Chronic Salpingitis

Chronic salpingitis is long-standing tubal inflammation with scarring, adhesions and tubal damage that follows repeated or untreated infection.

• Causes include chlamydia, gonorrhoea, tuberculosis, schistosomiasis and repeated pelvic inflammatory disease.
• It leads to tubal blockage, hydrosalpinx, chronic pelvic pain and infertility.
• Genital tuberculosis is a major cause in Africa.

Chronic lower abdominal pain, dyspareunia, dysmenorrhoea, menstrual irregularity, infertility, and previous episodes of pelvic infection.

• Fixed tender adnexal masses, a fixed uterus, nodular thickened tubes.
• Differential diagnosis: endometriosis, chronic pelvic inflammatory disease, ovarian tumour, ectopic pregnancy, adhesions from surgery, irritable bowel syndrome, genital tuberculosis.
• Complications: tubal infertility, ectopic pregnancy, hydrosalpinx, pyosalpinx, chronic pelvic pain.

Diagnosis rests on imaging and exclusion of active infection.

• Hysterosalpingography or sonosalpingography showing blocked or beaded tubes.
• Transvaginal ultrasound showing thick tubes, hydrosalpinx or adhesions.
• Laparoscopy with dye test, showing adhesions and tubal damage.
• Endocervical NAAT for chlamydia and gonorrhoea; HIV and syphilis tests.
• For tuberculosis: Xpert MTB/RIF and culture on menstrual blood or endometrial tissue, and chest X-ray.

Management depends on whether disease is active and on fertility goals.

• Supportive: heat to the lower abdomen; pelvic physiotherapy; counselling on fertility; partner testing.
• Pharmacological: active chlamydia or mixed infection: doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly for 14 days. Genital tuberculosis: isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg and ethambutol 15 mg/kg, all oral once daily for 2 months, then isoniazid and rifampicin once daily for 4 months, with pyridoxine 25 mg oral daily. Schistosomiasis: praziquantel 40 mg/kg oral single dose. Pain: naproxen 500 mg oral 12-hourly with food (maximum 1 g in 24 hours) and paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours).
• Procedures: laparoscopic adhesiolysis for pain or infertility; salpingectomy for hydrosalpinx before in vitro fertilisation; hysterectomy with bilateral salpingo-oophorectomy for intractable pain when childbearing is complete; in vitro fertilisation for infertility.
• Special groups: in HIV infection give standard four-drug tuberculosis treatment and use dolutegravir 50 mg oral twice daily with rifampicin. In liver impairment monitor liver enzymes. In pregnancy avoid doxycycline and give azithromycin 1 g oral single dose for chlamydia. In women aged 35 or over move early to in vitro fertilisation.
• Red flags: acute fever with pain (acute-on-chronic infection), adnexal mass, pregnancy with pain (ectopic), weight loss and night sweats.
• Follow-up: review at 3 months; liver tests monthly during tuberculosis treatment; fertility plan within 6 months.