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J. Obstet. Gynaecol. Res. 2014

doi:10.1111/jog.12617

Comparison of severe pelvic inflammatory disease, pyosalpinx and tubo-ovarian abscess Ho Yeon Kim1, Jeong In Yang2 and ChongSoo Moon1 1

Department of Obstetrics and Gynecology, College of Medicine, Hallym University, Seoul and 2Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea

Abstract Aim: Inflammation of the upper genital tract causes pelvic inflammatory disease (PID), which may be complicated by pelvic abscesses, such as pyosalpinx and tubo-ovarian abscess (TOA). This study aimed to determine the clinical differences between pyosalpinx and TOA in patients with PID. Material and Methods: We retrospectively evaluated 458 female patients who were admitted to Hallym University Kang Dong Sacred Heart Hospital for a clinical diagnosis of PID from 1 January 2007 to 30 April 2012. Sociodemographic, clinical and laboratory data were compared among the non-abscess, pyosalpinx, and TOA groups. Results: We identified 110 patients (24%) diagnosed with pelvic abscess associated with PID, including 34 with pyosalpinx and 76 with TOA. The pyosalpinx group had shorter hospital stays (P = 0.007), lower C-reactive protein levels (P = 0.015), smaller mass sizes (P < 0.001), and fewer surgical interventions (P < 0.001) than the TOA group. Conclusions: Pyosalpinx is a less severe form of PID that leads to shorter hospital stays and more favorable outcomes than TOA. Key words: pelvic inflammatory disease, pyosalpinx, tubo-ovarian abscess.

Introduction Pelvic inflammatory disease (PID) describes inflammation of the upper genital tract that causes salpingitis, endometritis, peritonitis, and occasionally pelvic abscess, including pyosalpinx and tubo-ovarian abscess (TOA). In the progression of PID, cervicitis and endometritis come first, followed by salpingitis, which causes purulent material spillage from the salpinx to the uterus and nearby peritoneum. Adhesions close the salpinges, which are filled with pus, form a pyosalpinx. Ultimately, during the final stage of PID, the nearby ovaries and tubes become infected, leading to TOA.1,2 There is little clinical evidence suggesting whether pyosalpinx or TOA is the more severe form of PID, and

no reports of the differences between these two forms of PID. Hence, in this retrospective study, we aimed to differentiate pyosalpinx and TOA according to demographic, clinical, and microbiological factors.

Methods Study population We retrospectively reviewed the medical records of all the patients diagnosed with PID at the Hallym University Kang Dong Sacred Heart Hospital, Seoul, Korea, between 1 January 2007 and 30 April 2012. The Institutional Review Board at the hospital approved this study. A total of 458 inpatient records with International Classification of Diseases-10 codes N70–N74

Received: January 5 2014. Accepted: September 10 2014. Reprint request to: Professor ChongSoo Moon, Department of Obstetrics and Gynecology, College of Medicine, Hallym University, #150 Seongnae-gil, Gangdong-gu, Seoul 134-701, Korea. Email: [email protected]

© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology

1

H. Y. Kim et al.

(a)

(b)

Figure 1 Pyosalpinx. (a) A fluidfilled dilated tube (mass) with a low-level echo beside the normal ovary (arrow). (b) A large dilated tubular structure filled with debris/purulent material and with incomplete septation (caliper) where the tube folds on itself.

were selected. According to the 2010 guidelines of the Centers for Disease Control and Prevention, PID was diagnosed when a combination of abdominal tenderness, cervical motion tenderness, and bilateral adnexal tenderness and at least one of the following minor diagnostic criteria were observed in sexually active women: documentation of a cervical infection with Chlamydia trachomatis or Neisseria gonorrhoeae, mucopurulent cervicitis, body temperature (BT) > 38.3°C, elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level, or presence of an inflammatory mass on pelvic sonography.3 Of the 458 hospitalized female patients, 348 were designated as the non-abscess group and 110 as the abscess group associated with PID. The abscess group was further divided into subgroups of pyosalpinx in 34 patients and TOA in 76. We excluded patients if they were pregnant, had similar pain from other gynecologic causes, such as an endometriotic cyst, refused treatment, and had pelvic abscesses of non-gynecologic origin.

Clinical analysis Pyosalpinx and TOA abscess were initially diagnosed using transvaginal ultrasound and/or computed tomography (CT). Ultrasound was performed by one of the presenting authors, who all have >5 years’ experience with gynecologic ultrasound. A CT scan was reviewed by experienced radiologists with no prior knowledge of the clinical and surgical data, other than the presence of acute lower abdominal pain. In patients who underwent surgery, gross findings and histologic examination confirmed the diagnosis. A pyosalpinx diagnosis was confirmed by ultrasound when a tubular structure filled with debris/purulent material and fluid/fluid layering was observed and when incomplete septation where the tube folds on itself was identified (Fig. 1).2 Despite the pyosalpinx, the ovarian tissue showed no signs of infection but was slightly

2

Figure 2 Tubo-ovarian abscess. A complex multilocular cystic mass (calipers) with thick irregular septations, mural nodules, and low-level echoes. A separate ovary could not be seen.

enlarged. We differentiated hydrosalpinx from pyosalpinx by ultrasound as the former appears as a tubular anechoic adnexal structure usually with a thin wall and incomplete septation.2 The CT scan showed a tubular juxta-uterine mass with complex internal fluid and thick enhancing walls.4 For TOA, the sonographic finding was an irregularly marginated solid or cystic mass with uniform internal septa with usually no discrepancy between the tube and the ovary (Fig. 2).2,4 The ovarian capsule and tissue were not definitively identified. A contrast-enhanced CT scan demonstrated a solid-cystic adnexal mass with enhancement of the

© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology

Pyosalpinx and TOA

wall and septa.4 We categorized 28 cases with one side TOA and the other side pyosalpinx into the TOA group. Cases were analyzed with respect to demographic factors, including age, parity, abortion, marital status, occupation, previous pelvic surgery, previous PID history, types of contraception, smoking, and abnormal Pap smear test result. We also assessed clinical factors, including BT, length of hospital stay, symptom duration, white blood cell (WBC) counts, segmented neutrophil counts, ESR, CRP level, surgical procedures, and mass size and laterality; and microbiological factors, including N. gonorrhoeae, C. trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, Actinomyces israelii, and others. All culture specimens were obtained from the cervix, an extracted intrauterine device, a blood sample, and/or intra-abdominal pus. The specimens were tested for C. trachomatis by enzyme-linked fluorescent assay (Seegene; sensitivity 98–100%, specificity 95–100%), N. gonorrhoeae by culture, and U. urealyticum and M. hominis using the mycoplasma IST 2 kit (Biomerieux; sensitivity 98%, specificity 98%). All patients received an intravenous antibiotic treatment that consisted of a second- or third-generation cephalosporin plus metronidazol and/or aminoglycoside or levofloxacin plus metronidazole, if the patient was hypersensitive to cephalosporin. Continuous variables were analyzed using an independent t-test for parametric variables and the

Mann–Whitney U-test for non-parametric variables. Categorical variables were evaluated using the χ2 and Fisher’s exact tests. Data distribution was tested for normality using the Kolmogorov–Smirnov test. In addition, a receiver–operator curve (ROC) was used to evaluate cut-off, sensitivity, and specificity values. A two-sided P < 0.05 was considered to indicate significance. All the statistical analyses were performed using spss 17.0.

Results Sociodemographic factors A total of 458 hospitalized PID cases were encountered in our institution during the study duration of 5 years, 4 months. There was no difference in age between the pyosalpinx and TOA groups. There was no significant difference in parity, abortion, marital status, and previous Cesarean delivery between the pyosalpinx and TOA groups. Only 20.7% of the patients were using contraception. No significant difference in intrauterine device use was observed between the pyosalpinx and TOA groups. The patients in the non-abscess group were less likely to use contraception than those in the TOA group (Table 1). Clinical and laboratory factors Clinical and laboratory factors are reported in Table 2. The mean BT was similar between the pyosalpinx and TOA groups, although the patients with TOA had

Table 1 Sociodemographic characteristics

Age (years) Parity Abortion Married Occupation Cesarean section Previous pelvic surgery Previous PID Contraception IUD Oral pills Tubal ligation Others No contraception Smoking Abnormal PAP

Non-abscess (n = 348)

Pyosalpinx (n = 34)

TOA (n = 76)

P-value

31.6 ± 9.9 1.8 ± 1.8 1.1 ± 1.2 180 (51.9) 193 (55.9) 57 (16.4) 62 (17.8) 50 (14.4)

35 ± 10.2 2.2 ± 1.7 1.3 ± 1.2 16 (47) 12 (35.3)* 4 (11.8) 12 (35.3)* 3 (8.8)

37.8 ± 10.6* 2.5 ± 1.8* 1.3 ± 1.3 48 (63.2) 34 (44.7) 17 (22.4) 11 (14.5)** 3 (3.9)*

Comparison of severe pelvic inflammatory disease, pyosalpinx and tubo-ovarian abscess.

Inflammation of the upper genital tract causes pelvic inflammatory disease (PID), which may be complicated by pelvic abscesses, such as pyosalpinx and...
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