Pelvic inflammatory disease is still a frequent
cause of infertility. Most of the time this infection
starts out as a sexually transmitted disease (STD)
caused by gonorrhea or chlamydia infections of the
cervix. The infection may be relatively asymptomatic
or cause some cervical discharge. If the bacteria
ascend into the uterus and faloppian tubes, the infection
causes pain from an accumulation of pus in the tubes.
Antibiotics given early may prevent damage, but the
body's normal host defense mechanism is to contain
the infection in a walled-off abscess. This abscess
will eventually resolve one of two ways. Either naturally,
or with the help of antibiotics, the abscess cavity
becomes sterilized and the fluid eventually becomes
cleared and the abscess goes away, or the abscess
ruptures and the infection spreads further to possibly
cause more abscesses.
An article by Livengood CH III: Tubo-ovarian abscess.
Contemporary Ob/Gyn 1999;44:108-116 points out how
such infection can become very severe and may even
result in death if a large abscess ruptures. The article
helps us to answer several questions.
How does pelvic inflammatory disease (PID) affect
fertility?
Once pathogenic bacteria such as Neisseria gonorrhoeae
or Chlamydia trachomatis gain access above the cervix
to the uterus and tubes, the inside surfaces of the
faloppian tubes are denuded of their skin (epithelial)
lining if a woman's immune system or antibiotics do
not stop the bacteria. White blood cells, bacteria
and fluids form in the tube which usually tries to
contain the infection by forming a closed space. If
a tube is filled with pus it is called a pyosalpinx.
Even if treated at that point, the denuded inside
of the tube may cause sticking together of the walls
of the tube so that there is a blockage of the tube(s)
later to sperm and eggs. For normal pregnancy, the
sperm and the egg meet in the tube where fertilization
takes place. Even if the tubes are not blocked by
agglutination from past infection, the lining of the
normal tube has a ciliary wave motion that serves
to move the fertilized ovum down to the uterus. When
that lining has been destroyed, infertility may result
because the fertilized ovum does not get to the uterus
in time for implantation.
If the abscess opens or leaks from the end of the
tube, the ovary may stick to the end of the tube and
become the far wall of another, bigger abscess cavity.
This then would be called a tubo-ovarian abscess.
When this happens, fertility on the side it occurs
is totally obliterated because the ovary itself and
all its eggs are destroyed.
How often does a pelvic infection lead to abscess
formation?
Approximately 5-10% of the time, women with pelvic
inflammatory disease (PID) develop the most severe
form which is a tubo-ovarian abscess (TOA). Women
who get TOAs tend to be older in their 30's and 40's.
They have severe pain and may have nausea, vomiting
and abdominal distension.
Pathology picture of tubo-ovarian abcess
Are there other causes of tubo-ovarian abscess formation
other than sexually transmitted diseases (STDs)?
Yes. Tubo-ovarian abscesses can form after other situations:
following any pelvic surgery
uterine perforation at time of a D&C or any vaginal
uterine procedure
bowel perforation from ruptured appendicitis
bowel perforation from ruptured diverticulitis
pelvic malignancy
Even if the abscess is due to causes other than STDs,
the clinical course is the same.
How will the doctor know if an infection has progressed
to an abscess?
On pelvic exam, the doctor can often feel an abscess
swelling. If the abscess is acute, a woman usually
has a fever and an elevated white blood count (WBC).
If it is chronic, she may not. Ultrasound is the best
imaging study to use to detect an abscess although
sometimes a CAT scan is used. In general, if the abscess
cavity is over 8 cm in size (over 3 inches) , it is
likely that surgery will be needed to treat the abscess
because antibiotic treatment alone is not very successful
when the abscess is that large.
What is the treatment for a tubo-ovarian abscess?
Even though the initial infection is often started
from an STD bacteria, the abscess cavities should
always be considered as a mixed infection with multiple
different bacteria, many from the bowel tract just
due to transmigration across swollen, inflamed bowel
wall involved near the abscess. Therefore broad spectrum
antibiotics are needed as soon as a diagnosis is made,
Usually this requires at least two or three different
antibiotics. If the infection does not improve within
48-72 hours, some sort of surgical drainage is needed.
That may be done under xray guidance from a vaginal
needle drainage, a needle drainage through the skin
of the abdomen or by laparoscopy. If those do not
work, then exploratory surgery with removal of all
of the infected tissues is needed.
|
