Exceptions to the common notion that tubal occlusion protects from recurrent pelvic inflammatory disease (PID) do exist. Since 1975, 71 cases of salpingitis and 38 tubo-ovarian abscesses (TOA) in sterilized women have been published. The majority of cases of salpingitis after previous tubal occlusion (SPOT) developed more than a year after either laparoscopic or laparotomy sterilization procedures. For tubo-ovarian abscess after previous tubal occlusion (TOAPOT), this time interval ranged from several weeks to almost two decades. Most cases of salpingitis showed inflammation of both tubal segments. When only one segment was involved, it was generally the proximal segment. The appearance of the TOAPOT at the time of surgery was typical to TOA.
The symptoms of salpingitis were not different from symptoms in any other case of PID, and those associated with TOAPOT were typical of TOA. Laboratory findings included leucocytosis and growth of Neisseria gonorrohoeae and Chlamydia trachomatis from the cervix, the infected tube, and the peritoneal fluid. Pus cultures obtained from cases of TOAPOT grew mixed or single organisms. Detailed histopathologic studies in tubal specimens after the failure of an occlusion procedure are available from cases with no infection. They have demonstrated distortion, loss of musculature, and loss of lumen configuration, all of which may have been the result of compromised blood supply to the tube. These findings may be extrapolated to cases of SPOT and TOAPOT, assuming similar changes may be present before the development of infection.
The mechanisms by which infection may develop in previously occluded tubes are divided into three groups: The first group consists of situations where there is persistence of free passage between the proximal and distal portions of the tube. These include tuboperitoneal fistula, spontaneous anastomosis at the occlusion site, recanalization of the occluded site, incomplete tubal occlusion due to a faulty surgical technique or rupture of the weakened tubal wall. The second group consists of infections initiated by the surgical procedure itself, such as introduction of pathogens at surgery, exacerbation of chronic PID, and ascending infection secondary to surgical manipulation. In the third group, the infection is initiated systemically by hematogenous spread, lymphatic spread, or change in immunologic status.
Obstetricians & Gynecologists, Family Physicians
After completion of this article, the reader will be able to estimate the incidence of salpingitis in patients that have been previously sterilized by tubal occlusion, to identify the possible etiologies associated with this condition, and to compare the presentation of salpingitis in a patient that has previously undergone sterilization by tubal occlusion.
Director of Outpatient Services of Ob/Gyn, Associate Director of Residency Program in Ob/Gyn, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn and Associate Professor, Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, New York
This article is the first of 36 that will be published in 2000 for which a total of up to 36 Catgory 1 CME credits can be earned. Instructions for how credits can be earned appear on the last page of the Table of Contents. This CME activity is supported by an unrestricted educational grant from Procter & Gamble.
Reprint requests to: Michael Levgur, MD, Department of Obstetrics and Gynecology, Maimonides Medical Center, 967 48th Street, Brooklyn, NY 11219.
The authors have disclosed that they have no significant financial or other relationship with any commercial entity pertaining to this educational activity. They also have affirmed that this activity includes no discussion of investigational or unlabeled use of products.