Goubaa Mohamed MD Djerba Tunisia

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This is a 40-year-old female presenting with acute right lower quadrant pain and fever (39°). Patiente de 40 ans se présentant pour une douleur de la fosse iliaque droite et de la fièvre a 39.



The transabdominal study demonstrates a normal-appearing uterus with intrauterine contraceptive divice(first small scan). Surrounding the right ovary is a large irregular anechoic tubular structure representing hydrosalpinx (tubular shape, well-defined walls, and a folded configuration) with active infection. L'échographie endovaginale montre un utérus d'aspect normal avec un DIU (stérilet) . Du coté de l'ovaire droit il existe une structure tubulaire anéchogène représentant un hydrosalpinx (aspect tubulaire, septations, plicature) et qui va se transformer en pyosalpinx.




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After 2 years

Apres 2 ans









2 years later: There are always Hydrosalpinx. 2 ans plus tard après traitement médical, l'écho de contrôle montre la persistance d'un hydrosalpinx
hydrosalpinx & pyosalpinx hydrosalpinx et pyosalpinx


hydrosalpinx & pyosalpinx &Tubo-ovarian Abscess / Pelvic Inflammatory Disease

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Introduction :
Pelvic Inflammatory Disease is usually part of a complex of recurrent infections superimposed on damaged tissue, although it may occur following an initial episode of acute salpingitis. Initially, there is salpingitis which resolves, but results in fibrinous attachments to nearby organs. Involvement of the adjacent ovary may serve including endometritis, salpingitis, salpingo-oophoritis, tubo-ovarian abscess, and pelvic peritonitis.

Clinical :
The symptoms of acute pelvic Inflammatory Disease include: fever, shaking chills, abdominal pain, nausea, vomiting, vaginal discharge, and irregular vaginal bleeding. Signs of acute pelvic Inflammatory Disease include abdominal guarding, rebound tenderness, increased pain with cervical or adnexal manipulation, dyspareunia, leuko-cytosis, elevated ESR, paralytic iléus, and shock from peritonitis.
3 criteria should be present :
* Lower abdominal tenderness
* Adnexal tenderness
* Tenderness with cervical motion
other symptoms:
* temperature
* Abnormal cervical and vaginal discharge
* Elevated erythrocyte sedimentation rate
* Elevated C-reactive protein level.
Symptoms of chronic pelvic Inflammatory Disease are persistent pelvic/lower abdominal pain, irregular menses, and possibly infertility. Signs of chronic Pelvic Inflammatory Disease may include presence of an adnexal masses without fever.

Etiology :
Pelvic inflammatory disease is a type of sexually transmitted disease, although this bilateral infection may be associated with the use of an intrauterine contraceptive device (11).
Chlamydia is more common than gonorrhea as a source of infection, but numerous aerobic and anaerobic organisms may also be present (pelvic actinomycosis) (11). In many cases, the symptoms of chlamydia and gonorrhea are mild or nonexistent in both females and males; however, males are more likely to seek treatment when symptoms are present. 85% of females and 40% of males with chlamydia infection are asymptomatic, but 75% to 80% of men do not know that gonorrhea and chlamydia can be asymptomatic and can have serious consequences.

Sonography :
1. Normal:
A normal appearance of all pelvic organs and structures. This is usually seen with acute inflammation involving only the fallopian tubes without dilatation.
2. Endometritis:
The endometrial echoes are usually absent. There may be fluid present within the uterus. The uterus is hypoechoic with indistinct margins and can appear enlarged and bulbous. No adnexal mass is identified.
3- Salpingitis :
Salpingitis may be acute, subacute, or chronic (6).
* The sonographic appearance of acute salpingitis includes nodular thickening of the walls of the fallopian tubes with diverticula. Hyperemia is also present and can be shown color Doppler imaging. Anechoic or echogenic (pus) fluid may be seen in the posterior cul-de-sac of Douglas as may uterine enlargement with endometrial fluid or thickening (endometritis).
* Subacute salpingitis indicates that infectious changes have taken place without significant clinical signs and symptoms.
* Chronic salpingitis is related to recurrent bouts of Pelvic inflammatory disease and may result in significant tubal scarring and the presence of hydrosalpinx. The patient may have pain during intercourse or bowel movements : from adhesions between the bowel and peritoneal surface, and during menses. frequently an adnexal structure, which may be separable from the ovary, is seen. The structure is anechoic, tubular, and 1 to 4 cm in diameter with hyperechoic walls. Tubal scarring may be seen sonographically as several cystic structures extending from the uterus to the adnexa; this is sometimes referred to as the "chain of lakes" or "string of pearls" sonographic appearance. Infertility and ectopic pregnancy may result from the tubal scarring.
4- Pyosalpinx :
Pyosalpinx is a progression of Pelvic inflammatory disease in which the fallopian tubes become swollen with purulent exudates. The mass is usually well-defined and clearly separable from the surrounding tissue. In 60% of cases, the walls are sharp and smooth; in the other 40%, they are irregular and ill-defined. The mass is usually between 3 and 10 cm and ovoid in shape (5).
The sonographic appearance of pyosalpinx is consistent with visualization of thick-walled tubular or serpiginous structures surrounding the ovaries. The interstitial portion of the tube is tapered at the corn of the uterus. The tube may also be described as sausage shaped. Echogenic material or debris related to the presence of pus may be seen within the fallopian tubes.
5- Hydrosalpinx :
Hydrosalpinx is a consequence of Pelvic inflammatory disease in which the fallopian tube or tubes become closed at the fimbriae and the pus within a pyosalpinx gradually liquefies, leaving serous fluid. In addition, the walls of the tubes become thinner and the tubes may dilate to twice the normal diameter. The patient may be asymptomatic or may have colicky pain. Hydrosalpinx may be present for a significant length of time before diagnosis of infertility from blockage of the fallopian tubes.
Sonographically, the fallopian tubes appear as anechoic thin-walled structures with a multicystic or fusiform mass effect. Color Doppler is useful to differentiate hydrosalpinx from bowel or prominent pelvic veins.
6- Tuboovarian abscess :
It involves a large portion of the pelvis. The pelvis will contain a disorganized heterogeneous echo pattern having solid or cystic areas. One-third of the time it will be impossible to identify the uterus. When the uterus is seen, its specular echo pattern will be absent. Tuboovarian abscess results from pus leaking from an infected fallopian tube :pyosalpinx, and may occur from communication with the ovary. Tuboovarian abscess is a result of serious pelvic infection and is generally seen in the later stages of Pelvic inflammatory disease.
Sonographically, tuboovarian Abscess appears as a thick-walled, complex hypoechoic mass with fluid in the cul-de-sac and adnexa. Tuboovarian Abscess may be bilateral or unilateral and can be found in the adnexa or in the posterior cul-de-sac. Additional sonographic appearances include a mass with septations, irregular margins, and fluid-debris levels. Serial ultrasound examinations can follow the response of the Tuboovarian Abscess to antibiotic therapy or can provide guidance during a drainage procedure. If untreated, Tuboovarian Abscess may progress to peritonitis. The presence of air or gas within the abscess may make sonographic detection and delineation of the disease process difficult unless the examination correlates with clinical findings. In pelvic abscess with peritonitis,diffuse spread of purulent fluid into thé surrounding pelvic cavity is seen.

Differential diagnosis of hydrosalpinx and pyosalpinx :
* Appendix abscess.
* Crohn's disease.
*Caecal diverticulitis.
*Multiloculated ovarian cysts.
*Hydatid or dermoid cysts.
*tubal torsion (4, 9).
*Fluid-filled bowel loops.
*Degenerated uterine leiomyoma.

treatment :
Large abscesses may be drained percutaneously or surgically (7, 8, 12). Transvaginal ultrasound-guided aspiration with anti-microbial therapy may be a useful alternative for treatment of unruptured tubo-ovarian abscess (10, 13). A surgical emergency can occur with massive perforation by a pelvic abscess during which the patient has a rapid progression of severe abdominal pain, nausea, vomiting, peritonitis, shock from peritonitis, and endotoxemia.
Small abscesses still respond to the antibiotic treatment.
Most cases of pelvic Inflammatory Disease improve on antibiotics alone.

Reference :
* 1: Lambert MJ, Villa M. Gynecologic ultrasound in emergency medicine. Emerg Med Clin North Am. 2004 Aug;22(3):683-96. Review.
* 2: Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti AM, Melis GB. Transvaginal ultrasonography associated with colour Doppler energy in the diagnosis of hydrosalpinx. Hum Reprod. 2000 Jul;15(7):1568-72.
* 3: Protopapas AG, Diakomanolis ES, Milingos SD, Rodolakis AJ, Markaki SN, Vlachos GD, Papadopoulos DE, Michalas SP. Tubo-ovarian abscesses in postmenopausal women: gynecological malignancy until proven otherwise? Eur J Obstet Gynecol Reprod Biol. 2004 Jun 15;114(2):203-9.
* 4: Zalel Y, Soriano D, Lipitz S, Mashiach S, Achiron R. Contribution of color Doppler flow to the ultrasonographic diagnosis of tubal abnormalities. J Ultrasound Med. 2000 Sep;19(9):645-9.
* 5: Varras M, Polyzos D, Perouli E, Noti P, Pantazis I, Akrivis Ch. Tubo-ovarian abscesses: spectrum of sonographic findings with surgical and pathological correlations. Clin Exp Obstet Gynecol. 2003;30(2-3):117-21.
* 6: Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol. 1998 Jul;12(1):56-66.
* 7: Caspi B, Zalel Y, Or Y, Bar Dayan Y, Appelman Z, Katz Z. Sonographically guided aspiration: an alternative therapy for tubo-ovarian abscess. Ultrasound Obstet Gynecol. 1996 Jun;7(6):439-42.
* 8: Perez-Medina T, Huertas MA, Bajo JM. Early ultrasound-guided transvaginal drainage of tubo-ovarian abscesses: a randomized study. Ultrasound Obstet Gynecol. 1996 Jun;7(6):435-8.
* 9: Jaluvka V, Entezami M, Becker R, Weitzel HK. [Acute torsion of hydrosalpinx. 2 cases after laparoscopic sterilization] Ultraschall Med. 1995 Feb;16(1):33-5. Review. German.
* 10: Hsu YL, Yang JM, Wang KG. Transvaginal ultrasound-guided aspiration in the treatment and follow-up of tubo-ovarian abscess: a report of two cases. Zhonghua Yi Xue Za Zhi (Taipei). 1995 Sep;56(3):211-4.
* 11: Garland SM, Rawling D. Pelvic actinomycosis in association with an intrauterine device. Aust N Z J Obstet Gynaecol. 1993 Feb;33(1):96-8. no symptoms and no pelvic abnormalities.
* 12: Shulman A, Maymon R, Shapiro A, Bahary C. Percutaneous catheter drainage of tubo-ovarian abscesses. Obstet Gynecol. 1992 Sep;80(3 Pt 2):555-7.
* 13: vanSonnenberg E, D'Agostino HB, Casola G, Goodacre BW, Sanchez RB, Taylor B. US-guided transvaginal drainage of pelvic abscesses and fluid collections. Radiology. 1991 Oct;181(1):53-6.