Objectivized diagnosis of acute pelvic inflammatory disease. Diagnostic and prognostic value of routine laparoscopy

At the University Hospital, Lund, Sweden, laparoscopy has been routinely used as a diagnostic aid in cases for acute pelvic inflammatory disease since 1960. No significant complications have been encountered. The material of the study comprises 905 cases covering an 8 year period, 1960-1967. The operation was always performed under general anesthesia. The laparoscope was inserted in the midline below the umbilicus and a cannula inserted 10 cm laterally to manipulate the pelvic organs. A previous clinical diagnosis was required. In 814 cases acute inflammatory disease was suspected on clinical grounds. In 532 of these cases (65%) acute salpingitis was visually confirmed. Observation through the instrument was seldom difficult or uncertain. In 98 cases (12%) laparoscopy revealed other pathologic conditions. In 184 cases (23%) no pathologic changes were found. In another 91 cases acute salpingitis was found unexpectedly at laparoscopy (or in some cases by exploratory laparotomy) undertaken on other provisional clinical diagnoses. Altogether 623 patients were visually diagnosed as having acute salpingitis. Acute appendicitis was found in 24 cases, ectopic pregnancy in 11 cases, pelvic endometriosis in 16 cases, and several other pelvic disorders occasionally. In the total series of 623 confirmed cases of acute salpingitis 223 (365) were of gonococcal origin. These were mostly in the younger, unmarried, and nulliparous patients. Previous curettage was responsible for most othe r cases. The authors conclude that the diagnosis of acute adnexal inflammation based on commonly accepted clinical criteria was found inaccurate to an unsatisfactory high degree as 12% proved to have other disorders, several of a serious nature. Also 23% had no inflammatory reaction of the tubes or other pelvic structures leaving 65% of cases correctly diagnosed on clinical grounds. The prognosis as to later tubal patency varied with the stage of development of the salpingitis. Later studies show that patency was more frequent in cases of salpingitis diagnosed and treated early before adnexal swelling or mass was diagnosed clinically. Gonococcal cases showed a lower subsequent bilateral occlusion than others. 5 of the salpingitis patients were later operated on for ectopic pregnancy.     

Clinical utility of CA125 levels in predicting laparoscopically confirmed salpingitis in patients with clinically diagnosed pelvic inflammatory disease.

OBJECTIVE: The purpose of this study was to determine the utility of serum CA125 determinations in diagnosing acute salpingitis. METHODS: CA125 levels were determined for 34 women with the clinical diagnosis of pelvic inflammatory disease (PID). Acute salpingitis was confirmed laparoscopically in 28 women (82.3%). RESULTS: Twenty patients (71.4%) with laparoscopically confirmed acute salpingitis had CA125 levels greater than 7.5 units, compared with no patients (0/6) with laparoscopically normal tubes (P = 0.002). The degree of elevation of CA125 levels correlated with the severity of tubal inflammation noted at laparoscopy. All patients with levels above 16 units had laparoscopically severe salpingitis. CONCLUSIONS: We conclude that while CA125 levels above 7.5 units may modestly improve the ability of the clinical diagnosis of PID to accurately reflect visually confirmed acute salpingitis, limitations of the test make its clinical utility questionable.     

Microbiological and histopathological findings in acute pelvic inflammatory disease

Upper genital tract infection was investigated in 45 women admitted to hospital for suspected acute pelvic inflammatory disease (PID). Salpingitis was diagnosed by laparoscopy in 30 (67%) women. Histopathological evidence of endometritis was found significantly more often in the 30 women with salpingitis (87%) than in the other 15 women without salpingitis (33%). C. trachomatis or N. gonorrhoeae, or both, were isolated from the upper genital tract in 14 of the 31 women who had both salpingitis and endometritis or endometritis only but in none of the four women who had salpingitis alone and in none of the 10 women who had no evidence of PID. Bacterial vaginosis was associated with histopathological evidence of upper tract infection. Non-chlamydial non-gonococcal organisms were frequently isolated from the upper genital tract. No organisms were isolated from the upper genital tract from 9 of 35 women with laparoscopic or histopathological evidence of PID compared with 7 of 10 women without evidence of PID. C. trachomatis or N. gonorrhoeae in the endometrium was associated with lymphoid follicles comprising transformed lymphocytes, and correlated with the density of plasma cells on biopsy. The microbiological results support the recommendations of broad spectrum antimicrobial therapy for PID.     

Pelvic inflammatory disease: medical treatment

Pelvic inflammatory disease (PID) refers to infection of the uterus (endometritis), fallopian tubes (salpingitis) and adjacent pelvic structures (tubo-ovarain complex, pelvic peritonitis). PID causes major medical, social, and economic problems. Long-term sequelae, especially tubal factor infertility and extra uterine pregnancy are common and their management is extremely costly. Medical treatment of PID should be immediate because sequelae are more frequent if the treatment is delayed or inadequate.     

Microbiology of specimens obtained by laparoscopy from controls and from patients with pelvic inflammatory disease or infertility with tubal obstruction: Chlamydia trachomatis and Ureaplasma urealyticum

We cultured for Chlamydia trachomatis, Ureaplasma urealyticum, and Mycoplasma hominis and performed chlamydial serologic studies in 99 women undergoing laparoscopy. These women included patients with acute salpingitis, infertile women with and without mild pelvic inflammatory disease, and controls. C. trachomatis infection was significantly more common in patients than in controls. We also identified low-grade “silent” PID among women with infertility resulting from tubal obstruction and suggest this may be caused by chlamydiae.     

Ectopic pregnancy and antibodies to Chlamydia trachomatis

Ectopic pregnancy is one of the most serious sequelae to acute salpingitis. Chlamydia trachomatis seems to be the most common etiologic agent of acute salpingitis. In the present study, we tested whether women with ectopic pregnancy had serologic evidence of a current or past chlamydial infection. Sixty-five percent of the women with ectopic pregnancy had IgG serum antibodies to C. trachomatis, and 21% of women pregnant in utero had such antibodies. Eleven percent of women with infertile husbands, 42% of women with cervicitis, and 69% of women with salpingitis had IgG serum antibodies to C. trachomatis. In women with ectopic pregnancy, there was a correlation between the occurrence of IgG antibodies and a history of salpingitis or gross evidence of a previous tubal inflammation. We conclude that previous chlamydial salpingitis may be a major etiologic factor leading to ectopic pregnancy.     

Infertility following pelvic inflammatory disease.

OBJECTIVE: To assess the frequency of infertility after pelvic inflammatory disease (PID) and factors important in postinfectious tubal damage in an urban population at high risk for sexually transmitted diseases. METHODS: From a cohort of 213 women with PID documented by laparoscopy and/or endometrial biopsy, 58 women (27% of the initial cohort) were interviewed by phone 2 to 9 years after an index episode of PID. Data regarding the initial history, physical examination, microbiology, laparoscopic, and serologic findings, and data concerning interval contraception, subsequent pregnancy, subsequent infection, and chronic pelvic pain were compared among those with and without infertility at follow up. RESULTS: Nineteen (40%) of the 48 women not using contraception were involuntarily infertile after the index episode of PID. Compared with those who had an interval pregnancy, infertile women were older (P = 0.02), more likely to have a history of infertility prior to the index episode of PID (P = 0.001), and were more likely to have occluded or partially occluded fallopian tubes (P = 0.03), peritubal adhesions (P = 0.007), or perihepatic adhesions (P = 0.02) seen by laparoscopy performed during the index episode. Surprisingly, recovery of Chlamydia trachomatis was negatively related to infertility (P = 0.001), although a similar proportion of both groups had chlamydia immunoglobulin M antibody (40% vs. 31%). Chlamydia heat shock protein was weakly related to infertility (P = 0.08). The isolation of Neisseria gonorrhoeae was not significantly different between groups (53% vs. 57%). CONCLUSIONS: The high rate of postinfection infertility found was probably related to a combination of tubal damage before and during the index episode of PID. Prevention of recurrent PID and better understanding of the pathophysiology of postinfection tubal damage (which may differ between chlamydia and gonorrhea) is needed to develop more effective strategies to reduce permanent tubal damage.     

Laparoscopy in women with chlamydial infection and pelvic pain: a comparison of patients with and without salpingitis

A review was made of clinical and laboratory findings in 104 women who, during 1978 to 1981, were subjected to laparoscopy because of symptoms suggestive of acute salpingitis, and who harbored Chlamydia trachomatis but not Neisseria gonorrhoeae in the genital tract. The patients with acute salpingitis (N = 76) did not differ significantly from those with visually normal fallopian tubes (N = 28) in regard to age distribution, parity, contraceptive method used, proportion of women with urethritis symptoms, increased vaginal discharge, vomiting, diarrhea, elevated rectal temperature, elevated white blood cell count, and palpable pelvic masses. The acute salpingitis patients more often had irregular bleeding and an elevated erythrocyte sedimentation rate, whereas the patients without acute salpingitis more often had a short history of pelvic pain. The two groups overlapped considerably with respect to the number of symptoms and clinical signs of pelvic infection. The results emphasize the value of laparoscopy in the diagnosis or exclusion of a tubal infection in association with a chlamydial genital infection and pelvic pain, even if there are comparatively few additional symptoms of ascending infection.     

Clinical consequences of immune response to CT upper genital tract infection in women

C. TRACHOMATIS (CT) infections of the upper genital tract in women are either acute, sub acute or chronic. CT infection has a tendency to be chronic, latent and persistent as a consequence of the host immune reaction to CT major outer membrane protein, 57 Kd heat shock protein and lipopolysaccharide. Chlamydial persistence can be induced as a result of inflammatory and/or immune regulated cytokines, Interferon gamma depletion of tryptophan causes a stress response involving development of abnormal forms with increased levels of stress response proteins which maintain host immune responses with continuous fibrin exudate.The main clinical consequences are acute and chronic pelvic inflammatory disease, with infertility, ectopic pregnancy and, less frequently, chronic pelvic pain as late sequelae.PID, WHEN ACUTE, IS MARKED BY BILATERAL PELVIC PAIN, PLUS OTHER INFECTIOUS SIGNS IN TYPICAL CASES: fever, leucorrhea, red and purulent cervix. In 50% cases, infectious signs are slight or absent or there is an atypical clinical situation. Laparoscopy is the key for diagnosis. It allows the surgeon to have a direct look at the pelvic organs and perform microbiologic and histologic sampling. In severe cases, laparoscopy allows the surgeon to aspirate the purulent discharge and successfully treat pelvic abscesses.Chronic PID usually is clinically silent. It is in most cases discovered some years after the onset of CT infection, in women operated on for tubal infertility or ectopic pregnancy. Further studies, to evaluate treatments efficiency in chronic cases and factors leading to ectopic pregnancy or to recurrence, are indicated.     

Use of laparoscopy in gynecology]

Paper concerns 1822 performed laparoscopies. The most frequent indications to laparoscopy were: sterility, adnexal mass, tubal pregnancy and pelvic pain syndrome. In 80% cases of sterility we found pathologic findings, which could be the cause of sterility. adnexal mass, tubal pregnancy and pelvic pain syndrome. In 80% cases of sterility we found pathologic findings, which could be the cause of sterility. In 75% of cases we confirmed adnexal mass, which were operated by laparoscopy or by laparotomy. In 17 cases we confirmed unruptured tubal pregnancy, which were conservatively operated by laparoscopy or by laparotomy. Laparoscopy is useful method in gynecology, especially in diagnostically difficult cases of gynecologic disease.     

Comparison of endometrial biopsy and peritoneal fluid cytologic testing with laparoscopy in the diagnosis of acute pelvic inflammatory disease

Twenty-seven women with suspected acute pelvic inflammatory disease were studied by laparoscopy and endometrial biopsy. Overall, 67% (18 of 27) of the women had acute salpingitis at laparoscopy, 70% (19 of 27) had plasma cell endometritis, and 67% (10 of 15) had an inflammatory cytologic pattern of the peritoneal fluid. In comparison to laparoscopically detected salpingitis, endometritis detected with biopsy had a sensitivity of 89%, a specificity of 67%, a positive predictive value of 84%, and a false negative rate of 22% in the diagnosis of pelvic inflammatory disease. The corresponding figures for inflammation of the peritoneal fluid were 75%, 67%, 90%, and 25%. This study demonstrates that nonpuerperal endometritis is an entity associated with pelvic inflammatory disease, most likely representing an intermediate stage between cervicitis and salpingitis. Endometrial biopsy as an office procedure is a good alternative to laparoscopy in the diagnosis of acute pelvic inflammatory disease and may in fact detect early cases not yet visible at laparoscopy.     

Physiopathologie,diagnostic et prise en charge des infections génitales hautes

Pelvic inflammatory diseases (PID) include salpingitis and endometritis. They usually result from the infection of upper genital tract by pathogens ascending from the cervix or the vagina. Since the clinical signs of uncomplicated forms are frequently mild or misleading, diagnosis require other exams such as microbiology (samples from the cervix and, if applicable, from the pelvis) and laparoscopy. Acute complications (pelvic abscesses, peritonitis) can occur, that call for both surgical drainage and antibiotics. Pelvic sequelae with permanent tubal alterations due to immuno-allergic reactions can also happen, that lead to chronic pelvic pain and infertility. Treatment consists in broad-spectrum antibiotics by oral route, combined with non steroid anti-inflammatory drugs. Atraumatic laparoscopic procedure can also be performed.     

A study of second-look laparoscopy after acute salpingitis

Acute salpingitis (AS) has a major impact on the reproductive health of women. In this study second-look laparoscopy was assessed for its ability to predict reproductive function after AS. We questioned 158 women who had had a second-look laparoscopy with tubal dye insufflation after laparoscopically proven AS between September 1984 and August 1989. The answers of 69 women with at least two years of involuntary infertility were analyzed. The mean follow-up period was 76 months (range 53–108 months). Second-look laparoscopy revealed bilateral tubal occlusion in 21.7% (15/69). Bilateral tubal occlusion was found in 9.5% (2/21) after mild stage, 20% (4/20) after moderate stage and 32.1% (9/28) after severe stage AS. The rate of infertility during follow-up was 9.5% (stage I), 35% (stage II) and 39.9% (stage III). Eighty per cent (12/15) of women with proven bilateral tubal occlusion after treated AS had involuntary infertility, and 14.8% (8/54; P=0.000001) of women with one or both tubes patent also had infertility. Specificity, sensitivity and positive predictive value for subsequent infertility were 85.2%, 80% and 84.1%, respectively. Pelvic adhesions (21/69) were strongly correlated with bilateral tubal occlusion (8/21; 38.1%; P=0.029), a history of chronic pelvic pain (14/21; 66.7%; P=0.00024), as well as failure to achieve an intrauterine pregnancy (10/21; 47.6%; P=0.024). Recurrent pelvic infections occurred in 16% (12/69) and ectopic pregnancies in 7.3% (5/69). Operations for infertility and pelvic pain (excluding ectopic pregnancy), were carried out in 11.6% (8/69). We conclude that second-look laparoscopy after treated AS have accurate evaluation of reproductive function. Received: 10 January 1996 / Accepted: 29 April 1996     

Bilateral tubal pregnancy after natural conception: a case report

BACKGROUND: Bilateral tubal pregnancy is very rare and usually follows ovulation stimulation. CASE: A 36-year-old woman with acute pelvic pain underwent emergency laparoscopy for suspected left ruptured tubal pregnancy. Bilateral hematosalpinx with a ruptured left tubal pregnancy and active bleeding from the right fallopian tube was noted during surgery, and bilateral salpingectomy was performed by laparoscopy. Pathologic examination of the left tube confirmed the presence of conception products and trophoblastic tissue. The right salpingectomy specimen contained some trophoblastic tissue resembling an earlier tubal pregnancy encased in a cyst. CONCLUSION: This was a rare case of spontaneous bilateral tubal pregnancy after conception at different times. The explanation of the presentation is uncertain. Laparoscopy remains the cornerstone of diagnosis and treatment in the majority of women with a tubal pregnancy; this is especially true in complex cases, such as bilateral tubal pregnancy.     

Pelvic inflammatory disease and involuntary infertility: prospective pilot observations

Objective: We prospectively evaluated the rate of adverse reproductive outcomes following pelvic inflammatory disease (PID) in a small cohort of American women.Methods: We enrolled 28 patients having either salpingitis confirmed by laparoscopy or endometritis confirmed by endometrial biopsy. The follow-up was maintained by clinic visits and telephone contact.Results: A median of 15.4 months of follow-up was accomplished for 82.1% of these women. Fifty-two percent (13/25) had unprotected sexual activity without conception for at least 6 months. Fully 55.6% (10/18) of the cohort were involuntarily infertile after at least 1 year of follow-up.Conclusion: In the first prospective cohort study of the reproductive outcomes of American women having had PID, high rates of infertility at 1 year of follow-up were experienced by these women.     

Histopathologic findings in ectopic tubal pregnancy

In 141 consecutive cases of tubal ectopic pregnancy at Hermann Hospital in Houston, Texas, the histologic appearance of 129 surgically removed fallopian tubes containing ectopic pregnancies was reviewed and compared with an age- and race-matched control population. There was a higher incidence of chronic salpingitis (88 versus 2%) and salpingitis isthmica nodosa (SIN) (43 versus 5%). The ectopic pregnancy patients had a higher incidence of pelvic inflammatory disease, gonorrhea, previous abortions, bitubal ligation, intrauterine device use, and previous abdominal surgery. In our population, chronic salpingitis was the most commonly associated finding. The increase in SIN was associated with postinflammatory changes (89%). We also found that ectopic tubal pregnancies may grow either intratubally or extratubally by villous invasion into the wall and blood vessels; therefore, surgical salvage of the fallopian tube by extracting the products of conception will not always be curative.     

Laparoscopic management of tubal ectopic pregnancy in obese women

OBJECTIVE: To study the surgical morbidity associated with the laparoscopic management of tubal ectopic pregnancy in an overweight population compared with a lean population. DESIGN: Retrospective study. SETTING: An academic tertiary referral obstetrics and gynecology center. PATIENT(S): One hundred seventeen patients in two groups, lean (n = 90; body mass index 30) who had pathology-confirmed tubal ectopic pregnancies that were managed laparoscopically. Each group was subdivided into a laparoscopically managed group and a group in which laparoscopy was converted to laparotomy. INTERVENTION(S): None.Operative time, blood loss, and complications of laparoscopic surgery as well as causes of conversion from laparoscopy to laparotomy, in obese compared with lean women, with ectopic pregnancy. RESULT(S): There was no significant difference in gestational age; beta-hCG level; or history of previous surgeries, ectopic pregnancy, pelvic inflammatory disease, or endometriosis or in any of the studied outcomes (conversion rate, blood loss, and operative time) between the lean and obese groups or their respective subgroups except for operative time between obese women who underwent laparotomy, which was significantly longer when compared with the case of lean women who underwent laparotomy. Intraoperative and postoperative complications were comparable between the lean and obese groups, and all complications occurred in the completed-laparoscopy group. CONCLUSION(S): Laparoscopic management of tubal ectopic pregnancy does not appear to significantly increase surgical morbidity in obese patients.     

The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: a review of the literature

Purpose

This review aims to sum up current knowledge on the sensitivity and specificity of ultrasound features suggestive of acute pelvic inflammatory disease (PID).

Methods

A PubMed database search was undertaken, using the MeSH terms “(pelvic inflammatory disease or salpingitis or adnexitis) and ultrasonography”. We included original articles evaluating the performance of vaginal ultrasound in detecting acute PID.

Results

Seven articles were selected, including between 18 and 77 patients each. The golden standard used was laparoscopy/endometrial biopsy in six studies and mostly clinical evaluation in one. “Thick tubal walls” proved to be a specific and sensitive ultrasound sign of acute PID, provided that the walls of the tubes can be evaluated, i.e., when fluid is present in the tubal lumen (100 % sensitivity). The cogwheel sign is also a specific sign of PID (95–99 % specificity), but it seems to be less sensitive (0–86 % sensitivity). Bilateral adnexal masses appearing either as small solid masses or as cystic masses with thick walls and possibly manifesting the cogwheel sign also seems to be a reasonably reliable sign (82 % sensitivity, 83 %specificity). Doppler results overlap too much between women with and without acute PID for them to be useful in the diagnosis of acute PID, even though acutely inflamed tubes are richly vascularized at color Doppler.

Conclusions

Even though the results of our review suggest that transvaginal ultrasound has limited ability to diagnose acute PID, it is likely to be helpful when managing women with symptoms of acute PID, because in some cases the typical ultrasound signs of acute PID can be detected.     

C-reactive protein in assessing antimicrobial treatment of acute pelvic inflammatory disease

Serial serum C-reactive protein (CRP) determinations were used in the evaluation of antimicrobial treatment of acute pelvic inflammatory disease (PID) as proven by laparoscopy and endometrial biopsy or microbiologic findings in the upper genital tract in 36 women. Sixteen patients were treated with ciprofloxacin and 20 with doxycycline plus metronidazole. The mean CRP levels did not differ significantly in patients with severe and moderate salpingitis in comparison with mild salpingitis on admission or during treatment, nor was there any significant difference between the mean CRP levels in patients with acute chlamydial/gonococcal and nonchlamydial/nongonococcal PID. The mean CRP levels decreased by the third day of treatment in all treatment groups, and the decrease by the sixth day of treatment was significant (P less than .05), reflecting the clinical response to therapy faster than did serial ESR determinations. After the documentation of acute PID, serial serum CRP determinations were a useful predictor of the short-term response to antimicrobial therapy.     

Diagnostic laparoscopy in infertile women with normal hysterosalpingograms

OBJECTIVE: To assess the value of laparoscopy in infertile women with normal hysterosalpingograms, with and without risk factors suggesting pelvic disease. STUDY DESIGN: We retrospectively reviewed 1,022 consecutive charts from a tertiary infertility practice. In 265 women, laparoscopies were performed after normal hysterosalpingograms. RESULTS: Laparoscopies were normal in 136 (51%) women, whereas 129 (49%) had one or more abnormal laparoscopic findings, including minimal or mild endometriosis (n = 85), moderate or severe endometriosis (n = 11), adnexal adhesions (n = 27), subserosal myomas (n = 17), ovarian neoplasms (n = 5), distal phimosis (n = 1) and salpingitis isthmica nodosa (n = 1). Only 7% of cases had findings that might require standard operative laparoscopy or laparotomy, although not all were causally related to infertility. A history of dysmenorrhea or dyspareunia increased the likelihood of detecting endometriosis from 41% to 64% and 69%, respectively. The presence of both symptoms increased the likelihood to 83%. CONCLUSION: In the presence of a normal hysterosalpingogram, laparoscopy identified other pelvic disease in about half of patients. Because most abnormalities were mild, this knowledge can be used to plan a micro-laparoscopic approach for many women, reserving traditional or operative laparoscopy for women with an abnormal hysterosalpingogram or extensive disease following micro-laparoscopy. Alternately, knowledge of the nature and severity of the expected laparoscopic findings might lead to bypassing laparoscopy in favor of assisted reproduction when the perceived benefit of surgical intervention is small.