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PH-RO24

Salpingitis, oophoritis and pelvic inflammatory disease

How bacteria climb from the cervix to inflame the endometrium, uterine tubes, ovaries and peritoneum, how pus collects and reaches the liver capsule, how tuberculosis and actinomycosis differ, and why the scars cause infertility and ectopic pregnancy.

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  • 6 steps · 10 questions
  • 3D normal anatomy

By the end, you can

  • Describe the defences of the lower genital tract and why the uterine tubes connect the peritoneal cavity with the outside.
  • Explain how Chlamydia, gonococci, Mycoplasma genitalium and vaginal anaerobes ascend to cause endometritis and salpingitis.
  • Relate pyosalpinx, tubo-ovarian abscess, pelvic peritonitis and Fitz-Hugh–Curtis perihepatitis to the spread of pus.
  • Contrast tuberculous salpingitis and pelvic actinomycosis with the usual non-specific infection.
  • Explain how healing by fibrosis leads to hydrosalpinx, tubal infertility, ectopic pregnancy and chronic pelvic pain.
  • Recognise the classic tissue changes, diagnostic criteria and tests of PID, and explain how the main treatments act on each mechanism.

What it is

Pelvic inflammatory disease (PID) is infection that ascends from the vagina and cervix to the upper genital tract, causing any combination of endometritis, salpingitis, oophoritis, tubo-ovarian abscess and pelvic peritonitis. Most is non-specific: sexually transmitted organisms and vaginal bacteria together. Specific forms, such as tuberculosis and actinomycosis, cause granulomatous or chronic abscess-forming inflammation.

4 types to tell apart
Acute non-specific PID
Ascending, usually polymicrobial infection: Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and bacteria of the vaginal flora, including anaerobes. Gonococcal disease tends to be acute and severe; chlamydial and mycoplasmal disease milder or silent.
Complicated PID
Pus trapped in a sealed tube (pyosalpinx) or walled off with the ovary (tubo-ovarian abscess), pelvic or generalised peritonitis, and perihepatitis (Fitz-Hugh–Curtis syndrome).
Specific (granulomatous and chronic) salpingitis
Tuberculous salpingitis, spread through the blood; pelvic actinomycosis, linked with long-term use of an intrauterine device (IUD); rarely schistosomiasis or a reaction to foreign material.
Sequelae of PID
Chronic salpingitis, hydrosalpinx, blocked tubes and adhesions, which cause infertility, ectopic pregnancy and chronic pelvic pain.

Normal function

From vagina to fimbriae: a tract open to the peritoneum

The female genital tract is a continuous passage: the , the , the cavity of the and the two uterine tubes, each running out through its narrow and wide to a funnel fringed by , which lie open beside the . Because the tubes open into the peritoneal cavity, this is the one route by which the cavity communicates with the outside of the body.

Three defences normally keep everything above the cervix sterile. Lactobacilli in the vagina make lactic acid and hold the pH below about 4.5, which few pathogens tolerate. The cervical canal, lined by mucus-secreting columnar epithelium, is plugged by cervical mucus, thick and hostile to bacteria for most of the cycle, thinner at ovulation. And the endometrium is shed each month.

The tube’s lining is folded into tall plicae, most elaborate in the ampulla, and covered by ciliated cells, whose cilia beat towards the uterus, and secretory cells, which make the fluid that nourishes the egg and embryo. Beneath lie smooth muscle and a serosa of peritoneum. Fluid in the peritoneal cavity circulates upwards along the paracolic gutters towards the diaphragm, and pools in the pelvis when upright.

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