, discharge from the genital tract of a cheesy nature, itching in the external genital area, intensifying after water procedures. These complaints are disturbing for 6 months. From a gynecological history: 2 years ago I applied to a women's consultation at the place of residence for heavy menstruation, twice received treatment for chlamydia (3b.) Together with a sexual partner, due to the lack of clinical effect from the treatment of STIs in the form of persistent menstrual irregularities, hysteroscopy was performed, separate diagnostic curettage of the uterus. Histological response: glandular polyp of the endometrium, endometrium of the secretory type (7b.). In the postoperative period of 6 months, she took oral contraceptives. When examined at the time of treatment: bimanually - soreness and limitation in uterine mobility, soreness and heaviness in the area of the appendages, signs of vaginitis (5b.), Endocervicitis, in the general analysis of blood and urine without abnormalities, CRP + (5b.), Bacterioscopic - vaginitis, colposcopically - endocervicitis, diffuse vaginitis, sonographically indirect signs of the inflammatory process of the uterus and ovaries, adhesions in the pelvis. Based on the presented algorithm of ball diagnostics of VZOMT, the weight of the sum of the criteria was determined:

Σ = 5 + 5 + 3 + 7 (b.) Σ = 20 (b.)

After conducting empirical antimicrobial, anti-inflammatory, resorbable therapy using physiotherapeutic treatment, the patient underwent diagnostic and treatment laparoscopy, chromosalpingosopia (CSU). Laparoscopic diagnosis: chronic bilateral salpingitis, adhesions in the pelvis II-III degree, with CSU fallopian tubes are impassable in the ampullar sections. Two-sided salpingo-ovariolysis was performed, after which fallopian tubes are passable during CSF. Thus, the obtained defining signs of PID have confirmed the validity of the expanded set of criteria that were present even at the stage of the patient’s initial request for gynecological help and, if the significance of the signs were timely assessed, could contribute to the targeted use of conservative therapy methods that could prevent the development of tubal-peritoneal infertility and questionable results of subsequent treatment.

Claims (1)

A method for the diagnosis of inflammatory diseases of the pelvic organs in women, including a clinical examination, the detection of febrile or hyperpyretic fever in a patient, pathological discharge from the cervix or vagina, peripheral blood leukocytosis, increased erythrocyte sedimentation rate, positive C-reactive protein, and sexually transmitted infections by (STI), characterized in that it additionally reveals the presence of polyps of the endometrium and / or cervical canal in the absence of mucosal hyperplasia glasses, transient anechogenic formations of the ovaries with a preserved rhythm of menstruation, keratosis or atypical zone of transformation of the cervical epithelium, condylomatosis of the vaginal mucosa and / or vulva combined with STIs, these points are assigned the appropriate scores, so if the patient has febrile or hypheniretic fever 10 points, pathological discharge from the cervix or vagina - 5 points, peripheral blood leukocytosis, increased erythrocyte sedimentation rate - 10 points, positive C-reactive protein - 5 points, in the presence of STIs, 3 points are determined, presence of polyps of the endometrium and / or cervical canal in the absence of mucosal hyperplasia - 7 points, transient anechogenic formations of the ovaries with a preserved rhythm of menstruation - also 7 points, with existing keratosis or atypical zones of transformation of the cervical epithelium, condylomatosis of the mucous membrane of the vagina and / or vulva-8, combined STIs - 7 points, and if their sum is more than 15, the presence of inflammatory disease of small organs is determined pelvis.