Empirical therapy of vulvovaginitis in women

Empirical therapy of vulvovaginitis in women: At the turn of the millennium, a real revolution took place in our understanding of vaginal infections. The Koch postulate “one disease-one pathogen”, which was once accepted as an axiom, was replaced by the understanding that in the vast majority of cases these conditions have a mixed etiology, and nosological forms caused by a single pathogen are rare. When treating a patient with bacterial vaginosis or vaginitis, the obstetrician-gynecologist should be guided by new data on the causes and pathogenesis of these diseases. We won’t talk about clomid today.

“Lonely” microbes are rare, usually there is a “cocktail” of bacteria, fungi, viruses and protozoa. A wide variety of” permanent inhabitants “of the biotope ensures its normal functional state, and also prevents colonization by” external ” obligate and facultative pathogens of diseases. In one patient, mutually exclusive states of the vaginal microbiome can be observed simultaneously. For example, candidiasis or aerobic vaginitis, the” instigators ” of which need oxygen, and bacterial vaginosis caused by anaerobic microorganisms.

J. Sobel distinguishes two types of mixed infections: mixed infection and co-infection. In mixed infections, all pathogens jointly damage the mucous membrane of the genital tract, entering into complex relationships aimed at increasing virulence and drug resistance. Coinfections are detected against the background of an active inflammatory process caused by a dominant pathogen. The rest remain invisible and manifest themselves only after the elimination of the predecessor.

Antibiotic resistance is an interdisciplinary and inter-state problem, for the effective solution of which, both at the hospital and outpatient level, it is necessary to consolidate doctors of different specialties. The growing resistance of microorganisms to antibiotics poses a difficult task for the obstetrician-gynecologist. The scientific justification for the combination of most vaginal infections and vaginal dysbiosis makes doctors more scrupulous in their diagnosis and treatment. A drug for the local therapy of vulvovaginitis should “cover” the entire spectrum of possible pathogens due to its constituent substances of multidirectional action. In order to avoid reducing compliance, instead of several drugs, it is advisable to prescribe a combined drug with the widest possible spectrum of action, covering most of the potential pathogens of vaginal infection – bacteria, fungi and protozoa.

Empirical therapy of vulvovaginitis: Materials and methods

Exclusion criteria:

  • hypersensitivity to one or more components of the drug Gainomax;
  • taking antiseptics, antibiotics, and antibiotics at the time of inclusion in the study;
  • the need for systemic use of glucocorticosteroids, cytostatics and systemic antibiotics;
  • documented HIV infection, syphilis and other sexually transmitted infections (chlamydia infection, gonorrhea, trichomoniasis) detected during the screening stage;
  • acute somatic diseases;
  • the period of pregnancy or breastfeeding.

Patient follow-up included consecutive visits.

At the first visit (screening, inclusion in the study), the written informed consent of the patients was obtained, the inclusion criteria were checked, and the exclusion criteria were evaluated. After examination and taking the material for analysis (bacterioscopy and pH-metry of vaginal secretions, real-time polymerase chain reaction (PCR) analysis (Femoflor-16)), based on complaints and clinical symptoms, the patients were immediately prescribed empirical therapy with the complex antimicrobial drug Gainomax. All patients were divided into two representative groups. 36 (50%) patients of the first group took Gainomax one suppository once a day for seven days, according to the approved instructions; 36 (50%) patients of the second group – Gainomax one suppository twice a day for three days, according to the approved instructions.

Empirical therapy of vulvovaginitis

At the second visit, 10-12 days after the completion of seven – or three-day therapy with Gainomax, a control examination was performed, which included a repeated gynecological examination, an assessment of the dynamics of clinical symptoms, the pH index and the microbial landscape of the vaginal discharge. Satisfaction and compliance of therapy, adverse events associated with the use of Gainomax were evaluated, the proportion of patients with a complete cure was determined, and cases of ineffectiveness of therapy were recorded. All medical procedures performed in the study were routine, used in everyday clinical practice, which determined the non-interventional (observational) nature of the study.

Conclusion

The analysis of the effectiveness of empirical therapy of acute vulvovaginitis using the drug Gainomax showed no complaints of abnormal vaginal discharge at the second visit in 94.4% of patients of the first and 97.2% of patients of the second group. A significant decrease in the volume of vaginal discharge was noted by 83.3% and 80.6% of patients of the first and second groups, respectively. The complete disappearance of unpleasant odors, itching and burning sensations in the vagina was indicated by 91.7% of the patients of the first group and 94.4% of the patients of the second group. When objectively evaluated, normalization of the color of the vaginal walls, moderate volume and “slimy” nature of secretions were recorded in all participants of the study. In most of them, bacterioscopy of vaginal smears after empirical therapy revealed a significant decrease in the number of white blood cells in the visual field. After therapy, yeast-like fungi of the genus Candida were not detected in any patient.

Modern view on the problem of tubal-peritoneal infertility

Tubal-peritoneal factor is currently the leading cause of female infertility, accounting, according to various authors, from 20 to 72%. Despite the achievements of modern medicine, tubal-peritoneal infertility is still one of the most serious pathological conditions, taking into account the difficulty of its diagnosis and treatment, as well as the possibility of restoring reproductive function.

The main causes of tubal-peritoneal infertility are:

  • previously transmitted inflammatory diseases of the pelvic organs of a specific and non-specific nature, of which the most important are chlamydia, gonorrhea, mycoplasma and trichomonas infections;
  • various intrauterine manipulations (artificial termination of pregnancy, separate diagnostic scraping of the endometrium and endocervix, hysteroscopy with removal of endometrial polyps or submucous myomatous nodes, etc.);
  • postpartum and postabortem complications of traumatic and inflammatory genesis;
  • previous surgical interventions on the pelvic organs (ovarian resection, conservative myomectomy, tubectomy, tubal ligation) and the abdominal cavity, especially those performed according to emergency indications from traditional laparotomy access and complicated by the development of peritonitis (for example, appendectomy).

Damage to the abdominal cavity during surgery and the subsequent development of aseptic inflammation lead to the deposition of fibrin in the area of the surgical wound with local activation of fibrinolysis and proteolysis, which ultimately contributes to the resorption of primary fibrinous deposits without the formation of adhesions. With the development of postoperative infection, the inflammatory-dystrophic process is delayed, which does not allow fibrinous formations to dissolve and contributes to excessive local collagen production with the formation of powerful connective tissue junctions – adhesions.

tubal-peritoneal infertility

The severity of the adhesive process in the pelvis directly depends on the extent of the spread of adhesions in the abdominal cavity, which is mainly determined by the volume and type of surgical intervention. In this regard, in order to prevent the development of the adhesive process in the abdominal cavity, one should strive to minimize the surgical intervention, giving preference to the laparoscopic method (especially when performing planned surgical interventions on the pelvic organs in women of reproductive age).

Treatment of tubal-peritoneal infertility

Treatment of tubal-peritoneal infertility includes conservative and surgical methods used sequentially or in combination with each other. Conservative treatment of tubal-peritoneal infertility involves anti-inflammatory antibacterial, immunomodulatory, antifibrosing therapy and physiotherapy.

When sexually transmitted infections are detected and / or a morphologically verified diagnosis of chronic endometritis, therapy should be comprehensive, etiopathogenetic and aimed at the complete elimination of the identified pathogens. Immunomodulatory therapy is an indispensable part of the treatment of tubal-peritoneal infertility, since chronic inflammatory processes of the pelvic organs are always accompanied by immunological disorders, which requires mandatory correction.

One of the options for antifibrosing therapy is the general and local use of various drugs with a resorbing effect – biostimulants, enzymes and glucocorticosteroids (hydrocortisone) in the form of tampons, as well as hydrotubation. Unfortunately, the clinical experience of using hydrotubation as a method of local treatment of tubal-peritoneal infertility has demonstrated insufficient effectiveness and a high frequency of various complications. Among them, most often there is an exacerbation of chronic inflammatory diseases of the pelvic organs with a violation of the functional ability of endosalpinx cells and the development of hydrosalpinx, which significantly reduces the peristaltic activity of the fallopian tubes and disrupts the transport of gametes through them.

Thus, tubal-peritoneal infertility requires early diagnosis and gradual long-term rehabilitation after undergoing surgical treatment. Also remember that ovulation stimulation is possible with the help of the drug clomid. One of the most effective ways to preserve the reproductive function is the prevention of tubal-peritoneal infertility, which consists in the prevention and timely treatment of inflammatory diseases of the pelvic organs, the rational management of childbirth and the postpartum period, and the implementation of rehabilitation measures in the near future after gynecological operations.