Pelvic infection affects the Fallopian tubes (salpingitis) and may involve ovaries and parametra. 90% are sexually acquired, mostly chlamydia: 60% of these are asymptomatic (‚=1:1) but infertility or ectopic pregnancy may be the result, which is why screening has been proposedeg by a urine ligase chain reaction DNA: see BOX. Other causes, eg the gonococcus are rarer (14%if found, retest after treatment). Organisms cultured from infected tubes are commonly different from those cultured from ectocervix, and are usually multiple. 10% follow childbirth or instrumentation (insertion of IUCD, ToP) and may be streptococcal. Infection can spread from the intestinal tract during appendicitis (Gram ve and anaerobic organisms) or be blood-borne (tuberculosis).
Salpingitis
Patients with acute salpingitis may be most unwell, with pain, fever, spasm of lower abdominal muscles (she may be most comfortable lying on her back with legs flexed) and cervicitis with profuse, purulent, or bloody vaginal discharge. Heavy menstrual loss suggests endometritis. Nausea and vomiting suggest peritonitis. Look for suprapubic tenderness or peritonism, cervical excitation, and tenderness in the fornices. It is usually bilateral, but may be worse on one side. Subacute infection can be easily missed, and laparoscopy may be needed to make either diagnosis.
Management
รข™£Prompt treatment and contact-tracing minimizes complications. Take endocervical and urethral swabs if practicable. Remember to check for chlamydia. Admit for blood cultures and IV antibiotics if very unwell (eg ceftriaxone 2g/24h slow IV with doxycycline 100mg/12h PO) initially, then doxycycline 100mg/12h PO and metronidazole 400mg/12h PO until 14 days treated. Seek advice from microbiologist if gonorrhoea isolated. If less unwell give ofloxacin 400mg/12h PO and metronidazole 400mg/12h PO for 14 days. If infection is severe remove intrauterine contraceptive device (not needed if mild).1 Trace contacts (from within last 6 months and ensure they seek treatmentseek help of the genito-urinary clinic). Advise avoidance of intercourse until patient and partner treatments complete.
Complications
If response to antibiotics is slow, consider laparoscopy. She may have an abscess (draining via the posterior fornix prevents perforation, peritonitis, and septicaemiabut laparotomy may be needed). Inadequate or delayed treatment leads to chronic infection and to long-term tubal blockage (8% are infertile after 1 episode, 19.5% after 2, 40% after 3). Advise that barrier contraception protects against infection. Ectopic pregnancy rate is increased 10-fold in those who do conceive.
Chronic salpingitis
Unresolved, unrecognized, or inadequately treated infection may become chronic. Inflammation leads to fibrosis, so adhesions develop between pelvic organs. The tubes may be distended with pus (pyosalpinx) or fluid (hydrosalpinx).
Pelvic pain, menorrhagia, secondary dysmenorrhoea, discharge, and deep dyspareunia are some of the symptoms. She may be depressed. Look for tubal masses, tenderness, and fixed retroverted uterus. Laparoscopy differentiates infection from endometriosis.
Treatment is unsatisfactory. Consider long-term broad-spectrum antibiotics (eg tetracycline 250mg/6h PO 1h before food for 3 months), short-wave diathermy and analgesia for pain, and counselling. The only cures are the menopause or surgical removal of infected tissue.
Advertisements
