ACUTE PELVIC PAIN AND SALPINGITIS


Salpingitis presentation:

  1. Pelvic pain (bilat., dull, crampy)
  2. Bilat adnexal tend., often with rebound; no masses in acute salpingitis
  3. CMT (95%)
  4. May have RUQ (perihepatitic) pain
  5. 55% have vag. d/c; some have bleeding
  6. Occ. urinary freq., dysuria
  7. Nau/vom are UNCOMMON
  8. Fvr (100-103?F), nl BP,
  9. Leukocytosis (15-20), high ESR
  10. Few WBCs in urine
  11. Pos. assay for Gonorrhea or Chlamydia
  12. 75% begin within 7d of menses
  13. US shows fluid in cul-de-sac, adnexal enlargement, "complex adnexal mass"
  14. Culdocentesis not indicated; should be neg., unless ruptured abcess
  15. Good prognosis if tx'd

Differential Dx of acute lower abd/pelvic pain:

1. Pregnancy-related

a. Ectopic pregnancy

i. Pt may not know she's pregnant
ii. More common in h/o PID, IUD, tubal surgery
iii. Us. rupture 6-10wks gest.
iv. Dull pain before rupture; severe pain + rectal pressure + occ. shoulder pain after
v. Abd px varies from soft, sl tend to acute abd.
vi. Cx tend (often unilat.), tender adnexal mass
vii. Intermittent spotty bleeding
viii. Fvr, nau/vom are UNCOMMON
ix. Sig. blood loss after rupture--shock, HCT
x. Us. nl/sl WBC
xi. Culdocentesis shows unclotted blood
xii. Mat. mort 0.1%

b. Ab (Septic, threatened, incomplete)
c. IUP with corpus luteum bleeding

2. GYN

a. Acute salpingitis (most common in nonpreg.)
b. Endometriosis
c. Ovarian cyst--Ca, inf., rupture, torsion, hemorrh.

  1. Occ. can feel abd. mass--mobility, smoothness suggest benignity
  2. With torsion get abd. tend., superficial mm. spasm; also occ. leukocytosis
  3. Ca us. mild abd. dist & discomfort
  4. Us. nl vital signs
  5. Culdocentesis may show cystic fluid
  6. US to diff. benign vs. malignant: unilat-erality, cystic mass, intact capsule, absence of ascites, smooth peritoneum suggest benignity
  7. Some recommend diagnostic aspiration of all ovarian cysts; probably not necessary
  8. In a series of 278 women aged 14-81 with "simple" ovarian cysts and CA-125 < 100U/l randomized to receive either fine-needle aspiration vs. 6mos of observation, resolution rates equivalent in both groups (around 44%) at 6mos; followed with observation 10-58mos more; 73 women had surgery, of whom one showed "borderline malignant changes" on path. So observation appears to be as safe & effective as aspiration (BMJ 313:1110, 1996-JW)

d. Adnexal torsion
e. Mittelschmerz
f. Uterine leiomyoma (torsion, degeneration)
g. Primary dysmenorrhea
h. Tumor

3. GI

a. Acute AP
b. IBD
c. Irritable bowel Sd
d. Mesenteric adenitis
e. Diverticulitis

4. Urinary tract

a. UTI, inc. pyelo--h/o freq UTIs, freq/dysur, flank pain & tend., CVA tend., sacrospinal mm. tend., no abd. tend, nl pelvic Px, chills, fever, often nau/vom, nl BP, high WBC, PMNs in urine
b. Calculus

 

*CMT present in 95% of women with acute salpingitis; 43% with ectopic pregnancy; 28% with acute AP*

If preg. test pos. in pt. with acute pelvic pain, do US or culdocentesis (blood on culdo suggests ectopic)

 

Diff dx of CMT:

1. Pelvic peritonitis, inc. ruptured AP, acute salpingitis
2. Lower abd. peritonitis, including ruptured AP, IBD with fistula, Meckel's, or peridiverticulitis
3. Hemoperitoneum, inc. trauma, organ rupture, vasc. disruption, ruptured ectopic, ovarian cyst, or corpus lut.
4. Uterine injection (inf. incomplete Ab), spread to parametrium or pelvic peritoneum
5. Acute cervicitis spread to parametrium
6. Chemical peritonitis, e.g. ruptured dermoid cyst