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Salpingitis

Salpingitides

Salpingitis is an infection of the fallopian tubes and it is one of the constitutive parts of pelvic inflammatory disease, a severe condition that may lead to infertility. Bacterial vaginosis and upward ascension of the bacterial pathogen is the main disease mechanism. Abdominal pain, nausea, vomiting, fever and vaginal bleeding are reported and the diagnosis is made through microbial investigations and imaging studies. Antibiotics are the mainstay of treatment.


Presentation

Patients may present in various stages, including asymptomatic, subclinical and acute. Symptoms, when present, often appear abruptly and include metrorrhagia, abdominal pain, presence of either mucopus or leukorrhea, postcoital bleeding, but also nausea, vomiting and high fever [5]. Abdominal pain is usually situated in the lower quadrants and may be either unilateral or bilateral, while rebound tenderness and guarding may be seen in severe stages [2]. Dysparenuria is also reported in various percentages.

Prostitute
  • A cohort of 243 prostitutes residing in Nairobi were followed between March 1985 and April 1988. Gonococcal cultures were performed at each visit, and acute salpingitis was diagnosed clinically.[ncbi.nlm.nih.gov]
Abdominal Pain
  • This case highlights the diagnostic dilemmas facing those caring for an adolescent girl with abdominal pain and presents an extremely rare etiology for abdominal pain in a nonsexually active adolescent.[ncbi.nlm.nih.gov]
  • A 20-year-old woman presented to the emergency department with a history of lower abdominal pain and recent loss of consciousness. She was admitted with a primary diagnosis of abdominal pain; ectopic pregnancy was ruled out.[ncbi.nlm.nih.gov]
  • We here present a case initially involving a complaint of lower abdominal pain, which was diagnosed after a long diagnostic work-up as tuberculous salpingitis and which is rare in women in developed countries.[ncbi.nlm.nih.gov]
  • A 25-year-old patient with MRKH syndrome who presented with lower abdominal pain. Clinical examination, transabdominal ultrasonography, laparoscopy, laparotomy.[ncbi.nlm.nih.gov]
  • Abdominal pain, nausea, vomiting, fever and vaginal bleeding are reported and the diagnosis is made through microbial investigations and imaging studies. Antibiotics are the mainstay of treatment.[symptoma.com]
Chronic Abdominal Pain
  • Female genital tuberculosis has only rarely been associated with Fitz-Hugh-Curtis syndrome and all cases presented with chronic abdominal pain and/or infertility. Ascites and peritoneal involvement was not present in any case.[ncbi.nlm.nih.gov]
Dyspareunia
  • Symptoms of chronic salpingitis may include: Recurring severe period pain P ainful intercourse (dyspareunia) Vaginal discharge Poor general health Infertility Initially, treatment is with antibiotics.[netdoctor.co.uk]
  • Adhesions Dyspareunia www.freelivedoctor.com 14. Complications Ectopic Pregnancy Also 2 to tubal scarring 7-10 fold increased risk after a single episode www.freelivedoctor.com 15. Complications Ectopic Pregnancy www.freelivedoctor.com 16.[slideshare.net]
  • Other possible symptoms are: Increase body temperature Perspiration Chills Occasional vaginal discharge In case of chronic salpingitis, following are the symptoms Severe pain during menstrual cycle Dyspareunia (pain during sexual intercourse) Malice Foul[medicalfoxx.com]
  • Prognosis In spite of treatment, one-fourth of women with acute disease develop long-term sequelae, including repeated episodes of infection, chronic pelvic pain, dyspareunia, ectopic pregnancy, or infertility.[health.am]
Dysmenorrhea
  • Pain during ovulation (Dysmenorrhea). Unpleasant, uncomfortable, and even painful sexual relations. Fever. Nausea and vomiting. Irregular menstrual bleeding Pain when urinating and to feel urge to urinate more frequently. Vaginitis.[invitra.com]
  • Other common symptoms include: Frequent urination Headache Malaise (a vague feeling of sickness) Nausea with possible vomiting Possible fever Abnormal vaginal discharge Spotting between periods Dysmenorrhea (painful periods) Pain during ovulation Uncomfortable[obgynecologistnyc.com]
  • Very painful menstrual periods (also called dysmenorrhea) can sometimes be caused by salpingitis (as well as by endometriosis, pelvic inflammatory disease, fibroid tumors, and other conditions). See your gynecologist for a complete exam.[wikihow.com]
Postcoital Bleeding
  • Symptoms, when present, often appear abruptly and include metrorrhagia, abdominal pain, presence of either mucopus or leukorrhea, postcoital bleeding, but also nausea, vomiting and high fever.[symptoma.com]

Workup

The majority of signs and symptoms reported by patients who are suffering from salpingitis are nonspecific, which is why a full physical examination and a thoroughly obtained patient history is vital in making an initial diagnosis. Abdominal tenderness and reports of intermenstrual bleeding indicate a gynecological cause and various studies can be performed to support the hypothesis. Laboratory studies may reveal leukocytosis and elevation of inflammatory markers such as CRP and ESR [10], but their appearance seems to significantly vary depending on the stage of the disease [5]. Microbial identification, either through blood cultures or PCR is necessary in order to determine optimal empiric therapy [11], while imaging studies such as MRI and vaginal ultrasonography can be highly useful in determining the extent of injury and its exact location [5] [12]. In some cases, however, microbial investigations may yield negative results in which case biopsy of the affected tissue is advocated, because of its superiority to bacterial detection via conventional methods [5]. If the diagnosis remains unclear after all these findings, laparoscopic investigation is necessary to gain a direct view into the site of injury [13].

Lymphocytic Infiltrate
  • The lymphocytic infiltrates presented mainly T cells with different proportions of CD4 and CD8 lymphocytes in each case. The tubal stroma was positive for CD10 in both cases.[onlinelibrary.wiley.com]

Treatment

Because of numerous complications this condition may cause, including infertility, early administration of antimicrobial therapy is absolutely vital in reducing the risk for such events. According to treatment guidelines, milder forms of infection should be managed in the outpatient setting using drugs such as ceftriaxone, 250 mg IV or IM as a single dose, together with doxycycline 100 mg PO q12h for 14 days, while metronidazole 500mg PO q12h for 14 days may or may not be added into the regimen, depending on the pathogen [6]. A similar regimen with cefoxitin 2 gm IM with probenecid 1 gm PO combined as a single dose instead of ceftriaxone exists and is shown to be equally effective. For patients with severe forms of salpingitis that progressed to PID, either cefotetan 2 gm IV q12h or cefoxiting 2 gm IV q6h combined with doxycycline 100 mg IV or PO q12h is recommended as first-line therapy [6], while gentamicin and clindamycin may be used as well. Intravenous administration of antibiotics should be conducted until the overall condition of the patient. When the diagnosis is confirmed and treated, the sexual partner of the patient should also be tested and treated accordingly.

Prognosis

Complications of salpingitis and PID include chronic pelvic pain as a result of tubal scarring, increased risk of ectopic pregnancy and infertility [3]. Tubo-ovarian abscess is a rare, but severe complication of salpingitis [10], and may cause significant damage to the fallopian tubes. Because deleterious complications may arise, the importance of an early diagnosis is detrimental. In the United Kingdom, it was estimated that more than 50% of patients with diagnosed PID did not receive adequate therapy, which further emphasizes the need for increased clinical suspicion in the presence of symptoms that are suggestive of it [1].

Etiology

Salpingitis and PID result from an ascending infection of the lower genital tract, mainly from bacterial vaginosis. A broad range of pathogens has been described in literature, but the two most common are Chlamydia trachomatis, which is shown to be responsible for up to 60% of cases, and Neisseria Gonorrhoeae [6]. Enterobacteriaceae such as E. coli, Bacteroides sp, Gardnerella vaginalis, Mycoplasma genitalium, Urealpasma urealyticum and several respiratory pathogens such as Streptococcus pyogenes and Haemophilus influenzae are other notable causes [1] [7]. It is not uncommon for this infection to be polymicrobial.

Epidemiology

It is estimated that up to 1 million women experience symptomatic PID in the United States every year [8], which illustrates the importance of this condition in general practice. Several risk factors for salpingitis and PID have been established and one of the most important is young age [9]. Incidence rates of Chlamydia and gonorrhea infection are highest in young adolescents and the risk of acquiring salpingitis is 1 in 8 for 15-year-old sexually active girls, compared to 1 in 80 for 24-year-old women [1]. Additionally, intercourse habits such as increased frequency and change of partners, bacteriospermia, menstrual cycle timing, as well as various surgical and contraceptive methods such as intrauterine device (IUD) have shown to be factors that promote development of salpingitis from lower genital tract infection [1] [2]. On the other hand, the use of oral contraceptive therapy reduces the risk for PID [1].

Sex distribution
Age distribution

Pathophysiology

The complete pathogenesis model of salpingitis is not yet formed. Presumably, initial infection occurs in the lower genital tract, mainly in the form of bacterial vaginosis and subsequent spread to the endocervix, endometrium and the fallopian tubes [8]. Various local and immune-mediated factors have shown to to be important. Firstly, a thick layer of mucus around the cervical canal is continuously produced, in the attempt to cease bacterial ascension, but in different periods of the menstrual cycle, the thickness of this layer significantly varies, thus creating favorable conditions for bacterial spread [3]. Toll-like receptors (TLRs), human leukocytic antigen (HLA) alleles, and T-cell mediated inflammatory response are involved in salpingitis development when it comes to host factors [3]. As the bacteria extends into the upper genital tract, significant tissue damage occurs and leads to the appearance of symptoms.

Prevention

Incidence rates of salpingitis and infertility may be significantly reduced by avoiding risk factors that promote their development. Evading unprotected sex or intercourse with those in whom suspected or already known presence of STDs is a must, together with adequate education of young adolescents of the risk they may face is strongly recommended. Screening of populations at risk have shown to be of significant benefit and large-scale screening strategies may surely reduce the presence of both asymptomatic and symptomatic forms of salpingitis.

Summary

The infection of the fallopian tubes is medically known as salpingitis and it is often used concomitantly with the term pelvic inflammatory disease (PID), a term that includes infection of the upper female genital tract, together with endometritis (infection of the uterus), ovaries (oophoritis) and peritonitis in severe cases [1]. In virtually all cases, bacterial spread from the lower genital tract is the most important mechanism of disease, which is most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae. Various other pathogens have been described as well, including Mycoplasma genitalium, Ureaplasma urealyticum, Escherichia coli, streptococci and several other [1]. Chlamydia and gonorrhea are sexually-transmitted diseases (STDs), leading to the fact that the most prominent risk factors for salpingitis are exposure to various partners and presence of either bacterial vaginosis or other STDs. Young age, lower socioeconomic status and previous PID are also important [2]. The pathogenesis model includes both host immune and bacterial virulence factors, whereas the role of the cervical mucus barrier, which changes its thickness during various stages of the menstrual cycle, is one of the most important barriers against bacterial colonization [3]. Because numerous complications may arise from salpingitis, infertility being one of the most feared, the diagnosis should be made as soon as possible. Although the clinical presentation of patients may be nonspecific, complaints such as abnormal vaginal or cervical discharge, fever, irregular bleeding, dysparenuria and lower abdominal pain should include this condition in the differential diagnosis [4]. Nausea, vomiting, increased urinary frequency and low back pain are also reported [5]. Symptoms may appear in acute fashion, but a subclinical form that presents with either mild or no symptoms is of particular concern and is often the cause of unexplained infertility [2]. To make the diagnosis, a high dose of clinical suspicion is necessary, while confirmation can be obtained through laboratory and microbiological investigation. Leukocyte count, inflammation markers such as C-reactive protein (CRP), fibrinogen and sedimentation rate (ESR) should be obtained, together with cervical and vaginal samples for bacterial identification. Cultivation and polymerase chain reaction (PCR), when possible, are the two methods of choice. The ability to identify the causative agent significantly improves treatment efficacy, primarily because of growing antimicrobial resistance. Imaging studies such as transvaginal ultrasonography and magnetic resonance imaging (MRI) may be very useful in determining the severity of inflammation and damage to the pelvic structures [5]. Finally, laparoscopic evaluation and biopsy can be performed for confirmation. Ceftriaxone, doxycycline, metronidazole, clindamycin, gentamycin and cefoxitin are all recommended in treatment of salpingitis and PID [2] [6].

Patient Information

Salpingitis is a medical term that is used to describe infection of the fallopian tubes, the anatomical structures that connect the ovaries and the uterus. Together with endometritis (infection and inflammation of the uterus) and oophoritis (infection of the ovaries), it is often mentioned as one of the forms of pelvic inflammatory disease (PID), one of the most severe forms of infection in the female genital tract. Numerous bacteria have been identified as causative agents, but Chlamydia trachomatis and Neisseria gonorrhoeae are shown to be the two most common. In virtually all cases, salpingitis develops from an infection of the lower genital tract (such as vaginosis) and its spread into higher structures through the cervix and the inner layers of the uterus (endometrium). Normally, a thick layer of mucus that protects the upper parts of the genital tract is secreted in the cervical canal, but this layer shows variable thickness depending on the time of menstrual cycle, while certain receptors and cells of the immune system are thought to contribute to inflammation and damage mediated by this process. In addition to menstrual timing, young age is shown to be the most important risk factor, as this form of infection is most commonly encountered among young female adolescents, together with intercourse habits that include frequent change of partners and contact with individuals who already have some sexually transmitted disease (STD). The disease may be asymptomatic, subclinical or acute and most common include abdominal pain, nausea, vomiting, lower back pain, increased urinating frequency, bleeding between cycles and postcoital bleeding. To make an initial diagnosis, a thorough physical examination and patient history that includes details regarding recent intercourse habits are vital. Laboratory studies, such as complete blood count may reveal increased levels of white blood cells, whereas markers of inflammation such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may be elevated. Identification of bacteria is essential in determining optimal treatment strategy and is performed by obtaining samples from the genitalia with subsequent cultivation or identification of their DNA through a technique called polymerase chain reaction (PCR). Since bacterial identification may not yield positive results, biopsy of the affected tissue or laparoscopic investigation may be necessary to confirm the diagnosis. Antibiotics are the mainstay of therapy and they may be given orally to patients who are treated in the outpatient care for milder forms, or intravenously in hospitalized women with severe forms of the disease. Ceftriaxone, cefoxitin, doxycycline, metronidazole and cefotetan are used in different regimens and provide good outcomes if administered early. The emphasis on prompt therapy stems from the fact that salpingitis may cause numerous complications, such as chronic pelvic pain, development of abscesses, but most importantly, infertility. For these reasons, various preventive strategies, such as wide-scale screening of young adolescents, avoiding risky intercourse and education of people regarding these potentially irreversible events is important in reducing the burden of this condition.

References

Article

  1. Trent M. Pelvic Inflammatory Disease. Pediatr Rev. 2013;34(4):163-172.
  2. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  3. Mitchell C, Prabhu M. Pelvic Inflammatory Disease: Current concepts in pathogenesis, diagnosis and treatment. Infect Dis Clin North Am. 2013;27(4): 10.1016/j.idc.2013.08.004.
  4. Terzić M, Kocijancić D. Pelvic inflammatory disease: contemporary diagnostic and therapeutic approach [Article in Serbian]. Srp Arh Celok Lek. 2010;138(9-10):658-663.
  5. Jaiyeoba O, Soper DE. A Practical Approach to the Diagnosis of Pelvic Inflammatory Disease. Infect Dis Obstet Gynecol. 2011;2011:753037.
  6. Gilbert DN, Chambers HF, Eliopoulos GN, Saag MS. The Sanford Guide to Antimicrobial Therapy 2015. 45th ed. Antimicrobial Therapy, Inc, Sperryville, VA; 2015.
  7. Cohen CR, Mugo NR, Astete SG, Odondo R, Manhart LE, Kiehlbauch JA, et al. Detection of Mycoplasma genitalium in women with laparoscopically diagnosed acute salpingitis. Sex Transm Infect. 2005;81(6):463-466.
  8. Mandell GL, Bennett JE, Dolin R. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.
  9. Gray-Swain MR, Peipert JF. Pelvic inflammatory disease in adolescents. Curr Opin Obstet Gynecol. 2006;18(5):503-510.
  10. Levgur M1, Duvivier R. Pelvic inflammatory disease after tubal sterilization: a review. Obstet Gynecol Surv. 2000;55(1):41-50.
  11. Hebb JK, Cohen CR, Astete SG, Bukusi EA, Totten PA. Detection of novel organisms associated with salpingitis, by use of 16S rDNA polymerase chain reaction. J Infect Dis. 2004;190(12):2109-2120.
  12. Romosan G, Bjartling C, Skoog L, Valentin L. Ultrasound for diagnosing acute salpingitis: a prospective observational diagnostic study. Hum Reprod. 2013;28(6):1569-1579.
  13. Soper DE. Diagnosis and laparoscopic grading of acute salpingitis. Am J Obstet Gynecol. 1991;164(5 Pt 2):1370-1306.

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Last updated: 2017-08-09 17:44