Purulent salpingitis - Diagnosis

During vaginal examination of patients with acute purulent salpingitis, it is not always possible to obtain objective information due to sharp pain and protective tension of the abdominal muscles. However, the most typical signs are pain when moving the cervix, detection of pastosity or a palpable formation of small sizes with unclear contours in the area of the appendages, as well as sensitivity when palpating the lateral and posterior fornices.

It is believed that the criteria for acute inflammation of the pelvic organs are an increase in temperature, increased ESR and the appearance of C-reactive protein.

Diagnosis of acute purulent salpingitis should be based on the identification of the following three mandatory signs:

• abdominal pain;
• sensitivity when moving the cervix;
• sensitivity in the area of the appendages in combination with at least one of the following additional symptoms:
  • temperature exceeding 38 degrees;
  • leukocytosis (above 10.5 thousand);
  • pus obtained by puncturing the posterior fornix;
  • the presence of inflammatory formations during bimanual or ultrasound examination;
  • ESR>15mm/h.

Symptoms of acute purulent salpingitis are confirmed by laboratory tests. The following changes are detected in the peripheral blood of patients: leukocytosis up to 10.5 thousand with a moderate shift in the leukocyte formula to the left (band leukocytes 6-9%), ESR 20-30 mm/h, and the presence of a sharply positive C-reactive protein.

Early detection of the process (at the stage of purulent salpingitis) and early initiation of adequate therapy play a decisive role in a favorable outcome. In addition to clinical and laboratory research methods, identification of the pathogen is of great importance. The material for research must be taken from all typical places, while the most reliable study is the material obtained directly from the tube or pelvic cavity during puncture of the posterior fornix or laparoscopy.

The insufficient information content of palpation data in acute purulent inflammation is not significantly supplemented by ultrasound examination.

The echographic signs of acute purulent salpingitis are “dilated, thickened, elongated fallopian tubes, characterized by decreased echogenicity; in every second patient, an accumulation of free fluid is noted in the recto-uterine pouch.”

Transvaginal sonography is considered to provide better detail in assessing changes in patients with salpingo-oophoritis, revealing “abnormalities” that were not noticed during transabdominal sonography in 71% of cases.

However, unlike formed inflammatory formations, with purulent salpingitis, echoscopic signs are not always informative, since with the initial signs of inflammation, slightly altered tubes are not always clearly visualized, and one has to rely more on the clinical picture and puncture results.

A highly informative diagnostic and treatment procedure for uncomplicated forms of purulent inflammation, especially purulent salpingitis, is a puncture of the posterior vaginal fornix. This diagnostic method allows obtaining purulent exudate for microbiological examination and excluding another urgent situation, such as ectopic pregnancy, ovarian apoplexy.

It is currently generally recognized that laparoscopy has the most pronounced diagnostic value, which is why it is the “gold standard” for diagnosing and treating patients with uncomplicated forms of purulent inflammation.

During laparoscopy, the clinical diagnosis of acute salpingitis was confirmed in 78.6% of cases, and the polymicrobial etiology of purulent inflammation was identified.

There are two factors that limit the use of the method: high cost and risk associated with the procedure. The method is certainly indicated for examining patients in a state of shock, with no history of sexual intercourse or uncertainty about the diagnosis.

Differential diagnosis of purulent salpingitis

First of all, acute salpingitis should be differentiated from acute appendicitis. Acute appendicitis is not characterized by a connection of the disease with the previously listed provoking, genital and extragenital risk factors for the development of inflammatory processes of the internal genital organs; the disease occurs suddenly.

An early sign of acute appendicitis is paroxysmal pain, initially localized in the navel area, more often above it (in the epigastrium). Somewhat later, the pain is concentrated in the cecum. Unlike acute inflammation of the appendages, the pain does not radiate anywhere, but intensifies with coughing. Nausea and vomiting appear, often repeated, although the absence of the latter does not exclude the presence of acute appendicitis. Stool and gas discharge are usually delayed. Diarrhea is rare. Multiple stools (10-15 times), especially with tenesmus, are not characteristic of acute appendicitis.

The body temperature rises to 37.8-38.7°C. As with any other acute abdominal disease, three criteria are of great importance: the state of the pulse, tongue and abdomen. In acute appendicitis, the pulse steadily increases to 90-100 beats per minute during the first day, the tongue is initially coated and moist, but soon becomes dry. Naturally, examination of the abdomen is of decisive importance. The location of the greatest pain depends to a certain extent on the localization of the appendix. In most patients, light tapping with the fingers on the abdominal wall helps to determine the location of the pain. It is better to palpate the abdomen not with the fingertips or even with the fingers, but with a “flat hand”, because it is logical to look for not a painful point, but a painful area without clearly defined boundaries. In acute appendicitis, the symptoms of Sitkovsky (increased pain in the right iliac region when the patient is lying on the left side) and Rovsing (increased pain in the cecum region with a push-like pressure in the left iliac region) are of decisive importance. Sharp pain is usually combined with protective muscle tension in a limited area. In the initial stages, the Shchetkin-Blumberg symptom appears in the right iliac region, and as the process spreads, it is also found on the left, as well as in the upper abdomen.

In gynecological pelvioperitonitis, symptoms of peritoneal irritation and protective tension of the abdominal muscles are also present, but local symptoms are less pronounced.

Laboratory data are not specific for acute appendicitis, since they reflect the presence of a pathological focus and the intensity of inflammation. However, when examining the blood, unlike purulent salpingitis, with acute appendicitis there is an hourly increase in the number of leukocytes, leukocytosis can reach 9-12 thousand.

A practicing physician often has to make a differential diagnosis between acute salpingitis and ectopic pregnancy, especially in the case of the formation of uterine hematomas and their suppuration, when the accompanying secondary inflammatory changes mask the original disease.

The distinctive features of ectopic pregnancy are the following symptoms:

• Almost all patients have menstrual cycle disorders - most often a delay in menstruation, followed by prolonged bloody discharge of a spotting nature; at the same time, patients may experience dubious and probable signs of pregnancy;
• the pain has a characteristic irradiation to the rectum;
• Often there is a periodic short-term disturbance of consciousness (dizziness, fainting, etc.), which is usually mistakenly associated with a possible uterine pregnancy or household factors;
• Patients with ectopic pregnancy do not have clinical and laboratory signs of acute inflammation, while almost all of them have symptoms of chronic salpingo-oophoritis.

Differential diagnosis is assisted by determination of chorionic gonadotropin in blood and urine (in the laboratory or by express tests), and in some women, by using echoscopic examination (visualization of decidually transformed endometrium or fertilized egg outside the uterus). In doubtful cases, puncture of the posterior vaginal fornix or laparoscopy is recommended.

Rarely, acute purulent salpingitis has to be differentiated from acute cholecystitis.

In 1930, Fitz-Hagh-Curtis first described a series of observations of female patients who underwent laparotomy for acute cholecystitis (later, all were diagnosed with gonococcal perihepatitis). It is now known that such lesions can also be caused by chlamydia. J. Henry-Suchet (1984) considers perihepatitis to be one of the characteristic signs of acute gonorrheal and chlamydial salpingitis. At the same time, gynecological patients are often mistakenly diagnosed with cholecystitis and treated for it.

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