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The Indications for Surgical Treatment in Pelvic Inflammatory Disease
THE INDICATIONS FOR SURGICAL TREATMENT IN PELVIC INFLAMMATORY DISEASE A. F. LASH, M.D., PH.D., F.A.C.S., F.I.C.S.* INTRODUCTION
Pelvic infections, like general infections, respond favorably to chemotherapy. The effect of the therapy is not only bactericidal but also bacteriostatic. There is a difference in degree of reaction of the tissue depending on the general condition of the patient, the local tissue reaction and the virulence of the organism. The effect of chemotherapy is antibacterial and therefore an aid to the body's immunologic reactions. Gonorrheal infections induce mild tissue response as compared to B. coli or streptococcal infections. Although it is assumed that chemotherapy is common knowledge, patients may still develop pelvic infections without benefit of this new therapy or, if they do receive it, it may be only partially or not at all effective. As a result, at present pelvic inflammatory disease is still prevalent, especially in the large public institutions like Cook County Hospital. Since pelvic inflammatory disease (upper genital tract) results from the inhibiting effect of the tissue cells to infection there follows anatomic and functional distortion of the involved structures. In the pelvis, the genital tract, the bladder and ureters, the large and small bowel, the omentum and peritoneum may be so involved in this inflammatory reaction and subsequent healing that the disturbed function of these organs may either incapacitate the individual or threaten her life. The indications for surgical treatment in pelvic inflammatory disease are many and vary from urgent or life-saving to elective or health restoring. Like all infections in the body, the incidence and severity of pelvic infections have decreased with the introduction of the sulfonamides and the antibiotics. However, at Cook County Hospital pelvic inflammatory disease still reigns supreme as our most common gynecologic surgical problem. It has been observed that although the febrile reactions subside earlier under sulfonamide and antibiotic management the inflammatory reaction does not subside as quickly. For this reason From the Department of Obstetrics and Gynecology, College of Medicine, University of Illinois and Department of Gynecology, Cook County Hospital, Chicago. * Associate Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine; Attending Gynecologist, Cook County Hospital; Attending Gynecologist and Obstetrician, Mt. Sinai Hospital; Associate Gynecologist and Obstetrician, Michael Reese Hospital.
299
300
A. F. LASH
the quiescent state of the inflammation cannot always be judged by the afebrile status alone as was formerly done. HISTORY
From the historical point of view we find at the close of the nineteenth century a divergence of opinions as what to do and how to do it in treating inflammatory diseases of the pelvic organs. There were proponents for the abdominal route, vaginal route, radical excision of all pelvic organs; conservation of tissue, tubal, ovarian and uterine; puncture, both suprapubic and vaginal; drainage both abdominal and vaginal; even transuterine catheterization of pus tubes. However, nothing was said as to the stage best suited for operation, a matter which was solved by the gynecologists of the beginning of this century. They learned that most pelvic infections will heal and that surgery is relatively safe in the quiescent state. ETIOLOGY AND PATHOLOGY
The treatment of the inflammatory diseases of the female organs can only be based on the adequate knowledge of the etiology and pathology. The etiology of pelvic inflammatory disease is well established, the predisposing factors being coitus, pregnancy, abortion, trauma, surgery and radium; the active or bacterial factors, single or multiple, are the various groups of gonococci, streptococci, B. coli, tubercle bacilli, Spirochaeta pallida and rare types of organisms. From our clinical study of pelvic inflammatory disease the fact has been established that the tissue reactions to the various infections could be depend~d upon to overcome the infection. However, the resulting reactions, even though the infections have subsided, in the process of healing left adhesions, thickened tissues and large and small masses which produced pain and interfered with the functions of the organs. Also the residual inflammatory structures were often the site of returning activity by reason of dormant foci or reinfections, so that in the interest of health, operation became necessary. Pelvic inflammatory disease includes the various pathologic stages of adnexitis, such as suppurative salpingitis, hydrosalpingitis, oophoritis and similar conditions. ACUTE STAGE
In dealing with the acute stage of the pelvic reaction to infection, conservative or medical treatment has been generally accepted, It is now considered factual that the pelvic structures, being relatively inactive compared to the intestines of the upper abdominal region, are quite capable of localizing and overcoming the infections by their inflamma-
PELVIC INFLAMMATORY DISEASE
301
tory reaction. In certain instances, the pelvic reaction can halt the progress of the infection but forms abscesses or cannot halt the aggressive infection, allowing generalized peritonitis to develop; then surgery may be necessary in the active or acute stage of the infection. When the acute stage of a pelvic infection is not interrupted by penicillin, sulfa drugs, rest and the usual medical measures, and there is a clinical picture of progressive or ascending peritonitis or of a pelvic abscess, surgical treatment is urgently indicated as a life-saving procedure. Drainage may be instituted by a posterior colpotomy or, if warranted, by laparotomy. CASE I.-Mrs. A. B., 24 years old, white, para I, gravida II, had a cesarean section on August 4, 1945, for a severe pre-eclampsia. Her present pregnancy was uneventful and term was calculated to be on May 8, 1949. On May 2,1949, her bag of waters ruptured and she was admitted to the hospital. Four hours later, slight labor began but since the head was high and the old cesarean scar was tender, a repeat low cervical cesarean section was performed under local anesthesia. No bowels or omentum were visible at any time but there was an escape of some meconium stained amniotic fluid on opening the uterine cavity. Otherwise the operation was without mishap. Twelve hours postoperatively, the patient complained of severe abdominal pain which was controlled with sedatives. Thirty-six hours postoperatively she vomited about three times and a Levin tube was passed and suction started. She had a chill but no temperature rise. On the third postoperative day her temperature was 104°F., pulse 132 and respirations 28. Penicillin (600,000 units) was given daily from the third day on and streptomycin (1 gm. daily) was added daily on the fourth postoperative day. Rectal tube brought results. The usual intravenous fluids were given (i.e., 2000 cc. of 5 per cent glucose in saline, 1000 cc. of 5 per cent glucose in water). The distention of the abdomen responded to a Miller-Abbott tube passed into the duodenum under fluoroscopic observation. Although the patient was comfortable, her course continued febrile. On May 13, 1949, a vaginal examination found a doughy, tender cul-de-sac. By May 20, 1949, the cul-de-sac was bulging, so a posterior colpotomy was performed and about 500 cc. of foul yellow pus escaped (culture yielded B. coli). Drainage was continued through a T-tube for about three days when it ceased and the tube was removed. Normal temperature was present twenty-four hours after the colpotomy and continued until the day of discharge.
Comment.-This case report illustrates the futility of penicillin and streptomycin, once the abscess has developed. Incision and drainage was essential in order to allow the healing of the inflammatory reaction to this infection. However, the time best indicated for surgery in this instance was when the infection was localized, unresponsive to medical therapy and the patient's general condition was good. Other indications are necrosis or degeneration of fibroids and torsion of ovarian neoplasms which may produce an acute pelvic inflammatory clinical picture and may demand surgery. As the result of repeated pelvic
302
A. F. LASH
infections either gonococcal or mixed bacterial in origin, a pelvic abscess may form in the posterior cul-de-sac having for its walls the small and large intestines, the omentum, the posterior uterine wall and adnexa, or may form from the fusion of two pus tubes. Tubo-ovarian abscesses may be bilateral fluctuant pelvic masses. Secondary to intrauterine manipulation (traumatic, puerperal, surgical or radium insertion), pyometra due to cervical stenosis or intramural abscesses may form and require surgical intervention. Only by careful observation of the clinical course of infection can one diagnose the presence of one of these abscesses. The usual clinical picture is characterized by the daily rise in temperature, leukocytosis and localized pain, with a boggy or fluctuant mass which persists in spite of the various chemotherapy and antibiotics. The indication becomes evident but the optimum time for interference must be determined by the general condition of the patient and the extent of the abscess formation. Blood transfusions may be necessary to improve the general condition. From the pelvic findings, the conclusion is reached as to the manner of incising the abscess wall and draining the cavity. It may be only an initial step for later surgery. A posterior colpotomy may serve the purpose of emptying a pelvic, tubo-ovarian or broad ligament abscess, while a laparotomy may be necessary for an abscess up in the iliac fossae or lower abdominal quadrants. With gentle dilatation of the cervix, held open with a rubber tube, drainage may be procured in a pyometra. Hysterectomy is rarely found necessary either in a pyometra or an intramural uterine abscess. Very rarely is a thrombophlebitis of the pelvic veins aided by extensive ligation of the internal iliac veins. The associated pathology of ovarian or uterine neoplasms undergoing degeneration and necrosis coincidental to pelvic inflammatory disease occasionally requires surgical interference in the acute stage when improvement and localization of the infection does not occur as expected. Although optimal conditions may not prevail, the best possible conditions may be produced by blood transfusions and antibiotics. Where foreign bodies (probes, instruments, gauze sponges or insoluble sutures) are suspected to be the basis of an abscess, these must be removed with the drainage of the abscess. Roentgenograms may reveal the foreign body in the abscess and direct the exploring finger or instrument. In addition to the above described conditions, colpocentesis and colpotomy are indicated in progressive pelvic peritonitis with beginning general peritonitis when ordinary conservative measures have failed. Clinical states indicating these simple procedures are persisting fever and chills, poor general condition or cachexia, the presence of intolerable pain not responding to other measures, threatening perforation into the in-
;"
,
... "
.
"
PELVtc IN:F'LAMMA'l'ORY DISEASE
303
testine and failure of the inflammatory tumors and exudate to retrogress. These surgical procedures are more desirable in the subacute and chronic stages. They are usually not adequate as a curative measure but rather as a supplementary treatment to the medical measures. Thereby, the patient's general as well as her local condition may improve and either allow for more adequate surgery later by laparotomy or for earlier ambulation or even rehabilitation. In sudden rupture of abscesses (tuboovarian, uterine or broad ligament) into the- abdominal cavity. immediate laparotomy may be a life-saving procedure. SUBACUTE AND CHRONIC STAGE
When the subacute and chronic stages of the pelvic inflammatory disease are approached, we are dealing with permanently destroyed structures. Methods of treatment other than surgical are at best palliative, particularly when incapacitating symptoms persist regardleRs of all medical measures. Because the patient is chronologically young even though pathologically old because of her distorted or destroyed genital tract, .the greatest amount of effort is exerted to restore or reprieve as much of the structures as possible. In the young female the indications for surgical approach to inflammatory disease are: disabling pain in the lower abdomen or back due to the conglomeration of loops of bowels, omentum and the adnexal, uterine and pelVic peritoneum; menorrhagia or even metrorrhagia resulting from the oophoritis or congestive state of the ovaries and uterus; bladder and bowel disturbances due to these same inflammatory reactions or masses producing irritative or obstructive effects on these neighboring structures. The indications for surgery may be obvious, but what is more important is judging the optimum time for executing the necessary surgery. In the presence of a so-called "frozen" pelvis where the conglomeration of pelvic inflammatory masses is such that anatomic structures cannot be defined, proper preoperative preparation is most important. Rest, antianemic diet, adequate vitamin therapy, blood transfusion if necessary, proper bowel elimination and hydration are all factors to allow for the subsidence of the pelvic inflammatory reaction. With the introduction of the sulfonamides and the antibiotics we have observed an earlier subsidence of the febrile state, but we have found that although the temperature has remained normal for ten days and laparotomy is performed, the hyperemia and edema of the pelvic structures have not subsided. Therefore, we should like to emphasize the fact that since inflammatory reaction subsidence does not follow the febrile drop to normal, one must depend upon the physical findings in bimanual pelvic examinatiC)n to determine the absence of tenderness and the better definition
304
A. F. LASH
of the pelvic structures. In the presence of this "wet" state of the pelvic structures, conservative surgery cannot be readily carried out in the young individual, and extensive or complete surgery in the older individual is unsatisfactory because bowel or bladder injury may be more likely to occur and proper healing is less likely. This point may be illustrated by the following case history. CASE II.-L. K., a white 24 year old woman, gravida 0, was admitted to Cook County Hospital because of generalized knifelike colicky abdominal pains of three weeks' duration. At the onset she had diarrhea and vomiting, chills and fever. The diagnosis of an acute exacerbation of a {)hronic pelvic inflammatory disease was made. She received penicillin (600,000 units) daily and after fortyeight hours her temperature became normal. Since she was afebrile for about a week, a laparotomy was performed. The tissues were hyperemic and edematous. A total abdominal hysterectomy and bilateral salpingectomy and right oophorectomy were done. The patient had a febrile course for fourteen postoperative days in spite of penicillin. A pelvic abscess was found and drained by a posterior colpotomy. Following this operation, the patient made an uneventful recovery.
The young female is anxious to retain as much of her genital tract as possible, even at the risk of another operation at some future time. Surgical intervention may be indicated not only as the life-saving measure described above, but also in instances of fixed retrodisplaced uteri with resulting chronic invalidism or sterility caused by the veils or layers of inflammatory adhesions around the fimbriated ends of the tubes and the ovaries. As a rule these patients have no acute inflammatory symptoms but show the end result or residue of the healing process. Here, again, the extent of the surgery will depend upon the age of the patient and extent of the pathologic changes. Associated pathologic conditions such as endometriosis, fibroids, or cystic degeneration of the ovaries are modifying factors in the treatment. Regardless of the low incidence of pregnancies following conservative surgery on healed closed tubes, it is still desirable in the young. At the same time, when there are hopelessly destroyed ovaries and tubes associated with adenomyosis or fibroids of the uterus, complete or adequate surgery is indicated so that a surgical "cripple" or invalid does not survive the therapy. Uterine bleeding, either in the form of menorrhagia or metrorrhagia, producing secondary anemia to the degree of incapacitating the patient merits immediate attention. The uterine bleeding induced by pelvic inflammatory disease is another indication for surgery when all acute inflammatory reaction has subsided. It is usually in the healed stage of the pelvic inflammatory disease that the pathologic ovaries are found, that is, perioophoritis or polycystic degeneration (follicular or corpus luteum). These pathologic ovaries are the etiologic basis for the uterine hemor-
PELVIC INFLAMMATORY DISEASE
305
rhages. In the young individual, diagnostic curettage and laparotomy are performed to remove the pathologic residual inHammatory tissue, and an effort is made to restore normal anatomic conditions in order to initiate normal physiology. In the older individual in whom childbearing or menstrual function need not be retained, extensive surgery is carried out for a more complete recovery without fear for future surgery. In obese middle-aged individuals with hypertension who are greater surgical risks because of their medical conditions, vaginal hysterectomy serves as an excellent means of stopping uterine bleeding with less risk than the abdominal approach. Leaving the adnexa is not harmful since no symptoms result and the bleeding is stopped. Traumatic, postoperative and postradiation pelvic inHammatory disease is usually a cellulitis and requires surgery only rarely when an abscess forms in the uterus, pelvic cavity or broad ligaments. Among the chronic infections of the genital tract, tuberculosis is encountered. It is only occasionally recognized clinically, and is often identified only at the time of operation. The indications for surgical intervention in tuberculous pelvic inflammatory disease are about the same as for the non tuberculous type, that is, pain in the lower abdomen or back, disturbed bowel or bladder function or uterine bleeding. It is advantageous to recognize the tuberculous nature of the pelvic disease preoperatively because a course of streptomycin over a period of four to six weeks may produce a more healed state of the inHammatory reaction. As a rule the extent of surgery performed depends on the degree of tuberculosis. First, in some instances a conservative operation may have been performed and only after microscopic examination is the tuberculous involvement realized. A course of streptomycin may then follow postoperatively. In a marked degree of tuberculous infection where the pathologic state of the pelvic structures and involved intestines is such that surgery is impossible, then it is wiser to close the abdomen and try streptomycin. Later evaluation of the inHammatory condition, that is, after six weeks of streptomycin, may reveal that degree of improvement which will allow another attempt at surgical removal. Since urinary tract tuberculosis is so often concomitantly present with the genital tract involvement, investigation of the urinary tract should be instituted as well as the respiratory tract. It is illogical to execute extensive pelvic surgery in the face of general, pulmonary or renal tuberculosis. The role of streptomycin in pelvic tuberculosis has not been definitely established. However, at present 1 gm. of streptomycin daily for six weeks is being tried therapeutically and the course of the inHammatory condition is followed as well as the general response of the patient to the antibiotic. To attempt to do adequate surgery in the presence of extensive tuberculosis without proper streptomycin preparation only leads to
306
A. F. LASH
disaster in the form of chronic draining abdominal or intestino-abdominaI fistulas. Pelvic inflammatory disease is occasionally associated with extragenital structures such as the bladder, ureters and bowels. Induration of any of these structures may lead to lacerations which usually heal if recognized and repaired immediately. Ureteral injuries may be dealt with depending on their location; that is, low ones may be corrected by bladder implantations, while higher ones may be either repaired or ligated. If these injuries are not recognized, fistulas, urinary extravasations or urinary peritonitis may occur. Diverticulitis or infected carcinoma of the colon associated with pelvic inflammatory disease cannot always be differentiated at the operating table. Therefore, it is well to deal with the pelvic pathologic condition and then do a colostomy if obstructive symptoms are present. In the presence of infection of the rectosigmoid secondary to diverticulitis or carcinoma, simple transverse colon colostomy is effective. This added operation is neither time-consuming nor shocking and allows for healing of the inflammatory process of the bowel and subsequent x-ray studies and proper preparation for the necessary surgery. On the other hand, if there is an obvious carcinoma of the colon, a first stage Mikulicz operation may be done. In the rare instances where pregnancy is a complication of pelvic inflammatory disease, surgery may be indicated. Thus an adherent retroflexed pregnant uterus may have to be freed from its confined position by lysis of adhesions. Occasionally an ectopic pregnancy may occur in the presence of pelvic inflammatory disease. In the presence of a ruptured ectopic pregnancy, with the peritoneal cavity filled with blood, only the pregnant tube (with or without the ovary, depending on its pathologic state) should be removed. No other surgery should be done because the patient's life is in jeopardy. The mortality risk is increased with any added surgery. The principle to follow under these circumstances is to get in and out as soon as possible. Of course, the situation is different if an ancient ectopic pregnancy is found; then the pelvic inflammatory disease is dealt with in the usual manner. In the later weeks of pregnancy or during labor, a quiescent tuboovarian abscess may rupture. Immediate laparotomy and drainage is a life-saving procedure. Also, in the advanced abdominal pregnancies the placenta and the amniotic sac with contents must be dealt with primarily, depending on the insertion of the placenta, while the pelvic inflammatory disease should be left for a future time. DISCUSSION
Since pelvic inflammatory disease (i.e., the various types of salpingitides, oophoritis and pelvic peritonitis) is still a daily gynecologic prob-
PELVIC INFLAMMATORY DISEASE
307
lem, all means must be utilized to prevent its occurrence. When pelvic inflammatory disease exists, a good number of cases will respond in an initial attack to sulfa drugs and/or antibiotics (penicillin, streptomycin, aureomycin) and complete healing will occur. The need for surgery continues in pelvic inflammatory disease because of abscess formation, advancing peritonitis or disturbed function. Surgery is aided by the sulfa drugs and antibiotics and is not replaced. Mortality has decreased with the use of the these drugs. However, proper and adequate preoperative preparation allows for more conservative surgery and also brings about the optimum time for intervention when surgery is indicated. CONCLUSIONS
1. Prophylaxis by proper asepsis is still the most important practice in preventing pelvic inflammatory disease. 2. All known medical measures (sulfa drugs, antibiotics, penicillin, streptomycin and others) plus diathermy are used to combat pelvic infections. 3. Surgical intervention is indicated in certain acute stages (abscesses) of pelvic inflammatory disease, but most often in the chronic stages. 4. The indications for surgical treatment are the symptoms of the disabling state produced by the resultant pathologic changes induced by the pelvic infection. 5. Not only must the indications be plesent to justify surgery but proper or optimum conditions should be present or produced in order to allow safe and physiologic surgery to be performed. 6. Preoperative and postoperative sulfonamides and antibiotics are of value in most instances.
Pelvic infections, like general infections, respond favorably to chemotherapy. The effect of the therapy is not only bactericidal but also bacteriostatic. There is a difference in degree of reaction of the tissue depending on the general condition of the patient, the local tissue reaction and the virulence of the organism. The effect of chemotherapy is antibacterial and therefore an aid to the body's immunologic reactions. Gonorrheal infections induce mild tissue response as compared to B. coli or streptococcal infections. Although it is assumed that chemotherapy is common knowledge, patients may still develop pelvic infections without benefit of this new therapy or, if they do receive it, it may be only partially or not at all effective. As a result, at present pelvic inflammatory disease is still prevalent, especially in the large public institutions like Cook County Hospital. Since pelvic inflammatory disease (upper genital tract) results from the inhibiting effect of the tissue cells to infection there follows anatomic and functional distortion of the involved structures. In the pelvis, the genital tract, the bladder and ureters, the large and small bowel, the omentum and peritoneum may be so involved in this inflammatory reaction and subsequent healing that the disturbed function of these organs may either incapacitate the individual or threaten her life. The indications for surgical treatment in pelvic inflammatory disease are many and vary from urgent or life-saving to elective or health restoring. Like all infections in the body, the incidence and severity of pelvic infections have decreased with the introduction of the sulfonamides and the antibiotics. However, at Cook County Hospital pelvic inflammatory disease still reigns supreme as our most common gynecologic surgical problem. It has been observed that although the febrile reactions subside earlier under sulfonamide and antibiotic management the inflammatory reaction does not subside as quickly. For this reason From the Department of Obstetrics and Gynecology, College of Medicine, University of Illinois and Department of Gynecology, Cook County Hospital, Chicago. * Associate Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine; Attending Gynecologist, Cook County Hospital; Attending Gynecologist and Obstetrician, Mt. Sinai Hospital; Associate Gynecologist and Obstetrician, Michael Reese Hospital.
299
300
A. F. LASH
the quiescent state of the inflammation cannot always be judged by the afebrile status alone as was formerly done. HISTORY
From the historical point of view we find at the close of the nineteenth century a divergence of opinions as what to do and how to do it in treating inflammatory diseases of the pelvic organs. There were proponents for the abdominal route, vaginal route, radical excision of all pelvic organs; conservation of tissue, tubal, ovarian and uterine; puncture, both suprapubic and vaginal; drainage both abdominal and vaginal; even transuterine catheterization of pus tubes. However, nothing was said as to the stage best suited for operation, a matter which was solved by the gynecologists of the beginning of this century. They learned that most pelvic infections will heal and that surgery is relatively safe in the quiescent state. ETIOLOGY AND PATHOLOGY
The treatment of the inflammatory diseases of the female organs can only be based on the adequate knowledge of the etiology and pathology. The etiology of pelvic inflammatory disease is well established, the predisposing factors being coitus, pregnancy, abortion, trauma, surgery and radium; the active or bacterial factors, single or multiple, are the various groups of gonococci, streptococci, B. coli, tubercle bacilli, Spirochaeta pallida and rare types of organisms. From our clinical study of pelvic inflammatory disease the fact has been established that the tissue reactions to the various infections could be depend~d upon to overcome the infection. However, the resulting reactions, even though the infections have subsided, in the process of healing left adhesions, thickened tissues and large and small masses which produced pain and interfered with the functions of the organs. Also the residual inflammatory structures were often the site of returning activity by reason of dormant foci or reinfections, so that in the interest of health, operation became necessary. Pelvic inflammatory disease includes the various pathologic stages of adnexitis, such as suppurative salpingitis, hydrosalpingitis, oophoritis and similar conditions. ACUTE STAGE
In dealing with the acute stage of the pelvic reaction to infection, conservative or medical treatment has been generally accepted, It is now considered factual that the pelvic structures, being relatively inactive compared to the intestines of the upper abdominal region, are quite capable of localizing and overcoming the infections by their inflamma-
PELVIC INFLAMMATORY DISEASE
301
tory reaction. In certain instances, the pelvic reaction can halt the progress of the infection but forms abscesses or cannot halt the aggressive infection, allowing generalized peritonitis to develop; then surgery may be necessary in the active or acute stage of the infection. When the acute stage of a pelvic infection is not interrupted by penicillin, sulfa drugs, rest and the usual medical measures, and there is a clinical picture of progressive or ascending peritonitis or of a pelvic abscess, surgical treatment is urgently indicated as a life-saving procedure. Drainage may be instituted by a posterior colpotomy or, if warranted, by laparotomy. CASE I.-Mrs. A. B., 24 years old, white, para I, gravida II, had a cesarean section on August 4, 1945, for a severe pre-eclampsia. Her present pregnancy was uneventful and term was calculated to be on May 8, 1949. On May 2,1949, her bag of waters ruptured and she was admitted to the hospital. Four hours later, slight labor began but since the head was high and the old cesarean scar was tender, a repeat low cervical cesarean section was performed under local anesthesia. No bowels or omentum were visible at any time but there was an escape of some meconium stained amniotic fluid on opening the uterine cavity. Otherwise the operation was without mishap. Twelve hours postoperatively, the patient complained of severe abdominal pain which was controlled with sedatives. Thirty-six hours postoperatively she vomited about three times and a Levin tube was passed and suction started. She had a chill but no temperature rise. On the third postoperative day her temperature was 104°F., pulse 132 and respirations 28. Penicillin (600,000 units) was given daily from the third day on and streptomycin (1 gm. daily) was added daily on the fourth postoperative day. Rectal tube brought results. The usual intravenous fluids were given (i.e., 2000 cc. of 5 per cent glucose in saline, 1000 cc. of 5 per cent glucose in water). The distention of the abdomen responded to a Miller-Abbott tube passed into the duodenum under fluoroscopic observation. Although the patient was comfortable, her course continued febrile. On May 13, 1949, a vaginal examination found a doughy, tender cul-de-sac. By May 20, 1949, the cul-de-sac was bulging, so a posterior colpotomy was performed and about 500 cc. of foul yellow pus escaped (culture yielded B. coli). Drainage was continued through a T-tube for about three days when it ceased and the tube was removed. Normal temperature was present twenty-four hours after the colpotomy and continued until the day of discharge.
Comment.-This case report illustrates the futility of penicillin and streptomycin, once the abscess has developed. Incision and drainage was essential in order to allow the healing of the inflammatory reaction to this infection. However, the time best indicated for surgery in this instance was when the infection was localized, unresponsive to medical therapy and the patient's general condition was good. Other indications are necrosis or degeneration of fibroids and torsion of ovarian neoplasms which may produce an acute pelvic inflammatory clinical picture and may demand surgery. As the result of repeated pelvic
302
A. F. LASH
infections either gonococcal or mixed bacterial in origin, a pelvic abscess may form in the posterior cul-de-sac having for its walls the small and large intestines, the omentum, the posterior uterine wall and adnexa, or may form from the fusion of two pus tubes. Tubo-ovarian abscesses may be bilateral fluctuant pelvic masses. Secondary to intrauterine manipulation (traumatic, puerperal, surgical or radium insertion), pyometra due to cervical stenosis or intramural abscesses may form and require surgical intervention. Only by careful observation of the clinical course of infection can one diagnose the presence of one of these abscesses. The usual clinical picture is characterized by the daily rise in temperature, leukocytosis and localized pain, with a boggy or fluctuant mass which persists in spite of the various chemotherapy and antibiotics. The indication becomes evident but the optimum time for interference must be determined by the general condition of the patient and the extent of the abscess formation. Blood transfusions may be necessary to improve the general condition. From the pelvic findings, the conclusion is reached as to the manner of incising the abscess wall and draining the cavity. It may be only an initial step for later surgery. A posterior colpotomy may serve the purpose of emptying a pelvic, tubo-ovarian or broad ligament abscess, while a laparotomy may be necessary for an abscess up in the iliac fossae or lower abdominal quadrants. With gentle dilatation of the cervix, held open with a rubber tube, drainage may be procured in a pyometra. Hysterectomy is rarely found necessary either in a pyometra or an intramural uterine abscess. Very rarely is a thrombophlebitis of the pelvic veins aided by extensive ligation of the internal iliac veins. The associated pathology of ovarian or uterine neoplasms undergoing degeneration and necrosis coincidental to pelvic inflammatory disease occasionally requires surgical interference in the acute stage when improvement and localization of the infection does not occur as expected. Although optimal conditions may not prevail, the best possible conditions may be produced by blood transfusions and antibiotics. Where foreign bodies (probes, instruments, gauze sponges or insoluble sutures) are suspected to be the basis of an abscess, these must be removed with the drainage of the abscess. Roentgenograms may reveal the foreign body in the abscess and direct the exploring finger or instrument. In addition to the above described conditions, colpocentesis and colpotomy are indicated in progressive pelvic peritonitis with beginning general peritonitis when ordinary conservative measures have failed. Clinical states indicating these simple procedures are persisting fever and chills, poor general condition or cachexia, the presence of intolerable pain not responding to other measures, threatening perforation into the in-
;"
,
... "
.
"
PELVtc IN:F'LAMMA'l'ORY DISEASE
303
testine and failure of the inflammatory tumors and exudate to retrogress. These surgical procedures are more desirable in the subacute and chronic stages. They are usually not adequate as a curative measure but rather as a supplementary treatment to the medical measures. Thereby, the patient's general as well as her local condition may improve and either allow for more adequate surgery later by laparotomy or for earlier ambulation or even rehabilitation. In sudden rupture of abscesses (tuboovarian, uterine or broad ligament) into the- abdominal cavity. immediate laparotomy may be a life-saving procedure. SUBACUTE AND CHRONIC STAGE
When the subacute and chronic stages of the pelvic inflammatory disease are approached, we are dealing with permanently destroyed structures. Methods of treatment other than surgical are at best palliative, particularly when incapacitating symptoms persist regardleRs of all medical measures. Because the patient is chronologically young even though pathologically old because of her distorted or destroyed genital tract, .the greatest amount of effort is exerted to restore or reprieve as much of the structures as possible. In the young female the indications for surgical approach to inflammatory disease are: disabling pain in the lower abdomen or back due to the conglomeration of loops of bowels, omentum and the adnexal, uterine and pelVic peritoneum; menorrhagia or even metrorrhagia resulting from the oophoritis or congestive state of the ovaries and uterus; bladder and bowel disturbances due to these same inflammatory reactions or masses producing irritative or obstructive effects on these neighboring structures. The indications for surgery may be obvious, but what is more important is judging the optimum time for executing the necessary surgery. In the presence of a so-called "frozen" pelvis where the conglomeration of pelvic inflammatory masses is such that anatomic structures cannot be defined, proper preoperative preparation is most important. Rest, antianemic diet, adequate vitamin therapy, blood transfusion if necessary, proper bowel elimination and hydration are all factors to allow for the subsidence of the pelvic inflammatory reaction. With the introduction of the sulfonamides and the antibiotics we have observed an earlier subsidence of the febrile state, but we have found that although the temperature has remained normal for ten days and laparotomy is performed, the hyperemia and edema of the pelvic structures have not subsided. Therefore, we should like to emphasize the fact that since inflammatory reaction subsidence does not follow the febrile drop to normal, one must depend upon the physical findings in bimanual pelvic examinatiC)n to determine the absence of tenderness and the better definition
304
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of the pelvic structures. In the presence of this "wet" state of the pelvic structures, conservative surgery cannot be readily carried out in the young individual, and extensive or complete surgery in the older individual is unsatisfactory because bowel or bladder injury may be more likely to occur and proper healing is less likely. This point may be illustrated by the following case history. CASE II.-L. K., a white 24 year old woman, gravida 0, was admitted to Cook County Hospital because of generalized knifelike colicky abdominal pains of three weeks' duration. At the onset she had diarrhea and vomiting, chills and fever. The diagnosis of an acute exacerbation of a {)hronic pelvic inflammatory disease was made. She received penicillin (600,000 units) daily and after fortyeight hours her temperature became normal. Since she was afebrile for about a week, a laparotomy was performed. The tissues were hyperemic and edematous. A total abdominal hysterectomy and bilateral salpingectomy and right oophorectomy were done. The patient had a febrile course for fourteen postoperative days in spite of penicillin. A pelvic abscess was found and drained by a posterior colpotomy. Following this operation, the patient made an uneventful recovery.
The young female is anxious to retain as much of her genital tract as possible, even at the risk of another operation at some future time. Surgical intervention may be indicated not only as the life-saving measure described above, but also in instances of fixed retrodisplaced uteri with resulting chronic invalidism or sterility caused by the veils or layers of inflammatory adhesions around the fimbriated ends of the tubes and the ovaries. As a rule these patients have no acute inflammatory symptoms but show the end result or residue of the healing process. Here, again, the extent of the surgery will depend upon the age of the patient and extent of the pathologic changes. Associated pathologic conditions such as endometriosis, fibroids, or cystic degeneration of the ovaries are modifying factors in the treatment. Regardless of the low incidence of pregnancies following conservative surgery on healed closed tubes, it is still desirable in the young. At the same time, when there are hopelessly destroyed ovaries and tubes associated with adenomyosis or fibroids of the uterus, complete or adequate surgery is indicated so that a surgical "cripple" or invalid does not survive the therapy. Uterine bleeding, either in the form of menorrhagia or metrorrhagia, producing secondary anemia to the degree of incapacitating the patient merits immediate attention. The uterine bleeding induced by pelvic inflammatory disease is another indication for surgery when all acute inflammatory reaction has subsided. It is usually in the healed stage of the pelvic inflammatory disease that the pathologic ovaries are found, that is, perioophoritis or polycystic degeneration (follicular or corpus luteum). These pathologic ovaries are the etiologic basis for the uterine hemor-
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rhages. In the young individual, diagnostic curettage and laparotomy are performed to remove the pathologic residual inHammatory tissue, and an effort is made to restore normal anatomic conditions in order to initiate normal physiology. In the older individual in whom childbearing or menstrual function need not be retained, extensive surgery is carried out for a more complete recovery without fear for future surgery. In obese middle-aged individuals with hypertension who are greater surgical risks because of their medical conditions, vaginal hysterectomy serves as an excellent means of stopping uterine bleeding with less risk than the abdominal approach. Leaving the adnexa is not harmful since no symptoms result and the bleeding is stopped. Traumatic, postoperative and postradiation pelvic inHammatory disease is usually a cellulitis and requires surgery only rarely when an abscess forms in the uterus, pelvic cavity or broad ligaments. Among the chronic infections of the genital tract, tuberculosis is encountered. It is only occasionally recognized clinically, and is often identified only at the time of operation. The indications for surgical intervention in tuberculous pelvic inflammatory disease are about the same as for the non tuberculous type, that is, pain in the lower abdomen or back, disturbed bowel or bladder function or uterine bleeding. It is advantageous to recognize the tuberculous nature of the pelvic disease preoperatively because a course of streptomycin over a period of four to six weeks may produce a more healed state of the inHammatory reaction. As a rule the extent of surgery performed depends on the degree of tuberculosis. First, in some instances a conservative operation may have been performed and only after microscopic examination is the tuberculous involvement realized. A course of streptomycin may then follow postoperatively. In a marked degree of tuberculous infection where the pathologic state of the pelvic structures and involved intestines is such that surgery is impossible, then it is wiser to close the abdomen and try streptomycin. Later evaluation of the inHammatory condition, that is, after six weeks of streptomycin, may reveal that degree of improvement which will allow another attempt at surgical removal. Since urinary tract tuberculosis is so often concomitantly present with the genital tract involvement, investigation of the urinary tract should be instituted as well as the respiratory tract. It is illogical to execute extensive pelvic surgery in the face of general, pulmonary or renal tuberculosis. The role of streptomycin in pelvic tuberculosis has not been definitely established. However, at present 1 gm. of streptomycin daily for six weeks is being tried therapeutically and the course of the inHammatory condition is followed as well as the general response of the patient to the antibiotic. To attempt to do adequate surgery in the presence of extensive tuberculosis without proper streptomycin preparation only leads to
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disaster in the form of chronic draining abdominal or intestino-abdominaI fistulas. Pelvic inflammatory disease is occasionally associated with extragenital structures such as the bladder, ureters and bowels. Induration of any of these structures may lead to lacerations which usually heal if recognized and repaired immediately. Ureteral injuries may be dealt with depending on their location; that is, low ones may be corrected by bladder implantations, while higher ones may be either repaired or ligated. If these injuries are not recognized, fistulas, urinary extravasations or urinary peritonitis may occur. Diverticulitis or infected carcinoma of the colon associated with pelvic inflammatory disease cannot always be differentiated at the operating table. Therefore, it is well to deal with the pelvic pathologic condition and then do a colostomy if obstructive symptoms are present. In the presence of infection of the rectosigmoid secondary to diverticulitis or carcinoma, simple transverse colon colostomy is effective. This added operation is neither time-consuming nor shocking and allows for healing of the inflammatory process of the bowel and subsequent x-ray studies and proper preparation for the necessary surgery. On the other hand, if there is an obvious carcinoma of the colon, a first stage Mikulicz operation may be done. In the rare instances where pregnancy is a complication of pelvic inflammatory disease, surgery may be indicated. Thus an adherent retroflexed pregnant uterus may have to be freed from its confined position by lysis of adhesions. Occasionally an ectopic pregnancy may occur in the presence of pelvic inflammatory disease. In the presence of a ruptured ectopic pregnancy, with the peritoneal cavity filled with blood, only the pregnant tube (with or without the ovary, depending on its pathologic state) should be removed. No other surgery should be done because the patient's life is in jeopardy. The mortality risk is increased with any added surgery. The principle to follow under these circumstances is to get in and out as soon as possible. Of course, the situation is different if an ancient ectopic pregnancy is found; then the pelvic inflammatory disease is dealt with in the usual manner. In the later weeks of pregnancy or during labor, a quiescent tuboovarian abscess may rupture. Immediate laparotomy and drainage is a life-saving procedure. Also, in the advanced abdominal pregnancies the placenta and the amniotic sac with contents must be dealt with primarily, depending on the insertion of the placenta, while the pelvic inflammatory disease should be left for a future time. DISCUSSION
Since pelvic inflammatory disease (i.e., the various types of salpingitides, oophoritis and pelvic peritonitis) is still a daily gynecologic prob-
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lem, all means must be utilized to prevent its occurrence. When pelvic inflammatory disease exists, a good number of cases will respond in an initial attack to sulfa drugs and/or antibiotics (penicillin, streptomycin, aureomycin) and complete healing will occur. The need for surgery continues in pelvic inflammatory disease because of abscess formation, advancing peritonitis or disturbed function. Surgery is aided by the sulfa drugs and antibiotics and is not replaced. Mortality has decreased with the use of the these drugs. However, proper and adequate preoperative preparation allows for more conservative surgery and also brings about the optimum time for intervention when surgery is indicated. CONCLUSIONS
1. Prophylaxis by proper asepsis is still the most important practice in preventing pelvic inflammatory disease. 2. All known medical measures (sulfa drugs, antibiotics, penicillin, streptomycin and others) plus diathermy are used to combat pelvic infections. 3. Surgical intervention is indicated in certain acute stages (abscesses) of pelvic inflammatory disease, but most often in the chronic stages. 4. The indications for surgical treatment are the symptoms of the disabling state produced by the resultant pathologic changes induced by the pelvic infection. 5. Not only must the indications be plesent to justify surgery but proper or optimum conditions should be present or produced in order to allow safe and physiologic surgery to be performed. 6. Preoperative and postoperative sulfonamides and antibiotics are of value in most instances.