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Salpingitis and Related Diseases

• Ryan Agema MS III

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Salpingitis and Related Diseases

• Etiology
• Risk Factors
• Diagnosis and DDx
• Management
• Treatment
• Complications
• References

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Etiology

• Salpingitis is really part of the larger family
  of pelvic inflammatory disease (PID).
• PID is a polymicrobial infection of the upper
  female genital tract (uterus, fallopian tubes,
  ovaries) caused by an ascending infection of the
  vagina or cervix.
• N. gonorrhea and C. trachomatis cause the
  majority but endogenous bacteria can also be
  present.

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Etiology

• N. gonorrhea
• Causes roughly 50 of salpingitis.
• 15 of GC cervicitis progresses to PID.
• C. trachomatis
• More common than GC by up to 101, but only
  accounts for 20-35 of PID.
• Classically produces a more mild form of PID with
  insidious onset.
• Other bugs
• Strep., Staph., E. coli, Bacteroides,
  Actinomyces, Peptococcus, Clostridium,
  Gardnerella, Haemophilus, CMV, etc.

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Risk Factors

• Young age (lt25)
• Prior history of STD
• IUD or other non-barrier contraception
• Multiple partners
• Promiscuous partners
• Iatrogenic factors

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Clinical Criteria for Diagnosis of PID

• All 3 of the following
• Abdominal tenderness with or without rebound.
• Adnexal tenderness
• Cervical motion tenderness
• Plus 1 of the following
• Temp. of gt101F
• WBC gt10,000 or elevated CRP or ESR
• Gram stain with gram neg. intracellular
  diplococci
• Inflammatory mass
• Purulent material from peritoneal cavity

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Differential Diagnosis

• Acute appendicitis
• Ectopic pregnancy
• Ruptured ovarian cyst
• Tubo-ovarian abscess
• Endometriosis
• Adnexal torsion
• Acute UTI
• Diverticulitis
• Crohns/Ulcerative Colitis

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Management

• Lab studies
• CBC to look for leukocytosis
• ß-HCH to r/o ectopic pregnancy
• Gonorrhea and Chlamydia cultures
• ESR/CRP
• UA to r/o cystitis or pyelonephritis
• Fecal occult blood test
• Wet mount
• R/o other concurrent STDs with RPR/VDRL and HIV
  test

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Management

• Imaging Studies
• Pelvic ultrasound to r/o tubo-ovarian abscess,
  ectopic pregnancy and ovarian torsion.
• Procedures
• Laparoscopy if still unsure of diagnosis
• Culdocentesis is now rarely required

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Treatment

• Outpatient therapy
• Regimen A
• Ofloxacin/Levofloxacin Metronidazole PO x 14
  days
• Regimen B
• Ceftriaxone or Cefoxitin (probenecid PO) IM x 1
  dose Doxycycline /- Metronidazole PO x 14
  days
• Remember to also provide treatment to the
  patients partner if the infection is due to an
  STD.

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Treatment

• Inpatient therapy
• Regimen A
• Cefotetan or Cefoxitin IV until clinical
  improvement Doxycyline x 14 days
• Regimen B
• Clindamycin Gentamycin IV until clinical
  improvement Doxycycline or Clindamycin PO x 14
  days
• Medical therapy alone results in an 85 cure rate
  with the rest requiring surgical intervention.

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Indications for Hospitalization

• Pregnancy
• Immunodeficient
• Nausea/Vomiting and high fever
• Unpredictable compliance
• Poor response to outpatient therapy
• Tubo-ovarian abscess

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Complications

• Infertility 2 tubal scarring
• 10 risk after a single episode of PID
• 30 risk after 2 episodes
• 50 risk after 3 or more episodes

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Complications

• Chronic pelvic pain
• Found in up to 18 of women after resolution of
  PID.
• Adhesions
• Dyspareunia

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Complications

• Ectopic Pregnancy
• Also 2 to tubal scarring
• 7-10 fold increased risk after a single episode

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Complications

• Ectopic Pregnancy

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Complications

• Tubo-ovarian abscess
• Serious sequelae of PID causing 350,000
  hospitalizations and 150,000 surgeries/yr.
• Occurs in 15-30 of women requiring
  hospitalization for PID treament.
• Ruptured TOA has a mortality rate as high as 9.

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Complications
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Complications

• Tubo-ovarian abscess
• Can be diagnosed by ultrasound with 94
  sensitivity.
• Can attempt conservative management with
  antibiotics but often require drainage or
  excision via laparoscopy.
• 86-93 infertility rate following TOA.

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Complications

• Fitz-Hugh-Curtis Syndrome
• Extrapelvic manifestation of PID associated with
  RUQ pain due to inflammation of the liver capsule
  and diaphragm.
• As with PID, it is mainly caused by N. gonorrhea
  and C. trachomatis.
• Probably spreads via direct seeding into the
  peritoneal cavity, although hematogenous and
  lymphatic spread cant be ruled out.
• Occurs in 15-30 of women with PID worldwide
  though this is probably less in developed
  countries.

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Complications

• Fitz-Hugh-Curtis Syndrome
• Vague symptoms often make it a diagnosis of
  exclusion.
• Amylase/Lipase to r/o gallbladder disease
• LFTs to r/o hepatitis
• UA to r/o pyelonephritis or kidney stones
• Hemoccult to r/o perforated ulcer
• Ultrasound and CT to r/o other diseases
• Gold standard for diagnosis is laparoscopy and
  visualization of adhesions or inflammation.

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Complications
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Complications
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Complications

• Fitz-Hugh-Curtis Syndrome
• As with PID, antibiotic therapy is the mainstay
  of therapy.
• Questionable benefit of lysis of adhesions with
  laparoscopy.

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References

• www.acog.org
• Current Diagnosis and Treatment in Infectious
  Disease (2001)
• Current Obstetric Gynecologic Diagnosis
  Treatment (2003)
• ACP's PIER Physicians' Information and Education
  Resource (2004)
• CDC. Guidelines for Treatment of Sexually
  Transmitted Diseases 2002, MMWR 2002 51 1041