Salpingitis 10 marks question types diagnostic complication treatment
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Salpingitis — 10 Marks
Definition
Salpingitis is inflammation of the fallopian tube(s), most commonly caused by ascending polymicrobial infection from the lower genital tract. It is the most significant component of Pelvic Inflammatory Disease (PID).
Types
| Type | Features |
|---|---|
| Acute salpingitis | Suppurative; dilated tube, edematous plicae infiltrated by neutrophils; lumen fills with purulent exudate |
| Chronic salpingitis | Scarring and fusion of tubal plicae forming gland-like spaces and blind pouches; leads to tubal occlusion |
| Salpingo-oophoritis | Spread to the ovary |
| Pyosalpinx | Pus accumulated within the tubal lumen |
| Hydrosalpinx | Dilated tube from fusion of fimbriae and accumulated secretions |
| Tuberculous salpingitis | Usually in older/postmenopausal women; granulomatous; presents with infertility and amenorrhea |
Etiology
- Primary/STI-related (most common): Neisseria gonorrhoeae (>60% of suppurative cases), Chlamydia trachomatis, Mycoplasma genitalium
- Polymicrobial (anaerobes/facultative): Prevotella spp., peptostreptococci, E. coli, H. influenzae, group B streptococci
- Post-procedure/puerperal: Staphylococci, streptococci, Clostridium perfringens — spread via lymphatics/venous channels rather than mucosal surfaces
- Secondary: From adjacent inflammation (appendicitis, diverticulitis), hematogenous (TB, staphylococcal bacteremia), or tropical infections (schistosomiasis)
Risk factors: IUD use, recent vaginal douching, prior salpingitis/PID, history of STIs, recent intrauterine procedures (D&C, termination of pregnancy, hysterosalpingography), onset around menstruation.
Clinical Features
Symptoms (classical progression):
- Yellow/malodorous vaginal discharge (due to mucopurulent cervicitis/BV)
- Midline abdominal pain and abnormal vaginal bleeding (endometritis)
- Bilateral lower abdominal and pelvic pain (salpingitis)
- Nausea, vomiting, increased abdominal tenderness (if peritonitis develops)
- Dysuria (20%), anorectal symptoms (gonococcal/chlamydial proctitis)
- Abnormal uterine bleeding precedes or coincides with pain in ~40%
Signs:
- Mucopurulent cervical discharge; easily induced cervical bleeding
- Cervical motion tenderness (pathognomonic)
- Uterine fundal tenderness (endometritis)
- Bilateral adnexal tenderness; adnexal swelling palpable in ~50%
- Temperature >38°C in only ~one-third of patients
- ESR elevated in 75%; leukocytosis in up to 60%
- Fitz-Hugh–Curtis syndrome (perihepatitis): right upper quadrant pleuritic pain in 3–10%; "violin-string" adhesions over liver on laparoscopy
Diagnosis
Clinical criteria (CDC — minimum to initiate treatment):
Sexually active woman with pelvic/lower abdominal pain plus one or more of:
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
Additional findings that increase diagnostic probability:
- Temperature >38°C
- Palpable adnexal mass
- ESR >15 mm/h
- Elevated CRP
- PMNs >30 per 1000× field in cervical mucus; leukocytes outnumbering epithelial cells in vaginal fluid
- Positive NAAT for N. gonorrhoeae / C. trachomatis
Investigations:
| Investigation | Findings |
|---|---|
| Cervical/vaginal swabs (NAAT) | Detect N. gonorrhoeae, C. trachomatis |
| Cervical Gram stain | PMNs + gram-negative intracellular diplococci → gonorrhoea |
| CBC | Leukocytosis |
| ESR, CRP | Elevated |
| Serum β-hCG | Must be done to exclude ectopic pregnancy |
| Transvaginal ultrasound / MRI | Detect tubo-ovarian abscess, increased tubal diameter, intratubal fluid, tubal wall thickening |
| Endometrial biopsy | Histologic endometritis (correlates well with salpingitis) |
| Laparoscopy | Gold standard — directly visualises tube; confirms/excludes surgical emergencies; confirms salpingitis in ~90% when cultures positive for GC/Chlamydia |
| Culdocentesis | Yields pus from abdominal cavity for diagnosis and culture (only method short of surgery) |
Nothing short of laparoscopy definitively identifies salpingitis, but routine laparoscopy for every case is impractical. — Harrison's, 22E
Complications
Acute:
- Pelvic peritonitis
- Tubo-ovarian abscess (TOA) / pyosalpinx
- Bacteremia → endocarditis, meningitis, septic arthritis
- Fitz-Hugh–Curtis syndrome (perihepatitis)
Chronic:
- Infertility (tubal occlusion — most important long-term sequela)
- Ectopic pregnancy (scarred/narrowed tube)
- Hydrosalpinx
- Chronic pelvic pain
- Intestinal obstruction (adhesions between bowel and pelvic organs)
- Dyspareunia
- Recurrent PID
Treatment
Indications for Hospitalisation
- Diagnosis uncertain; appendicitis/ectopic pregnancy cannot be excluded
- Patient is pregnant
- Pelvic/tubo-ovarian abscess suspected
- Severe illness; nausea/vomiting precluding outpatient management
- HIV infection
- Unable to tolerate/comply with oral regimen
- Failed outpatient therapy
Antibiotic Regimens (CDC Guidelines, 2021)
Outpatient (mild-moderate disease):
| Drug | Dose |
|---|---|
| Ceftriaxone | 500 mg IM single dose |
| + Doxycycline | 100 mg PO BD × 14 days |
| + Metronidazole | 500 mg PO BD × 14 days |
Parenteral (inpatient — continue until 48 h after clinical improvement, then switch to oral):
Regimen A:
- Cefotetan 2 g IV q12h or Cefoxitin 2 g IV q6h
- + Doxycycline 100 mg IV/PO q12h
Regimen B:
- Clindamycin 900 mg IV q8h
- + Gentamicin (loading 2 mg/kg IV/IM, then 1.5 mg/kg q8h)
Special situations:
- Cephalosporin intolerance: Azithromycin 500 mg IV OD × 1–2 doses then 250 mg PO OD × 12–14 days ± metronidazole; or amoxicillin-clavulanate + doxycycline
- M. genitalium suspected/confirmed: Moxifloxacin 400 mg OD × 14 days
- TOA not resolving on antibiotics: Surgical drainage/salpingectomy
Surgical Treatment
- Drainage of tubo-ovarian abscess (ultrasound-guided or laparoscopic)
- Salpingectomy / oophorectomy when conservative management fails
- Laparotomy for ruptured TOA (surgical emergency)
Key Points to Remember
- Bilateral adnexal tenderness + cervical motion tenderness = classic PID/salpingitis triad
- Chlamydia causes "silent" salpingitis; diagnosis often delayed → worse tubal damage
- Oral contraceptives decrease risk; tubal ligation prevents salpingitis by blocking ascent
- Treat sexual partners for STI simultaneously
- Follow-up in 72 hours to assess clinical response
Sources: Harrison's Principles of Internal Medicine, 22E; Robbins, Cotran & Kumar Pathologic Basis of Disease, 10E
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