ACUTE SALPINGITIS II, PYOSALPINX
In acute salpingitis
the tube is swollen and reddened, its tortuosity is more pronounced, the mucosal
folds are thickened and hyperemic, and its lumen is filled with pus. The serosa loses
its luster and may be covered with fibrinous or fibropurulent exudate (perisalpingitis).
In nongonorrheal salpingitis, all layers share about equally in the inflammatory changes. The lymphatics and blood vessels are dilated and filled with polynuclear leukocytes and thrombi. In gonorrheal salpingitis, the infiltrate is located chiefly in the mucosa. The epithelium of the edematous folds is destroyed in wide areas, and the denuded edges of the folds become adherent.
The course of any salpingitis may be very slow and indolent. In exceptional
cases, the acutely inflamed tube may heal with complete restoration of structure
and function. Usually, however, the acute stage is followed by a subacute and eventually
by a chronic inflammatory stage, with various anatomic and functional sequelae.
The polynuclear leukocytes gradually diminish in number and are replaced by plasma
cells, which are particularly numerous in gonorrheal salpingitis but are not pathognomonic
of this infection. The ampullary ostium, sometimes unilaterally, sometimes bilaterally,
may close early by inversion and conglutination of the fimbriae. The inflammatory
processes may also cause a closure of the uterine end of the tubes, and in other
instances both the uterine and ampullary sections may become partially or completely
occluded. When this closure occurs, the tube becomes more and more distended. It
loses its normal windings and changes into a sausage- or retort-shaped structure
called a pyosalpinx. Usually, the causative bacteria disappear in the purulent
contents, whereas they may survive for a long time in the depth of the tubal wall,
maintaining a chronic inflammatory condition. With gradual dilation of the tube,
its folds become lower and can definitely be destroyed. The tubal wall is usually
thickened, and the musculature is replaced by connective tissue in some areas. The
serosa is deprived of its endothelium in many places and becomes adherent to neighboring
organs. The content of a pyosalpinx may be liquid and show fibrinopurulent flakes
suspended in a serous exudate, or it may contain thick, greenish-yellow pus or mucopurulent fluid. Old pyosalpinges frequently contain cholesterol crystals or, sometimes,
aggregated cholesterol concrements.
Under favorable circumstances, the immunologic system eliminates the offending
organisms and the inflammatory processes halt, but they often leave a thickened,
closed tube densely adherent to the ovary and the posterior leaf of the broad ligament.
In other cases, the inflammatory changes progress, and the pyosalpinx perforates
into the rectum, into the peritoneal cavity or, less frequently, into the bladder.
Whereas the perforation into the rectum brings about temporary relief, the perforation
into the bladder causes considerable dysuria, and the perforation into the peritoneal
cavity results in serious peritonitis, which requires immediate surgical intervention.
The danger of such an accident is highly increased in cases of pregnancy complicated
by unilateral pyosalpinx. Loosening of protective adhesions, rupture of the pyosalpinx,
and escape of pus into the higher regions of the abdomen have been repeatedly observed
in such cases.
Very often an acute pyosalpinx combines, especially in puerperal sepsis, with
a parametritis. Then the infection spreads along the lymphatics and veins, as well
as along the mucosal lining. When the parametritic exudate, thanks to its greater
healing tendency, has been absorbed, the pyosalpinx may be palpated—in the
subacute and chronic cases—as a tender, fixed, sausage-shaped, or ovoid tumor, usually
situated in Douglas cul-de-sac, which, if large enough, pushes the uterus anteriorly
and toward the less affected side.
