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.
Inflammatory disorders of the uterus frequently extend to the tubes. The ciliary
current of the tube is a very weak protective apparatus, and the narrow communication
between tube and uterus is an ineffective barrier. Besides, the narrow lumen proves
to be a serious handicap when the tube is inflamed. Swelling of the mucous membrane
may cause complete occlusion of the uterotubal junction, thereby preventing drainage
of inflammatory secretions into the uterine cavity and potentially forcing infected
material further toward the fimbrial end and the peritoneal cavity.
The uterus, because of its free drainage and periodic menstrual shedding,
may appear healed, whereas the inflammation in the occluded tubes still persists.
On the other hand, the occurrence of tubal inflammatory disease is favored by
the tendency of the uterus to react to abnormal stimuli, such as bacteria or chemicals,
by spasm of the internal cervical os and severe contractions, which drive these
noxious agents into the tubes. Lipid imaging solutions, which are occasionally used
for hysterosalpingography, may cause serious damage to the tubes.
Bacteria may invade the tubes from the uterus or from the bloodstream. The
latter holds true for Mycobacterium tuberculosis, whereas gonococci, Chlamydia,
and most other bacteria reach the tube by way of the mucous membranes. Gonococci
settle mainly in the mucosa and have little tendency to invade deeper tissues,
though they do tend to cause a transluminal inflammatory response. In contrast, chlamydial
infections tend to engender a much milder but longer-lived inflammatory response,
accounting for their often indolent course and greater degree of long-term tubal
damage.
Streptococci and staphylococci also propagate in the mucosa but rapidly penetrate
the deeper structures and invade the lymphatics and blood vessels of the uterine
and tubal walls and adjacent connective tissue. The most conspicuous changes, which
occur in streptococcic and staphylococcic infections, take place in the pelvic connective
tissue.
The parametrial lymphatics and veins are filled with pus and partly solid,
partly liquefied thrombi, whereas the surrounding tissue is distended by serous and
seropurulent exudate. These changes constitute parametri- tis, which is mainly a
lymphangitis and thrombophlebitis. Because the blood and lymph vessels are contained
in the condensed zones of the pelvic connective tissue, the inflammatory infiltrate
assumes the shape of these zones. It is wedge-shaped, with the base directed toward
the pelvic wall and the blunt apex at the uterus. According to the arrangement of
the zones of condensed connective tissue, an anterior, posterior, and median
parametritis can be distinguished. In severe infections, all three zones are affected.
Sometimes the purulent infection destroys the parametrial structures, causing a
parametrial abscess, which may break into the zones of loose connective tissue and
rapidly spread within these zones and the connected areas. The rounded shape of
a large parametrial abscess can modify somewhat the wedge shape of the unliquefied,
rigid parametrial infiltrate.
Risk factors for salpingitis include early (age) sexual activity and multiple sexual partners. These and related risk factors primarily affect the likelihood of acquiring gonococcal and chlamydial infections of the cervix, which, in turn, ascend into the upper genital tract, causing salpingitis. Uterine instrumentation (hysterosalpingography, intrauterine contraceptive device placement, endometrial biopsy, dilation and curettage) can also cause salpingitis but this occurs infrequently in the absence of sexually transmitted infections.
