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.