Application of Preventive Treatment Theory in the Treatment of Pelvic Inflammatory Disease

ZHU Bei-bei (朱贝贝), CHEN Si (陈 思), CHEN Yue (陈 玥), WANG Pei-juan (王佩娟), LU Yan (卢 燕)

The Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine/Jiangsu Province Hospital of Integration of Chinese and Western Medicine, Nanjing 210023, China

ABSTRACT With a history of more than two thousand years, the theory of preventative treatment has been closely followed by the development of modern medical theories on the basis of inheritance by medical experts in the past dynasties, which has been constantly improved and enriched, and deeply applied in the prevention and treatment of serious and multiple diseases. It has achieved great benefits. For women with gynecological diseases, pelvic inflammatory disease patients accounted for a large proportion. Due to the lack of specificity in diagnosis and treatment, the condition is lingering and difficult to cure, so it seriously reduces the quality of life of women, thus affecting the harmony of family and society. From the perspective of prevention, according to the characteristics of each stage of the disease, this paper put forward substantive prevention suggestions and targeted treatment methods, ensuring preventing before disease,preventing progress after disease, and preventing reoccurring after recovery. It has important practical significance for the prevention and treatment of pelvic inflammatory diseases, as well as the development and inheritance of traditional Chinese medicine.

KEYWORDS Preventive treatment theory; Pelvic inflammatory disease; Sequelae of pelvic inflammatory disease; Preventive measures

Pelvic inflammatory disease (PID) is one of the most common gynecological diseases. It is difficult to cure and has a high incidence. The sequelae are harmful to women's physical and mental health. In recent years, research and discussion on the treatment of pelvic inflammatory disease and nursing intervention measures have gradually increased. However, the research that linking the"preventive treatment" idea of traditional Chinese medicine (TCM) with the prevention and treatment of pelvic inflammatory disease is rare. Therefore,based on the existing research results on the prevention and treatment of pelvic inflammatory diseases, combined with the occurrence factors,treatment methods and prognostic nursing methods of pelvic inflammatory disease and its sequelae,the concept of "preventing disease" in TCM is combined with pelvic inflammatory disease. The inter-personal relationship is elaborated in depth and systematically to achieve the purpose of early prevention, reducing morbidity, improving cure rate, reducing recurrence rate, and reducing sequelae.

UNDERSTANDING OF TRADITIONAL CHINESE AND WESTERN MEDICINE ON PELVIC INFLAMMATORY DISEASES

PID is an inflammatory disease that belongs to female upper genital tract infection.The lesions involve connective tissues such as the endometrium, fallopian tubes, ovaries and pelvic peritoneum. Clinically, it is divided into two categories: acute and chronic. Acute pelvic inflammatory disease is mostly manifested as fever, severe pain in the lower abdomen or lumbosacral soreness, and even more acute symptoms such as vomiting and diarrhea[1]. Chronic pelvic inflammatory disease is the development of acute pelvic inflammatory disease that is not standardized, untimely, and incompletely, with too aggressive virus, or poor immune system. It has the characteristics of long course, recurring attacks, and difficult to cure. Pelvic pain is the main clinical feature, often accompanied by abnormal vaginal discharge and menstrual disorders. Chronic pelvic inflammatory disease does not heal, and it is easy to cause adhesion of pelvic tissues, resulting in sequelae such as pelvic abscess, ectopic pregnancy, and infertility[2]. In treatment, the attack stage is mainly based on broad-spectrum, empiric antibiotics to fight infection, and surgical treatment is performed when necessary.

In the history of TCM, there is no definite name and record for pelvic inflammatory disease and its sequelae. According to the characteristics of the pelvic inflammatory episode, the later generations of physicians attributed the acute period with abdominal pain, fever and leucorrhea as the main characteristics to the "heat entering blood room","leukorrheal diseases" and "postpartum fever"categories. The sequelae of chronic pelvic pain,abnormalities of the pelvis, irregular menstruation,infertility, and pelvic abscess caused by pelvic inflammatory disease are divided into "women's abdominal pain", "leukorrheal diseases", "rrregular menstruation", "infertility", "abdominal mass" and other diseases[3]. TheGuidelines for the Diagnosis and Treatment of Common Gynecological Diseases in Traditional Chinese Medicine《中医妇科常见病诊治指南》points out that "heat toxin" is the main pathogenesis, which is divided into syndrome of flaming heat and syndrome of damp heat and stasis syndrome[4]. Most doctors believe that the cause of the disease is mainly due to the female suffering from damp heat and internal invasion of pathogen toxins. It goes straight into thoroughfare-conception meridian and the uterus and blood vessels, causing the body to fight with each other, leading to fever.If it fails, it causes abdominal pain. Over time,the body's healthy Qi (气) shows deficiency, and pathogen Qi lingers. Heathy Qi cannot fight against pathogen Qi, leading to Qi and blood congestion and stasis, or liver depression, Qi stagnation, and blood stasis cause mass for long-term. Stasis blocks thoroughfare-conception meridian, causing pain[5].

THE THEORETICAL BASIS OF TCM"PREVENTIVE TREATMENT"

The core idea of "preventive treatment" is mainly summarized into three aspects: "preventing before disease", "preventing progress after disease",and "preventing reoccurring after recovery". This ideological theory sprouted inBook of Changes(《周易》): "Water is on fire, and it is boiling, and people can think about troubles and prevent them."Then theInner Canon of Yellow Emperor(《黄帝内经》) puts forward "Great doctors usually pay less attention to the treatment of a disease, but more to the prevention of it." "To resort to treatment when a disease has already occurred and to resort to regulation when a disorder has already been caused."Synopsis of Golden Chamber(《金匮要略》) proposes that "the beginning of disease can be saved, but the pus will lead to death" and"seeing the disease of the liver, be the first to reinforce the spleen" has gradually developed and improved the theory. SUN Si-miao put forward that "to eliminate the premature disease, cure the disease before occurrence, cure before nothing happens". YE Tian-shi stated: "You must first treat the site free from pathogens" to further enrich this theory. From incubation, germination to birth,this idea has condensed the wisdom of the past dynasties of physicians. It is not a handful of ideas. It is a result of repeated scrutiny, summary,and polishing in profound theories and long-term practice. It has a leading position in TCM history."Preventive treatment", as the name suggests, refers to the human body is still in a sub-healthy state, with mild physiological function disorders, poor mental and psychological status, viscera meridians, Qi,blood, body fluid, etc. have not yet shown organic changes, and laboratory examinations did not show obvious abnormal changes[6]. The idea of "preventive treatment" is consistent with the theory of "threelevel prevention" emphasized in modern preventive medicine, emphasizing the importance of prevention during the occurrence and development of diseases.In 1996, the World Health Organization pointed out:"The medicine of the 21st century should not continue to focus on diseases as the main research object, but human health should be the main direction of medical research." It can be seen that "preventive treatment"has gradually become a common feature of research direction of Chinese medicine and Western medicine[7]. TheOpinions of the Central Committee of the Communist Party of China and the State Council on Promoting the Inheritance and Innovative Development of Traditional Chinese Medicine《中共中央国务院关于促进中医药传承创新发展的意见》emphasizes that in the implementation of the Healthy China initiative, we will attach importance to the construction of TCM preventive treatment, enrich the content of TCM preventive treatment, and encourage family doctors to provide TCM preventive treatment contracted services, promote the intervention program of TCM preventive treatment in key populations and patients with chronic diseases[8].

THE GUIDING SIGNIFICANCE OF"PREVENTIVE TREATMENT" IN THE PREVENTION AND TREATMENT OF PELVIC INFLAMMATORY DISEASES

A survey shows that the incidence of PID among women of childbearing age in developing countries is as high as 40%. In China, among the 3 590 patients surveyed by many hospitals led by Peking University First Hospital in gynecology and family planning clinics, about 10.1% of them were diagnosed as PID. Shaanxi province surveyed 8 529 married cases in rural areas in 2009, showing that the prevalence of PID among women of childbearing age was 3.73%. The NHANES survey in the United States shows that 4% of women have suffered from PID. The annual cost of pelvic inflammatory treatment in the United States is as high as 4 billion US dollars, and more than 1 million patients are treated for acute pelvic inflammatory disease every year[9]. It can be seen that pelvic inflammatory disease is a common gynecological disease that plagues many women of childbearing age. It not only damages women's physical and mental health, but also brings a certain amount of economic pressure, which leads to a series of family and social problems. In the early and acute phases of PID, antibiotics are used for symptomatic and supportive treatment. The disease has the characteristics of recurrent attacks. The application of antibiotics has the disadvantages of causing flora imbalance and drug resistance. The mutation of bacteria and the increase of adverse drug reactions make the potential risks continue to increase, and the clinical results are not ideal[10]. PID is usually accompanied by a variety of bacterial infections,with complicated etiology. The diseased part is often hidden in the pelvic cavity. There are many types of pathogenic bacteria and it is difficult to collect.Data show that the positive rate of PID bacterial culture is only 44.6%. The bacterial material of PID patients is mainly the female posterior vagina or the pus taken during laparotomy for culture, and the pus is mainly formed by degeneration and necrosis of white blood cells and tissue fragments. The number of bacterial survival is very few, which results in a low positive rate of bacterial culture, resulting in errors and difficulties in the diagnosis of pelvic inflammatory disease[11]. Early onset symptoms and signs are atypical and vary in severity. There is a lack of unique laboratory diagnostic methods for diagnosis and treatment. Therefore, it is difficult to make a clear diagnosis. This makes the disease easy to delay treatment and causes chronic pelvic inflammatory disease and its sequelae. Through the analysis of the clinical and incidence characteristics of the disease, guided by the theoretical basis of TCM treatment of disease, adhering to the principle of "early targeting susceptible populations, early prevention, early diagnosis, and early treatment",in order to achieve the goal of greatest avoidance of the disease occurrence or controlling the progression of the disease.

Preventing from the Disease before It Occurs and Target the Vulnerable Groups

Prevention before the disease emphasizes prevention before it occurs, pays attention to the protection of disease inducements, improves the body's resistance, and pays attention to the stage when the disease has not occurred or is about to occur[12].

Prevention of etiology

PID mainly occurs in sexually active women during the reproductive period in 25-40 years old.Frequent sex life, poor sexual hygiene, inappropriate use of intrauterine contraceptive devices, the history of abdominal and pelvic surgeries of abortion, vaginal irrigation, tubal angiography,tubal drainage, ascending infections of the lower genital tract such as vaginitis and cervicitis, and the spread of inflammation of adjacent organs such as appendicitis and peritonitis are the causes of the disease[13]. Studies have shown that the number of abortions [OR=21.157, 95%CI(1.567-22.135)] and the frequency of sex [OR=14.684, 95%CI(1.234-17.842)] are the essential factors that cause pelvic inflammatory infection and sequelae[14]. LI Guoyun's[15]clinical observation and analysis showed that in women around 30 years old, who have sex more than 3 times a week, the probability of suffering from vaginitis will increase by 10%. Therefore,women should take protective measures when they have sex, pay attention to personal hygiene,increase awareness of contraception, reduce the chance of miscarriage, avoid sex addiction, and reduce the frequency of changing partners. Women suffering from vaginitis and cervicitis should seek medical treatment in time, and take the correct medication under the guidance of a doctor to avoid the ascending infection of inflammation. Those with intrauterine contraceptive devices should regularly review the ring position with B-ultrasound and follow the doctor's advice to remove them in time. For those with a history of abdominal and pelvic surgery,avoid starting sexual life prematurely after surgery.Inner Canon of Yellow Emperorpointed out that "the accumulation of pathogen means the deficiency of Qi". It can be seen that the prevention of infection factors of pelvic inflammatory disease is the top priority of this disease.

Recognition of constitution

Constitution is a relatively stable inherent characteristic integrated in the form, structure,physiological function, and psychological state formed on the basis of innate endowments and acquired during the life of the human body. The constitution identification of TCM embodies the idea of "preventive treatment" in TCM, and plays an important role that cannot be replaced by modern medicine in preventing from chronic noncommunicable diseases[16].Inner Canon of Yellow Emperorsays that "Healthy Qi inside the body, and pathogen cannot invade" means that the occurrence of disease is determined by two aspects: physical constitution strength and pathogenic factors.Different constitution determines the susceptibility,tolerance and tilt of the individual to the disease,which runs through the entire process of the occurrence, development and outcome of the disease. Therefore, the prevention and treatment of diseases should pay attention to the classification and discrimination of personal physique[17].Physicians of the past dynasties combined their own clinical practices to classify common clinical physical conditions and clinical manifestations from different perspectives. ZHANG Jing-yue divided the constitution into three categories: Yin (阴) viscus person, Yang (阳) viscus person, and Natural viscus person from the aspects of Yin and Yang of endowment, the strength of the organs, the taste of diet, and the avoidance of medication. InFu Ren Gui Tai Yun Lei(《妇人规 · 胎孕类》), ZHANG proposes that women's medication must be treated separately according to different constitutions and the partial Yin and partial Yang of the viscera. In the process of disease differentiation and treatment, TCM emphasizes the "appropriate treatment according to the individual", the core of which is "constitution differentiation and treatment". According to the patient's constitution, the medicine and dosage are determined. To a certain extent, treatment is more targeted. It is recommended to introduce TCM constitution identification and TCM intervention in the health management of PID patients, develop personalized TCM health management plans for different TCM constitution types, and provide individualized TCM health care guidance for women of childbearing age based on the results of TCM constitution identification. Individualized health education is given from five aspects: emotional adjustment and recuperation, diet and recuperation,exercise health, acupoint health care, and daily adjustment, and establish a systematic, largescale and standardized health management plan to achieve the purpose of active prevention and reduce the risk of PID, which can consolidate the therapeutic effect[18].

Prevention of Progress after Diseases with Active Intervention and Treatment

The focus of prevention of changes after disease is to grasp the timing of treatment, and to actively diagnose and treat the disease early to prevent its further development and complications.Early diagnosis and treatment are critical to the effectiveness of the treatment of the disease, the protection of fertility and the avoidance of sequelae.

TCM treatment

The experience of physicians in summarizing TCM theory and clinical experience has enabled to treat pelvic inflammatory diseases in TCM in various forms on the basis of syndrome differentiation and treatment, with clear advantages and development prospects. The treatment is closely related to the core pathogenesis of damp-heat and blood stasis,and the principles of clearing heat and detoxification,removing dampness and resolving blood stasis are used throughout, combined with products for promoting Qi and tonifying deficiency, in order to achieve the goal of eliminating pathogen and not hurting the syndrome. In clinical practice, Guizhi Fuling Pills (桂枝茯苓丸), Shaofu Zhuyu Decoction(少腹逐瘀汤), Wuwei Xiaodu Decoction (五味消毒饮), etc. are commonly used in clinical prescriptions.TCM emphasizes the "adjusting with three factors".Individuals have different constitutions. The clinical symptoms are often different, complex and changeable, and the syndromes are mixed.Therefore, the medication should be flexibly used. In addition to the oral treatment of TCM decoctions, the external application of TCM, the inclusion of TCM suppositories, and acupuncture have also been proved to be effective methods for the treatment of pelvic inflammatory diseases. Scholars such as GUO Shu-hong[19]assisted TCM fumigation on the basis of the application of antibiotics in PID treatment.During the follow-up of six months to one year, the improvement rate of the TCM fumigation group was much higher than that of the antibiotic group alone.QIAN Yue-fang found in the clinical observation of Kangfuyan suppository (康妇炎栓) applied to treat PID that the TCM suppository effectively increases the content of CD4+, reduces CD8+, reduces the ratio between the two, improves the body's immune function, and reduces the recurrence rate of PID[20]."Acupuncture for healthy people" is one of the main methods of TCM preventive treatment. It aims to stimulate the body before the disease occurs,so as to achieve the purpose of supporting the healthy Qi.Synopsis of Golden Chamberstates that "Disease in the meridian, not spreading the viscera, that is to be treated". The early stage of the disease will often show some pathological states of"syndromes but no symptoms". PID high-risk groups have symptoms such as abnormal damp heat and irregular menstruation. At that time, acupuncture for healthy people intervention can be used to prevent the progression of the disease at an early stage[21].In addition, there are 14 kinds of treatment methods such as TCM enema therapy, infrared treatment,moxibustion, TCM iontophoresis, and microwave[22].Therefore, in the treatment of PID, comprehensive treatment of TCM should be actively applied to give full play to the advantages of low adverse reaction rate and long-term effect of TCM, in order to achieve the purpose of preventing progress in existing diseases.

Life regulation

Plain Conversation Discussion on Six-Plus-Six System and the Manifestations of the Viscera(《素问 · 六节藏象论》) pointed out that "the heavens provide man with five kinds of Qi and the earth provides man with five kinds of flavors",indicating that the development of disease is closely related to acquired diet. In the course of disease treatment, it is particularly important to strengthen the patient's awareness of the disease, increase the patient's cooperation and attention, and help the patient to develop good eating habits. Pelvic inflammatory diseases are mainly caused by the invasion of damp toxins and heat into the uterus and Qi and blood congestion. Therefore, patients should avoid spicy food in their diet. Smoking and alcohol are prohibited. "Frequent exercise and appropriate diet" warns people that they should avoid being hungry and over-satisfied when eating,eat regularly, strengthen body exercise, and improve their own immunity. During the treatment of pelvic inflammatory disease, sexual life should be prohibited to prevent from re-invasion of inflammatory factors.

Prevention of Recurrence after Recovery and Improvement of Long-Term Outcomes

Prevention of recurrence after recovery means that after the patient has undergone symptomatic and supportive treatment intervention, and the clinical symptoms disappear and the body function is restored as before. Then you should not relax your vigilance, and pay attention to prevention to avoid the recurrence of the disease and bring secondary damage to the body and mind.

Regulating Qi and blood

Because pelvic inflammatory disease has the characteristics of recurring and lingering illness,and the use of heat-clearing and detoxifying drugs during the onset of treatment will consume more Yang Qi, which makes the patient prone to loose stools or sticky stools, fatigue, weakness after treatment, or the heat syndrome is not obvious and the miscellaneous symptoms are clustered[23]."Only when Yin is at peace and Yang is compact can essence-spirit be normal." LIN Yan-zhao[24]and others proposed that focusing on the protection and regulation of Yang Qi is the key to"preventive treatment" and focusing on Yang Qi.The intention is to show that the initial prognosis of the disease should be focused on protecting healthy Qi, which requires long-term conditioning and health care.

Correct healthy care

PENG Li[25]found in clinical follow-up that in the pelvic inflammatory care, the health education group gave 95.83% prognosis satisfaction compared with the conventional care group, while the control group was only 79.17%. ZHA Yingbing[26]used psychological stress intervention in the treatment of pelvic inflammatory disease. After the intervention, the HAMD score in the observation group was lower than the control group, and the SF-36 score was higher than the control group.ZHOU Xiao-mei[27]found in a clinical case study that in the process of treating CPID, assisting pelvic exercises, the serum levels of IL-2, IL-10,and TNF-a decreased significantly. The above studies have fully proved the theory of "prevention of recurrence after recovery", indicating that correct and comprehensive care is essential to prevent recurrence, improve long-term outcomes, and achieve the goal of "preventing disease". Correct health care should include doing a good job of publicity and education for women of childbearing age, popularizing women's understanding of the causes and characteristics of pelvic inflammatory disease, strengthening the education and publicity of patients on how to develop good hygiene habits,and teaching patients how to prevent infection during the three periods of menstruation, pregnancy,and puerperium. We should attach importance to the psychological intervention of patients, give patients positive encouragement and confidence, and create a relaxing treatment atmosphere, so as to relieve the tension and anxiety of patients, thereby improving their enthusiasm and cooperation in treatment.We should also cultivate their good living habits and guide them to carry out reasonable diet and exercise. Based on the patient's specific condition and individualized characteristics, implementing correct and comprehensive health care is essential to prevent from recurrence and improve long-term outcomes, so as to achieve the goal of "preventive treatment".

CONCLUSION

In modern society, more and more attention has been paid to the idea of "preventive treatment".The essence of this theory has many similarities with the "three-level prevention" theory of modern medicine, which fully demonstrates the long history of TCM theory. Western medicine treats pelvic inflammatory diseases with empirical broadspectrum antibiotics. Due to the complex flora of the disease and the lack of gold standards for diagnosis and treatment, it is very easy to cause sequelae.Drug resistance is a shortcoming that cannot be ignored in antibiotic therapy, so the prognostic effect on this disease is not ideal. Many malpractices will inevitably cause certain mental and economic pressure on patients and their families. Therefore,it is of great significance to apply the "preventive treatment" thought of TCM to the prevention and treatment of pelvic inflammatory diseases. We should adhere to the principles of preventive work,early active treatment of the disease, and longterm prognosis, in order to eliminate or minimize the occurrence of pelvic inflammatory disease. It is of great significance for reducing the waste of medical resources, and contributing to human health and the development of world medicine.