Salpingitis, Acute Case File

Salpingitis, Acute Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 36

A 23-year-old G0P0 woman complains of lower abdominal tenderness and subjective fever. She states that her last menstrual period started 5 days previously and was heavier than usual. She also complains of dyspareunia of recent onset. She denies vaginal discharge or prior sexually transmitted diseases. Her appetite has been somewhat diminished. She has urinary urgency or frequency. On examination, her temperature is 100.8°F (38.2°C), blood pressure (BP) is 90/70 mm Hg, and heart rate (HR) is 90 beats per minute (bpm). Her heart and lung examinations are normal. The abdomen has slight lower abdominal tenderness. There is no rebound tenderness and no masses. No costovertebral angle tenderness is noted. On pelvic examination, the external genitalia are normal. The cervix is somewhat hyperemic, and the uterus as well as adnexa are bilaterally exquisitely tender. The pregnancy test is negative.

» What is the most likely diagnosis?

» What are long-term complications that can occur with this condition?

ANSWER TO CASE 36:

Salpingitis, Acute                                           

Summary: A 23-year-old G0P0 nonpregnant woman complains of lower abdominal tenderness, subjective fever, heavier menses than usual, and dyspareunia. Her temperature is 100.8°F (38.2°C). The cervix is hyperemic, and the uterus and adnexa are bilaterally exquisitely tender.

• Most likely diagnosis: Pelvic inflammatory disease (PID).
• Long-term complications that can occur with this condition: Infertility or ectopic pregnancy.

ANALYSIS

Objectives

1. Know the clinical presentation, complications, and treatment of gonococcal cervicitis.
2. Understand the clinical diagnostic criteria of salpingitis.
3. Understand that the long-term complications of salpingitis are infertility, ectopic pregnancy, and chronic pelvic pain.
4. Know that one of the outpatient treatment regimens of salpingitis is intramuscular ceftriaxone and oral doxycycline.

Considerations

This nulliparous woman has lower abdominal pain, adnexal tenderness, and cervical motion tenderness. The presence of cervical motion tenderness is indirect, based on the dyspareunia and hyperemic cervix. The patient also has fever. These are the clinical criteria for pelvic inflammatory disease or salpingitis (infection of the fallopian tubes). Salpingitis is most commonly caused by pathogenic bacteria of the endocervix that ascend to the tubes. In the tubes, the rule is multiple organisms such as Gram-negative rods, gonorrhea or Chlamydia, and anaerobes. The fallopian tubes can become damaged by the infection, leading to tubal occlusion and infertility or ectopic pregnancy. The pain occurs around the time of menses, and ascending infection often occurs at the time of menses, during endometrial breakdown. This patient has lower abdominal tenderness, which indicates peritoneal irritation of the pelvis; generalized peritonitis such as involving the entire peritoneal cavity may indicate a more extensive process, such as purulent material throughout the abdominal cavity, or another process. The differential diagnosis of salpingitis includes pyelonephritis, appendicitis, cholecystitis, diverticulitis, pancreatitis, ovarian torsion, and gastroenteritis. A tubo-ovarian abscess is difficult to diagnose on physical examination and can present without fever; thus, a pelvic ultrasound is typically performed on patients with suspected PID to assess for TOA.

APPROACH TO:

Cervicitis and Salpingitis                                              

DEFINITIONS

FITZ-HUGH–CURTIS: Perihepatitis caused by purulent tubal discharge which ascends to the right upper quadrant area. The patient will complain of right upper quadrant pain.

MUCOPURULENT CERVICITIS: Yellow exudative discharge arising from the endocervix with 10 or more polymorphonucleocytes per high-power field on microscopy.

LOWER GENITAL TRACT: The vulva, vagina, and cervix.

UPPER GENITAL TRACT: The uterine corpus, fallopian tubes, and ovaries.

PELVIC INFLAMMATORY DISEASE: Synonymous with salpingitis, or infection of the fallopian tubes.

CERVICAL MOTION TENDERNESS: Extreme tenderness when the uterine cervix is manipulated digitally, which suggests salpingitis.

ASCENDING INFECTION: Mechanism of upper genital tract infection whereby the offending microorganisms arise from the lower genital tract.

TUBO-OVARIAN ABSCESS (TOA): Collection of purulent material around the distal tube and ovary, which unlike the typical abscess, is often treatable by antibiotic therapy rather than requiring surgical drainage.

CLINICAL APPROACH

Lower Genital Tract Infections

An infection of the cervix is analogous to an infection of the urethra in the male. Thus, sexually transmitted pathogens, such as Chlamydia trachomatis, N. gonorrhoeae, or herpes simplex virus, may infect the cervix. Gonococcal and chlamydial organisms have a propensity for the columnar cells of the endocervix. Often, erythema of the endocervix is noted, leading to friability; these patients may complain of postcoital spotting. Mucopurulent cervical discharge is a common complaint, again analogous to the exudative urethral discharge of the male. The most common organism implicated in mucopurulent cervical discharge is C. trachomatis, although gonorrhea may also be a pathogen.

When a patient presents with purulent vaginal discharge, a speculum examination should be performed to discern the source of the discharge: to determine whether the source is vaginal versus cervical. Cervicitis will typically be mucopurulent discharge in the endocervix, and the cervix will be friable and bleed easily when touched. A primary vaginitis reveals frothy or green vaginal discharge, or erythematous vaginal mucosa. Trichomonas or H SV-2 can also cause a cervicitis. The patient should have a wet mount examination for Trichomonads, and assays for gonorrhea or chlamydial organisms. Treatment is based on the clinical impression, since microbiological confirmation may take several days.

When a patient presents with this type of cervical discharge, Gram stain may be helpful if available; if evidence of gonorrhea is present, that is, intracellular Gramnegative diplococci, then treatment should be directed toward gonococcal disease (ceftriaxone 125 to 250 mg IM). Because of the frequency of coexisting chlamydial infection, azithromycin 1 g orally or doxycycline 100 mg orally bid for 7 to 10 days is also often given. If the Gram stain of the cervical discharge is negative, then antimicrobial therapy directed at Chlamydia is warranted. Nevertheless, assays for both organisms should be performed. If the symptoms resolve, no follow-up tests need to be done (see Figure 36– 1 for one suggested management scheme). Additionally, it is important that the partner receives treatment in order to prevent reinfection. Many states have expedited partner therapy enabling the patient’s physician to provide medication for partners. Finally, the patient and partner should be counseled and offered testing for other sexually transmitted organisms such as HIV, syphilis, and hepatitis B and C.

Recently, urine nucleic acid amplification tests (NAAT) have been approved for confirmation of gonococcal or chlamydial cervicitis. For those patients who refuse a speculum examination, this test is helpful, with sensitivities and specificities slightly lower than that of directly sampling the endocervix.

aIf gram s ta in a va ilable , ce rvica l/va gina l dis cha rge Gram s ta in s howing gram-ne ga tive intra cellula r diplococcic highly s ugge s tive of GC; this s hould be tre ate d for both GC and CT.

Figure 36–1. Example of algorithm to assess vaginal discharge.

Gonococcal cervicitis may lead to more serious complications. The organism may ascend and infect the fallopian tubes, causing salpingitis. The term pelvic inflammatory disease is usually synonymous with acute salpingitis. The tubal infection in turn predisposes the patient to infertility and ectopic pregnancies due to tubal occlusion and/ or adhesions. If the infection is associated with profuse tubal discharge, the pus can ascend to the right upper quadrant region and cause a perihepatitis. These patients have right upper quadrant pain.

Gonococcal infections may lead to an infectious arthritis, usually involving the large joints, and classically is migratory. In fact, in the United States, gonorrhea is the most common cause of septic arthritis in young women. Disseminated gonorrhea can occur also; affected individuals will usually have eruptions of painful pustules with an erythematous base on the skin. The diagnosis is made by Gram stain and culture of the pustules.

Upper Genital Tract Infections

Pelvic inflammatory disease, or salpingitis, usually involves Chlamydia, gonorrhea, and other vaginal organisms, such as anaerobic bacteria. The mechanism is usually by ascending infection. A common presentation would be 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 and, therefore, the patient often complains of dyspareunia.

The diagnosis of acute salpingitis is made clinically by abdominal tenderness, cervical motion tenderness, and/ or adnexal tenderness (Table 36– 1). Most episodes are asymptomatic or have mild symptoms; previously, all three criteria were thought to be required before a diagnosis and treatment was initiated, which likely led to insufficient treatment and tubal damage. Consideration of purulent vaginal discharge and the patient’s risk for STDs also play a role. Confirmatory tests may include a positive Neisseria gonorrhea or Chlamydia culture, or an ultrasound suggesting a tubo-ovarian abscess. 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, must also be considered. Right upper quadrant pain may be seen with salpingitis when perihepatic adhesions are present, the so-called Fitz-Hugh and Curtis syndrome.

Findings highly suggestive of PID include endometrial biopsy showing endometritis, or transvaginal ultrasound or magnetic resonance imaging (MRI) showing thickened or fluid-filled tubes. However, its absence does not rule out PID. 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.

The treatment of acute salpingitis depends on whether the patient is a candidate for inpatient versus outpatient therapy (see Table 36– 2). Criteria for outpatient management include low-grade fever, tolerance of oral medication, and the absence of peritoneal signs. The woman must also be compliant. Single agent quinolone therapy had gained popularity previously, but recent evidence has shown increasing bacterial resistance. It is paramount to re-evaluate the patient in 48 hours for improvement. If the patient fails outpatient therapy, or is pregnant, or at the extremes of age, or cannot tolerate oral medication, she would be a candidate for inpatient therapy.

• One outpatient regimen: IM ceftriaxone 250 mg, as a single injection, and oral doxycycline 100 mg twice a day for 14 days, with or without metronidazole twice a day for 14 days.
• One inpatient regimen: Intravenous cefotetan 2 g IV every 12 hours and oral or IV doxycycline 100 mg twice daily to continue 24 hours after clinical improvement, then discharge on doxycycline 100 mg twice daily for 14 days.

Again, if the patient does not improve within 48 to 72 hours, the clinician should consider laparoscopy to assess the disease.

One important sequelae of salpingitis is tubo-ovarian abscess. This disorder generally has anaerobic predominance and necessitates the corresponding antibiotic coverage (clindamycin or metronidazole). The physical examination may suggest an adnexal mass, or the ultrasound may reveal a complex ovarian mass. A devastating complication of TOA is rupture, which is a surgical emergency and one that leads to mortality if unattended. In contrast to most abscesses, TOAs can often be treated with antibiotic therapy without surgical drainage; radiological percutaneous drainage may sometimes be used to hasten resolution.

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 episodes of PID. 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.

CASE CORRELATION See also Case 20 (Chlamydial Cervicitis in Pregnancy). The majority of chlamydial infection is asymptomatic. Gonococcal cervicitis can also be asymptomatic but more often produces mucopurulent discharge.

COMPREHENSION QUESTIONS

36.1 An 18-year-old adolescent female undergoes laparoscopy for an acute abdomen. Erythematous fallopian tubes are noted and a diagnosis of PID is made. Cultures of the purulent drainage would most likely reveal which of the following?

A. Multiple organisms

B. Neisseria gonorrhoeae

C. Chlamydia trachomatis

D. Peptostreptococcus species

E. Treponema pallidum

36.2 An 18-year-old adolescent female presents to the emergency department with a 36-hour history of abdominal pain and nausea. Her temperature is 100.5°F (38.05°C). Her abdominal examination reveals tenderness in the right lower quadrant with some mild rebound tenderness. Pelvic examination shows some cervical motion tenderness and adnexal tenderness, and also some right-sided abdominal tenderness. The pregnancy test is negative. In considering the differential diagnosis of appendicitis versus PID, which of the following is the most accurate method of making the diagnosis?

A. Following serial abdominal examinations

B. Sonography of the pelvis and abdomen

C. Serum leukocyte count and cell differential

D. Laparoscopy

36.3 A 24-year-old G0P0 woman is seen at the local sexually transmitted disease (STD) clinic. Chlamydia is discovered colonizing the endocervix. The patient is given oral azithromycin therapy and warned about the dangers of upper genital tract infection, such as PID. The physician notes that the patient is at risk for PID. Which of the following is a risk factor for developing PID?

A. Nulliparity

B. Candida vaginitis

C. Oral contraceptive agents

D. Depot medroxyprogesterone acetate

36.4 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. C. trachomatis

B. Nocardia species

C. N. gonorrhoeae

D. T. pallidum

E. Actinomyces species

36.5 A 28-year-old woman complains of lower abdominal pain for the last 6 months. The pain is worsened with menses. Which of the following descriptions for the pelvic pain is most accurate?

A. An elevated inhibin level corresponds to endometriosis

B. The presence of trigger points corresponds to fibromyalgia

C. The presence of microscopic hematuria corresponds to interstitial cystitis

D. Cyclic pain is consistent with the chronic pelvic pain of PID

36.6 An 18-year-old adolescent female has a yellowish vaginal discharge. On examination, the cervix is erythematous and the discharge reveals numerous leukocytes. The wet mount does not reveal trichomonads. Which of the following is the most likely etiology?

A. Neisseria gonorrhea

B. Chlamydia trachomatis

C. Ureaplasma species

D. Bacterial vaginosis

36.7 A 21-year-old college student has a sexually transmitted pharyngitis. Which of the following most likely corresponds to the etiology?

A. Neisseria gonorrhea

B. Chlamydia trachomatis

C. Human papillomavirus

D. HIV pharyngitis

ANSWERS

36.1 A. Multiple organisms are most likely encountered in acute salpingitis. N. gonorrhoeae and C. trachomatis are the two most common organisms involved. Other vaginal organisms, such as anaerobic bacteria, are also usually involved in the mix. Peptostreptococci are anaerobic, Gram-negative bacteria that are a natural part of human flora along the gastrointestinal (GI) and urinary tracts. They are not involved in salpingitis. Syphilis is not a common cause of salpingitis, although it is an STD like Chlamydia and gonorrhea. In the first stage of syphilis, chancres may appear on the external genitalia or along the vaginal wall, but not in the endocervix as with Chlamydia and gonorrhea.

36.2 D. Laparoscopy is considered the “gold standard” for diagnosing salpingitis. The surgeon has direct visualization of the tubes with this method, and looks for purulent discharge exuding from the fimbria of the tubes. Clinical criteria and sonography are not specific enough for this diagnosis, although findings of hydrosalpinx or TOA would be highly suggestive. The clinical criteria that may support this diagnosis include: abdominal tenderness, cervical motion tenderness, adnexal tenderness, vaginal discharge, fever, and pelvic mass on physical examination or ultrasound. A pelvic mass, such as a tubo-ovarian abscess, may be visualized using sonography; however, it would still not specify the origin of the mass. Of the imaging tests, CT scan is most helpful when appendicitis is suspected.

36.3 A. Nulliparity is associated with an increased risk of PID. IUD use increases the risk of PID. The most typical way this occurs is during the placement of the IUD, since it breaks the endocervical barrier as it enters the uterus and can spread infection from the endocervix into the tubes. Oral contraceptive agents, including depot medroxyprogesterone acetate, decrease the risk of PID by virtue of the progestin thickening the cervical mucus and thinning the endometrium. Candida vaginitis is a fungal infection, commonly called a yeast infection, that manifests due to an overgrowth of naturally occurring vaginal flora; fungal infections are typically not involved in the development of PID, and patients typically present with a chief complaint of severe itching and burning of the vagina with curd-like vaginal discharge.

36.4 E. Sulfur granules are classic for Actinomyces, which occurs more often in the presence of an IUD. Actinomycesisraelii is a Gram-positive anaerobe, which is generally sensitive to penicillin. Chlamydia and gonorrhea are the only other answer choices typically involved in the development of acute salpingitis; however, neither one of them are associated with sulfur granules.

36.5 B. Trigger points suggest a diagnosis of fibromyalgia. Chronic pelvic pain is defined as lower abdominal pain for 6 months. The differential diagnosis is lengthy. A careful history and physical exam is required. Central location of the pain and exacerbation with menses are more suggestive of a gynecologic etiology. Endometriosis is associated with a moderately elevated CA-125 level; irritable bowel syndrome should be suspected with bowel symptoms; pelvic adhesive disease from infection or adhesions is typically constant in nature; psychiatric disorders are common including depressive disorder; interstitial cystitis is diagnosed by cystoscopy. If a gynecologic etiology is suspected, then pelvic sonography is performed, and NSAID and/ or oral contraceptive agents are usually used, and if ineffective, then laparoscopy can be considered.

36.6 B. Chlamydial cervicitis is the most common cause of mucopurulent cervical discharge. Although gonorrhea is also associated with a mucopurulent discharge, it is less common than Chlamydia. The mucus in the mucopurulent discharge is due to involvement of the columnar (mucin-containing) glandular cells of the endocervix.

36.7 A. The diagnosis of gonococcal pharyngitis is made by swabbing the throat. The infection is typically located on the tonsils and back of the throat. Patients who engage in oral sex are at increased risk of acquiring gonococcal pharyngitis. Typically, no symptoms are noted by the patient unless the disease disseminates. Chlamydia is not a common cause of pharyngitis most likely because, unlike Neisseria gonorrhoeae, it lacks the pili that allow the gonococcal bacteria to adhere to the surface of the columnar epithelium at the back of the throat.

    CLINICAL PEARLS    

» The two most common etiologies of mucopurulent cervical discharge are chlamydial infection and gonorrhea (of which chlamydial infection is more common). » Purulent vaginal discharge should be evaluated for originating from the cervix or vagina. Trichomonas is a common “imitator” of cervicitis. » Gram-negative intracellular diplococci are highly suggestive of N. gonorrhoeae. » Chlamydia often coexists with gonococcal cervicitis. » Ceftriaxone treats gonorrhea, whereas doxycycline or azithromycin treat chlamydial infections. » The organisms responsible for salpingitis are polymicrobial including N.gonorrhea, Chlamydia, anaerobes, and Gram-negative rods. Therefore, the antibiotic therapy must be broad spectrum. » The classic clinical triad of PID is lower abdominal tenderness, cervical motion tenderness, and adnexal tenderness; however, the patient may present with only one finding. » Laparoscopy is the “gold standard” in the diagnosis of acute salpingitis, by the operator visualizing purulent drainage from the fallopian tubes. » Long-term sequelae of acute salpingitis include chronic pelvic pain, ectopic pregnancy, and involuntary infertility. » A tubo-ovarian abscess (TOA) should be suspected when there is an adnexal mass with clinical PID. Patients may present with subtle findings and sonography is usually required for diagnosis. » TOAs are often treated medically with IV antibiotics especially with anaerobic coverage.

REFERENCES

Centers for Disease Control and Prevention (CDC). Sexually-Transmitted Diseases Treatment Guidelines; 2015. http:/ / www.cdc.gov/ std/ tg2015/ ; Accessed 18.10.2015. 

McGregor JA, Lench JB. Vulvovaginitis, sexually transmitted infections, and pelvic inflammatory disease. In: Hacker NF, Gambone JC, Hobel CJ, eds. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders; 2009:265-275. 

Eckert LO, Lentz GM. Infections of the lower and upper genital tract. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology, 6e. Philadelphia, PA: Mosby; 2012:519-561.

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