Pyosalpinx

Pyosalpinx is a fallopian tube distended with pus, usually from acute pelvic inflammatory disease with blocked ends.

• It results from gonorrhoea, chlamydia, anaerobes or enteric organisms.
• It can progress to tubo-ovarian abscess or rupture.
• It needs antibiotics and often surgery.

Lower abdominal pain, fever, purulent vaginal discharge, nausea, and a tender, fixed adnexal mass.

• Cervical motion tenderness, peritonism with rupture.
• Differential diagnosis: tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy, appendiceal abscess, ovarian torsion, endometrioma.
• Complications: rupture, peritonitis, sepsis, tubo-ovarian abscess, tubal infertility, ectopic pregnancy and chronic pelvic pain.

Diagnosis is clinical, supported by ultrasound and cultures.

• Pregnancy test; full blood count; C-reactive protein; blood cultures.
• Transvaginal ultrasound: dilated tube with thick walls (cogwheel sign) and echogenic fluid; CT scan with contrast if unclear.
• Endocervical NAAT for gonorrhoea and chlamydia; HIV and syphilis tests.
• Laparoscopy and culture of pus.

Give IV antibiotics and drain or remove a tube that does not respond.

• Supportive: admission; IV fluids; analgesia; monitor vital signs; remove an intrauterine device if there is no response.
• 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. Alternative: clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily (maximum 480 mg). Paracetamol 1 g IV or oral 6-hourly (maximum 4 g in 24 hours).
• Procedures: laparoscopic drainage and salpingectomy for a persistent pus-filled tube, or if it does not improve after 48 to 72 hours of antibiotics; laparotomy with salpingectomy or hysterectomy with bilateral salpingo-oophorectomy for rupture or shock; ultrasound-guided drainage if surgery is not possible.
• 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 renal impairment adjust gentamicin or use ceftriaxone.
• Red flags: shock, peritonism, worsening pain on antibiotics, persistent fever after 72 hours.
• Follow-up: review at 1 and 4 weeks; ultrasound at 2 weeks; partner treatment; fertility counselling.