Acute Salpingitis

Acute salpingitis is sudden bacterial inflammation of the fallopian tubes, within days of ascending infection from the cervix.

• Chlamydia, gonorrhoea, Mycoplasma genitalium and mixed anaerobes are the commonest causes.
• It often follows childbirth, abortion or instrumentation in lower-resource settings.
• Delayed treatment leads to tubal blockage and infertility.

Sudden lower abdominal pain, fever, purulent vaginal discharge, dyspareunia, nausea, vomiting and abnormal bleeding.

• Marked lower abdominal tenderness with guarding, cervical motion tenderness, adnexal tenderness and purulent cervical discharge.
• Differential diagnosis: ectopic pregnancy, appendicitis, ruptured or twisted ovarian cyst, urinary tract infection, endometritis, diverticulitis.
• Complications: pyosalpinx, tubo-ovarian abscess, peritonitis, sepsis, perihepatitis, tubal infertility and ectopic pregnancy.

Diagnosis combines examination with investigations.

• Pregnancy test; temperature, pulse and blood pressure.
• Endocervical NAAT for gonorrhoea and chlamydia; high vaginal swab; HIV and syphilis tests.
• Full blood count; C-reactive protein; blood cultures if febrile; urinalysis.
• Transvaginal ultrasound for thick tubes, free fluid or abscess.
• Laparoscopy where the diagnosis is uncertain or the response is poor.

Treat on clinical suspicion.

• Supportive: admission for severe disease; IV fluids; bed rest; antipyretics; nil by mouth with vomiting; condoms and partner treatment.
• Pharmacological: ceftriaxone 1 g IV daily plus doxycycline 100 mg oral 12-hourly plus metronidazole 500 mg IV 8-hourly until afebrile for 24 to 48 hours, then doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly to complete 14 days. Mild disease (outpatient): ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly for 14 days. Paracetamol 1 g oral or IV 6-hourly (maximum 4 g in 24 hours).
• Procedures: remove an intrauterine device if no improvement in 48 to 72 hours; laparoscopy and drainage for abscess; laparotomy for rupture or peritonitis.
• Special groups: in pregnancy give ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly plus azithromycin 500 mg IV daily, and avoid doxycycline. In ceftriaxone allergy give gentamicin 5 mg/kg IV daily plus clindamycin 900 mg IV 8-hourly. In renal impairment adjust gentamicin.
• Red flags: shock, rigid abdomen, mass, pregnancy, no improvement within 72 hours.
• Follow-up: review at 72 hours and 2 weeks; retest at 3 months; contraception and fertility counselling.