Oophoritis

OOPHORITIS, oophoritis (from Greek oophoron-- ovary), inflammation of the ovaries, one of the frequent female diseases. The term oophoritis is used very widely, often designating diseases that occur under the guise of inflammation, yet have nothing in common with the inflammatory process either patho-anatomically or etiologically (see below--trophic O.). The principal mass of O. is of bacterial origin. It has been established, however, that similar processes can also occur with severe poisonings by poisons of non-microbial origin (phosphorus, arsenic). A distinction is made between acute and chronic forms of O. Acute inflammation of the ovary (oophoritis acuta) is observed mainly in gonorrhea, septic diseases, appendicitis, more rarely--in pneumonia, tuberculosis, typhus, mastoiditis, influenza, diphtheria, scarlet fever, angina and dysentery. The routes of spread of microbes are various. They can reach the ovary through the open fimbrial end of the affected tube (per continuitatem), through blood and lymphatic pathways (o. thrombophlebitica, o. lymphatica) from nearby and distant organs (uterus, intestine, etc.). O. manifests as a general increase in the mass of the organ, sometimes several times; edema, hemorrhages and dense small-cell infiltration of the interstitial tissue are noted, as well as degenerative changes in the cells of the granulosa layer of growing follicles, the appearance of leukocytes in them, hemorrhages into the cavities, a significant number of atretic primary follicles with an extraordinary abundance of maturing ones. The process can end with the formation of abscesses in the interstitial tissue, which is however rarely observed. More often microbes penetrate into the follicle or into the cavity of the corpus luteum, forming true abscesses here--follicular abscess and abscess of the corpus luteum. The latter can be macroscopically distinguished from the follicular abscess by its folds and yellow color of the inner layer, and microscopically--by the presence of lutein cells, which subsequently disappear; the cavity of the abscess in such cases is lined with a membrane, in the walls of which large vesicular, so-called false xanthomatous cells (of connective tissue origin), granulation tissue, abundant leukocytes and lymphocytes, and plasma cells can be found. The pus contains microbes, sometimes living in symbiosis (gonococcus together with streptococcus). After a certain period of time, the pus can become "sterile." Abscesses vary in size, but usually do not exceed the size of a fist. Often they are multiple. Sometimes the entire ovary turns into an abscess (pyoovarium). Very often O. is accompanied by inflammation of the peritoneal covering (perioophoritis). Although acute O., regardless of the type of bacteria that caused the inflammation, usually proceeds as described above, certain individual forms should still be distinguished. Gonorrheal O. is observed with a preceding gonorrhea, with an ascending process, with affected tubes, from which gonococci per continuitatem pass through the abdominal opening onto the peritoneum, causing inflammatory phenomena of the serous membrane of the small pelvis (pelveoperitonitis exsecutiva, periserositis) and the ovary (perioophoritis), and then the ovary itself itself. Only in particularly severe cases does the gonococcus spread through the lymphatic pathways. Bilateral O. is often observed. The course is prolonged, with repeated exacerbations, but benign, without threatening clinical phenomena and almost without fatal outcomes. If an abscess forms in the ovary, merging with a pyosalpinx, this gives a combined tubo-ovarian abscess. Clinically, this form is closely approached by tuberculous O. As a primary, isolated disease, it occurs extremely rarely. Only the secondary form has practical significance (in tuberculosis of peribronchial glands, lungs, intestine, mesenteric glands, peritoneum). A distinction is made between tuberculous perioophoritis, which is a partial manifestation of tuberculous peritonitis, and tuberculous O. In the latter, the process is localized mainly in the stroma of the cortical layer, but also affects other elements. A rarer miliary form is characterized by densely scattered nodular elevations, belonging to epithelioid tubercles. In the more common caseous form, foci of various sizes of caseous material are found. Combined forms are often observed. Clinical recognition is extremely difficult. The diagnosis is facilitated when nodules can be palpated on the pelvic peritoneum in the posterior Douglas. Septic O. Streptococci, staphylococci, bacillus coli, etc., can be the causative agents. It is observed mainly in the postpartum period, after abortion and after various types of intrauterine interventions. It proceeds according to the type of puerperal infection. The intensity of the entire process is significantly sharper than in gonorrheal and tuberculous O. From the very beginning, the disease has a very serious character. Often local phenomena are overshadowed by threatening general phenomena. In milder cases, persistent degenerative-atrophic changes remain or an abscess forms, usually unilateral. The outcome of acute O. is not always the same. Even with a favorable course, complete recovery is rarely observed. Often the process passes from the subacute phase into a chronic form. Small abscesses either resolve, leaving scar tissue, or become calcified. Abscesses of larger size can exist for years, sometimes rupturing and emptying into the intestine, bladder, uterus, etc., if they are not promptly removed by surgery. In rarer cases (in neglected cases), the rupture of an abscess can cause pelveoperitonitis and peritonitis. Symptoms of acute O. may be imperceptible, overshadowed by phenomena from the concurrently affected organs (tube, peritoneum). Nevertheless, the appearance of fairly intense pains in the depth of the pelvis with an aggravated febrile state and the usual signs of peritoneal irritation (meteorism, nausea) indicates that the inflammatory process has spread to the ovary. Recognition is associated with great difficulties in the presence of significant exudate and large adhesions with neighboring organs. Sometimes examination through the rectum helps to detect an enlarged, edematous and painful ovary. Correct differentiation is of immense practical importance. It is necessary to keep in mind acute appendicitis, general peritonitis, extrauterine pregnancy, twisting of the cyst stalk and other diseases. A carefully collected history and comprehensive objective examination with the use of laboratory methods (composition of vaginal secretion, rate of settling of blood cells, etc.) in most cases make it possible to make a correct diagnosis. Treatment of acute O. is strictly conservative: rest, bed rest, ice. For pains--narcotics: morphine or opium in suppositories or in enemas. After the cessation of acute phenomena and the return to normal temperature, one proceeds to resorption treatment. Acute O. that does not resolve completely into recovery passes into a chronic form (oophoritis chronica). Macroscopically, the ovary in this case is usually enlarged, denser, sometimes its surface is covered with a series of protrusions due to the excessive number of prominent follicles, alternating with sharp indentations and folds on the thickened cortical layer. Microscopically, thickening of the tunica albuginea, decrease or complete disappearance of primary follicles, massive appearance of corpora albicantia, in which hyaline degeneration is often found, as well as in the walls of mostly obliterated vessels. A large number of follicles of various sizes, in which the eggs and part of the cells of the granulosa layer have died, sometimes give a picture of small-cystic degeneration. Finally, the entire ovary can undergo fibrous degeneration; then it shrinks, decreases in size, becomes sclerosed and becomes extremely dense (sclero-cystic O.). Symptoms of chronic O. manifest as pains localized in the area corresponding to the position of the ovary. The pains intensify during menstruation, physical exertion, prolonged standing, constipation, coitus and radiate to the thigh and sacrum. The menstrual cycle changes (menorrhagia or, conversely, amenorrhea). Infertility is more often caused by inflammatory changes in other parts of the genital apparatus (tube, uterus). All together they greatly disturb the general condition of patients. Irritability, depressed mood, symptoms of hysteria and neurasthenia--the usual consequences of chronic O. The diagnosis of chronic O. can be considered justified only when an enlarged, dense, painful, often nodular ovary is found, displaced from its normal position due to adhesions and fusions that significantly limit its mobility. It is definitely erroneous to make a diagnosis of chronic O. only on the basis of pains and tenderness of the ovary on examination. It should be remembered that pain can be purely of functional origin (so-called Charcot's ovaries), having nothing in common with O. and representing a particular manifestation of central neurosis. This also includes the so-called ovarian neuralgia (ovarialgia, ovariodynia) and a number of other diseases of a non-sexual nature. Treatment of chronic.

O. consists in the application of hot douches, tampons (with ichthyol and tigenol in glycerin), diathermy, ultraviolet rays (quartz lamp) and mud therapy. Only in exceptional cases, when many years of conservative therapy are without result, it is necessary to resort to surgical intervention (ovariotomy). In contrast to these anatomically and clinically well-defined O., there is also the so-called trophic (idiopathic) form of non-infectious origin. The causative factors are most often constitutional diseases (tuberculosis, syphilis), anemia, diabetes, or local nutritional disorders (venous stasis in marked retroversion-flexion of the uterus). This form of O. gives neither a characteristic patho-anatomical picture nor typical clinical symptoms. What has been said also applies to the so-called microcystic degeneration of the ovary, in which the entire ovary is penetrated by cysts of various sizes. The origin of these changes is very different. Sometimes they represent a certain phase in the development of a chronic inflammatory process. In such cases, there are signs of a past or continuing inflammatory process. On the other hand, microcystic degeneration can also occur in perfectly healthy women during pregnancy, in the secretory phase of the menstrual cycle, and even in newborns, which indicates the existence of some other causes that bring about its development. These causes await their elucidation.