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Salpingitis-and-Related-Diseases

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					Salpingitis and Related Diseases
                  Ryan Agema MS III
Salpingitis and Related Diseases

 Etiology
 Risk Factors
 Diagnosis and DDx
 Management
 Treatment
 Complications
 References
                   Etiology

   Salpingitis is really part of the larger family
    of pelvic inflammatory disease (PID).
   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.
   N. gonorrhea and C. trachomatis cause the
    majority but endogenous bacteria can also
    be present.
                      Etiology
   N. gonorrhea
       Causes roughly 50% of salpingitis.
       15% of GC cervicitis progresses to PID.
   C. trachomatis
       More common than GC by up to 10:1, but only
        accounts for 20-35% of PID.
       Classically produces a more mild form of PID with
        insidious onset.
   Other bugs
       Strep., Staph., E. coli, Bacteroides, Actinomyces,
        Peptococcus, Clostridium, Gardnerella,
        Haemophilus, CMV, etc.
           Risk Factors

 Young age (<25)
 Prior history of STD
 IUD or other non-barrier contraception
 Multiple partners
 Promiscuous partners
 Iatrogenic factors
Clinical Criteria for Diagnosis of PID

   All 3 of the following:
       Abdominal tenderness with or without rebound.
       Adnexal tenderness
       Cervical motion tenderness
   Plus 1 of the following:
       Temp. of >101°F
       WBC >10,000 or elevated CRP or ESR
       Gram stain with gram neg. intracellular
        diplococci
       Inflammatory mass
       Purulent material from peritoneal cavity
        Differential Diagnosis

   Acute appendicitis
   Ectopic pregnancy
   Ruptured ovarian cyst
   Tubo-ovarian abscess
   Endometriosis
   Adnexal torsion
   Acute UTI
   Diverticulitis
   Crohns/Ulcerative Colitis
              Management

   Lab studies
     CBC to look for leukocytosis
     β-HCH to r/o ectopic pregnancy
     Gonorrhea and Chlamydia cultures
     ESR/CRP
     UA to r/o cystitis or pyelonephritis
     Fecal occult blood test
     Wet mount
     R/o other concurrent STDs with
      RPR/VDRL and HIV test
               Management

   Imaging Studies
       Pelvic ultrasound to r/o tubo-ovarian
        abscess, ectopic pregnancy and ovarian
        torsion.
   Procedures
     Laparoscopy if still unsure of diagnosis
     Culdocentesis is now rarely required
                         Treatment

   Outpatient therapy
       Regimen A
          Ofloxacin/Levofloxacin   + Metronidazole PO x
          14 days
       Regimen B
                     or Cefoxitin (+probenecid PO) IM
          Ceftriaxone
          x 1 dose + Doxycycline +/- Metronidazole PO
          x 14 days
       Remember to also provide treatment to the
        patient’s partner if the infection is due to
        an STD.
                  Treatment

   Inpatient therapy
       Regimen A
                  or Cefoxitin IV until clinical
         Cefotetan
          improvement + Doxycyline x 14 days
       Regimen B
         Clindamycin + Gentamycin IV until clinical
          improvement + Doxycycline or Clindamycin
          PO x 14 days
   Medical therapy alone results in an
    85% cure rate with the rest requiring
    surgical intervention.
    Indications for Hospitalization

 Pregnancy
 Immunodeficient
 Nausea/Vomiting and high fever
 Unpredictable compliance
 Poor response to outpatient therapy
 Tubo-ovarian abscess
                 Complications
   Infertility 2° tubal scarring
       10% risk after a single episode of PID
       30% risk after 2 episodes
       50% risk after 3 or more episodes
                  Complications
   Chronic pelvic pain
       Found in up to 18% of women after resolution of PID.
   Adhesions
   Dyspareunia
                      Complications

   Ectopic Pregnancy
       Also 2° to tubal scarring
       7-10 fold increased risk after a single episode
            Complications
   Ectopic Pregnancy
                    Complications
   Tubo-ovarian abscess
       Serious sequelae of PID causing 350,000
        hospitalizations and 150,000 surgeries/yr.
       Occurs in 15-30% of women requiring hospitalization
        for PID treament.
       Ruptured TOA has a mortality rate as high as 9%.
Complications
             Complications

   Tubo-ovarian abscess
      Can be diagnosed by ultrasound with
       94% sensitivity.
      Can attempt conservative management
       with antibiotics but often require
       drainage or excision via laparoscopy.
      86-93% infertility rate following TOA.
                     Complications

   Fitz-Hugh-Curtis Syndrome
       Extrapelvic manifestation of PID associated with RUQ
        pain due to inflammation of the liver capsule and
        diaphragm.
       As with PID, it is mainly caused by N. gonorrhea and
        C. trachomatis.
       Probably spreads via direct seeding into the peritoneal
        cavity, although hematogenous and lymphatic spread
        can’t be ruled out.
       Occurs in 15-30% of women with PID worldwide
        though this is probably less in developed countries.
                      Complications

   Fitz-Hugh-Curtis Syndrome
       Vague symptoms often make it a diagnosis of
        exclusion.
          Amylase/Lipase  to r/o gallbladder disease
          LFTs to r/o hepatitis
          UA to r/o pyelonephritis or kidney stones
          Hemoccult to r/o perforated ulcer
          Ultrasound and CT to r/o other diseases

       Gold standard for diagnosis is laparoscopy and
        visualization of adhesions or inflammation.
Complications
Complications
             Complications

   Fitz-Hugh-Curtis Syndrome
     As with PID, antibiotic therapy is the
      mainstay of therapy.
     Questionable benefit of lysis of
      adhesions with laparoscopy.
               References

   www.acog.org
   Current Diagnosis and Treatment in
    Infectious Disease (2001)
   Current Obstetric & Gynecologic Diagnosis
    & Treatment (2003)
   ACP's PIER: Physicians' Information and
    Education Resource (2004)
   CDC. Guidelines for Treatment of Sexually
    Transmitted Diseases 2002, MMWR 2002:
    51: 1041

				
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