Salpingitis and related diseases


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Salpingitis and related diseases

  1. 1. Salpingitis and Related Diseases <ul><li>Etiology </li></ul><ul><li>Risk Factors </li></ul><ul><li>Diagnosis and DDx </li></ul><ul><li>Management </li></ul><ul><li>Treatment </li></ul><ul><li>Complications </li></ul><ul><li>References </li></ul>
  2. 2. Etiology <ul><li>Salpingitis is really part of the larger family of pelvic inflammatory disease (PID). </li></ul><ul><li>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. </li></ul><ul><li>N. gonorrhea and C. trachomatis cause the majority but endogenous bacteria can also be present. </li></ul>
  3. 3. Etiology <ul><li>N. gonorrhea </li></ul><ul><ul><li>Causes roughly 50% of salpingitis. </li></ul></ul><ul><ul><li>15% of GC cervicitis progresses to PID. </li></ul></ul><ul><li>C. trachomatis </li></ul><ul><ul><li>More common than GC by up to 10:1, but only accounts for 20-35% of PID. </li></ul></ul><ul><ul><li>Classically produces a more mild form of PID with insidious onset. </li></ul></ul><ul><li>Other bugs </li></ul><ul><ul><li>Strep., Staph., E. coli, Bacteroides, Actinomyces, Peptococcus, Clostridium, Gardnerella, Haemophilus, CMV, etc. </li></ul></ul>
  4. 4. Risk Factors <ul><li>Young age (<25) </li></ul><ul><li>Prior history of STD </li></ul><ul><li>IUD or other non-barrier contraception </li></ul><ul><li>Multiple partners </li></ul><ul><li>Promiscuous partners </li></ul><ul><li>Iatrogenic factors </li></ul>
  5. 5. Clinical Criteria for Diagnosis of PID <ul><li>All 3 of the following: </li></ul><ul><ul><li>Abdominal tenderness with or without rebound. </li></ul></ul><ul><ul><li>Adnexal tenderness </li></ul></ul><ul><ul><li>Cervical motion tenderness </li></ul></ul><ul><li>Plus 1 of the following: </li></ul><ul><ul><li>Temp. of >101 °F </li></ul></ul><ul><ul><li>WBC >10,000 or elevated CRP or ESR </li></ul></ul><ul><ul><li>Gram stain with gram neg. intracellular diplococci </li></ul></ul><ul><ul><li>Inflammatory mass </li></ul></ul><ul><ul><li>Purulent material from peritoneal cavity </li></ul></ul>
  6. 6. Differential Diagnosis <ul><li>Acute appendicitis </li></ul><ul><li>Ectopic pregnancy </li></ul><ul><li>Ruptured ovarian cyst </li></ul><ul><li>Tubo-ovarian abscess </li></ul><ul><li>Endometriosis </li></ul><ul><li>Adnexal torsion </li></ul><ul><li>Acute UTI </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Crohns/Ulcerative Colitis </li></ul>
  7. 7. Management <ul><li>Lab studies </li></ul><ul><ul><li>CBC to look for leukocytosis </li></ul></ul><ul><ul><li>β -HCH to r/o ectopic pregnancy </li></ul></ul><ul><ul><li>Gonorrhea and Chlamydia cultures </li></ul></ul><ul><ul><li>ESR/CRP </li></ul></ul><ul><ul><li>UA to r/o cystitis or pyelonephritis </li></ul></ul><ul><ul><li>Fecal occult blood test </li></ul></ul><ul><ul><li>Wet mount </li></ul></ul><ul><ul><li>R/o other concurrent STDs with RPR/VDRL and HIV test </li></ul></ul>
  8. 8. Management <ul><li>Imaging Studies </li></ul><ul><ul><li>Pelvic ultrasound to r/o tubo-ovarian abscess, ectopic pregnancy and ovarian torsion. </li></ul></ul><ul><li>Procedures </li></ul><ul><ul><li>Laparoscopy if still unsure of diagnosis </li></ul></ul><ul><ul><li>Culdocentesis is now rarely required </li></ul></ul>
  9. 9. Treatment <ul><li>Outpatient therapy </li></ul><ul><ul><li>Regimen A </li></ul></ul><ul><ul><ul><li>Ofloxacin/Levofloxacin + Metronidazole PO x 14 days </li></ul></ul></ul><ul><ul><li>Regimen B </li></ul></ul><ul><ul><ul><li>Ceftriaxone or Cefoxitin (+probenecid PO) IM x 1 dose + Doxycycline +/- Metronidazole PO x 14 days </li></ul></ul></ul><ul><ul><li>Remember to also provide treatment to the patient’s partner if the infection is due to an STD. </li></ul></ul>
  10. 10. Treatment <ul><li>Inpatient therapy </li></ul><ul><ul><li>Regimen A </li></ul></ul><ul><ul><ul><li>Cefotetan or Cefoxitin IV until clinical improvement + Doxycyline x 14 days </li></ul></ul></ul><ul><ul><li>Regimen B </li></ul></ul><ul><ul><ul><li>Clindamycin + Gentamycin IV until clinical improvement + Doxycycline or Clindamycin PO x 14 days </li></ul></ul></ul><ul><li>Medical therapy alone results in an 85% cure rate with the rest requiring surgical intervention. </li></ul>
  11. 11. Indications for Hospitalization <ul><li>Pregnancy </li></ul><ul><li>Immunodeficient </li></ul><ul><li>Nausea/Vomiting and high fever </li></ul><ul><li>Unpredictable compliance </li></ul><ul><li>Poor response to outpatient therapy </li></ul><ul><li>Tubo-ovarian abscess </li></ul>
  12. 12. Complications <ul><li>Infertility 2 ° tubal scarring </li></ul><ul><ul><li>10% risk after a single episode of PID </li></ul></ul><ul><ul><li>30% risk after 2 episodes </li></ul></ul><ul><ul><li>50% risk after 3 or more episodes </li></ul></ul>
  13. 13. Complications <ul><li>Chronic pelvic pain </li></ul><ul><ul><li>Found in up to 18% of women after resolution of PID. </li></ul></ul><ul><li>Adhesions </li></ul><ul><li>Dyspareunia </li></ul>
  14. 14. Complications <ul><li>Ectopic Pregnancy </li></ul><ul><ul><li>Also 2 ° to tubal scarring </li></ul></ul><ul><ul><li>7-10 fold increased risk after a single episode </li></ul></ul>
  15. 15. Complications <ul><li>Ectopic Pregnancy </li></ul>
  16. 16. Complications <ul><li>Tubo-ovarian abscess </li></ul><ul><ul><li>Serious sequelae of PID causing 350,000 hospitalizations and 150,000 surgeries/yr. </li></ul></ul><ul><ul><li>Occurs in 15-30% of women requiring hospitalization for PID treament. </li></ul></ul><ul><ul><li>Ruptured TOA has a mortality rate as high as 9%. </li></ul></ul>
  17. 17. Complications
  18. 18. Complications <ul><li>Tubo-ovarian abscess </li></ul><ul><ul><li>Can be diagnosed by ultrasound with 94% sensitivity. </li></ul></ul><ul><ul><li>Can attempt conservative management with antibiotics but often require drainage or excision via laparoscopy. </li></ul></ul><ul><ul><li>86-93% infertility rate following TOA. </li></ul></ul>
  19. 19. Complications <ul><li>Fitz-Hugh-Curtis Syndrome </li></ul><ul><ul><li>Extrapelvic manifestation of PID associated with RUQ pain due to inflammation of the liver capsule and diaphragm. </li></ul></ul><ul><ul><li>As with PID, it is mainly caused by N. gonorrhea and C. trachomatis . </li></ul></ul><ul><ul><li>Probably spreads via direct seeding into the peritoneal cavity, although hematogenous and lymphatic spread can’t be ruled out. </li></ul></ul><ul><ul><li>Occurs in 15-30% of women with PID worldwide though this is probably less in developed countries. </li></ul></ul>
  20. 20. Complications <ul><li>Fitz-Hugh-Curtis Syndrome </li></ul><ul><ul><li>Vague symptoms often make it a diagnosis of exclusion. </li></ul></ul><ul><ul><ul><li>Amylase/Lipase to r/o gallbladder disease </li></ul></ul></ul><ul><ul><ul><li>LFTs to r/o hepatitis </li></ul></ul></ul><ul><ul><ul><li>UA to r/o pyelonephritis or kidney stones </li></ul></ul></ul><ul><ul><ul><li>Hemoccult to r/o perforated ulcer </li></ul></ul></ul><ul><ul><ul><li>Ultrasound and CT to r/o other diseases </li></ul></ul></ul><ul><ul><li>Gold standard for diagnosis is laparoscopy and visualization of adhesions or inflammation. </li></ul></ul>