Clinical Approach

PID, or salpingitis, usually involves Chlamydia, gonorrhea, and other vaginal organisms, such as anaerobic bacteria. The mechanism usually is ascending infection. A common presentation is a young, nulliparous female complaining of lower abdominal or pelvic pain and vaginal discharge. The patient may also have fever and nausea and vomiting if the upper abdomen is involved. The cervix is inflamed; therefore, the patient often complains of dyspareunia.

The diagnosis of acute salpingitis is made clinically by abdominal tenderness, cervical motion tenderness, and adnexal tenderness (Table 21-1). Confirmatory tests may include a positive gonorrhea or Chlamydia culture or an ultrasound suggesting a TOA. Other diseases that must be considered are acute appendicitis, especially if the patient has right-sided abdominal pain and ovarian torsion, which usually presents as colicky pain and is associated with an ovarian cyst on ultrasound. Renal disorders, such as pyelonephritis or nephrolithiasis, also must be considered. Right upper quadrant pain may be seen with salpingitis when perihepatic adhesions are present, the so-called Fitz-Hugh-Curtis syndrome. When the diagnosis is in doubt, the best method for confirmation is laparoscopy. The surgeon would look for purulent discharge exuding from the fimbria of the tubes.

Treatment of acute salpingitis depends on whether the patient is a candidate for inpatient versus outpatient therapy. Criteria for outpatient management include low-grade fever, tolerance of oral medication, and absence of peritoneal signs. The woman must also be compliant. One regimen consists of intramuscular ceftriaxone, as a single injection, and oral doxycycline twice per day for 10 to 14 days. It is paramount to reevaluate the patient in 48 hr for improvement. If the patient fails outpatient therapy, is pregnant, is at the extremes of age, or cannot tolerate oral medication, she would be a candidate for inpatient therapy. One such therapeutic combination is intravenous cefotetan and doxycycline. Again, if the patient does not improve within 48 to 72 hr, the clinician should consider laparoscopy to assess the disease.

One important sequela of salpingitis is TOA. This disorder generally has anaerobic predominance and necessitates the corresponding antibiotic coverage (clindamycin or metronidazole). The physical examination may suggest an

Table 21-1

SIGNS AND SYMPTOMS OF ACUTE SALPINGITIS

Abdominal tenderness Cervical motion tenderness Adnexal tenderness Vaginal discharge Fever

Pelvic mass on physical examination or ultrasound adnexal mass, or the ultrasound may reveal a complex ovarian mass. A devastating complication of TOA is rupture, which is a surgical emergency and leads to mortality if unattended.

Long-term complications of salpingitis include chronic pelvic pain, involuntary infertility, and ectopic pregnancy. The risk of infertility due to tubal damage is directly related to the number of PID episodes. The intrauterine contraceptive device (IUD) places the patient at greater risk for PID. whereas oral contraceptive agents (progestin thickens the cervical mucus) decrease the risk of PID.

Comprehension Questions

[21.11 An 18-year-old woman undergoes laparoscopy for an acute abdomen. Erythematous fallopian tubes are noted. Cultures of the purulent drainage most likely would reveal which of the following?

A. Multiple organisms

B. Neisseria gonorrhoeae

B. Chlamydia trachomatis

C. Peptostreptococcus species

D. Treponema pallidum

[21.2| Which of the following is the most accurate method for diagnosing acute salpingitis?

A. Clinical criteria

B. Sonography

C. Computed tomographic scan

D. Laparoscopy

[21.31 Which of the following is a risk factor for developing PID?

A. IUD use

B. Candida vaginitis

C. Oral contraceptive agents

D. Depot medroxyprogesterone acetate

[21.4| A 33-year-old woman with an intrauterine contraceptive device develops symptoms of acute salpingitis. On laparoscopy, sulfur granules appear at the fimbria of the tubes. Which of the following is the most likely organism?

A. Chlamydia trachomatis

B. Nocardia species

C. Neisseria gonorrhoeae

D. Treponema pallidum

E. Actinomyces species

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