Adhesions in the pelvis in women - symptoms, diagnosis, treatment, surgery

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Gynecology
Adhesions in the pelvis

Interview with Prof. Puchkov on Medical Channel 1 on the topic: “Adhesive disease and infertility”

Adhesions in the pelvis are adhesions of connective tissue that appear on the surface of the pelvic organs. As a result, their mobility is limited and function may be impaired. When these organs are displaced, the adhesions become tense, which leads to pain.

The formation of adhesions refers to a protective reaction of the body aimed at delimiting a pathological focus from healthy tissues that appears due to various reasons: trauma, inflammation, exposure to air, circulatory disorders, etc. With any damage, the body strives to grow a new one on the unprotected area of the mesothelium, and substances are released , synthesizing fibrin. As a result, nearby organs are “glued together” with fibrin fibers.

Most often this occurs during surgical interventions, for example, after myomectomy, and adhesions in the pelvis after cesarean section are not uncommon. They also appear in urgent conditions associated with bleeding (for example, during ectopic pregnancy, ovarian apoplexy, abscesses, etc.), and adhesions in the pelvis in women are formed due to various diseases, for example, endometriosis, salpingitis, oophoritis, fibroids. The likelihood of the formation of adhesions depends on a number of factors: the properties of connective tissue determined genetically, weakened immunity and the individual predisposition of tissues to adhesions.

Symptoms of adhesions in the pelvis

At the initial stage, there are no complaints, adhesions are detected by chance. Over time, pain appears - with adhesions in the pelvis, they can be constant or occur during physical activity, sexual intercourse, and even when changing position. Nausea and vomiting may occur. In severe cases, intestinal obstruction develops due to compression of the intestinal lumen and circulatory disorders.

One of the serious consequences of adhesive disease is infertility. There are three stages of the process:

I - the appearance of single adhesions near the ovary, tube, uterus is typical; nothing prevents the advancement of the egg;
II - the ovary and tube are connected by dense adhesions, but half of the surface of the ovary is free; adhesions prevent the fimbriae from capturing the egg;
III - the ovary is almost entirely covered with dense adhesions, the fallopian tubes are deformed and impassable, the lumen is blocked.

If pregnancy does occur, there is a risk of ectopic development due to an obstruction to the movement of the egg. At later stages, blood flow in the uterus may be disrupted, leading to miscarriage.

Symptoms

Symptoms in the presence of adhesions in a woman are very different, however, several common signs can be identified:

Chronic pelvic pain syndrome is a constant, sometimes almost imperceptible, dull pain in the area of adhesion formation. It occurs due to tension and deformation of organs. In some cases, it can radiate to surrounding organs, the lower back and legs. The pain may intensify during sexual intercourse, physical exercise and prolonged exercise, hypothermia, and when the bladder is full.
Impaired organ function - reduction or disappearance of menstruation, lack of ovulation, inability to become pregnant.
In cases of formation of adhesions with intestinal loops - constipation, feeling of bloating, intestinal obstruction.

It is also worth noting that if a woman has adhesions, it is quite possible for her to experience increased pain during menstruation and ovulation. But it is worth considering that in half of the cases, adhesions do not cause any symptoms and are detected only during an ultrasound of the pelvic organs or a visual examination.

Diagnostics

The disease can be suspected if there are relevant patient complaints and medical history. To confirm the diagnosis, a number of examinations are carried out, which include:

Ultrasound - adhesions in the pelvis are detected in the form of heterogeneous echo signals;
Hysterosalpingography and hysterosalpingoscopy - performed to assess tubal involvement;
MRI of the pelvic organs;
Diagnostic laparoscopy is effective for visualizing adhesions between organs.

To identify the causes of adhesions, laboratory tests may be prescribed: determination of flora, STIs, PCR diagnostics, etc.

Causes

The adhesive process in the pelvis can begin after diseases of the internal organs of the small pelvis, improper treatment and for other reasons. It can be:

abortion or wearing an intrauterine device,
surgical interventions using the laparoscopic method,
pathological endometriosis of the peritoneum,
infectious diseases of the female genital area,
hemorrhages in the abdominal cavity (ectopic pregnancy, ovarian apoplexy),
inflammation of the appendix (appendix) and appendectomy.

In all of these cases, adhesions of the pelvic organs can be prevented if you follow the doctor’s recommendations in the postoperative period or regularly engage in the prevention of the formation of adhesions.

Any advanced pelvic disease leads to the inevitable onset of adhesions in the pelvis.

Treatment of adhesions in the pelvis in women

Conservative therapy is recommended to prevent complications; if the disease appears as a result of an infection, antibacterial drugs may be prescribed; for endometriosis, hormone therapy; for pain relief, as well as for the inflammatory process, anti-inflammatory drugs may be recommended; fibrinolytics are prescribed for resorption.

The goal of surgical treatment is to cut the adhesions and free the organs. Indications for surgery are:

severe pain syndrome;
risk of developing intestinal obstruction;
female infertility.

How does adhesive disease develop?

Mostly this process does not cause concern. In the human body, on the intestines and abdominal organs, connective tissues grow, which block blood flow in the organs and disrupt their functioning.

Laparoscopy for adhesions in the pelvis

Video from the operating room. Laparoscopic cystadnexectomy for severe adhesions

The gold standard for the surgical treatment of adhesions is laparoscopy, during which all adhesions are sequentially intersected. At the same time, I select the choice of instruments taking into account the area of intervention; when dissecting adhesions between the peritoneal wall and the omentum or intestine, I use the Liga Sure device, which allows for bloodless manipulations while simultaneously sealing the vessels. Between intestinal loops, I always use a cold method for dissection, without electrosurgery, to avoid damage to the intestinal wall with subsequent perforation.

To prevent adhesions and fusion of organs, I use special anti-adhesion barriers, which dissolve without a trace after 7-10 days. These drugs are effective in the presence of exudate and blood, are safe, encapsulation is excluded, and do not require fastening with sutures.

The advantage of laparoscopy is the absence of extensive damage; there is no drying out of the operation area, since carbon dioxide is introduced instead of air (in open surgery), which dries out the peritoneum. When washing, solutions are used, which, unlike napkins, does not injure the mesothelium. Also among the advantages of laparoscopy are the absence of blood loss and high precision of manipulation due to the possibility of visualization. To prevent adhesions and fusion of organs, I use special membranes that dissolve without a trace after 7-10 days.

Our patients are usually discharged on days 2-4; three days after discharge, we conduct a follow-up examination and make recommendations for further treatment. After laparoscopy, a woman can return to her usual lifestyle within two weeks.

I have been performing such interventions since 1993, and have performed more than 900 operations to remove adhesions. I also use modern technologies to prevent the appearance of adhesions during any surgical procedure. Thanks to the modern approach, the likelihood of developing adhesions during surgery in our clinic has been reduced tenfold.

Adhesive disease with a predominance of dyspeptic disorders

This is when, in addition to pain, other, unpleasant signs appear, which indicate that the adhesive process is actively developing. What worries a person:

Nausea, vomiting, often occurring after eating, and it can be episodic in nature and appear after eating certain foods.
Abnormal bowel movements, frequent constipation that are not related to lifestyle or diet.
Belching that occurs after eating, with possible backflow of stomach contents into the esophagus and oral cavity.

In women, pain can be localized in the area of the organs of the reproductive system, which makes diagnosis difficult. However, other signs are also present.

Symptoms of adhesions

Symptomatic manifestations of adhesions vary greatly. Some women come to us for help with complaints of pelvic pain, i.e. dull pain localized in the pelvic area. It is usually caused by anatomical disorders (displacement of organs), and therefore cannot be relieved by conventional painkillers. If adhesions affect an area of the intestine, a woman may suffer from long-term chronic constipation.

The process of formation of cords may not manifest itself at all, but the patient cannot become pregnant, and it is with this problem that she turns to a specialist. There is also a common tendency to consult a gynecologist with symptoms of an ectopic pregnancy. It is impossible to identify specific single manifestations of adhesive disease.

The key method of treating adhesions today is a fairly gentle operation - laparoscopy.

The occurrence of synechiae inside the uterine cavity

Intrauterine adhesions occur mainly due to injury to the mucous membrane during abortion, miscarriage, complicated childbirth, and infectious inflammation. This pathology in gynecology is called Asherman's Syndrome. This disease is characterized by a decrease in the internal volume of the uterus and a deterioration in the quality of endothermy. Asherman's syndrome reduces the ability to conceive and bear a child. The functions of the uterus in this case are hampered by adhesions. With the syndrome, the amount of menstrual flow decreases significantly and may disappear.

The presence of adhesions in the uterine cavity is detected using ultrasound, as well as hysteroscopy. Diagnostic hysteroscopy is considered the most effective, allowing to determine the type of adhesions, their development, and also examine the endometrium. Based on the diagnostic results, the doctor selects treatment methods, taking into account the individual characteristics of each patient.

For Asherman's Syndrome, therapeutic hysteroscopy with excision of synechiae and the prescription of hormonal treatment gives good results. As a result of this operation, the uterus is restored, the endometrium improves to a normal state. The success of treatment largely depends on the degree of endometrial damage. A woman’s chances of becoming pregnant naturally or with the help of assisted reproductive technologies can be assessed already at the diagnostic stage.

Video on the topic

Treatment

Conventionally, therapy can be divided into several stages, it includes:

Carrying out operations aimed at removing adhesions.
The use of drugs that promote the resorption of connective tissue formations.
Carrying out physiotherapeutic procedures to help reduce adhesions in size.
Nutritional corrections are carried out if a person does not have serious bowel dysfunction.

Surgical therapy

Abdominal surgery is rarely performed if a person is concerned about intestinal obstruction. Abdominal surgery does not solve the problem; it can provoke the formation of new adhesions.

But if it is not possible to correct the patient’s condition in any other way, doctors do the following:

open the abdominal cavity in the area of the affected organ;
adhesions are excised through surgery using a scalpel;
restore the functioning of the digestive system and close the patient’s abdominal cavity.

Laparoscopy is considered gentle, as it does not involve opening the abdominal cavity, and therefore reduces the risk of adhesions.

Often, adhesions are cut with a laser beam, which helps eliminate formations and reduce potential risks. But such an operation is considered expensive and is performed on certain patients, if indicated.

Recovery after surgery

Carrying out abdominal surgery involves going through a recovery period. It consists of following certain rules that will help avoid the re-formation of adhesions on the abdominal organs.

The recovery period may take several weeks or months. Depending on the complexity of the surgical intervention performed on the patient.