Salpingitis

Salpingitis is inflammation of the fallopian tubes, usually from infection that ascends from the cervix. It is the central part of pelvic inflammatory disease.

• Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, anaerobes and enteric bacteria are common causes.
• It causes tubal damage, ectopic pregnancy and infertility.
• Prompt treatment prevents long-term damage.

Lower abdominal pain, abnormal vaginal discharge, intermenstrual or post-coital bleeding, dyspareunia, fever and dysuria; some women have mild or no symptoms.

• Lower abdominal tenderness, cervical motion tenderness, adnexal tenderness, purulent cervical discharge.
• Differential diagnosis: ectopic pregnancy, appendicitis, ovarian torsion, ruptured cyst, endometriosis, urinary tract infection, irritable bowel.
• Complications: tubo-ovarian abscess, hydrosalpinx, tubal infertility, ectopic pregnancy, chronic pelvic pain, perihepatitis.

Diagnosis is clinical, supported by the following tests.

• Pregnancy test; speculum examination; bimanual examination.
• Endocervical NAAT for gonorrhoea and chlamydia (Xpert CT/NG where available) and Mycoplasma genitalium where available; wet mount for white cells.
• Full blood count; C-reactive protein; HIV and syphilis tests.
• Transvaginal ultrasound for thickened tubes, free fluid or abscess.
• Laparoscopy when the diagnosis is unclear.

Treat on clinical suspicion without waiting for results.

• Supportive: rest; analgesia; abstain from intercourse until treatment finishes and partners are treated; condoms; partner notification for the last 60 days.
• Pharmacological: outpatient treatment for mild to moderate disease: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly, both oral drugs for 14 days. Admit and give IV treatment for severe illness, pregnancy, tubo-ovarian abscess, vomiting, or no response in 72 hours: ceftriaxone 1 g IV daily plus doxycycline 100 mg oral 12-hourly plus metronidazole 500 mg IV 8-hourly, continued until afebrile for 24 to 48 hours, then oral treatment to complete 14 days. Analgesia with paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) and ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours).
• Procedures: remove an intrauterine device if there is no response in 48 to 72 hours; drainage of abscess; laparoscopy for diagnosis.
• 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 HIV infection give the full regimen. In ceftriaxone allergy give gentamicin 5 mg/kg IV daily plus clindamycin 900 mg IV 8-hourly.
• Red flags: fever above 38.5 degrees Celsius, peritonism, shock, adnexal mass, pregnancy.
• Follow-up: review at 72 hours; retest at 3 months; counsel on contraception and fertility.