Hydrosalpinx is a sac formation resulting from the accumulation of fluid in the lumen of the fallopian tube. In acute course it is characterized by fever and pain in the groin area, in chronic — infertility and a feeling of heaviness in the lower abdomen. In some cases, with a sluggish process, moderate pelvic pain and periodic watery vaginal discharge are possible. Gynecological examination, hysterosalpingography and ultrasound hysterosalpingoscopy, laparoscopy and fertiloscopy are used for diagnosis. Treatment is most often surgical with the preliminary appointment of antibiotics. Tubal plastic surgery or tubectomy is recommended.
According to various studies in the field of obstetrics and gynecology, the prevalence of hydrosalpinx in patients who cannot get pregnant ranges from 7.3 to 28%. Often, the disease becomes an accidental finding during a comprehensive examination for infertility. Accumulation of serous exudate or pus in one or both fallopian tubes is usually detected in young women (up to 30 years old), which is associated with the peculiarities of their sexual behavior. Hydrosalpinx is almost never primary, usually complicates the course of other gynecological pathology, primarily inflammatory diseases caused by specific and non-specific infections.
Causes of hydrosalpinx
Serous fluid or pus accumulates in the lumen of the fallopian tubes in the presence of obstacles to its outflow in conditions of normal or increased secretion. The main reasons for the development of the hydrosalpinx are:
- Inflammatory processes. With chronic salpingitis and salpingoophoritis, adhesions are formed inside the tubes that can block the ampullary part, the lumen and exit into the uterine cavity. Usually, the adhesive process develops with chronic inflammation, although it can also be the result of an acute process. Spikes occur with nonspecific infections and STDs (chlamydia, gonorrhea, mycoplasmosis, syphilis, genital herpes, etc.).
- Invasive manipulations. The impetus for the formation of synechiae are invasive diagnostic and therapeutic manipulations on the female genital organs. Connective tissue splices in the intramural part are formed after abortions and diagnostic curettage. The formation of synechiae in all parts of the tube is facilitated by hysterosalpingography, kimopertubation, hydrotubation, reconstructive surgery for tubal infertility.
- Endometriosis of the fallopian tubes. With the cyclic functioning of endometrioid growths in the tubes, aseptic inflammation is maintained. As a result, both the formation of adhesions and increased formation of mucosal secretions occur. In addition, rejected tissues and blood periodically enter the lumen of the pipe.
- Cancer of the tube or uterus. The exit to the uterine cavity can be blocked mechanically due to the growth of a volumetric neoplasm. Depending on the histological composition and localization of the tumor, sometimes the process is aggravated by increased formation of tubal secretions.
Factors predisposing to the development of hydrosalpinx are frequent changes of partners and unprotected sex. Women who are engaged in heavy physical labor and work in conditions of constant hypothermia also belong to the risk group.
The mechanism of hydrosalpinx formation is based on an imbalance between secretion and outflow of fluid from the fallopian tubes. Normally, the mucous membrane produces a small amount of exudate, which, due to the contraction of muscle fibers, is freely excreted into the uterus. In the presence of synechiae or tumor obturation, the outflow of serous fluid is first disrupted, and as the hydrosalpinx progresses, it completely stops. An additional link in the pathogenesis is the increased secretion of mucosal epithelium in inflammatory diseases, endometriosis and neoplasia. The addition of infection is often accompanied by the accumulation of purulent secretions.
When systematizing the disease, criteria such as the type of secretion, localization, structural features, the nature of the course and the possibility of exudate outflow are taken into account. The following types of hydrosalpinx are distinguished:
By type of secret:
- Serous (hydrosalpinx). The accumulation of serous fluid occurs with impaired outflow and absence of inflammation, its aseptic nature and at the beginning of the infectious process.
- Purulent (pyosalpinx). Pus accumulates in the fallopian tube when the hydrosalpinx is complicated by nonspecific or specific inflammation.
- One-sided. It is manifested by the delay of exudate in one of the pipes. It can be right- or left-sided.
- Two-sided. Both fallopian tubes are involved in the pathological process.
According to the features of the structure:
- Plain. It is represented by one cavity with exudate.
- Follicular. It consists of several cavities separated by splices.
- Acute (active). It is characterized by a rapid course, pronounced symptoms and rapid formation of a cavity with fluid.
- Chronic (sluggish). Develops gradually, proceeds asymptomatically or with minimal complaints.
According to the possibilities of fluid outflow:
- Constant. An independent outflow of exudate is impossible.
- Ventilated. The fluid periodically spontaneously pours into the uterus.
Symptoms of hydrosalpinx
The clinic of the disease is determined by the peculiarities of the course. Acute hydrosalpinx occurs rarely, manifested by hyperthermia and pain syndrome. The severity of hyperthermia depends on the nature of the exudate. With serous inflammation, the temperature rises to subfebrile figures, with serous-purulent — up to +38 ° C, with purulent — up to +39 ° C and above. The pain is localized in the groin area from one or two sides, it feels like bursting or throbbing. The patient may experience weakness, bruising, rapid heartbeat. Sometimes there is excessive sweating and feverish blush on the cheeks.
Chronic hydrosalpinx is mostly asymptomatic. Often its only sign is infertility. With large-volume formations, a woman has a feeling of heaviness and swelling in the lower abdomen. If the disease is combined with pelvic adhesions, the syndrome of chronic pelvic pain is characteristic, which increases with exertion, hypothermia, during sexual intercourse. The temperature rises only with an exacerbation of the inflammatory process and rarely reaches high figures. With the spread of inflammation to the ovarian tissue, a violation of the menstrual cycle is possible (oligomenorrhea, algodismenorrhea, irregular menstruation). A typical sign of a ventilated hydrosalpinx is periodic abundant watery discharge from the vagina.
The main complication of bilateral hydrosalpinx is tubal infertility. Since the accumulation of fluid usually occurs with complete obstruction of the tubes, the egg cannot get into the ampullary part and further into the uterus, fertilization and implantation become impossible. In 5-7% of cases (more often with ventilated hydrosalpinx) pregnancy may occur, but the risk of its ectopic tubal localization increases. A formidable complication of the disease is the rupture of the pipe and the ingress of its contents onto the peritoneum. In such cases, pelvioperitonitis and peritonitis usually develop, which are especially severe with a ruptured pyosalpinx. Sometimes pus breaks out into the vagina, bladder, rectum or accumulates in the form of an isolated abscess of the Douglas space.
Since the symptoms of the hydrosalpinx are not pathognomonic, studies are prescribed to diagnose the accumulation of fluid in the fallopian tube. The following diagnostic methods are the most informative:
- Examination on the chair. During a bimanual examination in the appendage area, a voluminous, tight-elastic, painless formation with a smooth surface is palpated from one or both sides.
- Ultrasound of the pelvic organs. A volumetric liquid structure is determined between the ovaries and the uterus. The folds of the fallopian tubes are smoothed or absent.
- Ultrasound hysterosalpingoscopy. The probable hydrosalpinx is indicated by the accumulation of fluid in the uterus and the expansion of its cavity.
- Hysterosalpingography. With a constant variant of the disease, the contrast agent does not enter one or both tubes and accumulates in the uterus. With a vent hydrosalpinx, the affected tube is defined as expanded, flask-shaped.
- Endoscopic methods. Traditional laparoscopy and fertiloscopy with the introduction of an endoscope through a micro-incision into the vagina allow you to see an expanded tube with fluid accumulated in it, identify adhesions and foci of endometriosis in the pelvic cavity.
In addition to instrumental studies, laboratory diagnostic methods are used. The results of PCR, which allows detecting gonococci, spirochaetes, chlamydia, ureaplasmas, mycoplasmas, trichomonads and other possible pathogens of urogenital infections, against which hydrosalpinx appeared, are particularly indicative. Differential diagnosis is carried out with other diseases of the female genital organs — salpingitis, oophoritis, salpingoophoritis, endometritis, endometriosis, pelvic adhesive disease, tuberculosis and neoplasms of the ovaries, tubes, uterus and other pelvic organs, appendicular abscess, etc. In difficult cases, oncogynecologist, urogynecologist, surgeon, phthisiologist are involved in the diagnosis.
The choice of medical tactics is determined by the clinical phase of the disease, the volume and structure of the cavity formation, age and reproductive plans of the patient. Since in most cases hydrosalpinx is formed against the background of inflammation, the first stage of treatment is conservative therapy with antibacterial drugs. When choosing an antibiotic, the type and sensitivity of the infectious agent are taken into account. Antibiotic therapy is supplemented with the appointment of desensitizing, immunomodulating, resorbing agents, vitamin and mineral complexes, physiotherapy techniques. With pain syndrome, the appointment of nonsteroidal anti-inflammatory drugs is indicated.
After the inflammation is relieved, the tactics of surgical intervention are determined. Taking into account the degree of obliteration of the tube, the tendency of the hydrosalpinx to relapse and the woman’s plans for the birth of a child, the following operations are recommended:
- Laparoscopic reocclusion. Performing salpingostomy and salpingoneostomy with the creation of an alternative opening, applying salpingo-salpingo-anastomosis, transplanting a tube to another part of the uterus in some cases can restore exudate evacuation and eliminate hydrosalpinx.
- Laparotomy or laparoscopic tubectomy. If the formation is large, the plastic was ineffective, there was a relapse of the disease or the woman’s age exceeds 35 years, removal of the tube (tubectomy) is indicated. If the patient wishes to become pregnant, one of the IVF methods is subsequently used.
Prognosis and prevention
The prognosis for uncomplicated course and timely adequate treatment is favorable. A certain risk to life occurs only when the sac formation breaks. However, the reproductive function in hydrosalpinx can be restored in less than half of the patients. According to various data, the effectiveness of plastic surgery ranges from 20 to 60%, while the risk of tubal ectopic pregnancy increases significantly. For preventive purposes, periodic gynecologist examinations are recommended for the timely detection and treatment of diseases of the female genital area. It is important to take a responsible approach to pregnancy planning with the restriction of casual intimate relationships and the use of barrier contraception, the rejection of unjustified invasive interventions.