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This discussion of acute pelvic inflammatory disease (PID) -- usually a spontaneous infection that occurs among sexually active, menstruating, nonpregnant women -- covers: pathophysiology; microbial etiology (gonorrhea, chlamydia, genital mycoplasmas, and aerobic and anerobic bacteria); epidemiology (number of sexual partners, age, IUDs, previous PID, previous gonorrhea, untreated male sexual contacts, and perihepatitis associated with PID); diagnosis (physical examination, laboratory examination, culdocentesis, examination of the male partner, cultures, and ultrasonography); treatment; and sequelae (recurrent PID, infertility, ectopic pregnancy, and pain). The majority of infections are caused by bacteria and a polymicrobial bacterial infection is common. Neisseria gonorrhea, Chlamydia trachomatis, and a wide variety of aerobic and anerobic bacteria are most frequently isolated from women with PID. Primary PID is usually and acute infection in which organisms ascend into the uterus and fallopian tubes from the cervix. Chronic active infections are unusual except in neglected cases and in Actinomyces infection, but sterile chronic inflammatory adhesions are common residuals of acute infection. Except for women who have an IUD in place or the 15% who have had uterine instrumentation, spontaneous PID is almost totally confined to women who are sexually active. There is a much higher PID rate among younger than older women. Women who use an IUD for contraception are at least 2-4 times more likely to develop PID than nonusers. Women who have had PID are twice as likely to develop the infection as those who have never had it. A history of a prior uncomplicated gonococcal infection is more common among women with PID than among women without disease. Untreated males with urethral N. gonorrhea and possibly with C. trachomatis infection are an important source of infection both for the initial and for recurrent episodes of PID. Abdominal pain is the most common symptom although the pain may be mild or even absent in at least 5% of patients with PID verified by laparoscopy. In patients who have overt PID, it is possible to establish the diagnosis with reasonable certainty by a combination of history, physical examination, Gram stain of cervical secretions, culdocentesis, and examination of the male sexual partner. Adequate treatment of salpingitis includes an assessment of the severity of the infection, administration of appropriate antibiotics, employment of other health measures, close patient follow-up, and treatment of the male sexual patner. 25% of women with 1 episode of salpingitis develop a subsequent episode.
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PMID:Acute pelvic inflammatory disease. 636 7

The increased prevalence of venereal disease among adolescents has resulted in a rise in nonacute salpingitis. Laparoscopy was evaluated as an aid in the diagnosis and treatment of presumed nonacute salpingitis in 29 adolescents. The patients had a mean duration of symptoms of 5.5 months, 50% had a recent history of discharge and/or bilateral pelvic pain, and on examination 50% had pain on motion of the cervix, 75% had adnexal tenderness, and 50% had a palpable adnexal fullness or mass. Anatomic findings at laparoscopy included normal pelvic structures in 8, active salpingitis in 13 and nonacute disease in 8. The anaerobic, aerobic, and viral peritoneal cultures obtained at laparascopy from 22 patients resulted in no growth in 18. The four with positive cultures had one organism identified in three cases and two organisms in one case. Anatomic findings were more helpful in diagnosis than the bacteriologic analysis, and our results suggest that laparoscopy increases diagnostic accuracy in the management of presumed nonacute salpingitis.
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PMID:Laparoscopy for presumed nonacute salpingitis: a new look at an old problem. 645 21

This discussion of vaginal bleeding in adolescents reviews the causes of dysfunctional uterine bleeding (complications of pregnancy, pelvic inflammatory disease and/or complications of the use of oral contraceptives or IUDs, blood dyscrasias, trauma and foreign bodies, tumors, and other causes) as well as the diagnosis and treatment of dysfunctional uterine bleeding. Menstrual irregularities are the most common cause of abnormal vaginal bleeding in adolescence and can be managed easily in the office. On occasion an adolescent needs to be hospitalized for acute menorrhagia; very rarely a surgical procedure such as dilatation and curettage is necessary. Dysfunctional uterine bleeding is defined as abnormal uterine bleeding without local anatomic causes. It is a diagnosis of exclusion and requires an adequate examination of the vagina, cervix, and other pelvic organs. Some local bleeding presents as irregular vaginal bleeding in adolescents and is diagnosed as dysfunctional bleeding. The diagnosis of pregnancy and related complications (threatened abortion, incomplete or complete abortion, ectopic pregnancy, and postabortal trophoblastic disease) may present as irregular bleeding in the practitioner's office. A teenager may give a history of pregnancy if she is questioned about it closely and confidentially. A high index of suspicion will help the clinician to make this diagnosis. Salpingitis should be suspected in any teenager who presents with low abdominal tenderness, pain, abnormal bleeding, low grade fever, and tenderness on cervical movement. Approximately 10% of teenagers with blood dyscrasias present with cyclic hypermenorrhea. Vaginal ulcerations and objects introduced into the vagina occasionally cause irregular bleeding. Such tumors as clear cell adenocarcinoma of the vaginal and sarcoma botyroides may present as metrorrhagia. These etiologic factors comprise as most only about 5% of adolescents who complain of irregular vaginal bleeding. The most common cause of such bleeding is anovulation or oligoovulation due to the noncyclic release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) during adolescence. Although the most common cause of this cyclic disturbance is the hypothalamic pituitary ovarian axis, some well known endocrine disorders can also produce this picture. 95-97% of adolescents will have no organic reason for their irregular bleeding. The diagnosis of dysfunctional uterine bleeding is then made. Detailed suggestions are provided on how to proceed which will prevent grave errors in the diagnosis and treatment of dysfunctional uterine bleeding in adolescents. The patient who has been bleeding very heavily and has a hematocrit less than 30 may have to be hospitalized. A medical D and C can be done with a progestational agent. Such patients may need a transfusion of packed cells and should be kept on oral iron. They also need cycling with Ovral for 2-3 months and must be followed carefully.
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PMID:Vaginal bleeding in adolescents. 674 72

Currently, the most used IUD's are those containing copper and the ones containing progestins. The foreign body reaction to these IUDs leads to biochemical and biological changes in the uterus which affect ovum and sperm transport and the development of the blastocyst. Copper augments this foreign body reaction and has a cytotoxic effect on sperm and blastocyst. Progesterone causes atrophy of the glands, a pseudodecidual stroma reaction of the endometrium and a change in blastocyst metabolism preventing implantation. Indications for IUD are: 1) older women with completed families, 2) between desired pregnancies, 3) with contraindications for hormonal contraception, 4) low compliance (e.g. mental disorders). Patients should be carefully examined before insertion of a well-fitting IUD. Patient education must include the occurrence of cramplike pain after insertion; light bleeding for a few days; more bleeding at first and, possibly, subsequent menstruation. Patients should be encouraged to see their doctor with more severe pain, bleeding, or fever. IUD should not be inserted immediately following pregnancy or abortion; higher expulsion and/or pregnancy rates have been observed with this in various studies. Follow-up with sonography after insertion should be done the 1st 2 months, then every 6 months. Pregnancy rates for various IUD's in the 1st year of use are between 0.5 and 2.6/100 women. Side effects of IUD's are spontaneous expulsion (1.4-15.7/100 women) in 1st year, bleeding disorders, pain, adnexitis, uterus perforation and ectopic pregnancy. Various contraindications for IUDs are listed. Indications for removal are: desire for children, pregnancy with in-situ IUD, pathological bleeding over more than 3 cycles, severe pain which does not disappear with spasmolytic analgesics, and occurrence of salpingitis.
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PMID:[The intrauterine device from today's perspective]. 685 15

Drs. Edelman and Bergers' report "Contraceptive practice and tuboovarian abscess (Am. J. Obstet. Gynecol. 138:541, 1980) may produce the impression in the medical profession that the IUD does not predispose to salpingitis, salpingo-oophoritis, and tubo-ovarian abscess, as published data and clinical experience would suggest. Also, the diagnostic criteria for diagnosing 'acute pelvic inflammatory disease' stated in the report, and published studies of Jacobson and Westrom and Chaparro et al question a diagnosis of pelvic inflammatory disease that is not confirmed endoscopically or by some direct visualization obtained surgically. 35% of patients who had laparoscopy by Jacobson and Westrom and who were suspected of having salpingitis, or pelvic inflammatory disease, and 54% of laparoscoped patients suspected by Chaparoo et.al. of having pelvic inflammatory disease were found not to have either salpingitis or pelvic inflammatory disease of gynecologic etiology. As pelvic inflammation may be caused by a variety of disorders, such as appendicitis, colitis, diverticulitis, and others, the term pelvic inflammatory disease is an imprecise diagnostic term. Edelman and Berger's results can also be questioned on the ground that numerous reports (e.g., Second Report on Intrauterine Contraceptive Devices, Food and Drug Administration, 1978; Population Reports, Series B, No. 3, May 1979, the Johns Hopkins University) indicate an increased incidence of salpingitis with its attendant pelvic crippling pain and infertility that is many times more common in IUD users than in nonIUD users. Available published data therefore strongly suggest that an IUD user is at far greater risk of developing inflammatory disease of infectious etiology in her reproductive tract with its attendant pain, morbidity, infertility, and even death than nonIUD users.
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PMID:Inflammatory disease with use of IUD. 727 Jun 16

200 women threatened with abortion during the first 16 weeks of pregnancy were examined with diagnostic ultrasound to determine whether there were signs of intrauterine life. Of the 90 who showed positive signs, 8 aborted spontaneously later, the other 82 continued their pregnancy. The ultrasound investigation revealed no signs of intrauterine life in 110 patients. Of these, spontaneous abortion or later evacuation because of missed abortion 101 (histopathological examination showed degenerated villi in 98), not pregnant 4, mola hydatidosa 3, extrauterine pregnancies 2. An ultrasound examination was performed to ascertain whether 136 women with suspected ectopic pregnancy had intrauterine pregnancies. 61 of them had an intrauterine gestational sac, confirmed at clinical follow-up. One of the 61 was operated on with laparoscopy because of pain; no abnormalities were found. In 36 of the other 75, laparoscopy was performed. Ectopic pregnancy 21, ovarian or parovarian cyst 11, adhesions 2, salpingitis 1, and normal 1. Diagnostic ultrasound is excellent for accurate prognosis in threatened abortion. Unnecessary operations avoided; hospitalization in suspected ectopic pregnancies reduced.
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PMID:Diagnostic ultrasound in threatened abortion and suspected ectopic pregnancy. 742 1

The Fitz-Hugh and Curtis syndrome is a perihepatitis following a genital infection. It usually occurs in young women but male cases have been reported. Chlamydia trachomatis is the most frequent causal agent observed in Europe and the United States. This germ is the number one cause of salpingitis in developed countries. Clinical signs include acute or recurrent pain in the right hypochondria. Liver tests are not modified and the sonographic examination is normal. The diagnosis can be suspected on the basis of serology results using either indirect immunofluorescence with live antigens specific for serotype D or K or ELISA. Positive predictive value is 80-90% and negative predictive value 96-99%. Diagnosis is formally established with laparoscopy. In our experience with more than 100 patients, the perihepatitis (glissonitis with pseudo-membranes) is frequently associated with adherences. The peritoneum is inflammatory and there are usually a small amount of liquid. Specimens are taken for culture. Polymerase chain reaction will improve the detection of Chlamydia since this germ is very difficult to culture. Antibiotic treatment with adapted drugs given for sufficient time is effective.
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PMID:[Fitz-Hugh and Curtis syndrome]. 749 47

Between July and November 1991, 32 women (mean age 24.8 years) were examined laparoscopically in our department for suspected tubal sterility. All women had smears taken from cervix, vagina, and urethra, and all were negative regarding an infection with Chlamydia trachomatis. All women had open fallopian tubes, however, with inflammatory changes that varied in degree. Fifteen women reported pains and were classified as PID (pelvis inflammatory disease)-positive, as compared to the PID-negative group of 17 women without pain. In the group of the 15 PID-positive women, we could detect Chlamydia trachomatis in the form of salpingitis in 11 cases in the direct demonstration of the infectious agent. IgA antibodies were detected in the serum of all of these women, in 12 of them IgA + IgG antibodies. In the group of the 17 PID-negative women, three were positive in the direct detection of the infectious agent, and IgA and/or IgG antibodies were detected in five cases. 38% of the women in the PID-positive group and 68% in the PID-negative group conceived within a period of one year after having completed a treatment with antibiotics.
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PMID:Salpingitis caused by Chlamydia trachomatis and its significance for infertility. 797 47

Salmonella spp. infections can be particularly challenging when they manifest as acute abdominal problems and lead to emergency surgery. Examples of such serious conditions are Salmonella-related intestinal perforation, gallbladder involvement, salpingitis, and peritonitis. Mesenteric lymphadenitis associated with Salmonella typhimurium mimics acute appendicitis and can make it difficult to establish a timely and definitive diagnosis in young patients who present with right lower abdominal pain. Paralytic ileus is a fairly common manifestation of Salmonella infection at all ages, but complete intestinal obstruction requiring surgical intervention is very rare. Because of the nature of the diagnostic process, a significant number of patients with Salmonella infection present with acute abdomen and undergo needless operations. This report describes the cases of 2 pediatric patients who underwent surgery to address persistent pain in the right lower abdominal quadrant and complete intestinal obstruction, respectively. The first patient had inflamed mesenteric lymph nodes that caused appendicitislike symptoms, and the second had dense adhesions between the mesentery and the terminal segments of the ileum that led to intestinal blockage. Serology results showed that both patients' titers for BO ("B and O agglutinating [BO]") antibodies rose to 1:640 in the week after their admission to hospital, a pattern and level that is indicative of S typhimurium infection. J Pediatr Surg 36:1849-1852.
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PMID:Acute abdomen caused by Salmonella typhimurium infection in children. 1173 22

The Gyne T 380 IUD is similar to the Gyne-T 200 available in France since 1979 except that it contains a ball on the extremity of the vertical arm designed to prevent cervical perforation and it has a higher copper content. A multicenter study found cumulative annual event rates/100 women for the Gyne T 200 and the Gyne T 380 respectively of 4.9 and .7 for pregnancy, 10.1 and 6.8 for expulsion, 13.7 and 21.5 for removal because of pain or bleeding, 4.9 and 4.3 for removal because of other medical reason, and 5.9 and 10.4 removal to achieve pregnancy. The continuation rates were 54.9 and 50.1, while number of months of utilization were 82,800 for the Gyne T 200 and 17,652 for the Gyne T 380. An American study of 3536 insertions of the Gyne T 380 showed rates after 1, 2, and 3 years of use respectively of .7, .8, and 1.1 for pregnancy, 5.5, 7.5, and 8.5, for expulsion, 13.1, 21.8, and 26.7 for removal because of pain or bleeding, 3.0, 4.6, and 5.4 for removal for other medical reasons, and 73.0, 53.7, and 41.1 for continuation. 68.2% of participants in the American study were under 25 and 63.7% were nulliparas. Additional data after 4 years of use of the Gyne T 380 showed a cumulative net pregnancy rate of 1.9. The risk of extrauterine pregnancy was estimated at .38/1000 women after 3 years. The frequency of expulsions appeared to be negatively connected with age and parity. Rates of removal for pain or bleeding appeared to be negatively correlated with age. In the comparative study, rates of removal for pain or bleeding were higher in nulliparas. Most medical reasons for removal other than pain or bleeding referred to pelvic inflammations, salpingitis, endometritis, or vaginitis, and their frequency declined after the 1st 6 months of use. Continuation rates were identical for the Gyne T 380 and for the other T devices in the American study. Among 293 women requesting removal of the device for pregnancy, 78.4% became pregnant within the next 12 months. 1767 women in the American study had Pap smears before and during Gyne T 380 use; the proportion in classes III and IV did not change after insertion of the device. 2 Indian studies demonstrated no neoplasic transformations or aggravations of dysplasic lesions. Analysis of a small number of randomly selected Gyne T 380 IUDs removed for study showed an average release during the 1st year of 50.3 mcg/day of copper, varying from 17.5 to 63.9 mcg in 8 of the 9 devices. The rate declined with time and was half as high in the 3rd and 4th years. Fragmentation of the copper wire apparently is less frequent in the Gyne T 380 than in the Gyne T 200. The location of the copper wires on both horizontal arms may explain the greater contraceptive efficacy of the Gyne T 380.
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PMID:[The TCu380 IUD: initial international experimental results with the latest "T" family IUD]. 1226 1


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