eMedicine Specialties > Obstetrics and Gynecology > Infections

Salpingitis: Follow-up

Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Coauthor(s): Clarisa R Gracia, MD, Staff Physician, Department of Obstetrics and Gynecology, University of Pennsylvania; Evan M Meiner, MD, Director of Emergency Medicine Trauma Care, Department of Emergency Medicine, North Shore University Hospital; William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Contributor Information and Disclosures

Updated: Aug 16, 2007

Follow-up

Further Inpatient Care

  • All patients should demonstrate substantial clinical improvement, with decreased fever and abdominal tenderness within 48-72 hours of initiation of therapy. When a patient's condition is unchanged or has deteriorated after 3 days, either adjunctive treatment with another antibiotic regimen or laparoscopic evaluation may be warranted.
  • Laparoscopy can confirm the diagnosis and exclude other entities that may require different treatment. Cultures obtained directly from the pelvis can be used to tailor antibiotic therapy. Laparoscopic pelvic lavage and drainage of abscesses have been reported to be therapeutic as well.
  • In the case of a TOA, 60-80% of patients respond to antibiotics alone. The remaining 20-40% will require either percutaneous or surgical drainage (see Surgical Care).

Further Outpatient Care

  • All women who are treated as outpatients with a PO regimen must be reevaluated in 48-72 hours to assess their response to PO therapy. Admit patients who are not significantly improved to the hospital for IV antibiotics. This will also allow the provider to ensure that the patient is taking prescribed antibiotics as directed. An institutional intervention study using strict guidelines, straightforward and specific patient directions, and which provided patient antibiotics, found that 57% of their patients did not follow up for care and almost 40% of patients did not complete their antibiotics as directed.
    • Continue IV antibiotics until the patient has been improved for 24 hours. Then the patient can be switched to PO antibiotics.
    • Continue PO antibiotics for a full 2-week course. Given that 25-60% of cases of PID are caused by mixed infection, and also that no testing method is perfect, medications should be completed once the diagnosis is made, even if the gonorrhea/chlamydia studies are negative.
  • Women should remain abstinent from sexual activity until they are cured of symptoms and they have completed their full regimen of antibiotics.
  • Sexual partners of women with salpingitis have rates of infection with N gonorrhoeae and/or C trachomatis of approximately 50%, and most of these individuals are asymptomatic and do not seek treatment.
    • To prevent reinfection of the patient, ensure that all sex partners of women with this disease are treated before resuming unprotected intercourse.
    • Treat all sex partners that the patient has had within the 60 days prior to symptom onset.

Transfer

  • Patient transfer is reserved for patients who are stable and only if the hospital is unable to manage a patient with acute gynecologic conditions.

Deterrence/Prevention

  • Because the sequelae of salpingitis, both overt and silent, are related to the number of infections women experience, further prevention cannot be overemphasized. Three types of prevention must be employed.
    • Primary prevention involves avoiding either exposure to STDs or acquisition of infection following exposure. Counsel patients regarding safe sex practices in a manner appropriate to both the patient's understanding of sexual issues and stage of development.
      • When used consistently and correctly throughout sexual activity, a condom appears to be highly effective in preventing acquisition and transmission of the organisms that cause salpingitis. Barrier methods, such as the diaphragm, appear to decrease the risk of upper tract infection. The CDC now recommends against using any form of nonoxynol-9 for STD prevention. Condoms lubricated with nonoxynol-9 have been found to offer no protection against gonorrhea or chlamydial infection. A study of sex workers in Africa demonstrated that spermicide may actually increase infection. Condoms lubricated with nonoxynol have a short shelf life.
      • Advise patients to avoid high-risk sex partners and limit their number of sex partners. Patients who present for STD evaluation should be given hepatitis B vaccination or referred for vaccination. Hepatitis A vaccine should be administered, or the patient referred for vaccination, to men who have sex with men or patients who use illegal drugs.
      • Prompt urination and washing of the genitals and postcoital douching have been suggested as methods of preventing STD transmission, but none has proven effective.
      • Young age also is associated with both biological and behavioral factors that may increase the risk of cervical infection and salpingitis. Teenagers also apparently delay seeking treatment longer than older women. Advise these patients to delay the onset of sexual activity until at least age 16 years, and increase teenagers' awareness of symptoms of cervical infection and salpingitis.
      • In addition, the use of hormonal contraception may be encouraged to help protect women from ascending infections, but it should not be substituted for barrier methods.
      • In order to prevent salpingitis following gynecologic procedures, prophylactic antibiotics may be warranted in high-risk patients.
    • Secondary prevention involves preventing lower genital tract infection from ascending to the upper tract or from being further transmitted in the community.
      • Because many infected women have no symptoms and their partners often are asymptomatic, routine screening for Chlamydia and Gonorrhea infection is indicated.
      • Early detection of lower tract infection is crucial to salpingitis prevention strategies. Treat patients with lower tract infection or presumptive lower tract infection in accordance with the CDC guidelines for cervicitis.
    • Tertiary prevention involves preventing upper tract infection sequelae and educating the patient to seek early treatment for signs and symptoms of salpingitis.

Complications

  • Complications of salpingitis include tubal damage and infertility; the rate of infertility increases with the degree of tubal inflammation produced and with increasing numbers of episodes of infection.
  • Ectopic pregnancy is a major complication of salpingitis and is approximately 7-10 times more common in women who have had 1 episode of salpingitis.
  • Other complications of the disease include chronic pelvic pain, dyspareunia, and adhesions.

Prognosis

  • The prognosis for salpingitis is very good if the disease is diagnosed and treated early, although a small percentage of patients will become infertile despite early treatment.
  • Prognosis is poor for patients with recurrent episode of disease.

Patient Education

  • Studies have shown that only about one third of patients understood their diagnosis of salpingitis, and 30% of patients had poor understanding of the disease.
  • In the past, 60-70% of patients were thought to be compliant with the treatment regimens that they were prescribed. However, multiple studies have demonstrated recently that the rate of strict compliance with oral doxycycline therapy for outpatient treatment of salpingitis is approximately 25%, and another 50% of patients are only somewhat compliant, stopping therapy early. Approximately 20-25% of patients never even fill their prescriptions. In addition, only a small minority of patients follows up with an OB/GYN within 3 days of their ED visit.
  • Therapeutic levels of antibiotic must be maintained for several days to ensure eradication of the infectious organisms. Because 80% of PID cases are treated on an outpatient basis, success depends highly on patients' compliance with their antibiotic regimen. For this reason, the ED physician must spend time to educate these patients about the potential long-term complications of their illness, about why they must finish the full 14 days of medications, and about the need for follow-up with a gynecologist.
  • Educate patients about behavioral and contraceptive methods to prevent acquisition of STDs, as well as about the importance of treatment of their partners to prevent reinfection.
  • Counsel patients about HIV testing and hepatitis B and A vaccinations.
  • For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Birth Control Overview and Birth Control FAQs.

Miscellaneous

Medicolegal Pitfalls

  • The most serious potential pitfall is failing to test for pregnancy and thereby missing an ectopic pregnancy.
  • Another pitfall is failure to diagnose and treat mild or atypical cases in a timely fashion or to misdiagnose them as a simple urinary tract infection (UTI) due to not performing a pelvic examination.
  • In the ED, patients often leave false phone numbers or are unable to be contacted for follow-up. When patients are diagnosed with possible salpingitis in the ED, discharging them and withholding treatment pending culture results is a pitfall unless adequate follow-up is ensured. If this cannot be accomplished, treat patients empirically to avoid progression to upper tract disease and possible long-term sequelae.
  • Remember that all patients also must be tested for syphilis.
  • A frequent major oversight is the importance of adequate patient education in an attempt to encourage follow-up and compliance with medications, as well as prevention of future episodes. Additionally, failure to appropriately treat sexual partners is a common pitfall.
 


More on Salpingitis

Overview: Salpingitis
Differential Diagnoses & Workup: Salpingitis
Treatment & Medication: Salpingitis
Follow-up: Salpingitis
References
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Further Reading

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Keywords

salpingitis, pelvic inflammatory disease, PID, pelvic inflammation, oviduct inflammation, oviduct infection, gynecologic infection, fallopian tube inflammation, fallopian tube infection, tuboovarian abscess, TOA, tubo-ovarian abscess, infertility, Neisseria gonorrhoeae, N gonorrhoeae, C trachomatis, Chlamydia trachomatis, Bacteroides, Peptostreptococcus, Peptococcus, gonorrhea, chlamydia, sexually transmitted disease, STD complication, STD

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Contributor Information and Disclosures

Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Clarisa R Gracia, MD, Staff Physician, Department of Obstetrics and Gynecology, University of Pennsylvania
Clarisa R Gracia, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, and American Society for Reproductive Medicine
Disclosure: Nothing to disclose.

Evan M Meiner, MD, Director of Emergency Medicine Trauma Care, Department of Emergency Medicine, North Shore University Hospital
Evan M Meiner, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Glaxo Smith Kline Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Medical Editor

Bruce A Meyer, MD, MBA, Vice President for Medical Affairs, Associate Dean for Health System Affairs and Director of the Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School
Bruce A Meyer, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physician Executives, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Medical Group Management Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gail F Whitman-Elia, MD, Professor, Department of Obstetrics and Gynecology, University of South Carolina School of Medicine
Gail F Whitman-Elia, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Clinical Endocrinologists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Medical Women's Association, American Public Health Association, American Society for Reproductive Medicine, Endocrine Society, and South Carolina Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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