Pyosalpinx

PYQSALPINX (from Greek pyos-pus and salpinx-tube) (purulent salpingitis, tubal empyema), accumulation of pus in the Fallopian tube due to blockage of its abdominal opening. Pyosalpinx can be of primary or secondary origin. In the first case, pus accumulates in the tube canal directly following purulent salpingitis (see Salpingitis), in the second, pus forms in a pre-existing hydropsalpinx (see) under the influence of pathogenic bacteria or saprophytes penetrating the tube cavity. The agents of suppuration are most often gonococci, pyogenic cocci (streptococci and staphylococci) and tubercle bacilli, much less frequently Pseudomonas pyocyaneus, Friedlander's pneumobacillus and others. Secondary suppuration is also caused by the intestinal bacillus (Bacillus coli commune) penetrating the tube from the lower parts of the large intestine. The agents of suppuration can be carried into the tube cavity via the lymphatic and blood vessels, or finally penetrate into it from the abdominal cavity, which is most often observed in tuberculous peritonitis. According to the latest data of Holtz (1930), based on the study of 1,262 cases of salpingitis, pus was sterile in 60%, gonococci were found in 78%, pyogenic cocci in 20%, and only in 2% was a mixed pyogenic-gonococcal infection established. The pathological-anatomical picture of pyosalpinx in typical cases reduces to the presence of a bag stretched with purulent contents, having the shape of a pear, a retort, an oval or a sausage, sometimes with beaded thickening. Thanks to reactive inflammation of the surrounding peritoneum, pyosalpinx is almost always wrapped in false pelvoperitonitic adhesions (pelvoperitonitis adhaesiva), gluing it to the ovary, uterus, intestines, omentum and parietal peritoneum, as a result of which a large or small voluminous conglomerate is obtained, fixed mainly to the posterior surface of the uterus due to the predominant formation of adhesions in the posterior Douglas space. In most cases, pyosalpinx is bilateral. The thickness of the walls of the purulent bag varies and depends on the amount of pus, on the degree and depth of the spread of inflammatory changes in the thickness of the tube walls; with a significant accumulation of pus, especially liquid, the walls can be so thinned that the tumor gives the impression of hydropsalpinx externally. Sometimes, on the contrary, the walls of pyosalpinx reach considerable thickness - up to 2 1/2-3 and more cm. In size, pyosalpinx rarely reaches the size of a male fist, although cases of huge tumors, for example, the size of a uterus at 8-9 months of pregnancy, are described. The contents of pyosalpinx are pus of varying consistency, from watery-liquid (in more recent cases) to very thick, cream-, sour cream-like and even curd-like mass. The color of the pus is yellowish with a grayish or greenish tint, sometimes darker, brownish or brownish (chocolate, coffee); the latter depends on the admixture of blood pigment and is most often observed in pyosalpinx of tuberculous origin or in secondary suppuration of a tubal blood tumor after an interrupted ectopic pregnancy. Changes in the inner layers of the tube in pyosalpinx are identical to those in salpingitis. The entire inner surface of the tube loses its mucous character and turns into granulation tissue similar to the granulation wall of an abscess. Sometimes ulcers form on the surface of the tubal mucosa, which is most often observed in tuberculous pyosalpinx. In old cases, the deep layers of the tube wall present more pronounced changes, consisting of fatty and hyaline degeneration of the submucosa, the walls of blood vessels and muscle fibers with the formation of persistent fibrous (scar) connective tissue. Between bundles of muscle fibers, as well as under the peritoneum covering the tube and between the adhesions wrapping it, individual encapsulated purulent accumulations (perisalpingitic abscesses) are encountered, as well as cavities filled with transparent contents, representing dilated lymph and blood vessels under the influence of stasis. In microscopic examination in pyosalpinx, accumulations of a large number of plasma cells in the thickness of the mucosa and submucosa (see Salpingitis) and special large vacuolated cells filled with doubly refracting light lipoids ("xanthoma cells") are noted. Cholesterol agglomerates are encountered very rarely both in the purulent cavity and in the thickness of the tube walls. The course of pyosalpinx is prolonged, chronic. The purulent tumor of the tube can exist for years, giving itself away only from time to time during exacerbation of the process under the influence of activation of both specific (fresh infection) and non-specific irritants (active hyperemia of pelvic organs, accidental general diseases, such as influenza, introduction of foreign protein into the body parenterally, etc.). Over time, the purulent contents of the cavity thicken due to the resorption of liquid components, the walls of the tube sclerose more and more, so that in the end spontaneous relative healing may occur, whereby the tubes turn into relatively small dense formations firmly fixed to the angles, to the posterior surface or to the lateral edges of the uterus by inflammatory membranes and strands. In other, more rare cases, the amount of pus may increase so much that due to the sharp thinning of the walls of pyosalpinx, rupture of the latter occurs with leakage of pus into the abdominal cavity and subsequent development of general acute purulent peritonitis. Sometimes pus breaks through into one of the hollow organs fused with pyosalpinx - into the rectum or bladder. After rupture and emptying of the abscess into the rectum, the purulent cavity may become empty and relative healing occur; in other cases (and when breaking into the bladder, as a rule), a persistent purulent fistula is formed, through which fresh infection re-enters the cavity of pyosalpinx, which leads to constant, sometimes strengthening, sometimes weakening purulent discharge, very exhausting for patients and sometimes leading to amyloid degeneration of parenchymatous organs. In extremely rare cases, rupture of pyosalpinx occurs through the anterior abdominal wall, into the vaginal vault or into the uterine cavity. Finally, the formation of so-called tubo-ovarian cysts, i.e., the occurrence of a communication between the cavity of pyosalpinx and some pre-existing cavity of an ovary fused with it (follicular or other cyst, corpus luteum abscess, etc.), is relatively often observed. The clinical picture of pyosalpinx corresponds to that of chronic inflammation of the tubes, ovaries and pelvic peritoneum. Subjective symptoms consist mainly of complaints of pain in the lower abdomen, on the sides, in the sacrum and in the lower back, appearing mainly after strenuous movements and physical exertion; pains in the region of sacroiliac synchondroses can be considered typical; these are painful upon pressure (V. F. Snezhirev). Menstrual function is disturbed, there are profuse, painful menstruations, sometimes irregular - frequent, less often delayed. Sexual intercourse is often painful. In some cases, evening chills, painful frequent urination and pain during defecation are noted. All these complaints are caused not so much by the size and character of the pyosalpinx itself as by the amount and predominant localization of pelvoperitonitic adhesions. Leucorrhea is often, but by no means always, present, usually not profuse, liquid, watery, irritating, having a clearly expressed alkaline reaction. In bilateral pyosalpinx, absolute infertility is always observed, which sometimes is the only symptom in the complete absence of any other pathological phenomena. Among general phenomena in cases accompanied by persistent pain, disorders of the nervous system, increased sensitivity, nervousness, irritability come to the fore. Sometimes a characteristic premenstrual rise in temperature is observed (rarely, however, above 37.2°-37.8°). The diagnosis of pyosalpinx is established on the basis of anamnestic data, clinical picture and data of bimanual examination, which reveals the presence in the small pelvis of immobile, closely adjacent to the uterus tumors of uneven consistency, sometimes dense, sometimes elastic, giving sometimes the sensation of deep fluctuation, surrounded by dense, large or small painful, diverging in various directions strands. The connection of pyosalpinx with the uterus is sometimes so intimate that with considerable density of the tumor, differentiation of pyosalpinx even from uterine fibromyoma may be necessary; elastic tumors can be confused with ovarian cyst, hydropsalpinx or with encapsulated pelvoperitonitic effusion (pelvoperitonitis saccata). With delayed menstruation, a more mobile pyosalpinx can give occasion for confusion with ectopic pregnancy. Cases are described when an atypically located, fixed high outside the small pelvis pyosalpinx was taken for a tumor of the intestine (Antonopoulos). Repeated careful examination of patients, very careful sounding of the uterus, correlating objective data with anamnestic, as well as determining the leukocyte formula and the rate of erythrocyte sedimentation, allow in most cases to establish the correct diagnosis.

The differential diagnosis between a pyosalpinx located in the posterior Douglas space, enclosed by an exudative pelvic peritonitis, and a hematoma of the pouch of Douglas (see Pregnancy, Ectopic) is sometimes achieved only by means of a puncture through the posterior vaginal fornix; however, due to the risk of exacerbating the process by introducing fresh infection, this method should by no means be abused, and it should be resorted to only in extreme cases, for example when deciding on the necessity of surgical intervention. The prognosis for pyosalpinx is favorable in terms of preservation of life (with the exception of rare cases of perforation into the abdominal cavity), but is doubtful regarding complete restoration of health and bodily functions; in the overwhelming majority of cases, permanent infertility remains; pyosalpinx results in a high percentage of loss of working capacity. Treatment of pyosalpinx consists mainly of the application of heat in the most diverse forms: hot water bottles, warming compresses, hot (45°-50°) vaginal douches with hypertonic solutions of common salt, warm light electric baths, general saline water baths, mud treatment both general and in the form of vaginal tampons; the latter act very well when the vaginal thermophore of Livanov, which significantly enhances their thermal effect, is used. Special attention deserves local diathermy with electrodes placed in different positions, depending on the localization of the tumor. In pyosalpinx of tubal origin, light treatment—heliotherapy—and illumination of large areas of the body with a mercury-quartz lamp act well. In the presence of abundant dense adhesions and a small size of the tumor, it is useful to apply weight treatment in the form of a vaginal ring filled with mercury and a bag of sand or shot placed on the abdomen of the patient lying in a slightly elevated pelvis. Most of these methods are applicable only in the absence of signs of an active process; with the slightest exacerbation of which (intensification of pain, increase in body temperature, acceleration of erythrocyte sedimentation rate), all of them must be stopped and replaced by complete rest of the patient, with the application depending on the case of either a bag of ice or warming compresses and hot water bottles. Intramuscular injections of a 20% ichthol solution (Azatyan) act very well in terms of stopping pain and shortening the course of the acute period. Treatment is very prolonged, lasting from several months to 2-3 years (on average about 1.7 years), but with patience and persistence on the part of the patient and the doctor, it makes it possible to achieve the elimination of distressing symptoms and restoration of working capacity in 60-65% of all cases. Only when conservative treatment is completely ineffective can one decide on surgery, which consists in the removal of the affected organs, and sometimes even the uterus itself; such a radical course of action is dictated by the necessity to prevent the formation of postoperative adhesions in the pelvis, which cause displacement of the remaining organs and the recurrence of pain. Surgery has to be performed almost exclusively by the abdominal route, since the vaginal route is inapplicable due to the abundance of adhesions. Radical surgery gives a primary mortality rate of 5-6% and up to 75-80% of permanent recovery, if one does not count the phenomena associated with the removal of the ovaries. More conservative surgical intervention has to be resorted to in cases of symptoms of a threatening rupture of a purulent sac; it consists in the opening of the pyosalpinx, which is usually performed by posterior colpotomy. Treatment of general peritonitis when pus penetrates into the free abdominal cavity is the usual one (see Peritonitis).