Impact of vaginal laser and magnetic therapy on the clinical course of acute pelvic inflammatory diseases and on the endothelial functional status

Female pelvic inflammatory disease (PID) is one of the most common gynecological conditions. About 30–40% of patients with acute PID require emergency hospitalizations in gynecological hospitals [1, 2]. Currently, the clinical course of PID has changed and more often has a vague clinical presentation with periods of exacerbation against the background of multiple antibiotic-resistant microbial associations. Immunosuppression and worsening microcirculation in the inflammatory foci contribute to adhesion formation [3–5]. Currently, endothelial dysfunction (ED) is thought to play an important role in the pathogenesis of many diseases with an inflammatory component. The studies formed the conception of ​​vascular endothelium as an active metabolic system that modulates vascular tone and regulates inflammatory and reparative processes in response to local injury [6–8]. Acute inflammatory stress triggers an oxidative “explosion,” resulting in damage to the endothelial wall with the development of vascular dystonia exacerbating inflammatory changes in the tissues [9–11].

The current literature is lacking clinical studies investigating ED markers of PID. However, some studies demonstrated that persistently impaired perfusion of the internal genital organs with local inflammation is associated with a change in vascular endothelial function, which allows considering ED as a universal manifestation of the inflammatory process [12–15]. The complex therapy of patients with an acute episode of PID includes anti-inflammatory, antibacterial, and infusion therapy followed by correction of metabolic disorders, prevention of adhesions, and resorption of already formed pelvic adhesions [16–18]. The achievement of these goals is possible by normalizing the function of the vascular endothelium. The treatment is often accompanied by polypragmasia and further worsening of ED, which warrants wider use of physical factors. However, they are usually recommended at the rehabilitation stage, which does not prevent chronic inflammation [19-21].

The aim of this study was pathogenic validation and assessment of the clinical effectiveness of the advanced complex therapy comprising some physical factors and based on the investigation of the state of the vascular endothelium in patients with acute PID.

Materials and methods

This randomized prospective study comprised 164 patients with acute PID who sought medical care at the Multidisciplinary Clinic VitaNova and were referred for hospitalization to the Department of Obstetrics and Gynecology, Volgograd Regional Clinical Hospital Nо.1. The inclusion criteria for the study patient selection were as follows: reproductive age, clinical and laboratory manifestations of acute pelvic inflammatory disease (ICD-10 codes70-72), and signed informed consent to take part in the study. The study did not include women younger than 18 and older than 44 years, patients with tubo-ovarian abscess, pelviperitonitis, severe extragenital pathology, various tumors, and endometriosis. The mean age was 32 (3.1) years. The diagnosis was made based on the clinical manifestations of the inflammatory process, including complaints of lower abdominal pain, fever, and results of bimanual pelvic examination. A laboratory workup included complete blood count, C-reactive protein, smear for vaginal flora, the culture of cervical bacteriological specimens, polymerase chain reaction for chlamydia and gonorrhea, and pelvic ultrasound examination (US).

Upon admission to the hospital, all patients underwent complex therapy including infusion, detoxification, and antibacterial therapy according to the order of the Ministry of Health of the Russian Federation No. 532n, namely: intravenous infusions of Stabisol, Ringer’s solution, sodium chloride 0.9% up to 1,500 ml controlled by urine output; ceftriaxone 2 g intravenously for 5-7 days with the transition to oral intake (Suprax) up to 14 days, or ofloxacin 0.4 g twice daily intravenously for 5-7 days, then 0.4 g twice daily orally; amikacin 0.5 g twice daily intramuscularly for 7 days; metronidazole 0.5 g 3 times a day intravenously for 2 days with the transition to oral intake 0, 5 g 3 times a day for up to 7 days; diclofenac 75 mg intramuscularly (1 ampoule) twice daily for 1 day, then 75 mg (1 ampoule) once daily for 5 days.

Patients were divided into the study group (n = 84) and comparison group (n = 80). After two days of drug treatment, the study group patients were administered laser-magnetopuncture, which was applied to organ-specific points of the vagina using KAP-ELM-01 Androgin device. A single-stage single-speed (in-phase) laser continuous exposure with a total power of 7 mW and magnetic induction of 15 mT was carried out by a vaginal probe, which was installed in the projection of the neurovascular bundles running along the lateral sides of the uterus. Ten-minute sessions were performed daily in the morning for five days [22]. The study was approved by the regional research ethics committee of the Volgograd region (protocol No. 211-2015 of 03/17/2015). Functional activity and structural integrity of the vascular endothelium was estimated using post-occlusion vasodilation (POVD) of the brachial artery (BA) and reactive hyperemia (RH) according to D.S. Celermajer [23] technique. The percentage of BA dilatation in response to RH was calculated from the measurement results. BA dilatation less than 10% was considered a moderate ED.

A narrowing of the BA diameter was considered a sign of pronounced ED. The plasma level of circulating endothelial cells (CEC) was determined by J. Hladovec [24]. CEC levels from 6 to 10x105/L, 11-25x105/L, and 26x105/L and higher were categorized as a mild, moderate, and severe injury to the blood vessel wall, respectively. Serum concentrations of ED biochemical markers including nitric oxide (NO) metabolite, inducible nitric oxide synthase (iNOS), and endothelin-1 (ET-1) were determined using an immunoassay by the Cloud-CloneCorp test system (China). The tests were performed upon patients’ admission to the hospital and on day seven after the treatment initiation. ED markers were also determined in 20 healthy women volunteers of reproductive age seeking advice on the choice of a contraceptive method (control group).

Statistical analysis was performed using the STATISTICA 6.0 (StatSoft.Inc) software. The normality of the distribution of continuous variables was verified by the Kolmogorov-Smirnov test. Variables showing normal distribution were presented as mean (M) and the standard deviation (SD) using M (SD) format. Categorical variables were reported as counts and percentages. Continuous variables showing normal distribution were compared between two groups using the Student’s t-test. Paired samples were compared using the paired Student’s t-test. The χ2 test was used to compare categorical variables. Differences between the groups were considered statistically significant at p < 0.05.

Results and discussion

All patients with acute PID complained of lower abdominal pain accompanied by a fever above 37.5°C. Vaginal speculum examination revealed the presence of cervicitis in 157 (95.7%) and pathological leucorrhoea in 159 (96.9%) patients. On bimanual pelvic examination, 139 (84.8%) patients were found to have acute metroendometritis and acute salpingo-oophoritis. There was leukocytosis accompanied by a left shift with an increase in the number of band neutrophils (12 (2.8)%). The number of segmented neutrophils averaged 62 (1.3)%. All patients had an elevated C-reactive protein concentration of 11 (4.6) mg /L. The pelvic US confirmed the presence of salpingoophoritis in 142 (86.6%) and endometritis in 164 (100%) patients. Composition of vaginal and cervical microbiota canal was characterized by a decrease in the detection rate of lactobacilli <104 CFU/ml (98.7%) (p < 0.001) and an increase in the detection rate of Enterobacteriaceae (E. coli), enterococci and anaerobic (Staphylococcus spp.) flora ˃106 CFU/ml (96.3%) (p < 0.001). None of the patients had a gonococcal or chlamydial infection. Clinical, laboratory, and instrumental data indicating an acute pelvic inflammatory disease were accompanied by changes in vascular endothelium (table 1).

PA diameter did not significantly differ between the groups when the test was performed with patients at rest. Women in the control group had a normal BA reaction in the RH test, where vasodilation was more than 10%. Patients with acute PID had a 4.1-fold decrease in the brachial artery POVD compared with the control subjects (p < 0.001), which indicated a paradoxical vasomotor reaction due to vasoconstriction. The baseline BA blood flow velocity was 1.1 times higher than in the control group; however, in the RH phase it showed a 1.6 and 1.2 - fold increase compared with the control group and baseline level, respectively (p < 0.001). The level of NO was 2.5 times higher compared with the control group (p < 0.001), while the level of serum i-NOS was also increased. Also noteworthy was an increase in ET-1 level, which was 2.8 times higher than that in the control subjects (p < 0.001). Therefore, the acute stage of inflammation was associated with impaired endothelial vasomotor function and vasoconstriction, which was confirmed by RH test showing a significantly lesser percentage increase in the BA diameter than in the control group (p < 0.001). The number of CEC as an indicator of vascular wall injury in patients with acute PID also increased (p < 0.001) compared with healthy women in the control group. CEC count was 2.64 (0.76) × 105/L, 24.2 (1.64) × 105/L, and 23.8 (1.42) x105/ l in healthy women, comparison group, and study group, respectively (p < 0.001). These findings confirm the presence of ED in patients with acute PID.

On day 7 after the treatment initiation, 80 (95.2%) patients in the study group reported complete resolution of the pain syndrome versus 68 (85%) in the comparison group (p = 0.03), and the temperature returned to normal in all patients (table 2).

The uterine enlargement was absent in 95.2% and 76.4% of patients in the study and comparison group, respectively; 98.8% of patients in the study group had uterine tenderness versus 80% in the comparison group (p < 0.001). This was also confirmed by the pelvic US, which showed that sonographic size of uterus and ovaries returned to normal in 78 (92.6%) patients of the study group versus 52 (65%) in the comparison group (p < 0.001). At the same time, leukocytosis persisted only in one patient in the study group, and 56.8% fewer patients in the study group had positive C-reactive protein compared with the comparison group (p < 0.001). The changes in clinical and laboratory parameters in the study group were confirmed by examining vascular endothelium markers (table 3).

On day 7 after the treatment initiation, POVD increased in all patients with acute PID, though not reaching the values ​​of healthy women. In the comparison group, POVD increased only 1.9 times and remained negative (p <0.001). Such a vascular reaction indicated persisting paradoxical vasoconstriction and severe ED despite ongoing drug therapy. In the study group, a more noticeable increase in POVD was observed compared with the baseline level (p <0.001), though not reaching that of healthy women, which indicated moderate ED. The maximum BA post-occlusion blood flow velocity in the comparison group did not significantly change relative to baseline values, while in the study group this difference was statistically significant (p < 0.001) and Vmax approached the values ​​of healthy subjects (p < 0.001). Serum NO concentration in patients of the study group decreased 1.5 times compared with baseline values and was only 1.4 times higher than the control group versus 1.7 times in the comparison group (p < 0.001). ET-1 levels in patients of the study group decreased 2.3 times compared with baseline and were only 1.5 times higher than in healthy women (p < 0.001). Serum levels of ET-1 in patients of the comparison group remained unchanged and 2.5 times higher than in healthy women (p < 0.001).

The suboptimal effect of conventional drug therapy on the vessel wall was confirmed by changes in CEC counts, which decreased during therapy in all patients with acute PID (p < 0.001). However, in patients of the comparison group, it decreased only 2.3 times and was 3.9 times higher than that in healthy women (p < 0.001). In the study group, CEC count decreased 3.9 times approaching levels close to the ones observed in the control group (p < 0.001).

The study confirmed the features of the PID course at the present stage. During an exacerbation, none of the patients was found to have “pure” pathogens in polymicrobial aerobic associations. Despite this, the disease was accompanied by intoxication with clinical and laboratory confirmation of the inflammatory response. At the initial stages of the disease, patients with acute PID had a pronounced ED in the form of paradoxical vasoconstriction with an increase in BA blood flow in response to post-occlusion test with RH and an increase in serum levels of ED markers. A 2.5 – fold increase in the level of NO in response to acute inflammation with intoxication is a “protective” reaction of the body, but its combination with an increase in ET-1 proves the increased synthesis of both vasoconstrictor and vasodilating substances that contribute to the vascular wall injury and increases the number of CECs in peripheral blood.

Despite the treatment and resolution of the intoxication syndrome, the patients in the comparison group continued to have clinical, laboratory, and ultrasound signs of the inflammatory process. This was accompanied by persistent ED presented as negative values of POVD, a slight decrease in NO with a high level of ET-1, and moderately elevated counts of CECs, significantly exceeding those of healthy women. Consequently, persistent ED may result in impaired tissue repair and regeneration and contribute to the chronization of the inflammatory process. The study findings are consistent with the evidence indicating the presence of ED in patients with inflammatory processes in other organs [25, 26].

Given the identified changes in endothelial function during conventional treatment, we have developed and applied a method for the treatment of patients with acute PID using laser-magnetic radiation. The combined effect of preformed and medicinal factors in the acute phase of the disease resulted in a more than 3-fold reduction in the duration of the pain syndrome. Bimanual vaginal examination showed a significant increase in the number of patients in the study group, who had no signs of inflammation compared with the comparison group by the end of the treatment course. This was confirmed by the normalization of leukocyte count in 98.8% and the absence of C-reactive protein in 90.5% of patients, as well as data from the pelvic US, which showed that inflammatory changes in the uterus and adnexa were noted only in 7.5% of patients. The decrease in blood flow velocity and an increase in the POVD in BA testified to the restoration of vasomotor endothelial function, which was accompanied by a more than 3 - fold decrease in the number of CECs in peripheral blood.

The achievement of a more pronounced clinical effect and restoration of endothelial function, in our opinion, was due to the specific effect of the selected physical factors on the vascular component of the inflammatory process. Magneto-laser stimulation helps restore blood flow velocity, eliminate vascular spasm, and improve the rheological properties of blood and microcirculation. Stimulation of biologically active points of the vagina provides a quick transmission of impulses to the central nervous system and causes a sedative and analgesic effect of the procedure [22]. It is necessary to emphasize the moment of exposure – the 2nd day from the treatment initiation, when after the start of drug therapy that helps suppress the microbial flora, eliminate hypovolemia, reduce edema and pain; physiotherapy is added with weak energies that are not able to cause a paradoxical reaction against the background of inflammation that has not yet been resolved. The presented technique creates the conditions for a smooth and continuous transition of therapeutic effects from intensive to rehabilitative. This prevents the formation of persistent morphological and functional disorders in the form of fibro-sclerotic processes in the pelvis.

Conclusion

The study findings suggest that acute inflammation of the female pelvic organs is associated with the signs of ED that are not completely resolved by drug therapy. Early administration (on day 2 after treatment initiation in the acute phase of the disease) of vaginal magnetic laser therapy, which helps eliminate vascular disorders not only in the focus of inflammation, but also in the body as a whole, reduces the duration of pain and intoxication syndromes, lowers the risk of chronic inflammation and prevents adhesion formation.