salpingitis and related diseases

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 10:1, 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 (<25)• 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 >101°F– WBC >10,000 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– β-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

patient’s 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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Complicationswww.freelivedoctor.com

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 can’t 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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