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Tuesday, October 26, 2021

PARAOVARIAN OR EPOÖPHORON CYST

PARAOVARIAN OR EPOÖPHORON CYST

PARAOVARIAN OR EPOÖPHORON CYST

Mesonephric cysts can develop from the permanent portion of the mesonephron, which is the paraovarian or epoöphoron, or from the inconstant residue of the wolffian (Gartner) duct. The former, called paraovarian or epoöphoron cysts, may be small and may represent simple retention cysts; some, however, are true blastomas, which grow continuously and may finally attain an enormous size. As a rule, even the giant cysts remain unilocular.

PARAOVARIAN OR EPOÖPHORON CYST


Owing to the intraligamentary location of the epoöphoron, the paraovarian cysts are always intraligamentary and are covered by the distended peritoneum of the broad ligament. Exceptionally, the cyst is fixed to its surroundings by dense inflammatory adhesions or, instead of expanding upward toward the peritoneal cavity, it may grow downward toward the pelvic floor or into the mesosigmoid.

SALPINGITIS ISTHMICA NODOSA, CARCINOMA

SALPINGITIS ISTHMICA NODOSA, CARCINOMA

SALPINGITIS ISTHMICA NODOSA, CARCINOMA

SALPINGITIS ISTHMICA NODOSA, CARCINOMA


The nodular enlargement of the innermost isthmic portion of the tube, called salpingitis isthmica nodosa, once was the subject of lively discussion among gynecologists and pathologists with regard to its origin or pathogenesis. It consists of glandular ramified projections of the mucosa into the thickened tubal wall. Most authors assume that nodular isthmic salpingitis is of inflammatory origin. However, it may be, in some or even in the majority of cases, the result of a noninflammatory endosalpingosis, a condition closely related in its nature to uterine adenomyosis or endometriosis. (Approximately two-thirds of women with adenomyosis have coexistent pelvic pathology, including salpingitis isthmica nodosa.) Some studies indicate that salpingitis isthmica nodosa can be documented histologically in more than 50% of patients with ectopic pregnancies. The diagnosis is best made radiographically at hystero-salpingography, where the characteristic finding consists of multiple nodular diverticular spaces in close approximation to the true tubal lumen. Visualization of nodular thickening of the tubes on laparoscopy also suggests the diagnosis.

TUBERCULOSIS

TUBERCULOSIS

TUBERCULOSIS

TUBERCULOSIS


At one time, about 10% of all inflammatory disease of the tubes was tuberculous. Tuberculosis of the upper genital tract, primarily chronic salpingitis and chronic endometritis, is now a rare disease in the United States. However, pulmonary tuberculosis is steadily increasing in the United States, and with this rise it is likely that the incidence of pelvic tuberculosis also will increase. Tuberculosis is a frequent cause of chronic pelvic inflammatory disease and infertility in other parts of the world and may be encountered in immigrants, especially those from Asia, the Middle East, and Latin America. Genital tuberculosis may occur at any age but is most often encountered in women between 20 and 30 years old, though it will occur in postmenopausal women 10% of the time. Both tubes almost always are involved in the tuberculous disease, whereas the uterus is affected in slightly more than 50%. The other reproductive organs are only rarely involved.

TUBOOVARIAN ABSCESS

TUBOOVARIAN ABSCESS

TUBOOVARIAN ABSCESS

Occasionally, a pyosalpinx communicates with a ruptured follicle or a corpus luteum, leading to a tubo-ovarian abscess. Combined lesions of the fallopian tubes and the ovaries are, however, not limited to this particular formation, but they are the rule in all tubal inflammations. The ovary may be the site of true bacterial inflammation or may merely be involved in a circulatory disorder and degenerative changes arising from the inflammation of the neighboring tube. The latter changes consist of hyperemia, hemorrhages, and edema of the ovarian stroma, disintegration of the follicular apparatus, loss of surface epithelium, and formation of periovarian adhesions.

TUBOOVARIAN ABSCESS


The bacterial inflammation may be slight and may heal in the course of time, with or without fibrosis of the ovarian parenchyma, or it may be severe and may result in the formation of abscesses, which may develop in ruptured follicles or in corpora lutea or within the ovarian connective tissue. The follicular and luteal abscesses occur usually when the infection takes place on the surface of the ovary, as is the case in purulent salpingitis or appendicitis. Abscesses in the ovarian stroma are often of hematogenic origin and may remain within the limits of the ovary, though they may reach a large size. Sometimes, however, they burst into the tube or into the peritoneal cavity or a neighboring organ, such as the rectum or the bladder.

OBSTRUCTION FOLLOWING CHRONIC SALPINGITIS

OBSTRUCTION FOLLOWING CHRONIC SALPINGITIS

OBSTRUCTION FOLLOWING CHRONIC SALPINGITIS

OBSTRUCTION FOLLOWING CHRONIC SALPINGITIS


Recurrent or chronic adnexal infections may result in a cystic dilation of the fallopian tube (hydrosalpinx), which may present as an adnexal mass. The chronically inflamed tube, with the exception of the tuberculous tube, is usually closed. It often remains open at its ampullary end, but, owing to the changes in the tubal wall, it only rarely allows the fertilization of the ovum and its transportation into the uterus. Forty percent of female infertility is the result of tubal damage, including the most severe form, hydrosalpinx. Most hydrosalpinx are sterile and are the inactive end stage of the disease. The occlusion of the tube may be located at the uterotubal junction, the isthmic section, or the fimbrial end of the tube. It may be restricted to a closely limited area or may involve large portions of the tube, especially in the narrow isthmic section. If only the inter-stitial portion is closed, or there is obliteration of the isthmic portion, the outer aspect of the tube may remain unchanged. Only rarely is there a nodular enlargement of the isthmic section of tube.

CHRONIC SALPINGITIS, ADHESIONS

CHRONIC SALPINGITIS, ADHESIONS

CHRONIC SALPINGITIS, ADHESIONS

In chronic salpingitis, the uterine tubal ostium is often obliterated, and the tube cannot be visualized by hysterosalpingography. This must be differentiated from spasms of the isthmic portion of the tube, which are frequently encountered and offer resistance to uterotubal insufflation, which can be overcome using moderate pressure or at the time of laparoscopy under general anesthesia.

CHRONIC SALPINGITIS, ADHESIONS


Peritoneal adhesions connecting the tube with the ovary and the posterior leaf of the broad ligament may kink the tube and thus cause sterility. They are recognizable on hysterosalpingography by a characteristic spill pattern. Frequently, these pelvioperitonitic adhesions involve all pelvic organs, including the omentum and low intestinal loops. The adhesions are richly vascular at first, but gradually they become poorly vascularized, frail, and spiderweb-like. Only in rare cases may they disappear entirely.

PELVIC PERITONITIS, ABSCESS

PELVIC PERITONITIS, ABSCESS

PELVIC PERITONITIS, ABSCESS

PELVIC PERITONITIS, ABSCESS


As long as the ampullary ostium is patent, the purulent contents of the infected tube escape into the peritoneal cavity, causing a peritonitis, which is at first diffuse but, in favorable cases, may become confined to the pelvic cavity. Even when the tubes have become blocked, widespread peritonitis may result from spread of perisalpingitis, tubal lymphangitis, or rupture of a tube. Whereas acute parametritis often leads to septicemia, if the loose or liquefied infected thrombi enter the general circulation, acute salpingitis causes a diffuse or circumscribed pelvic peritonitis. Thus, pelvic inflammatory disease (PID) is a serious, diffuse, frequently multiorganism infection of the pelvic organs that results in significant morbidity.

HYDROSALPINX

HYDROSALPINX

HYDROSALPINX

Recurrent or chronic adnexal infections may result in a cystic dilation of the fallopian tube (hydrosalpinx), which may present as an adnexal mass. The purulent contents of the pyosalpinx may thicken and gradually be replaced by granulation tissue, which is sometimes calcified and, in rare instances, even ossified. More often, however, the solid constituents of the tubal contents are gradually liquefied and changed into a serous or serosanguineous fluid, thus transforming the pyosalpinx into a hydrosalpinx.

HYDROSALPINX


After resorption of the inflammatory infiltrate and the degenerated tissue, the tubal wall becomes thin and poor in muscle fibers and assumes a translucent appear- ance. The size of the hydrosalpinx can vary from twice that of a normal tube to that of a large sausagelike creation 3 cm or more in diameter, which, in form, has completely lost all resemblance to the tube from which it derived. The fimbriae in such a hydrosalpinx may have completely disappeared.

ACUTE SALPINGITIS II, PYOSALPINX

ACUTE SALPINGITIS II, PYOSALPINX

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).

ACUTE SALPINGITIS II, PYOSALPINX


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.

BACTERIAL ROUTES, PARAMETRITIS, ACUTE SALPINGITIS I

BACTERIAL ROUTES, PARAMETRITIS, ACUTE SALPINGITIS I

BACTERIAL ROUTES, PARAMETRITIS, ACUTE SALPINGITIS I

BACTERIAL ROUTES, PARAMETRITIS, ACUTE SALPINGITIS I


Inflammatory diseases are not only frequent but also potentially serious—with both immediate and longterm consequences. The tubes, which are inserted between the uterus and the ovaries, are easily infected from either of these organs. The open communication of the tube with the peritoneal cavity exposes the tube to any peritoneal infection and vice versa. Appendicitis is a frequent source of infection of the right or of both tubes; sigmoiditis or diverticulitis often migrates to the left tube. Sometimes the hematogenous route infects the tubes. This is the rule in tuberculous salpingitis.

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