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Introduction :
Pelvic Inflammatory Disease is usually part of a complex of recurrent
infections superimposed on damaged tissue, although it may occur
following an initial episode of acute salpingitis. Initially,
there is salpingitis which resolves, but results in fibrinous
attachments to nearby organs. Involvement of the adjacent ovary
may serve including endometritis, salpingitis, salpingo-oophoritis,
tubo-ovarian abscess, and pelvic peritonitis.
Clinical :
The symptoms of acute pelvic Inflammatory Disease include: fever,
shaking chills, abdominal pain, nausea, vomiting, vaginal discharge,
and irregular vaginal bleeding. Signs of acute pelvic Inflammatory
Disease include abdominal guarding, rebound tenderness, increased
pain with cervical or adnexal manipulation, dyspareunia, leuko-cytosis,
elevated ESR, paralytic iléus, and shock from peritonitis.
3 criteria should be present :
* Lower abdominal tenderness
* Adnexal tenderness
* Tenderness with cervical motion
other symptoms:
* temperature
* Abnormal cervical and vaginal discharge
* Elevated erythrocyte sedimentation rate
* Elevated C-reactive protein level.
Symptoms of chronic pelvic Inflammatory Disease are persistent
pelvic/lower abdominal pain, irregular menses, and possibly infertility.
Signs of chronic Pelvic Inflammatory Disease may include presence
of an adnexal masses without fever.
Etiology :
Pelvic inflammatory disease is a type of sexually transmitted
disease, although this bilateral infection may be associated with
the use of an intrauterine contraceptive device (11).
Chlamydia is more common than gonorrhea as a source of infection,
but numerous aerobic and anaerobic organisms may also be present
(pelvic actinomycosis) (11). In many cases, the symptoms of chlamydia
and gonorrhea are mild or nonexistent in both females and males;
however, males are more likely to seek treatment when symptoms
are present. 85% of females and 40% of males with chlamydia infection
are asymptomatic, but 75% to 80% of men do not know that gonorrhea
and chlamydia can be asymptomatic and can have serious consequences.
Sonography :
1. Normal:
A normal appearance of all pelvic organs and structures. This
is usually seen with acute inflammation involving only the fallopian
tubes without dilatation.
2. Endometritis:
The endometrial echoes are usually absent. There may be fluid
present within the uterus. The uterus is hypoechoic with indistinct
margins and can appear enlarged and bulbous. No adnexal mass is
identified.
3- Salpingitis :
Salpingitis may be acute, subacute, or chronic (6).
* The sonographic appearance of acute salpingitis includes
nodular thickening of the walls of the fallopian tubes with diverticula.
Hyperemia is also present and can be shown color Doppler imaging.
Anechoic or echogenic (pus) fluid may be seen in the posterior
cul-de-sac of Douglas as may uterine enlargement with endometrial
fluid or thickening (endometritis).
* Subacute salpingitis indicates that infectious changes
have taken place without significant clinical signs and symptoms.
* Chronic salpingitis is related to recurrent bouts of
Pelvic inflammatory disease and may result in significant tubal
scarring and the presence of hydrosalpinx. The patient may have
pain during intercourse or bowel movements : from adhesions between
the bowel and peritoneal surface, and during menses. frequently
an adnexal structure, which may be separable from the ovary, is
seen. The structure is anechoic, tubular, and 1 to 4 cm in diameter
with hyperechoic walls. Tubal scarring may be seen sonographically
as several cystic structures extending from the uterus to the
adnexa; this is sometimes referred to as the "chain of lakes"
or "string of pearls" sonographic appearance. Infertility and
ectopic pregnancy may result from the tubal scarring.
4- Pyosalpinx :
Pyosalpinx is a progression of Pelvic inflammatory disease in
which the fallopian tubes become swollen with purulent exudates.
The mass is usually well-defined and clearly separable from the
surrounding tissue. In 60% of cases, the walls are sharp and smooth;
in the other 40%, they are irregular and ill-defined. The mass
is usually between 3 and 10 cm and ovoid in shape (5).
The sonographic appearance of pyosalpinx is consistent with visualization
of thick-walled tubular or serpiginous structures surrounding
the ovaries. The interstitial portion of the tube is tapered at
the corn of the uterus. The tube may also be described as sausage
shaped. Echogenic material or debris related to the presence of
pus may be seen within the fallopian tubes.
5- Hydrosalpinx :
Hydrosalpinx is a consequence of Pelvic inflammatory disease in
which the fallopian tube or tubes become closed at the fimbriae
and the pus within a pyosalpinx gradually liquefies, leaving serous
fluid. In addition, the walls of the tubes become thinner and
the tubes may dilate to twice the normal diameter. The patient
may be asymptomatic or may have colicky pain. Hydrosalpinx may
be present for a significant length of time before diagnosis of
infertility from blockage of the fallopian tubes.
Sonographically, the fallopian tubes appear as anechoic thin-walled
structures with a multicystic or fusiform mass effect. Color Doppler
is useful to differentiate hydrosalpinx from bowel or prominent
pelvic veins.
6- Tuboovarian abscess :
It involves a large portion of the pelvis. The pelvis will contain
a disorganized heterogeneous echo pattern having solid or cystic
areas. One-third of the time it will be impossible to identify
the uterus. When the uterus is seen, its specular echo pattern
will be absent. Tuboovarian abscess results from pus leaking from
an infected fallopian tube :pyosalpinx, and may occur from communication
with the ovary. Tuboovarian abscess is a result of serious pelvic
infection and is generally seen in the later stages of Pelvic
inflammatory disease.
Sonographically, tuboovarian Abscess appears as a thick-walled,
complex hypoechoic mass with fluid in the cul-de-sac and adnexa.
Tuboovarian Abscess may be bilateral or unilateral and can be
found in the adnexa or in the posterior cul-de-sac. Additional
sonographic appearances include a mass with septations, irregular
margins, and fluid-debris levels. Serial ultrasound examinations
can follow the response of the Tuboovarian Abscess to antibiotic
therapy or can provide guidance during a drainage procedure. If
untreated, Tuboovarian Abscess may progress to peritonitis. The
presence of air or gas within the abscess may make sonographic
detection and delineation of the disease process difficult unless
the examination correlates with clinical findings. In pelvic abscess
with peritonitis,diffuse spread of purulent fluid into thé surrounding
pelvic cavity is seen.
Differential diagnosis of hydrosalpinx
and pyosalpinx :
* Appendix abscess.
* Crohn's disease.
*Caecal diverticulitis.
*Multiloculated ovarian cysts.
*Hydatid or dermoid cysts.
*tubal torsion (4, 9).
*Fluid-filled bowel loops.
*Degenerated uterine leiomyoma.
treatment :
Large abscesses may be drained percutaneously or surgically (7,
8, 12). Transvaginal ultrasound-guided aspiration with anti-microbial
therapy may be a useful alternative for treatment of unruptured
tubo-ovarian abscess (10, 13). A surgical emergency can occur
with massive perforation by a pelvic abscess during which the
patient has a rapid progression of severe abdominal pain, nausea,
vomiting, peritonitis, shock from peritonitis, and endotoxemia.
Small abscesses still respond to the antibiotic treatment.
Most cases of pelvic Inflammatory Disease improve on antibiotics
alone.
Reference :
* 1: Lambert MJ, Villa M. Gynecologic ultrasound
in emergency medicine. Emerg Med Clin North Am. 2004 Aug;22(3):683-96.
Review.
* 2: Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti AM,
Melis GB. Transvaginal ultrasonography associated with colour
Doppler energy in the diagnosis of hydrosalpinx. Hum Reprod. 2000
Jul;15(7):1568-72.
* 3: Protopapas AG, Diakomanolis ES, Milingos SD, Rodolakis
AJ, Markaki SN, Vlachos GD, Papadopoulos DE, Michalas SP. Tubo-ovarian
abscesses in postmenopausal women: gynecological malignancy until
proven otherwise? Eur J Obstet Gynecol Reprod Biol. 2004 Jun 15;114(2):203-9.
* 4: Zalel Y, Soriano D, Lipitz S, Mashiach S, Achiron
R. Contribution of color Doppler flow to the ultrasonographic
diagnosis of tubal abnormalities. J Ultrasound Med. 2000 Sep;19(9):645-9.
* 5: Varras M, Polyzos D, Perouli E, Noti P, Pantazis I,
Akrivis Ch. Tubo-ovarian abscesses: spectrum of sonographic findings
with surgical and pathological correlations. Clin Exp Obstet Gynecol.
2003;30(2-3):117-21.
* 6: Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy
KE, Heller DS. Transvaginal sonographic markers of tubal inflammatory
disease. Ultrasound Obstet Gynecol. 1998 Jul;12(1):56-66.
* 7: Caspi B, Zalel Y, Or Y, Bar Dayan Y, Appelman Z, Katz
Z. Sonographically guided aspiration: an alternative therapy for
tubo-ovarian abscess. Ultrasound Obstet Gynecol. 1996 Jun;7(6):439-42.
* 8: Perez-Medina T, Huertas MA, Bajo JM. Early ultrasound-guided
transvaginal drainage of tubo-ovarian abscesses: a randomized
study. Ultrasound Obstet Gynecol. 1996 Jun;7(6):435-8.
* 9: Jaluvka V, Entezami M, Becker R, Weitzel HK. [Acute
torsion of hydrosalpinx. 2 cases after laparoscopic sterilization]
Ultraschall Med. 1995 Feb;16(1):33-5. Review. German.
* 10: Hsu YL, Yang JM, Wang KG. Transvaginal ultrasound-guided
aspiration in the treatment and follow-up of tubo-ovarian abscess:
a report of two cases. Zhonghua Yi Xue Za Zhi (Taipei). 1995 Sep;56(3):211-4.
* 11: Garland SM, Rawling D. Pelvic actinomycosis in association
with an intrauterine device. Aust N Z J Obstet Gynaecol. 1993
Feb;33(1):96-8. no symptoms and no pelvic abnormalities.
* 12: Shulman A, Maymon R, Shapiro A, Bahary C. Percutaneous
catheter drainage of tubo-ovarian abscesses. Obstet Gynecol. 1992
Sep;80(3 Pt 2):555-7.
* 13: vanSonnenberg E, D'Agostino HB, Casola G, Goodacre
BW, Sanchez RB, Taylor B. US-guided transvaginal drainage of pelvic
abscesses and fluid collections. Radiology. 1991 Oct;181(1):53-6.
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