Pyosalpinx is a closed accumulation of purulent exudate in the lumen of the fallopian tube due to obliteration of its uterine and ampullary parts. Pyosalpinx is characterized by pain in the lower abdomen, increased body temperature, and often signs of an acute abdomen. The diagnosis of pyosalpinx is established by vaginal examination, ultrasound, ultrasound hysterosalpingoscopy, puncture of the posterior vaginal arch, diagnostic laparoscopy. The treatment of pyosalpinx is operative – opening and sanitation of the fallopian tube or tubectomy. With pyosalpinx, intensive antibacterial and detoxification therapy is carried out, followed by physiotherapy.
Pyosalpinx is most often the outcome of acute salpingitis (salpingoophoritis). Inflammatory changes lead to obliteration (overgrowth) of the uterine and fimbrial parts of the fallopian tube with the formation of a closed sac cavity filled with purulent contents in it. With pyosalpinx, the walls of the fallopian tube stretch and thicken, the mucosa gradually atrophies and is replaced by granulation tissues. The ampullary part of the fallopian tube is usually fused with neighboring organs – the omentum, ovary, intestinal loops, the body of the uterus, forming a single inflammatory conglomerate with them.
The purulent secret of pyosalpinx is initially liquid, containing virulent microorganisms; over time it can become thick and aseptic. When the ovary is involved in the process, an abscess forms in it, and with purulent melting of the ovarian tissue, a piovar, which can merge with the pyosalpinx into a single cavity, a tuboovarial abscess.
The proteolytic effect of pus on the capsule is accompanied by perforation of the pyosalpinx. When the walls of the pyosalpinx rupture, pus can pour into the rectum, bladder, vagina with the formation of a long-term non-healing tubo-intestinal, tubo-vesicular or tubo-vaginal fistula; sometimes the abscess breakthrough occurs in the free abdominal cavity and the pelvic cavity with the development of diffuse peritonitis or pelvioperitonitis.
The cause of pyosalpinx is the penetration of infectious agents into the fallopian tube with the development of septic inflammation in it. Most often, streptococci, E. coli, staphylococci, gonococci, chlamydia, mycoplasmas, Mycobacterium tuberculosis, proteus, klebsiella, enterococci are detected with pyosalpinx, which act in isolation or form microbial associations.
Pathogens enter the appendages in an ascending way – from the vagina, the cervical canal, the body of the uterus; sometimes they penetrate hematogenically or lymphogenically (with tuberculosis). Infection often develops after surgical abortions, diagnostic curettage, spontaneous termination of pregnancy, childbirth; salpingitis or adnexitis of gonococcal or septic etiology often leads to the development of pyosalpinx. The use of an IUD, menstruation, and a decrease in the reactivity of the body predisposes to the formation of a pyosalpinx.
Pyosalpinx with septic infection often has a unilateral localization, with gonococcal – bilateral. By the nature of the course, pyosalpinx can be acute or chronic.
The clinic of piosalpinx is characterized by bursting, throbbing pains in the lower abdomen and, especially, on the affected side. Pain often radiates to the lower back, sacrum, lower limb, groin area.
Characterized by high fever with chills, which is replaced by periods of subfebrility. There are signs of intoxication, deterioration of well-being, malaise, weakness, sweating, tachycardia. Nausea, dyspeptic and dysuric phenomena, stool retention and gas discharge may be observed. Pyosalpinx is often accompanied by a violation of menstrual function, the appearance of serous-purulent or purulent discharge from the genital tract. In chronic cases of pyosalpinx, the pains are of an unstable dull nature, they increase after hypothermia, sexual intercourse, physical effort, menstruation.
The most severe course is characterized by pyosalpinx caused by septic flora, especially in association with Staphylococcus and E. coli. Pyosalpinx, caused by gonococci, mycoplasmas, chlamydia infection, is distinguished by a less vivid clinic and a more protracted nature of the course. In the case of the development of pelvioperitonitis or spilled peritonitis, signs of an acute abdomen appear: cramping pains, symptoms of muscle protection, vomiting, dryness and overlaid tongue, etc.
The data of anamnesis, gynecological, laboratory and instrumental studies make it possible to differentiate pyosalpinx from acute appendicitis, cholecystitis, pyelonephritis, complicated ovarian cysts. In the process of bimanual vaginal examination, a painful tumor-like formation that does not have clear contours is determined in the area of the affected appendage. With bilateral pyosalpinx, enlarged fallopian tubes can occupy the entire cavity of the pelvis; the uterus is not defined or contoured with great difficulty. During palpation, foci of fluctuation are felt. To clarify the diagnosis of piosalpinx, a puncture is performed through the posterior arch of the vagina.
According to transvaginal ultrasound or transabdominal ultrasound of the pelvis behind the uterus, an enlarged fallopian tube of heterogeneous echogenicity with a fine suspension is determined. The study of peripheral blood reflects the picture of inflammation: leukocytosis, a shift in the leukoformula to the left, an increase in ESR, a positive test for CRP. To determine infectious pathogens, a bacteriological smear is seeded on the microflora.
Among the additional studies that gynecology uses, with pyosalpinx, the most informative is diagnostic laparoscopy, which allows to determine the nature of the process, its localization, the presence of effusion and adhesions in the abdominal cavity. In addition, laparoscopy can be performed for therapeutic purposes – aspiration of purulent contents, local administration of antibiotics. In case of perforation of the pyosalpinx into hollow organs, consultation of a urologist, proctologist, cystoscopy, bladder ultrasound, rectoromanoscopy may be required.
Detection of pyosalpinx requires hospitalization of the patient in a gynecological hospital. Treatment of pyosalpinx is exclusively surgical in combination with antibacterial, detoxification, immunostimulating therapy.
Surgical tactics are determined by the age of the patient and the nature of the piosalpinx. In young women, if it is necessary to preserve the fallopian tube, salpingostomy is preferable – performing a targeted puncture of the pyosalpinx with aspiration of the contents and sanitation of the abscess cavity with antiseptics, antibiotics, enzymes. Punctures are carried out through the posterior arch of the vagina under ultrasound control in a course of 3-5 procedures, every other day.
The opening of the fimbrial part of the tube (tubotomy) with pyosalpinx can also be performed during laparoscopy. Among other things, laparoscopy allows for the lysis of adhesions, the opening of purulent formation, sanitation or drainage of the abdominal cavity, intra-abdominal infusion of medicinal solutions.
In the absence of the effect of salpingostomy, the need or possibility of preserving the fallopian tube, tubectomy is performed on one or both sides; with tubovarial purulent tumor, appendages are removed (adnexectomy). In complicated cases with pyosalpinx, removal of the uterus may be required – supravaginal amputation or hysterectomy with appendages.
In the postoperative period, autohemotherapy, UV, electrophoresis, ultrasound, laser therapy, magnotolaser therapy, paraffin, ozokerite or mud applications are indicated for the prevention of scarring and adhesions. It is possible to carry out gynecological, segmental, point, vibration massage, balneotherapy.
Prognosis and prevention
With pyosalpinx, the prognosis may be aggravated by a violation of the menstrual cycle, the development of a persistent form of infertility, an increase in the likelihood of ectopic pregnancy. When planning pregnancy, repeated laparoscopic treatment is usually required with the restoration of the lumen (reocclusion) and subsequent assessment of the patency and functional state of the fallopian tubes (hysterosalpingography, ultrasound examination).
Prevention of pyosalpinx in gynecology dictates the need for timely treatment of salpingitis, exclusion of STIs (gonorrhea, chlamydia, mycoplasmosis, etc.), prevention of abortions, postoperative and postpartum complications.