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Medical versus Surgical Treatment of Pelvic Inflammatory Disease
MEDICAL VERSUS SURGICAL TREATMENT OF PELVIC INFLAMMATORY DISEASE ROBERT
B.
WILSON
GENERAL CONSIDERATIONS FROM this title it might appear that medical treatment and surgical treatment of pelvic inflammatory disease are antagonistic. Actually, both are employed either singly or in combination, depending on the cause, symptoms, physical findings and the clinical course in the individual case. Experience constantly emphasizes that the two methods of treatment are complementary. However, with the availability of sulfonamides, antibiotic substances and improved methods of heating the pelvis by diathermy, it has become evident that more and more patients can be effectively managed with medical treatment alone. Certain aspects of the treatment of this condition have become so well established that they hardly deserve repetition. In the acute case surgical treatment is rarely employed, since it is necessary to allow the acute inflammatory process to subside before operation can safely be performed. Occasionally it is necessary to effect cul-de-sac drainage of an acute pelvic abscess through a colpotomy incision. Aside from this, and with the previously mentioned methods for medical treatment, one may emphasize that the need for surgical management is indeed extremely rare. Medical treatment is thus the treatment of choice in the acute case; if such treatment is thoroughly carried out, it will often be found that surgical treatment is not necessary. On the other hand, the patient who has large adnexal masses, who gives a long-standing history of repeated flare-ups and who has disabling symptoms is hardly a candidate for medical treatment. Surgical treatment in these cases becomes the only therapy which will cure the patient and is frequently necessary for correction of the results of infection rather than for the infection itself. One should remember that adhesions, involvement of the bowel and bladder, chronic symptoms referable to the intestinal or urinary tracts and persistent pain are the results of infection and are not necessarily evidence of active infection. These symptoms are largely the result of mechanical conditions such as those produced by torsion or by interference with the blood supply due to adherent retroversion or prolapsed adherent tubes and ovaries. Evidences of ovarian failure are often seen which are not due to active infection but are probably due to change in position, adherence, interference with the blood supply or to actual destruction of ovarian tissues. Such changes may cause various types
866
TREATMENT OF PELVIC INFLAMMATORY DISEASE
867
of ovarian dysfunction, such as vaginal bleeding, which may be sufficient to require surgical intervention. Etiology.-Most attacks of pelvic inflammatory disease are caused by gonorrheal infection or by streptococcal or staphylococcal infection following abortion which has usually been induced, but which may have been spontaneous. More rarely this condition may follow parturition. Tuberculosis may involve the pelvic viscera; in this presentation, however, treatment of pelvic tuberculosis will not be considered, as ,the diagnosis is seldom made preoperatively and in usual practice the disease is comparatively uncommon. Pelvic cellulitis following either roentgen or radium therapy for malignant lesions of the pelvic viscera is not uncommon and is often severe. Pathology.-The pathologic picture-of pelvic infection varies with the cause and with the tissues involved. When Neisseria gonorrhoeae is the causative agent the acute inHammatory process involves the tubal mucosa primarily. There are the usual findings of an acute inHammatory prqcess with the lumen of the tube being filled with purulent exudate. Commonly the fimbriated tubal extremity becomes occluded and the resultant pyosalpinx often eventually becomes a relatively quiescent hydrosalpinx. There is a varying amount of involvement of the surrounding structures. The ovary is not infrequently involved in an abscess. Adherence of the tubal serosa to any adjacent peritoneal surface is quite common, this adhesive process being the cause of much of the difficulty in the operative treatment in these cases. In cases in which infection follows gestation the causative organism is usually some strain of streptococcus. In such infections the inHammatory process usually involves the mural portion of the tube, the tubal mucosa being relatively free of inflammatory changes. Invasion of the tissue in and about the pelvic organs commonly occurs. In such types of infection subsidence, with minimal residual involvement, is rather likely to occur so that surgical treatment is necessary infrequently. Tubal patency is more likely to be maintained after this type of infection than it is after gonorrheal salpingitis. TREATMENT
The physician usually first sees a patient with pelvic inHammatory disease during the acute or subacute phase of the condition, the pain in the lower part of the abdomen, the fever and chills being of sufficient intensity to cause the patient to seek medical care. Before treatment is started a history may lead to a probable diagnosis as to the causative agent. Evidence of pregnancy or a history suggestive of. venereal infection may be obtainable. A history of previous attacks of pelvic inflammatory disease is important, as the type of treatment used in chronic disease may vary from that for an initial attack.
868
ROBERT B.· WILSON
a
Minimal laboratory procedures include count of the erythrocytes and leukocytes, differential count, estimation of the value for hemoglobin, determination of the sedimentation rate, urinalysis and examination of cultures and stained smears from the urethra and cervix. The necessary general physical examination, including examination of the pelvis, must be made. It probably cannot be emphasized too strof!gly that the pelvic examination should be conducted as gently as ptissible, the physician palpating the pelvic viscera only sufficiently to establish a diagnosis and to gain some idea of extent of the disease. Procedures in medical treatment may well be divided into three categories: (1) general and supportive measures, (2) use of sulfonamides or antibiotic agents or both and '3) pelvic heating. General and Supportive Measures.-The need for general and slJflPortive measures varies considerably with the severity of the disease. Some patients will have only mild pain and minimal evidence of disease on examination while others will have severe pain, high fever, abdominal distention, perhaps ileus, and a frozen pelvis, all associated with dehydration and debility. Such patients require parenteral administration of adequate amounts of fluids, sedation and rest in bed. Any aberrations of the chemical contents of the blood must be corrected in these severe cases. Sulfonamides and Penicillin.-Sulfonamides or penicillin should be administered to all patients who exhibit evidence of acute infection. At the Clinic treatment with penicillin generally is effective in nearly all cases of pelvic cellulitis. Penicillin is generally administered in doses of 30,000 to 40,000 units every three hours until the fever subsid~s and the clinical course indicates that the antibiotic substance is no longer necessary. Early treatment of both speciRc and nonspeciRc . infections is most important; this is particularly true in gonorrheal urethritis and cervicitis. Before present-day methods were available, prolonged periods of rest in bed were necessary and even then the occurrence of ascending infection was not infrequent. Today in early stages of infection a dose of 300,000 units of penicillin in beeswax and Qil is administered daily for three days. The patient may remain ambulatory, but even so the incidence of acute salpingitis is relatively low after such treatment. Occasionally sulfonamides are administered also, either sulfadiazine or sulfathiazole being the drug used. A concentration of 12 to 14 mg. per 100 C.c. of blood is maintained; the usual safeguards are observed as to maintenance of urinary output and careful review of the values for hemoglobin and the leukocyte counts. Diathermy.-Diathermy is considered to be one of the most effective measures in the elimination of pelvic inflammatory disease and its well-known residua. Use of the conventional or so-called long wave type of diathermy has been continued at the Clinic for several reasons.
I
TREATMENT OF PELVIC INFLAMMATORY DISEASE
869
With this type of diathermy it is possible to observe the temperature of the vaginal electrode without shutting off the applicator. This is important, as one can then be certain that adequate heat is being delivered to the pelvis. It is thought that vaginal applicators for conventional diathermy are better than others. Tlie Bierman-Horwit~ vaginal applicator, molded from metal, is used; it has a flattened oval shape, with a depression for the cervix, and comes in three sizes. With this type of diathermy and electrode it is possible effectively to localize the heat at the desired sites. Actually it probably makes little difference whether short wave or so-called long wave diathermy is used so long as the procedure is carefully carried out. There are adequate and satisfactory electrodes for the short wave machine but, as already noted, it is difficult adequately to control the temperature with such machines. Patients may be started on diathermy one or two days' after admission and after treatment with sulfonamides or penicillin has been started. In very acute and severe cases it may be necessary to wait longer than a few days before diathermy can safely be started. Usually the first treatment is given by means of a short wave coil over the lower abdomen. If this is tolerated, intrapelvic or vaginal long wave therapy is started. The only contraindication to pelvic diathermy is vaginal bleeding. In some instances profuse leukorrhea may interfere but usually a discharge is not considered a contraindication. Such a leukorrhea may be due to gonorrheal vaginitis and cervicitis; in this event it is cared for by the penicillin given. If the leukorrhea is due to a trichomonal infection, it should be treated by appropriate measures; if it is due to a moniliasis, it can usually be readily controlled by applying 1 per cent solution of gentian violet and 0.5 per cent solution of acriflavine in glycerin to the vagina, cervix and external genitalia. At first, but one diathermy treatment, which lasts for fifteen to thirty minutes, is given each day. The time is increased to forty-five to sixty minutes daily; if this amount of treatment is tolerated well, then two such treatments are given each day. If any of these treatments a.re not tolerated, as evidenced by the occurrence of fever or increase in pain, the time is shortened but usually treatment is not discontinued. Observation of the thermometer in the applicator permits maintenance of the temperature at 106 0 to 107 0 F.; the rectal temperature will be found to be about 103 0 to 104 0 F. Twice daily, treatments are continued for two or three weeks or longer according to need as indicated by the clinical findings and by the results of pelvic examination. If improvement has been satisfactory but resolution is not complete, it is often wise to give the patient a rest from treatment for several weeks and then to administer another course of treatment with diathermy.
870
ROBERT B. WILSON
Consideration of Surgical Treatment.-Only after trial of such a course of medical treatment as has been outlined should surgical treatment be considered. Often after such medical treatment the pelvis may be found to be completely free of disease. Even if there has been no real improvement in the physical findings the patient may be relatively free of symptoms; it is then possible to wait before surgical treatment is considered. The length of this waiting period varies a great deal with individual patients. In general, observation of a long, rather than a short interval before surgical intervention is considered is wise, as the longer the interval the more likely is the pelvis to be free of bacterial residua. Of course, for the patient who has frequently recurring attacks of pelvic inflammatory disease and who has palpable evidence of considerable disease in the pelvis it is necessary to select what one considers an optimal time for operation. In general, pelvic operation should not be attempted in the presence of fever or an elevated leukocyte count. The sedimentation rate may not have reached a normal value but should be appreciably lower than during the acute phase of the disease. A valuable clinical method of determining whether or not a patient can be safely operated on consists of performing a rather vigorous pelvic examination. If such an examination is followed by fever and other symptoms one has adequate evidence that the process is still in an active stage and that operation should be deferred. Obviously such an examination should not be done when other evidence of activity is present. Before operation it is important to improve the general condition of the patient as much as possible and to give penicillin preoperatively for three or four days. In performance of operative procedures much difficulty may be encountered in the mobilization of the pelvic viscera; due care must be exercised to prevent injury to the bowel, bladder and ureters. If possible a young woman should be left with her reproductive function intact. In the woman past forty years of age little is gained by performing a conservative operation. It is debatable as to whether or not the uterus should be allowed to remain if the reproductive function is destroyed. As a rule, surgical treatment is employed because of persistence of symptoms and the patient, therefore, expects to be relieved of them; accordingly, treatment frequently must be radical. For this reason, unless there is technical difficulty, it is usually in the best interests of the patient to remove all of the pelvic genitalia. Ovarian function should be preserved, when possible, in women forty or under. However, it is now possible to relieve satisfactorily, by oral or parenteral administration of estrogens, symptoms that occur after bilateral oophorectomy. The surgeon, therefore, must often choose whether or not to leave in the pelvis a questionable ovary which may cause further trouble or to remove such an ovary and depend on sub-
TREATMENT OF PELVIC INFLAMMATORY DISEASE
871
stitution therapy. Drainage through the abdominal wall or through the vagina is usually not emplQyed by surgeons at the Clinic. Often, however, a cigaret drain or a drain made of a split rubber tube is placed in the wound down to the peritoneum. REPORT OF CASES CASE I.-A woman was admitted to the Clinic on April 23, 1937. She had heen well until April 9, when she had begun to suffer from pain in the lower part of the abdomen, chills and fever. The temperature had varied from 100 0 to 103.6 0 F. The patient stated that she had been married twenty-eight years; during that time she had had one pregnancy which had ended in spontaneous abortion. She gave no history of a previous attack of pelvic inflammatory disease. The pelvic examination revealed a large abscess which filled the entire lower part of the pelvis. Laboratory data were as follows: hemoglobin, 12.9 grn. per 100 C.c. of blood; erythrocytes, 3,240,000 and leukocytes, 21,500 (85 per cent polymorphonuclear leukocytes) per cubic millimeter of blood; result of Wassermann test, negative; results of cultures on chocolate blood agar and of examination of smears, negative for gonococci; sedimentation rate, 58 mm. in one hour on April 23 and 115 mm. on April 28. Treatment with conventional diathermy was started on April 30 and given daily until May 17. The temperature returned to normal soon after diathermy was started. The sedimentation rate on May 1 was 91 mm. and on May 11 it was 24 mm. in one hour. The leukocyte count on May 11 was 5,800 per cubic millimeter. A pelvic examination on May 14 revealed remarkable resolution of the pelvic abscess, with only minimal residual thickening. The patient subsequently was examined twice in 1937 and once in 1940, 1942 and 1945. At each examination the'pelvis was found to be completely clear.
The case just reported is instructive because it illustrates what diathermy can do, particularly if used early in the course of the disease. This case has been used as an illustration because there has been adequate follow-up and because diathermy was the only therapeutic agent used. It may be significant that in this case the patient had but five or six menstrual periods (lfter the treatment until spontaneous menopause occurred; this may have been a factor in her complete recovery, as the menstrual stimulus to a recurrence of the infection was not present. CASE 2.-A woman, thirty-two years old, was registered at the Clinic on October 5, 1936. She had been married twelve years. She stated that she had had an induced instrumental abortion performed in 1925, with no complications. However, eight months later she had suffered from symptoms indicative of acute pelvic inflammatory disease and was hospitalized for six weeks. Four months after that, another attack occurred and she was hospitalized for ten days. At the time of her admission to the Clinic, the patient complained of abdominal soreness, which was not incapacitating, and of constipation. The pelvic examination revealed an adherent retroverted uterus and bilateral adnexal prolapse, with adhesion. Results of all laboratory tests, including leukocyte count and sedimentation rate, were within normal limits. Cultures on chocolate blood agar gave negative results for gonococci. The medical gynecologist who saw this patient stated that conditions in the pelvis were probably sufficiently pathologic to justify
872
ROBERT B. WILSON
operation. The gynecolo.gic surgeo.n tho.ught that co.nservative o.peratio.n was indicated and necessary. Therefore, o.n Octo.ber 26, 1936, the pelvis was explored and the fo.IIo.wing surgical procedures accomplished: ventral suspension o.f an adherent retroverted uterus, bilateral salpingecto.my because o.f bilateral hydro.salpinx, left o.o.pho.recto.my because o.f hemo.rrhagic cystic o.o.pho.ritis, and appendecto.my. On the sixth Po.sto.perative day sympto.ms o.f obstructio.n o.f the small bo.wel develo.ped and the pelvis was re-explored o.n the fourteenth Po.stoperative day. A lo.o.P o.f ileum was fo.und adherent in the pelvis; this was freed and a necro.tic area in the bo.wel was excised. Entero.sto.my was done. Generalized peritonitis develo.ped and the patient died sixteen days after the o.riginal o.peratio.n.
In all fairness it must be emphasized that this fatality occurred prior to the availability of the sulfonamides and the antibiotic agents. This Case does illustrate what often happened prior to the time these drugs became available. It further illustrates the inherent risk in all surgery and emphasizes that the surgical treatm~nt of pelvic inflammatory disease should not be undertaken lightly. This is true even though administration of the sulfonamides and antibiotic substances now available markedly lowers the mortality rate in generalized peritonitIs. Adherence of a loop of small bowel to a raw surface in the pelvis, with subsequent obstruction, is not a rare occurrence. It can be prevented by adequate peritonization and, if this is not possible, by suture of the sigmoid over the raw area. When this latter procedure is carried out, the large bOWiel adheres and seldom, if ever, becomes obstructed because of such adherence.
•
CASE 3.-A white wo.man, fo.rty-six years o.ld, was admitted September 9, 1946. She had been married ten years and had had no. pregnancies o.r o.peratio.ns. Three mo.nths prio.r to. admissio.n, the usual sympto.ms of pelvic inflammato.ry disease developed. The patient's home physician ho.spitalized her for six weeks during which penicillin was given and po.sterio.r co.lpoto.my was perfo.rmed. Prio.r to admissio.n to. the Clinic she had had o.ne recurrence which had been contro.lled by penicillin. She stated that she had lo.st appro.ximately 20 Po.unds (9.1 kg.). On admissio.n the temperature, pulse, respiratio.ns and blo.o.d pressure were no.rmal. The uterus was fo.und to. be fixed and tender o.n mo.tio.n; it was no.t much enlarged. A mass, 8 to. 10 cm. in diamet~r, was present in the left adnexa and the right adnexa was the site o.f thickening and induratio.n, grade 4 (o.n the basis o.f 1 to. 4, in which 1 represents least, and 4 mo.st severe co.nditio.n). The pertinent labo.rato.ry data were as fo.IIo.ws: hemo.gIo.bin, 9.3 gm. per 100 c.c. o.f blo.o.d; erythro.cytes, 3,780,000 and leuko.cytes, 22,700 per cubic millimeter o.f blo.o.d; results o.f urine culture, po.sitive fo.r Escherichia co.li; andsedimentatio.n rates, 106 to. 127 mm. in o.ne ho.ur. The patient was immediately ho.spitalized and treated with pelvic diathetmy, penicillin, a diet high in calories and in vitamins, iro.n and vitamin supplements. Administratio.n o.f penicillin was. disco.ntinued ten days after admissio.n, hut the o.ther measures were co.ntinued fo.r fifty days. Little change had o.ccurred in the pelvis when the patient was dismissed fro.m the ho.spital o.n Octo.ber 28; she was advised to. return in one mo.nth. At readmissio.no.n No.vember 28 the sedimentatio.n rate was 55 mm. in o.ne ho.ur and the leuko.cyte co.unt was 7,900. The temperature was no.rmal and no. change was no.ted in the pelvic lesio.ns. Diathermy and penicillin were given in preparatio.n fo.r o.peratio.n; this caused so.me elevatio.n o.f both the sedimentatio.n rate and the leuko.cyte co.unt.
TREATMENT OF PELVIC INFLAMMATORY DISEASE
873
When the pelvis was explored on December 18, bilateral tubo-ovarian abscesses were found. Subtotal abdominal hysterectomy, bilateral salpingo-oophorectop1y and appendectomy were done. The surgeon stated that there was too much inHammatory reaction about the base of the bladder and the broad ligaments to permit performance of total hysterectomy. The postoperative course was afebrile, the patient being dismissed from the hospital on the tenth postoperative day. During the postoperative period penicillin and dicumarol were administered.
It is obvious that in this case the patient did not respond to conservative medical management that was thorough and prolonged. The medical management had considerable value, however, as it gave assurance of a relatively safe surgical risk. It might be that diathermy would have been more effective had it been started at the onset of the illness. The efficacy of administration of penicillin as a preoperative and postoperative measure is emphasized by this patient's smooth postoperative course which was completely afebrile. CASE 4.-A white woman, forty-two years old, was first registered at the Clinic on June 4, 1946. Physical examination revealed a squamous cell epithelioma of the cervix, grade 3 (Broders' method), stage 2. Laboratory data were negative except that the Wassermann test gave strongly positive results. From June 20 to July 13 full courses of radium and roentgen therapy were administered for the carcinoma of the cervix. On October 2 examination revealed a good local result from this treatment. A second course of roentgen therapy was administered from October 3 to October 7. On October 14 the patient returned complaining of a great deal of pain in the lower part of the abdomen. On examination the temperature was found to be 103 0 F. The pelvis was exquisitely tender and the uterus was fixed to the right. The uterus was probed, with negative results. The sedimentation rate was 129 mm. in one hour. The patient was immediately hospitalized and given large doses of penicillin plus the usual supportive treatment. Diathermy was started a few days after admission. On November 4 the pelvic disease had extended to points above the umbilicus on the right and just below the umbilicus on the left. The sedimentation rate remained elevated. The septic type of temperature subsided on November 8 and the patient was dismissed from the hospital on November 23. On December 4 the patient was readmitted to the hospital with chills, fever and low back pain. Her temperature was 104 F. the day after admission and her sedimentation rate was 133 mm. in one hour. The temperature was immediately lowered after administration of pen,iciliin. Pelvic diathermy was again started. The symptoms were found to be due to infection of the urinary tract. The patient was dismissed from the hospital on December 15 but was continued on treatment of the infection of the urinary tract and on treatment with pelvic diathermy as an outpatient. A pelvic examination on December 19 was essentially negative; no clinical evidence of either carcinoma or pelvic inHammatory disease was found. When last seen on January 29, 1947, the patient was gaining weight and was feeling well. 0
It is probably true that pelvic inflammatory disease following radiation therapy given for a malignant lesion can be treated only by conservative or medical measures. It is believed that diathermy and therapy with antibiotic substances were entirely responsible for this patient's recovery.
874
ROBERT B. WILSON
SUMMARY AND COMMENT
One should re-emphasize the fact that the medical and surgical treatments of pelvic inHammatory disease are to be used to complement one another. We feel that all patients suffering from such disease should first receive conservative medical management. Early and adequate medical treatment by our present-day methods should cause a marked decrease in the number of instances in which surgical intervention is required. If possible, therapy should be started when the infectious process is limited to the urethra and cervix in the gonorrheal type of infection and when the very first sign of visceral involvement occurs in other types of infection. Certainly a good end result, with salvage of the reproductive function, will hinge to a great extent on such early and adequate treatment. With such treatment a clinical cure will often be effected; in those cases in which cure is not effected by such treatment, the patient will be in better condition to undergo operation.
B.
WILSON
GENERAL CONSIDERATIONS FROM this title it might appear that medical treatment and surgical treatment of pelvic inflammatory disease are antagonistic. Actually, both are employed either singly or in combination, depending on the cause, symptoms, physical findings and the clinical course in the individual case. Experience constantly emphasizes that the two methods of treatment are complementary. However, with the availability of sulfonamides, antibiotic substances and improved methods of heating the pelvis by diathermy, it has become evident that more and more patients can be effectively managed with medical treatment alone. Certain aspects of the treatment of this condition have become so well established that they hardly deserve repetition. In the acute case surgical treatment is rarely employed, since it is necessary to allow the acute inflammatory process to subside before operation can safely be performed. Occasionally it is necessary to effect cul-de-sac drainage of an acute pelvic abscess through a colpotomy incision. Aside from this, and with the previously mentioned methods for medical treatment, one may emphasize that the need for surgical management is indeed extremely rare. Medical treatment is thus the treatment of choice in the acute case; if such treatment is thoroughly carried out, it will often be found that surgical treatment is not necessary. On the other hand, the patient who has large adnexal masses, who gives a long-standing history of repeated flare-ups and who has disabling symptoms is hardly a candidate for medical treatment. Surgical treatment in these cases becomes the only therapy which will cure the patient and is frequently necessary for correction of the results of infection rather than for the infection itself. One should remember that adhesions, involvement of the bowel and bladder, chronic symptoms referable to the intestinal or urinary tracts and persistent pain are the results of infection and are not necessarily evidence of active infection. These symptoms are largely the result of mechanical conditions such as those produced by torsion or by interference with the blood supply due to adherent retroversion or prolapsed adherent tubes and ovaries. Evidences of ovarian failure are often seen which are not due to active infection but are probably due to change in position, adherence, interference with the blood supply or to actual destruction of ovarian tissues. Such changes may cause various types
866
TREATMENT OF PELVIC INFLAMMATORY DISEASE
867
of ovarian dysfunction, such as vaginal bleeding, which may be sufficient to require surgical intervention. Etiology.-Most attacks of pelvic inflammatory disease are caused by gonorrheal infection or by streptococcal or staphylococcal infection following abortion which has usually been induced, but which may have been spontaneous. More rarely this condition may follow parturition. Tuberculosis may involve the pelvic viscera; in this presentation, however, treatment of pelvic tuberculosis will not be considered, as ,the diagnosis is seldom made preoperatively and in usual practice the disease is comparatively uncommon. Pelvic cellulitis following either roentgen or radium therapy for malignant lesions of the pelvic viscera is not uncommon and is often severe. Pathology.-The pathologic picture-of pelvic infection varies with the cause and with the tissues involved. When Neisseria gonorrhoeae is the causative agent the acute inHammatory process involves the tubal mucosa primarily. There are the usual findings of an acute inHammatory prqcess with the lumen of the tube being filled with purulent exudate. Commonly the fimbriated tubal extremity becomes occluded and the resultant pyosalpinx often eventually becomes a relatively quiescent hydrosalpinx. There is a varying amount of involvement of the surrounding structures. The ovary is not infrequently involved in an abscess. Adherence of the tubal serosa to any adjacent peritoneal surface is quite common, this adhesive process being the cause of much of the difficulty in the operative treatment in these cases. In cases in which infection follows gestation the causative organism is usually some strain of streptococcus. In such infections the inHammatory process usually involves the mural portion of the tube, the tubal mucosa being relatively free of inflammatory changes. Invasion of the tissue in and about the pelvic organs commonly occurs. In such types of infection subsidence, with minimal residual involvement, is rather likely to occur so that surgical treatment is necessary infrequently. Tubal patency is more likely to be maintained after this type of infection than it is after gonorrheal salpingitis. TREATMENT
The physician usually first sees a patient with pelvic inHammatory disease during the acute or subacute phase of the condition, the pain in the lower part of the abdomen, the fever and chills being of sufficient intensity to cause the patient to seek medical care. Before treatment is started a history may lead to a probable diagnosis as to the causative agent. Evidence of pregnancy or a history suggestive of. venereal infection may be obtainable. A history of previous attacks of pelvic inflammatory disease is important, as the type of treatment used in chronic disease may vary from that for an initial attack.
868
ROBERT B.· WILSON
a
Minimal laboratory procedures include count of the erythrocytes and leukocytes, differential count, estimation of the value for hemoglobin, determination of the sedimentation rate, urinalysis and examination of cultures and stained smears from the urethra and cervix. The necessary general physical examination, including examination of the pelvis, must be made. It probably cannot be emphasized too strof!gly that the pelvic examination should be conducted as gently as ptissible, the physician palpating the pelvic viscera only sufficiently to establish a diagnosis and to gain some idea of extent of the disease. Procedures in medical treatment may well be divided into three categories: (1) general and supportive measures, (2) use of sulfonamides or antibiotic agents or both and '3) pelvic heating. General and Supportive Measures.-The need for general and slJflPortive measures varies considerably with the severity of the disease. Some patients will have only mild pain and minimal evidence of disease on examination while others will have severe pain, high fever, abdominal distention, perhaps ileus, and a frozen pelvis, all associated with dehydration and debility. Such patients require parenteral administration of adequate amounts of fluids, sedation and rest in bed. Any aberrations of the chemical contents of the blood must be corrected in these severe cases. Sulfonamides and Penicillin.-Sulfonamides or penicillin should be administered to all patients who exhibit evidence of acute infection. At the Clinic treatment with penicillin generally is effective in nearly all cases of pelvic cellulitis. Penicillin is generally administered in doses of 30,000 to 40,000 units every three hours until the fever subsid~s and the clinical course indicates that the antibiotic substance is no longer necessary. Early treatment of both speciRc and nonspeciRc . infections is most important; this is particularly true in gonorrheal urethritis and cervicitis. Before present-day methods were available, prolonged periods of rest in bed were necessary and even then the occurrence of ascending infection was not infrequent. Today in early stages of infection a dose of 300,000 units of penicillin in beeswax and Qil is administered daily for three days. The patient may remain ambulatory, but even so the incidence of acute salpingitis is relatively low after such treatment. Occasionally sulfonamides are administered also, either sulfadiazine or sulfathiazole being the drug used. A concentration of 12 to 14 mg. per 100 C.c. of blood is maintained; the usual safeguards are observed as to maintenance of urinary output and careful review of the values for hemoglobin and the leukocyte counts. Diathermy.-Diathermy is considered to be one of the most effective measures in the elimination of pelvic inflammatory disease and its well-known residua. Use of the conventional or so-called long wave type of diathermy has been continued at the Clinic for several reasons.
I
TREATMENT OF PELVIC INFLAMMATORY DISEASE
869
With this type of diathermy it is possible to observe the temperature of the vaginal electrode without shutting off the applicator. This is important, as one can then be certain that adequate heat is being delivered to the pelvis. It is thought that vaginal applicators for conventional diathermy are better than others. Tlie Bierman-Horwit~ vaginal applicator, molded from metal, is used; it has a flattened oval shape, with a depression for the cervix, and comes in three sizes. With this type of diathermy and electrode it is possible effectively to localize the heat at the desired sites. Actually it probably makes little difference whether short wave or so-called long wave diathermy is used so long as the procedure is carefully carried out. There are adequate and satisfactory electrodes for the short wave machine but, as already noted, it is difficult adequately to control the temperature with such machines. Patients may be started on diathermy one or two days' after admission and after treatment with sulfonamides or penicillin has been started. In very acute and severe cases it may be necessary to wait longer than a few days before diathermy can safely be started. Usually the first treatment is given by means of a short wave coil over the lower abdomen. If this is tolerated, intrapelvic or vaginal long wave therapy is started. The only contraindication to pelvic diathermy is vaginal bleeding. In some instances profuse leukorrhea may interfere but usually a discharge is not considered a contraindication. Such a leukorrhea may be due to gonorrheal vaginitis and cervicitis; in this event it is cared for by the penicillin given. If the leukorrhea is due to a trichomonal infection, it should be treated by appropriate measures; if it is due to a moniliasis, it can usually be readily controlled by applying 1 per cent solution of gentian violet and 0.5 per cent solution of acriflavine in glycerin to the vagina, cervix and external genitalia. At first, but one diathermy treatment, which lasts for fifteen to thirty minutes, is given each day. The time is increased to forty-five to sixty minutes daily; if this amount of treatment is tolerated well, then two such treatments are given each day. If any of these treatments a.re not tolerated, as evidenced by the occurrence of fever or increase in pain, the time is shortened but usually treatment is not discontinued. Observation of the thermometer in the applicator permits maintenance of the temperature at 106 0 to 107 0 F.; the rectal temperature will be found to be about 103 0 to 104 0 F. Twice daily, treatments are continued for two or three weeks or longer according to need as indicated by the clinical findings and by the results of pelvic examination. If improvement has been satisfactory but resolution is not complete, it is often wise to give the patient a rest from treatment for several weeks and then to administer another course of treatment with diathermy.
870
ROBERT B. WILSON
Consideration of Surgical Treatment.-Only after trial of such a course of medical treatment as has been outlined should surgical treatment be considered. Often after such medical treatment the pelvis may be found to be completely free of disease. Even if there has been no real improvement in the physical findings the patient may be relatively free of symptoms; it is then possible to wait before surgical treatment is considered. The length of this waiting period varies a great deal with individual patients. In general, observation of a long, rather than a short interval before surgical intervention is considered is wise, as the longer the interval the more likely is the pelvis to be free of bacterial residua. Of course, for the patient who has frequently recurring attacks of pelvic inflammatory disease and who has palpable evidence of considerable disease in the pelvis it is necessary to select what one considers an optimal time for operation. In general, pelvic operation should not be attempted in the presence of fever or an elevated leukocyte count. The sedimentation rate may not have reached a normal value but should be appreciably lower than during the acute phase of the disease. A valuable clinical method of determining whether or not a patient can be safely operated on consists of performing a rather vigorous pelvic examination. If such an examination is followed by fever and other symptoms one has adequate evidence that the process is still in an active stage and that operation should be deferred. Obviously such an examination should not be done when other evidence of activity is present. Before operation it is important to improve the general condition of the patient as much as possible and to give penicillin preoperatively for three or four days. In performance of operative procedures much difficulty may be encountered in the mobilization of the pelvic viscera; due care must be exercised to prevent injury to the bowel, bladder and ureters. If possible a young woman should be left with her reproductive function intact. In the woman past forty years of age little is gained by performing a conservative operation. It is debatable as to whether or not the uterus should be allowed to remain if the reproductive function is destroyed. As a rule, surgical treatment is employed because of persistence of symptoms and the patient, therefore, expects to be relieved of them; accordingly, treatment frequently must be radical. For this reason, unless there is technical difficulty, it is usually in the best interests of the patient to remove all of the pelvic genitalia. Ovarian function should be preserved, when possible, in women forty or under. However, it is now possible to relieve satisfactorily, by oral or parenteral administration of estrogens, symptoms that occur after bilateral oophorectomy. The surgeon, therefore, must often choose whether or not to leave in the pelvis a questionable ovary which may cause further trouble or to remove such an ovary and depend on sub-
TREATMENT OF PELVIC INFLAMMATORY DISEASE
871
stitution therapy. Drainage through the abdominal wall or through the vagina is usually not emplQyed by surgeons at the Clinic. Often, however, a cigaret drain or a drain made of a split rubber tube is placed in the wound down to the peritoneum. REPORT OF CASES CASE I.-A woman was admitted to the Clinic on April 23, 1937. She had heen well until April 9, when she had begun to suffer from pain in the lower part of the abdomen, chills and fever. The temperature had varied from 100 0 to 103.6 0 F. The patient stated that she had been married twenty-eight years; during that time she had had one pregnancy which had ended in spontaneous abortion. She gave no history of a previous attack of pelvic inflammatory disease. The pelvic examination revealed a large abscess which filled the entire lower part of the pelvis. Laboratory data were as follows: hemoglobin, 12.9 grn. per 100 C.c. of blood; erythrocytes, 3,240,000 and leukocytes, 21,500 (85 per cent polymorphonuclear leukocytes) per cubic millimeter of blood; result of Wassermann test, negative; results of cultures on chocolate blood agar and of examination of smears, negative for gonococci; sedimentation rate, 58 mm. in one hour on April 23 and 115 mm. on April 28. Treatment with conventional diathermy was started on April 30 and given daily until May 17. The temperature returned to normal soon after diathermy was started. The sedimentation rate on May 1 was 91 mm. and on May 11 it was 24 mm. in one hour. The leukocyte count on May 11 was 5,800 per cubic millimeter. A pelvic examination on May 14 revealed remarkable resolution of the pelvic abscess, with only minimal residual thickening. The patient subsequently was examined twice in 1937 and once in 1940, 1942 and 1945. At each examination the'pelvis was found to be completely clear.
The case just reported is instructive because it illustrates what diathermy can do, particularly if used early in the course of the disease. This case has been used as an illustration because there has been adequate follow-up and because diathermy was the only therapeutic agent used. It may be significant that in this case the patient had but five or six menstrual periods (lfter the treatment until spontaneous menopause occurred; this may have been a factor in her complete recovery, as the menstrual stimulus to a recurrence of the infection was not present. CASE 2.-A woman, thirty-two years old, was registered at the Clinic on October 5, 1936. She had been married twelve years. She stated that she had had an induced instrumental abortion performed in 1925, with no complications. However, eight months later she had suffered from symptoms indicative of acute pelvic inflammatory disease and was hospitalized for six weeks. Four months after that, another attack occurred and she was hospitalized for ten days. At the time of her admission to the Clinic, the patient complained of abdominal soreness, which was not incapacitating, and of constipation. The pelvic examination revealed an adherent retroverted uterus and bilateral adnexal prolapse, with adhesion. Results of all laboratory tests, including leukocyte count and sedimentation rate, were within normal limits. Cultures on chocolate blood agar gave negative results for gonococci. The medical gynecologist who saw this patient stated that conditions in the pelvis were probably sufficiently pathologic to justify
872
ROBERT B. WILSON
operation. The gynecolo.gic surgeo.n tho.ught that co.nservative o.peratio.n was indicated and necessary. Therefore, o.n Octo.ber 26, 1936, the pelvis was explored and the fo.IIo.wing surgical procedures accomplished: ventral suspension o.f an adherent retroverted uterus, bilateral salpingecto.my because o.f bilateral hydro.salpinx, left o.o.pho.recto.my because o.f hemo.rrhagic cystic o.o.pho.ritis, and appendecto.my. On the sixth Po.sto.perative day sympto.ms o.f obstructio.n o.f the small bo.wel develo.ped and the pelvis was re-explored o.n the fourteenth Po.stoperative day. A lo.o.P o.f ileum was fo.und adherent in the pelvis; this was freed and a necro.tic area in the bo.wel was excised. Entero.sto.my was done. Generalized peritonitis develo.ped and the patient died sixteen days after the o.riginal o.peratio.n.
In all fairness it must be emphasized that this fatality occurred prior to the availability of the sulfonamides and the antibiotic agents. This Case does illustrate what often happened prior to the time these drugs became available. It further illustrates the inherent risk in all surgery and emphasizes that the surgical treatm~nt of pelvic inflammatory disease should not be undertaken lightly. This is true even though administration of the sulfonamides and antibiotic substances now available markedly lowers the mortality rate in generalized peritonitIs. Adherence of a loop of small bowel to a raw surface in the pelvis, with subsequent obstruction, is not a rare occurrence. It can be prevented by adequate peritonization and, if this is not possible, by suture of the sigmoid over the raw area. When this latter procedure is carried out, the large bOWiel adheres and seldom, if ever, becomes obstructed because of such adherence.
•
CASE 3.-A white wo.man, fo.rty-six years o.ld, was admitted September 9, 1946. She had been married ten years and had had no. pregnancies o.r o.peratio.ns. Three mo.nths prio.r to. admissio.n, the usual sympto.ms of pelvic inflammato.ry disease developed. The patient's home physician ho.spitalized her for six weeks during which penicillin was given and po.sterio.r co.lpoto.my was perfo.rmed. Prio.r to admissio.n to. the Clinic she had had o.ne recurrence which had been contro.lled by penicillin. She stated that she had lo.st appro.ximately 20 Po.unds (9.1 kg.). On admissio.n the temperature, pulse, respiratio.ns and blo.o.d pressure were no.rmal. The uterus was fo.und to. be fixed and tender o.n mo.tio.n; it was no.t much enlarged. A mass, 8 to. 10 cm. in diamet~r, was present in the left adnexa and the right adnexa was the site o.f thickening and induratio.n, grade 4 (o.n the basis o.f 1 to. 4, in which 1 represents least, and 4 mo.st severe co.nditio.n). The pertinent labo.rato.ry data were as fo.IIo.ws: hemo.gIo.bin, 9.3 gm. per 100 c.c. o.f blo.o.d; erythro.cytes, 3,780,000 and leuko.cytes, 22,700 per cubic millimeter o.f blo.o.d; results o.f urine culture, po.sitive fo.r Escherichia co.li; andsedimentatio.n rates, 106 to. 127 mm. in o.ne ho.ur. The patient was immediately ho.spitalized and treated with pelvic diathetmy, penicillin, a diet high in calories and in vitamins, iro.n and vitamin supplements. Administratio.n o.f penicillin was. disco.ntinued ten days after admissio.n, hut the o.ther measures were co.ntinued fo.r fifty days. Little change had o.ccurred in the pelvis when the patient was dismissed fro.m the ho.spital o.n Octo.ber 28; she was advised to. return in one mo.nth. At readmissio.no.n No.vember 28 the sedimentatio.n rate was 55 mm. in o.ne ho.ur and the leuko.cyte co.unt was 7,900. The temperature was no.rmal and no. change was no.ted in the pelvic lesio.ns. Diathermy and penicillin were given in preparatio.n fo.r o.peratio.n; this caused so.me elevatio.n o.f both the sedimentatio.n rate and the leuko.cyte co.unt.
TREATMENT OF PELVIC INFLAMMATORY DISEASE
873
When the pelvis was explored on December 18, bilateral tubo-ovarian abscesses were found. Subtotal abdominal hysterectomy, bilateral salpingo-oophorectop1y and appendectomy were done. The surgeon stated that there was too much inHammatory reaction about the base of the bladder and the broad ligaments to permit performance of total hysterectomy. The postoperative course was afebrile, the patient being dismissed from the hospital on the tenth postoperative day. During the postoperative period penicillin and dicumarol were administered.
It is obvious that in this case the patient did not respond to conservative medical management that was thorough and prolonged. The medical management had considerable value, however, as it gave assurance of a relatively safe surgical risk. It might be that diathermy would have been more effective had it been started at the onset of the illness. The efficacy of administration of penicillin as a preoperative and postoperative measure is emphasized by this patient's smooth postoperative course which was completely afebrile. CASE 4.-A white woman, forty-two years old, was first registered at the Clinic on June 4, 1946. Physical examination revealed a squamous cell epithelioma of the cervix, grade 3 (Broders' method), stage 2. Laboratory data were negative except that the Wassermann test gave strongly positive results. From June 20 to July 13 full courses of radium and roentgen therapy were administered for the carcinoma of the cervix. On October 2 examination revealed a good local result from this treatment. A second course of roentgen therapy was administered from October 3 to October 7. On October 14 the patient returned complaining of a great deal of pain in the lower part of the abdomen. On examination the temperature was found to be 103 0 F. The pelvis was exquisitely tender and the uterus was fixed to the right. The uterus was probed, with negative results. The sedimentation rate was 129 mm. in one hour. The patient was immediately hospitalized and given large doses of penicillin plus the usual supportive treatment. Diathermy was started a few days after admission. On November 4 the pelvic disease had extended to points above the umbilicus on the right and just below the umbilicus on the left. The sedimentation rate remained elevated. The septic type of temperature subsided on November 8 and the patient was dismissed from the hospital on November 23. On December 4 the patient was readmitted to the hospital with chills, fever and low back pain. Her temperature was 104 F. the day after admission and her sedimentation rate was 133 mm. in one hour. The temperature was immediately lowered after administration of pen,iciliin. Pelvic diathermy was again started. The symptoms were found to be due to infection of the urinary tract. The patient was dismissed from the hospital on December 15 but was continued on treatment of the infection of the urinary tract and on treatment with pelvic diathermy as an outpatient. A pelvic examination on December 19 was essentially negative; no clinical evidence of either carcinoma or pelvic inHammatory disease was found. When last seen on January 29, 1947, the patient was gaining weight and was feeling well. 0
It is probably true that pelvic inflammatory disease following radiation therapy given for a malignant lesion can be treated only by conservative or medical measures. It is believed that diathermy and therapy with antibiotic substances were entirely responsible for this patient's recovery.
874
ROBERT B. WILSON
SUMMARY AND COMMENT
One should re-emphasize the fact that the medical and surgical treatments of pelvic inHammatory disease are to be used to complement one another. We feel that all patients suffering from such disease should first receive conservative medical management. Early and adequate medical treatment by our present-day methods should cause a marked decrease in the number of instances in which surgical intervention is required. If possible, therapy should be started when the infectious process is limited to the urethra and cervix in the gonorrheal type of infection and when the very first sign of visceral involvement occurs in other types of infection. Certainly a good end result, with salvage of the reproductive function, will hinge to a great extent on such early and adequate treatment. With such treatment a clinical cure will often be effected; in those cases in which cure is not effected by such treatment, the patient will be in better condition to undergo operation.