Imaging findings in inflammatory disease of the genital organs

This review focuses on inflammatory diseases of female and male genital organs and discusses their epidemiology, pathogenesis, clinical presentation, and imaging findings. The female section covers pelvic inflammatory disease (PID) primarily caused by sexually transmitted infections (STIs) that affect the uterus, fallopian tubes, and ovaries. Unusual causes such as actinomycosis and tuberculosis have also been explored. The male section delves into infections affecting the vas deferens, epididymis, testes, prostate, and seminal vesicles. Uncommon causes such as tuberculosis, and Zinner syndrome have also been discussed. In addition, this review highlights other conditions that mimic male genital tract infections such as vasculitis, IgG4-related diseases, and sarcoidosis. Accurate diagnosis and appropriate management of these inflammatory diseases are essential for preventing serious complications and infertility. Imaging modalities such as ultrasound, magnetic resonance imaging, and computed tomography play a crucial role in diagnosis. Understanding the diverse etiologies and imaging findings is vital for the effective management of inflammatory diseases of the genital organs.

Mycoplasma genitalium: Key Information for the Primary Care Clinician

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection, which appears to be a cause of urethritis and cervicitis and has been associated with pelvic inflammatory disease (PID), epididymitis, proctitis, infertility, complications during pregnancy, and human immunodeficiency virus (HIV) transmission. Three Food and Drug Administration (FDA) approved tests are available. Testing should be focused to avoid inappropriate antibiotic use. The Center of Disease Control and Prevention (CDC) guidelines recommend testing for persistent male urethritis, cervicitis, and proctitis and state that testing should be considered in cases of PID. Testing is also recommended for sexual contacts of patients with MG. Testing is not recommended in asymptomatic patients, including pregnant patients, who do not have a history of MG exposure. Although resistance-guided therapy is recommended, there are currently no FDA approved tests for MG macrolide resistance, and tests are not widely available in the United States. The CDC recommends 2-step treatment with doxycycline followed by azithromycin or moxifloxacin. Moxifloxacin is recommended if resistance testing is unavailable or testing demonstrates macrolide resistance..

A New Marker for the Diagnosis of Acute Pelvic Inflammatory Disease: Immature Granulocyte

BACKGROUND

The goal is to assess the role of immature granulocytes (IG) in the diagnosis of acute pelvic-inflammatory-disease (PID) and to determine whether they are useful for discriminating mild/moderate and severe PID.

METHODS

Patients admitted with the diagnosis of acute PID were retrospectively assessed. Diagnosis was based on CDC criteria. Patients were grouped as severe and mild/moderate PID based on need for hospitalization. Control group consisted of patients in whom PID was excluded by laparoscopy. Sample size was calculated with statistical methods. IGs were compared within the groups. Cutoff values were determined for prediction of diagnosis and severity of acute PID.

RESULTS

There were 74 severe, 32 mild/moderate acute PID, and 41 control patients. Thirty patients had surgery following no response to antibiotic treatment or tubo-ovarian abscess. IGs were significantly higher in the severe group compared to mild/moderate and control groups. ROC analysis showed IG counts (≥ 0.035 µL) and percentages (≥ 0.35%) were significantly effective in predicting acute PID and were associated with severity when they were ≥ 0.055 µL and ≥ 0.42%, respectively. IG count ≥ 0.085 was found to have 58.6% sensitivity and 63.1% speci-ficity for prediction of surgical intervention need.

CONCLUSIONS

IGs are components of simple CBC tests and are easily obtainable, cheap markers. They were found to be elevated in acute PID and correlated significantly with the severity of the disease. These markers may serve as adjunctive markers for the diagnosis of acute PID and may be useful in discrimination between mild/moderate and severe PID.

Clinical observation on inverted T-shaped herb-separated moxibustion for chronic pelvic pain in sequelae of pelvic inflammatory diseases

OBJECTIVES

To compare the clinical effect between inverted T-shaped herb-separated moxibustion combined with western medication and simple western medication on chronic pelvic pain(CPP)in sequelae of pelvic inflammatory diseases.

METHODS

A total of 60 patients with CPP in sequelae of pelvic inflammatory diseases were randomly divided into an observation group and a control group, 30 cases in each group. The control group was given ibuprofen tablets 10 days before menstruation, 0.2 g each time, once a day for 10 days. After menstruation, the medication was stopped, and the treatment was given for 3 menstrual cycles.On the basis of the treatment in the control group, the observation group was treated with inverted T-shaped herb-separated moxibustion at the connection between Zhongwan(CV 12)and Zhongji(CV 3), and the connection between Zigong(EX-CA 1)on both sides.The treatment was performed once a week, with an interval of 6 days. The moxibustion was stopped during the menstrual period, the treatment was given for 3 menstrual cycles.Before and after treatment, the visual analogue scale(VAS)score of lower abdominal and lumbosacral pain, local symptom (uterine tenderness, adnexal tenderness and uterosacral ligament tenderness) score and quality of life assessment (QOL) score of the two groups were observed.

RESULTS

After treatment, the lower abdominal and lumbosacral pain VAS scores, the local symptom scores of uterine tenderness, adnexal tenderness, uterosacral ligament tenderness and total scores in the two groups were lower than those before treatment(P<0.01).The lower abdominal and lumbosacral pain VAS score in the observation group was lower than that in the control group(P<0.01),and the changes of local symptom scores of uterine tenderness, adnexal tenderness and uterosacral ligament tenderness and total score in the observation group were greater than those in the control group(P<0.01). After treatment, the QOL scores of the two groups were higher than those before treatment(P<0.01), and the score in the observation group was higher than that in the control group(P<0.01).

CONCLUSIONS

Inverted T-shaped herb-separated moxibustion combined with western medication can effectively reduce the pain in patients with CPP in sequelae of pelvic inflammatory diseases, relieve the local symptoms, improve the quality of life, and the curative effect is better than western medication alone.

Acupuncture therapies for relieving pain in pelvic inflammatory disease: A systematic review and meta-analysis

BACKGROUND

Studies investigating the effectiveness of acupuncture therapies in alleviating pain in pelvic inflammatory disease (PID) have gained increasing attention. However, to date, there have been no systematic reviews and meta-analyses providing high-quality evidence regarding the efficacy and safety of acupuncture therapies in this context.

OBJECTIVE

The objective of this review was to assess the efficacy and safety of acupuncture therapies as complementary or alternative treatments for pain relief in patients with PID.

METHOD

A comprehensive search was conducted in eight databases from inception to February 20, 2023: PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and Chinese Biomedical Literature Database. Randomized controlled trials (RCTs) investigating acupuncture therapies as complementary or additional treatments to routine care were identified. Primary outcomes were pain intensity scores for abdominal or lumbosacral pain. The Cochrane risk of bias criteria was applied to assess the methodological quality of the included trials. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was used to evaluate the quality of evidence. Data processing was performed using RevMan 5.4.

RESULT

This systematic review included twelve trials comprising a total of 1,165 patients. Among these, nine trials examined acupuncture therapies as adjunctive therapy, while the remaining three did not. Meta-analyses demonstrated that acupuncture therapies, whether used alone or in combination with routine treatment, exhibited greater efficacy in relieving abdominal pain compared to routine treatment alone immediately after the intervention (MD: -1.32; 95% CI: -1.60 to -1.05; P < 0.00001). The advantage of acupuncture therapies alone persisted for up to one month after the treatment (MD: -1.44; 95% CI: -2.15 to -0.72; P < 0.0001). Additionally, acupuncture therapies combined with routine treatment had a more pronounced effect in relieving lumbosacral pain after the intervention (MD: -1.14; 95% CI: -2.12 to -0.17; P < 0.00001) in patients with PID. The incidence of adverse events did not increase with the addition of acupuncture therapies (OR: 0.56; 95% CI: 0.21 to 1.51; P = 0.25). The findings also indicated that acupuncture therapies, as a complementary treatment, could induce anti-inflammatory cytokines, reduce pro-inflammatory cytokines, alleviate anxiety, and improve the quality of life in patients with PID.

CONCLUSION

Our findings suggest that acupuncture therapies may effectively reduce pain intensity in the abdomen and lumbosacral region as complementary or alternative treatments, induce anti-inflammatory cytokines, decrease pro-inflammatory cytokines, alleviate anxiety, and enhance the quality of life in patients with PID, without increasing the occurrence of adverse events. However, due to the low quality of the included trials, the conclusion should be interpreted with caution, highlighting the need for further high-quality trials to establish more reliable conclusions.

Association Between Pelvic Inflammatory Disease and Risk of Endometriosis: A Systematic Review and Meta-Analysis

Background: Endometriosis is a common chronic disorder, which leads to dysmenorrhea, dyspareunia, pelvic chronic pain, and infertility. It affects ∼6% to 10% of the general female population. However, the etiology of endometriosis remained unclear. We aimed to systematically assess the association between pelvic inflammatory disease (PID) and the risk of endometriosis. Materials and Methods: Eligible studies published until May 21, 2022, were retrieved from the PubMed, EMBASE, and Web of Science databases. The studies were included based on the following criteria: (1) original articles on the association between PID and risk of endometriosis; (2) randomized controlled trials and cross-sectional, case-control, and cohort studies; and (3) studies involving humans. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of the studies included in this systematic review. The association between PID and risk of endometriosis was evaluated using the overall odds ratio (OR) and correlative 95% confidence interval (CI). Results: The meta-analysis included 14 studies with 747,733 patients. The mean prevalence of PID in women with endometriosis was 33.80%. Our quantitative synthesis revealed that endometritis was associated with a significantly increased risk of endometriosis (OR: 1.63, 95% CI: 1.53-1.74, I2 = 59%). Conclusion: We study a statistically significant association between PID and the risk of endometriosis. In particular, endometritis might play an important role in endometriosis, based on the lower heterogeneity of the subgroup analysis. This finding suggests that reducing the incidence of endometritis might aid in the prevention and treatment of endometriosis.

Global burden of pelvic inflammatory disease and ectopic pregnancy from 1990 to 2019

BACKGROUND

Pelvic inflammatory disease (PID) is a widespread female public problem worldwide. And it could lead to infertility, preterm labor, chronic pelvic pain, and ectopic pregnancy (EP) among reproductive-aged women. This study aimed to assess the global burden and trends as well as the chaning correlation between PID and EP in reproductive-aged women from 1990 to 2019.

METHODS

The data of PID and EP among reproductive-aged women (15 to 49 years old) were extracted from the Global Burden of Disease study 2019. The disease burden was assessed by calculating the case numbers and age-standardized rates (ASR). The changing trends and correlation were evaluated by calculating the estimated annual percentage changes (EAPC) and Pearson's correlation coefficient.

RESULTS

In 2019, the ASR of PID prevalence was 53.19 per 100,000 population with a decreasing trend from 1990 (EAPC: - 0.50), while the ASR of EP incidence was 342.44 per 100,000 population with a decreasing trend from 1990 (EAPC: - 1.15). Globally, PID and EP burdens changed with a strong positive correlation (Cor = 0.89) globally from 1990 to 2019. In 2019, Western Sub-Saharan Africa, Australasia, and Central Sub-Saharan Africa had the highest ASR of PID prevalence, and Oceania, Eastern Europe, and Southern Latin America had the highest ASR of EP incidence. Only Western Europe saw significant increasing PID trends, while Eastern Europe and Western Europe saw increasing EP trends. The highest correlations between PID and EP burden were observed in Burkina Faso, Laos, and Bhutan. General negative correlations between the socio-demographic index and the ASR of PID prevalence and the ASR of EP incidence were observed at the national levels.

CONCLUSION

PID and EP continue to be public health burdens with a strong correlation despite slightly decreasing trends detected in ASRs globally. Effective interventions and strategies should be established according to the local situation by policymakers.

Diagnosed Gonorrhea Among Privately Insured Women: Analysis of United States Claims Data

Background: Gonorrhea incidence in the United States has risen by nearly 50% in the last decade, while screening rates have increased. Gonorrhea sequelae rates could indicate whether increased gonorrhea incidence is due to better screening. We estimated the association of gonorrhea diagnosis with pelvic inflammatory disease (PID), ectopic pregnancy (EP), and tubal factor infertility (TFI) in women and detected changes in associations over time. Materials and Methods: This retrospective cohort study included 5,553,506 women aged 18-49 tested for gonorrhea in the IBM MarketScan claims administrative database from 2013-2018 in the United States. We estimated incidence rates and hazard ratios (HRs) of gonorrhea diagnosis for each outcome, adjusting for potential confounders using Cox proportional hazards models. We tested the interaction between gonorrhea diagnosis and the initial gonorrhea test year to identify changes in associations over time. Results: We identified 32,729 women with a gonorrhea diagnosis (mean follow-up time in years: PID = 1.73, EP = 1.75, TFI = 1.76). A total of 131,500 women were diagnosed with PID, 64,225 had EP, and 41,507 had TFI. Women with gonorrhea diagnoses had greater incidence per 1000 person-years for all outcomes (PID = 33.5, EP = 9.4, TFI = 5.3) compared to women without gonorrhea diagnoses (PID = 13.9, EP = 6.7, TFI = 4.3). After adjustment, HRs were higher in women with a gonorrhea diagnosis vs. those without [PID = 2.29 (95% confidence interval, CI: 2.15-2.44), EP = 1.57, (95% CI: 1.41-1.76), TFI = 1.70 (95% CI: 1.47-1.97)]. The interaction of gonorrhea diagnosis and test year was not significant, indicating no change in relationship by initial test year. Conclusion: The relationship between gonorrhea and reproductive outcomes has persisted, suggesting a higher disease burden.

Evaluation of Acute Pelvic Pain in Women

Acute pelvic pain is defined as noncyclic, intense pain localized to the lower abdomen and/or pelvis, with a duration of less than three months. Signs and symptoms are often nonspecific. The differential diagnosis is broad, based on the patient's age and pregnancy status and gynecologic vs. nongynecologic etiology. Nongynecologic etiologies include gastrointestinal, urinary, and musculoskeletal conditions. Urgent gynecologic conditions include ectopic pregnancy, ruptured ovarian cyst, adnexal torsion, and pelvic inflammatory disease. Approximately 40% of ectopic pregnancies are misdiagnosed at the presenting visit. Urgent nongynecologic conditions include appendicitis and pyelonephritis. Less urgent etiologies include sexually transmitted infections, pelvic floor myofascial pain, dysmenorrhea, and muscle strain. Approximately 15% of untreated chlamydia infections lead to pelvic inflammatory disease. History and physical examination findings guide laboratory testing. Questions should focus on the type, onset, location, and radiation of pain; timing and duration of symptoms; aggravating and relieving factors; and associated symptoms. Performing a urine pregnancy test or beta human chorionic gonadotropin test is an important first step for sexually active, premenopausal patients. Imaging options should be considered, with transvaginal ultrasonography first, followed by computed tomography. Magnetic resonance imaging can be useful if ultrasonography and computed tomography are nondiagnostic.

Mycoplasma Genitalium: A Lesser-Known Cause of Pelvic Inflammatory Disease

Mycoplasma genitalium (MG) is a bacterium that can be spread through sexual contact with another person who is infected. If misdiagnosed and left untreated, this newer, emerging sexually transmitted infection (STI) can cause complications such as urethritis and pelvic inflammatory disease (PID) in both men and women. In males, MG can be asymptomatic and undetectable. In females, MG may present with nonspecific symptoms, such as dysuria, vaginal discharge, and/or pelvic pain. In addition to chlamydia and gonorrhea, MG may result in PID. Due to the complications of MG, health care providers in the emergency department setting need to consider this as a differential diagnosis when performing STI and vaginitis screenings on sexually active patients who may present with urinary or vaginal complaints. As patients with pelvic pain are frequently seen in the emergency department, providers need to be aware of the role that MG may play in STIs and the subsequent sequelae if not treated properly.

Diagnosis of complicated gynaecological inflammations by computed tomography - one center experience

The aim of this article is to acquaint the gynaecological public with our experience with the use of computed tomography in the diagnosis of fluid collections in women with clinical suspicion of complicated pelvic inflammation or a complication after gynaecological surgery. We present diagnostic dilemmas that radiologists deal with, including differential diagnoses. We also deal with the benefits for the referring gynaecologist, and we also discuss the possible discrepancy between his expectations and the result of the examination.

Myometritis with pelvic septic vein thrombophlebitis secondary to Fusobacterium necrophorum sepsis

A young woman in her 20s presented with fever, abdominal pain and malodourous vaginal discharge. She was found to be in septic shock, in the setting of a recent medical abortion with subsequent intrauterine device placement. Her blood cultures grew Fusobacterium necrophorum Despite appropriate antibiotic therapy, the fever failed to defervesce. Subsequent evaluation revealed septic thrombophlebitis of the right gonadal vein and branches of the right iliac vein. She improved with a prolonged course of targeted antimicrobial therapy.

Analysis of Infertility Factors Caused by Gynecological Chronic Pelvic Inflammation Disease Based on Multivariate Regression Analysis of Logistic

In order to solve the complex and recurrent problem of chronic pelvic inflammation disease (CPID) in the process of the clinical treatment, a method of understanding the influencing factors of CPID by investigating the actual situation of clinical cases and using logistics regression analysis was proposed in this study. A total of 204 outpatients were selected from a certain hospital. The ratio of the cases in the experimental group to those in the control group stands at 1 : 1. The results were obtained as follows. According to the data of CPID patients collected in the paper, the majority of patients had a high school education background or below technical secondary school education background, accounting for 66.7%. And the majority of patients were manual workers, accounting for 69.1%. All the exp (B) values of the frequency of sex life per month ≥ 9 times, frequent sex life during menstruation, IUD contraception, no contraception, abortion ≥ 3 times, vaginal irrigation per week ≥ 1 time, and intrauterine surgery ≥ 3 times were more than 1. These seven factors were the risk factors for chronic pelvic inflammation. Oral contraceptives were a weak protective factor of chronic pelvic inflammation. These factors including early drug withdrawal (53.1%), without understanding the condition of the disease (35.7%), no time to review the disease (24.5%), and irregular medication (21.4%) accounted for a large proportion. They were associated with the recurrence of CPID. This method is aimed at providing some foundations for establishing effective prevention and control measures for chronic pelvic inflammation and providing a recognized clinical diagnosis and efficacy evaluation criteria for the treatment of chronic pelvic inflammation.

Brain abscess as a rare complication of pelvic inflammatory disease

OBJECTIVE

Description of the case history of a brain abscess as a rare complication of pelvic inflammatory disease.

CASE REPORT

We discuss a woman of reproductive age who had inserted a non-hormonal intrauterine device for seven years and developed pelvic inflammatory disease with no response to antibio-tic therapy. After surgery, some neurological symptoms led to a dia-gnosis of a brain abscess.

CONCLUSION

Brain abscess is a rare but potentially lethal complication from pelvic inflammatory disease, needing prompt dia-gnosis and interdisciplinary cooperation.

Ectopic pregnancy at the Gambian Tertiary hospital

BACKGROUND/AIMS

Ectopic pregnancy is a gynaecological emergency with significant burden of maternal mortality and morbidity in the tropics. The incidence reported in the literature range from 1:60 to 1:250 pregnancies. The aim was to determine incidence and risk factors of ectopic pregnancy in the Gambia.

METHODOLOGY

A longitudinal study of ectopic pregnancy at Gambian tertiary hospital from January 2016 to April 2018. Data was collected from patients' folders, entered into SPSS version 20 and analysed with descriptive statistics. The test of variation and significance was by ANOVA and Chi-square respectively with error margin set at 0.05 and confidence interval of 95%.

RESULTS

A total number of 2562 pregnancies were recorded, 43 were ectopic pregnancies. The estimated incidence was 0.2%. Majority of the patients were between 26 - 35 years (56%), primiparous (32%), heterogeneous marriage (82%) and housewives (86%). Occupation was not associated with ruptured or unruptured ectopic pregnancy (p-0.421). Low parity was associated with more ectopic pregnancy than high parity (p-0.001). The commonest clinical feature was abdominal pain (65.1%), whilst the most prominent risk factors were pelvic inflammatory disease (27.9%) and previous abortion (23.3%). Ectopic pregnancy was seasonal.

CONCLUSION

The incidence rate of 0.2% was in the range reported in the literature. Low parity, previous abortion and pelvic inflammatory disease were the risk factors.

Acupuncture for chronic pelvic pain in patients with SPID: A protocol for systematic review and meta-analysis

BACKGROUND

Chronic pelvic pain (CPP) is one of the common sequela of pelvic inflammatory disease, the pathological factors are adhesions, scarring and pelvic congestion which caused by inflammation, often cause abdominal pain and lumbosacral soreness, and aggravated after fatigue, sexual intercourse and during menstruation. It is difficult to treat because special pathological changes. Although acupuncture has gained increased popularity for the management of CPP, evidence regarding its efficacy is lacking. Therefore, a systematic review of acupuncture for chronic pelvic pain in patients with SPID is required to provide available evidence for further study.

METHODS AND ANALYSIS

We will conduct a systematic review of randomized controlled trials (RCTs) that investigate the effect and safety of acupuncture for the treatment of chronic pelvic pain patients with SPID. We will electronically search the literature in the databases of PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, the Web of Science, China National Knowledge Infrastructure (CNKI), Wan-fang Digital Periodicals, Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP) and select eligible articles. Data extraction will be conducted by 2 researchers independently, and risk of bias of the meta-analysis will be evaluated based on the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcomes will be total effective rate and VAS pain score, and the secondary outcomes include the recurrence rate and adverse reaction. All data analysis will be conducted by software Review Manager V.5.3.

RESULTS

This study will provide the latest analysis of the currently available evidence for the efficacy of acupuncture for chronic pelvic pain in patients with SPID.

PROSPERO REGISTRATION NUMBER

CRD42020193826.

Inflammation calls for more: Severe pelvic inflammatory disease with or without endometriosis. Outcomes on 311 laparoscopically treated women

OBJECTIVE

To study possible associations between endometriosis and pelvic inflammatory disease (PID).

DESIGN

Retrospective cohort analysis over 14 consecutive years, based on medical records and insurance coding in a tertiary care endometriosis reference center.

SETTING

Tertiary care reference center for endometriosis.

PATIENTS

Retrospective analysis on all women submitted to laparoscopy in our Unit MAIN OUTCOME MEASURES: Intra-operative data about complications and fertility-impairing procedures, intra-, peri- and post-operative complications.

INTERVENTIONS

Retrospective disease codes-triggered chart analysis.

RESULTS

The study population was divided into two groups: Group 1 included women with PID and no endometriosis (n = 115); Group 2 included women with PID and endometriosis (n = 96). Endometriosis had a prevalence of 63 % in patients submitted to surgery for PID, significantly higher than the one reported in general population and than the one reported in a Tertiary Care Endometriosis Unit. A significantly higher number of salpingectiomes was needed in group 2 patients (208 versus 80, p < 0.0001).

CONCLUSIONS

This study seems to confirm an higher prevalence of pelvic inflammatory disease in endometriosis patients. Intra-operative findings of PID with associated endometriosis show more aggressive patterns.

[Pelvic inflammatory disease is a rare cause of acute abdomen in a child]

Pelvic inflammatory disease (PID) is a frequent cause of acute abdomen among sexually active females, although rarely seen in girls prior to their sexual debut. In this case report, a 12-year-old girl was hospitalised due to abdominal pain. She was virgo and premenarcheal. A laparoscopy showed a normal appendix but revealed pyosalpinx. A follow-up with ultrasound of the genitalia interna showed normal relations. PID should be considered in all females with compatible symptoms, irrespective of their age.

Relationships between female infertility and female genital infections and pelvic inflammatory disease: a population-based nested controlled study

OBJECTIVES

Our purpose was to examine the associations of female genital infections and certain comorbidities with infertility.

METHODS

The Taiwan National Health Research Database was searched for women with a new diagnosis of infertility between 2000 and 2013. Women without a diagnosis of infertility served as a control group and were matched with the infertility cases by age (±3 years) and index year. They were divided into two groups: ≤40 years old and >40 years old. Univariate and multivariate conditional logistic regression models were employed to identify the risk factors associated with infertility.

RESULTS

A total of 18,276 women with a new diagnosis of infertility and 73,104 matched controls (mean cohort age, 31±6.2 years) were included. According to the adjusted multivariate analysis, pelvic inflammatory disease involving the ovary, fallopian tube, pelvic cellular tissue, peritoneum (odds ratio (OR)=4.823), and uterus (OR=3.050) and cervical, vaginal, and vulvar inflammation (OR=7.788) were associated with an increased risk of infertility in women aged ≤40 years. In women aged >40 years, pelvic inflammatory disease of the ovary, fallopian tube, pelvic cellular tissue, and peritoneum (OR=6.028) and cervical, vaginal, and vulvar inflammation (OR=6.648) were associated with infertility. Obesity, lipid metabolism disorders, dysthyroidism, abortion (spontaneous or induced), bacterial vaginosis, endometritis, and tubo-ovarian abscess were associated with an increased risk of infertility according to the univariate analysis but not the multivariate analysis.

CONCLUSIONS

Female genital tract infections, but not the comorbidities studied here, are associated with an increased risk of infertility.

An incidental finding of chronic salpingitis complications: Tubo-uterine fistula

Pelvic inflammatory disease (PID) is an infection of the upper genital tract in women that can include endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, and peritonitis. The spectrum of the disease ranges from subclinical and asymptomatic infection to severe, lifethreatening illness; squealae include chronic pelvic pain, ectopic pregnancy, and infertility. In this case we report an uncommon complication of pelvic inflammatory disease, a tubo-uterian fistula. Our case was diagnosed by laparoscopy incidentally during assessment of infertility.

Mycoplasma genitalium: Accurate Diagnosis Is Necessary for Adequate Treatment

Background

Mycoplasma genitalium is very difficult to grow in culture but has been more able to be studied for disease associations since the advent of research molecular amplification assays. Polymerase chain reaction (PCR) and other molecular assays have demonstrated an association with adverse disease outcomes, such as urethritis or nongonococcal urethritis in men and adverse reproductive sequelae in women-for example, cervicitis, endometritis, and pelvic inflammatory disease (PID), including an association with risk for human immunodeficiency virus. The lack of commercially available diagnostic assays has limited widespread routine testing. Increasing reports of high rates of resistance to azithromycin detected in research studies have heightened the need available commercial diagnostic assays as well as standardized methods for detecting resistance markers. This review covers available molecular methods for the diagnosis of M. genitalium and assays to predict the antibiotic susceptibility to azithromycin.

Methods

A PubMed (US National Library of Medicine and National Institutes of Health) search was conducted for literature published between 2000 and 2016, using the search terms Mycoplasma genitalium, M. genitalium, diagnosis, and detection.

Results

Early PCR diagnostic tests focused on the MPa adhesion gene and the 16S ribosomal RNA gene. Subsequently, a transcription-mediated amplification assay targeting ribosomes was developed and widely used to study the epidemiology of M. genitalium. Newer methods have proliferated and include quantitative PCR for organism load, AmpliSens PCR, PCR for the pdhD gene, a PCR-based microarray for multiple sexually transmitted infections, and multiplex PCRs. None yet are cleared by the Food and Drug Administration in the United States, although several assays are CE marked in Europe. As well, many research assays, including PCR, gene sequencing, and melt curve analysis, have been developed to detect the 23S ribosomal RNA gene mutations that confer resistance to azithromycin. One recently developed assay can test for both M. genitalium and azithromycin resistance mutations at the same time.

Conclusions

It is recommended that more commercial assays to both diagnose this organism and guide treatment choices should be developed and made available through regulatory approval. Research is needed to establish the cost-effectiveness of routine M. genitalium testing in symptomatic patients and screening in all individuals at high risk of acquiring and transmitting sexually transmitted infections.

Mycoplasma genitalium in Women: Current Knowledge and Research Priorities for This Recently Emerged Pathogen

Health consequences of sexually transmitted diseases disproportionately affect women, making it important to determine whether newly emerged pathogens cause sequelae. Although the pathogenic role of Mycoplasma genitalium in male urethritis is clear, fewer studies have been conducted among women to determine its pathogenic role in the female reproductive tract. Pelvic inflammatory disease (PID) is an important cause of infertility and ectopic pregnancy, and Chlamydia trachomatis and Neisseria gonorrhoeae are recognized microbial causes. Emerging data demonstrate an association between M. genitalium and PID, and limited data suggest associations with infertility and preterm birth, yet the attributable risk for female genital tract infections remains to be defined. Further investigations are needed to better define the impact of M. genitalium on women's reproductive health. Importantly, prospective studies evaluating whether screening programs and targeted treatment of M. genitalium improve reproductive outcomes in women are necessary to guide public health policy for this emerging pathogen.

Comparison of the population excess fraction of Chlamydia trachomatis infection on pelvic inflammatory disease at 12-months in the presence and absence of chlamydia testing and treatment: Systematic review and retrospective cohort analysis

BACKGROUND

The impact of Chlamydia trachomatis (chlamydia) control on the incidence of pelvic inflammatory disease (PID) is theoretically limited by the proportion of PID caused by chlamydia. We estimate the population excess fraction (PEF) of treated chlamydia infection on PID at 12-months in settings with widespread chlamydia control (testing and treatment) and compare this to the estimated PEF of untreated chlamydia.

METHODS

We used two large retrospective population-based cohorts of women of reproductive age from settings with widespread chlamydia control to calculate the PEF of treated chlamydia on PID at 12-months. We undertook a systematic review to identify further studies that reported the risk of PID in women who were tested for chlamydia (infected and uninfected). We used the same method to calculate the PEF in eligible studies then compared all estimates of PEF.

RESULTS

The systematic review identified a single study, a randomised controlled trial of chlamydia screening (POPI-RCT). In the presence of testing and treatment <10% of PID at 12-months was attributable to treated (baseline) chlamydia infections (Manitoba: 8.86%(95%CI 7.15-10.75); Denmark: 3.84%(3.26-4.45); screened-arm POPI-RCT: 0.99%(0.00-29.06)). In the absence of active chlamydia treatment 26.44%(11.57-46.32) of PID at 12-months was attributable to untreated (baseline) chlamydia infections (deferred-arm POPI-RCT). The PEFs suggest that eradicating baseline chlamydia infections could prevent 484 cases of PID at 12-months per 100,000 women in the untreated setting and 13-184 cases of PID per 100,000 tested women in the presence of testing and treatment.

CONCLUSION

Testing and treating chlamydia reduced the PEF of chlamydia on PID by 65% compared to the untreated setting. But in the presence of testing and treatment over 90% of PID could not be attributed to a baseline chlamydia infection. More information is needed about the aetiology of PID to develop effective strategies for improving the reproductive health of women.

Pelvic Inflammatory Disease and the Risk of Ovarian Cancer and Borderline Ovarian Tumors: A Pooled Analysis of 13 Case-Control Studies

Inflammation has been implicated in ovarian carcinogenesis. However, studies investigating the association between pelvic inflammatory disease (PID) and ovarian cancer risk are few and inconsistent. We investigated the association between PID and the risk of epithelial ovarian cancer according to tumor behavior and histotype. We pooled data from 13 case-control studies, conducted between 1989 and 2009, from the Ovarian Cancer Association Consortium (OCAC), including 9,162 women with ovarian cancers, 2,354 women with borderline tumors, and 14,736 control participants. Study-specific odds ratios were estimated and subsequently combined into a pooled odds ratio using a random-effects model. A history of PID was associated with an increased risk of borderline tumors (pooled odds ratio (pOR) = 1.32, 95% confidence interval (CI): 1.10, 1.58). Women with at least 2 episodes of PID had a 2-fold increased risk of borderline tumors (pOR = 2.14, 95% CI: 1.08, 4.24). No association was observed between PID and ovarian cancer risk overall (pOR = 0.99, 95% CI: 0.83, 1.19); however, a statistically nonsignificantly increased risk of low-grade serous tumors (pOR = 1.48, 95% CI: 0.92, 2.38) was noted. In conclusion, PID was associated with an increased risk of borderline ovarian tumors, particularly among women who had had multiple episodes of PID. Although our results indicated a histotype-specific association with PID, the association of PID with ovarian cancer risk is still somewhat uncertain and requires further investigation.

[Tubo-ovarian abscess in the 39th week of pregnancy (case report)]

OBJECTIVE

A case of tubo-ovarian abscess in a patient with term pregnancy.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, Nemocnice s poliklinikou Karviná Ráj.

CASE REPORT

I hereby report a case of a patient in her 39th week of pregnancy hospitalized for abdominal pain and vomiting. Due to unclear aetiology and growing dynamics of inflammatory markers the ending of the pregnancy by induction of labour was indicated. Postpartum examination performed through computed tomography determines the cause of current problems. Conservative therapy of the diagnosed adnexal abscess, however, is insufficient. In the fourth postpartum day, the patient is indicated for surgical intervention and unilateral salpingo oophorectomy is performed.

CONCLUSION

Even though rare during this period, some forms of clinical pelvic inflammatory disorders during pregnancy have to be taken into consideration. Timely and correct diagnosis combined with adequate therapy is of vital importance for reduction of perinatal and maternal mortality and morbidity.

The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will require surgical treatment

OBJECTIVE

To determine if the ultrasonographic morphology of a tubo-ovarian abscess (TOA) could be used to predict if a patient will require surgical treatment.

METHOD

A retrospective cohort study reviewed medical records from patients diagnosed with TOA via ultrasonography between January 2009 and January 2014 at a tertiary referral center in Turkey. Patients with pelvic inflammatory disease and an inflammatory adnexal mass, identified during sonographic examination, were included in the study. Ultrasonographic morphology, demographic characteristics, and clinical and laboratory findings were compared between patients who required surgical treatment and those who did not.

RESULTS

Records were included from 164 patients; medical therapy was successful in 121 (73.8%) patients and 43 (26.2%) required surgical treatment. TOA morphology was identified, using ultrasonography, as unilocular cystic, complex multicystic mass, or pyosalpinx in 56 (34.1%), 73 (44.5%), and 35 (21.3%) patients, respectively. No correlation was present between ultrasonographic TOA morphology and patients requiring surgical treatment (all P>0.05). Multivariate analyses demonstrated that an abscess larger than 6.5 cm in size (P=0.027), fever at admission (P<0.001), and parity greater than two (P=0.026) were independent predictors of patients requiring surgical treatment for TOA.

CONCLUSION

Although increased TOA size, fever at admission, and parity were associated with increased odds of patients with TOA requiring surgical treatment, ultrasonographic TOA morphology was not.

Endometriosis and infertility

Endometriosis remains a very enigmatic and perplexing disease. The exact mechanism by which endometriosis causes infertility is still unclear. In the present paper, we will review possible mechanisms leading to subfertility or infertility in women with endometriosis and examine them according to location. Endometriosis in the pelvic cavity is a pathology associated with a general inflammatory response and should therefore be considered an inflammatory disease. Inflammatory changes affect the peritoneal fluid and hence the intratubal milieu, since the ampulla (where fertilization takes place) is exposed to peritoneal fluid through the fimbria. Any inflammatory change at this level may therefore impact fertilization and natural conception. The relationship between ovarian endometriomas and infertility may, of course, be explained by the presence of periovarian endometriosis. In the ovary, fibrosis observed in some cortical areas is induced by the inflammatory reaction caused by the presence of endometriomas. The association between fibrosis and a reduced ovarian reserve was demonstrated. Upregulated recruitment and the subsequent demise of early follicles may result in focal exhaustion of primordial follicles. Burn-out of early follicles by a local pelvic inflammatory environment caused by endometriomas may therefore be suggested. However, intraovarian inflammation, subsequent fibrosis and depletion of the ovarian reserve constitute another reason that should also be given due consideration. In addition, surgery should not be ruled out as a possible cause of ovarian reserve depletion. In conclusion, potential mechanisms leading to infertility are numerous, and while some of them remain hypothetical for now, others are supported by clear evidence. These possible mechanisms were reviewed in the present paper.

Correlation Between Bladder Pain Syndrome/Interstitial Cystitis and Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) has been investigated in Western countries and identified to be associated with chronic pelvic pain and inflammation. Bladder pain syndrome/interstitial cystitis (BPS/IC) is a complex syndrome that is significantly more prevalent in women than in men. Chronic pelvic pain is a main symptom of BPS/IC, and chronic inflammation is a major etiology of BPS/IC. This study aimed to investigate the correlation between BPS/IC and PID using a population-based dataset.We constructed a case-control study from the Taiwan National Health Insurance program. The case cohort comprised 449 patients with BPS/IC, and 1796 randomly selected subjects (about 1:4 matching) were used as controls. A Multivariate logistic regression model was constructed to estimate the association between BPS/IC and PID.Of the 2245 sampled subjects, a significant difference was observed in the prevalence of PID between BPS/IC cases and controls (41.7% vs 15.4%, P < 0.001). Multivariate logistic regression analysis revealed that the odds ratio (OR) for PID among cases was 3.69 (95% confidence interval [CI]: 2.89-4.71). Furthermore, the ORs for PID among BPS/IC cases were 4.52 (95% CI: 2.55-8.01), 4.31 (95% CI: 2.91-6.38), 3.00 (95% CI: 1.82-4.94), and 5.35 (95% CI: 1.88-15.20) in the <35, 35-49, 50-64, and >65 years age groups, respectively, after adjusting for geographic region, irritable bowel syndrome, and hypertension. Joint effect was also noted, specifically when patients had both PID and irritable bowel disease with OR of 10.5 (95% CI: 4.88-22.50).This study demonstrated a correlation between PID and BPS/IC. Clinicians treating women with PID should be alert to BPS/IC-related symptoms in the population.

The approach to chronic pelvic pain in the adolescent

Adolescents present to outpatient and acute care settings commonly for evaluation and treatment of chronic pelvic pain (CPP). Primary care providers, gynecologists, pediatric and general surgeons, emergency department providers, and other specialists should be familiar with both gynecologic and nongynecologic causes of CPP so as to avoid delayed diagnoses and potential adverse sequelae. Treatment may include medications, surgery, physical therapy, trigger-point injections, psychological counseling, and complementary/alternative medicine. Additional challenges arise in caring for this patient population because of issues of confidentiality, embarrassment surrounding the history or examination, and combined parent-child decision making.

Identification of Clostridium septicum in a tubo-ovarian abscess: a rare case and review of the literature

INTRODUCTION

Tubo-ovarian abscess (TOA) is a conglomerated mass of pelvic organs including the tube, the ovary, and the bowel. The most commonly isolated organisms from TOAs are Escherichia coli (E. coli) and Bacteroides species.

CASE REPORT

We reported a case of Clostridium septicum (C. septicum) infection from a ruptured TOA with atypical clinical features. Culture of intra-abdominal free fluid obtained during surgery yielded C. septicum. VITEK II (bioMérieux, France) automated system was used for advanced identification of the bacteria. Parenteral clindamycin in combination with an aminoglycoside was used. The patient was discharged 19 days after the surgery and was clinically asymptomatic 6 months after the surgery.

CONCLUSION

The differential diagnosis of TOA caused by C. septicum can be difficult, due to the lack of the symptoms. Tissues infected with C. septicum can become necrotic. A combination of early, adequate antibiotic therapy and surgery is the key point of the treatment.

Transvaginal ultrasound assessment of women presenting with infertility and menstrual irregularity in Calabar, Nigeria

AIMS AND OBJECTIVES

This study was designed to document the Transvaginal Scan (TVS) findings in women presenting with infertility and menstrual irregularities at the University of Calabar Teaching Hospital.

MATERIALS AND METHODS

Subjects were women of reproductive age presenting at the University of Calabar Teaching Hospital with menstrual irregularities and infertility over a two year period, February 2011-January 2013. As part of their management, transvaginal scans were done and findings included a substantial number with polycystic ovarian cysts. Therefore the ovaries were further analysed with controls.

RESULTS

Out of seventy-one women with age distribution of 22 to 46years, twenty- four(33.8%) presented with infertility, the rest presented with either menstrual irregularity alone or in combination with infertility. Polycystic ovaries (PCO), chronic pelvic inflammatory disease and fibroids were the main pathologies seen. PCO was by far the commonest. Ovarian volumes and follicular numbers were significantly higher in women with PCO than in controls, whereas their average follicular sizes were lower.

CONCLUSION

PCO is the major finding in women with menstrual irregularity and infertility in the Calabar area. This hitherto poorly recorded pathology should be actively investigated in women representing with these symptoms by the use of TVS.

Risk and protective factors in the origin of atrial septal defect secundum--national population-based case-control study

The aim of this study was to assess the risk factors in the origin of lethal or surgically corrected isolated atrial septal defect secundum. The population-based Hungarian Case-Control Surveillance of Congenital Abnormalities (conducted between 1980 and 1996) comprised 472 atrial septal defect secundum cases, 678 matched controls and 38,151 available controls without any defects; in addition, 21,022 malformed controls with other isolated defects. Medically recorded chronic disorders in the prenatal maternity logbook were evaluated, while acute maternal diseases, drug treatments and pregnancy supplements were analyzed on the basis of both prospective medically recorded data and retrospective maternal information. Acute pelvic inflammatory disease, paroxysmal supraventricular tachycardia and phenolphthalein treatment due to severe constipation of mothers were shown to contribute to the development of atrial septal defect secundum of their children. High doses of folic acid in early pregnancy had positively influenced a minor part of isolated atrial septal defect secundum in foetuses. In conclusion, the obvious genetic predisposition for atrial septal defect secundum is connected with maternal paroxysmal supraventricular tachycardia and triggered by acute pelvic inflammatory diseases and phenolphthalein treatment, while the manifestation of atrial septal defect secundum can be reduced by high doses of folic acid supplementation in early pregnancy.

Hospitalisations for pelvic inflammatory disease temporally related to a diagnosis of Chlamydia or gonorrhoea: a retrospective cohort study

OBJECTIVES

The presence and severity of pelvic inflammatory disease (PID) symptoms are thought to vary by microbiological etiology but there is limited empirical evidence. We sought to estimate and compare the rates of hospitalisation for PID temporally related to diagnoses of gonorrhoea and chlamydia.

METHODS

All women, aged 15-45 years in the Australian state of New South Wales (NSW), with a diagnosis of chlamydia or gonorrhoea between 01/07/2000 and 31/12/2008 were followed by record linkage for up to one year after their chlamydia or gonorrhoea diagnosis for hospitalisations for PID. Standardised incidence ratios compared the incidence of PID hospitalisations to the age-equivalent NSW population.

RESULTS

A total of 38,193 women had a chlamydia diagnosis, of which 483 were hospitalised for PID; incidence rate (IR) 13.9 per 1000 person-years of follow-up (PYFU) (95%CI 12.6-15.1). In contrast, 1015 had a gonorrhoea diagnosis, of which 45 were hospitalised for PID (IR 50.8 per 1000 PYFU, 95%CI 36.0-65.6). The annual incidence of PID hospitalisation temporally related to a chlamydia or gonorrhoea diagnosis was 27.0 (95%CI 24.4-29.8) and 96.6 (95%CI 64.7-138.8) times greater, respectively, than the age-equivalent NSW female population. Younger age, socio-economic disadvantage, having a diagnosis prior to 2005 and having a prior birth were also associated with being hospitalised for PID.

CONCLUSIONS

Chlamydia and gonorrhoea are both associated with large increases in the risk of PID hospitalisation. Our data suggest the risk of PID hospitalisation is much higher for gonorrhoea than chlamydia; however, further research is needed to confirm this finding.

[Spontaneous renal forniceal rupture with suspicious ovarian mass]

Extravasation of urine following rupture of the renal fornix is a rare complication mostly caused by obstruction secondary to distal ureteric stones. This 35-year-old woman was referred with back pain. Her CT scan revealed rupture of the renal fornix secondary to a pelvic mass. Laparoscopy subsequently confirmed this to be an ovarian abscess. We report the first case of spontaneous renal forniceal rupture secondary to pelvic inflammatory disease.

Can the impact of pelvic inflammatory disease on fertility be prevented? Epidemiology, clinical features and surgical treatment: evolution over 8 years

OBJECTIVE

To assess the epidemiological features and the trend of care of patients diagnosed with pelvic inflammatory disease (PID) and to assess most predictive parameters of severe disease, for which surgical management is warranted, in particular when surgery is certain to cause permanent infertility.

STUDY DESIGN

The study population was divided into 3 groups: medical therapy only, conservative surgery, and destructive surgery (surgical procedures that impaired fertility). Data from the 3 groups were compared with respect to general and medical history data, clinical signs on admission, laboratory tests, and ultrasound findings. The p value was considered significant when < 0.05.

RESULTS

The non-Italian women in the study appeared to be more at risk of developing PID and were overrepresented in the surgically treated groups. C-reactive protein (CRP) and D-dimer values most likely correlated with disease severity. Ultrasound evidence of ovaritis generally led to medical therapy. Conversely, when sonography revealed pyosalpinx or tuboovarian abscesses, surgery was performed.

CONCLUSION

Clinical presentation is fundamental in diagnostic counseling but should be supplemented with further laboratory tests to detect inflammation and sonograms. The latter, along with CRP and D-dimer assays, may represent useful parameters to consider when planning patient management because they appear indicative of the need for surgical treatment.

Key Pharmacokinetic Parameters of Isepamicin in Febrile Neutropenic Cancer Patients and in Women with Acute Pelvic Inflammatory Disease

The pharmacokinetics (PK) of isepamicin were studied in 8 febrile neutropenic patients with hematologic malignancy and in 20 young women with acute pelvic inflammatory disease (PID). Isepamicin was given as a slow intravenous infusion over 30 min at a dose of 15 mg/kg once daily (OD). Serum levels of isepamicin were determined by fluorescence polarization immunoassay, and PK analyses were obtained based on a one-compartment open model after 24 hours (steady state) and after 7 days. On day 1, the volume of distribution (Vd) of isepamicin, for both populations, appeared about 30% higher than classically reported in healthy individuals: 0.31 and 0.36 L/kg for neutropenic and PID patients respectively. However on day 7, Vd displayed significant reduction (0.28 and 0.27 L/kg, respectively for neutropenic and PID patients). A reduction of isepamicin clearance was also observed between day 1 and day 7 (137 vs 120 mL/min and 130 vs 101 mL/min for neutropenic and PID populations, respectively). Such changes are consistent with a significant increase in the Cmax concentrations (45 vs 50 mg/L, and 38 vs 49 mg/L) and in the AUC (136 vs 158 and 137 vs 162 mg/L.h) observed after a week of treatment in neutropenic and PID patients, respectively. In conclusion, taking into account the importance of reaching early active concentrations, we recommend the use of higher loading dose of isepamicin (>15 mg/kg) in neutropenic cancer patients and in women with PID, particularly in case of a combination with a possibly ineffective antibacterial agent, in case of infection with bacteria at upper limit of susceptibility, in the presence of high infectious inoculum or in the presence of sequestered sites of infection.

MASSIVE RECTORRHAGIA IN A RURAL HOSPITAL IN KENYA

A young female patient presented to our hospital for massive rectorrhagia associated with clinical signs of peritonitis. The provisional diagnosis was of sigmoid volvolus, but laparatomy demonstrated that the problem originated from Pelvic Inflammatory Disease (PID). Despite prompt and uncomplicated surgery the patient did not survive, probably because of septicaemia or pulmonary embolism.

Bacteriological agents which play a role in the development of infertility

This study was carried out to determine the prevalence of the bacterial agents Chlamydia trachomatis (C. trachomatis), Neisseria gonorrhoeae (N. gonorrhoeae), Mycoplasma hominis (M. hominis) and Ureaplasma urealyticum (U. urealyticum) and the conditions which may play a role in the development of female infertility, in the county of Iaşi in North-Eastern Romania. Cervical and blood samples were collected from 176 infertile women and 45 pregnant women in the third trimester. Classical methods and real time PCR were applied to each cervical sample to detect the presence of these sexually transmitted microorganisms; the ELISA method was applied to blood samples to detect C. trachomatis antibodies (IgA, IgM and IgG). The proportion of C. trachomatis IgG was significantly higher in the infertile group (23.8%) than in the pregnant group (4.4%), p < 0.05. For C. trachomatis antigen (Ag) and N. gonorrhoeae Ag no differences were observed between the two groups. The prevalence of mycoplasma genital infections was higher in the pregnant group (U. urealyticum - 53.3% and M. hominis - 20%) than in the infertile group (U. urealyticum - 39.7% and M. hominis - 7.3%). Higher rate of co-infection with C. trachomatis and mycoplasma were observed among the infertile women (25.7%) than among the pregnant women (7.7%). This combination could be involved in the appearance of pelvic inflammatory disease (PID) and its sequela, including infertility. C. trachomatis IgG determination still remains the gold standard for the diagnosis of PID and should be used as a screening test for the prediction of tubal damage in infertile women. In view of the large number of cases involving the co-existence of genital infections with C. trachomatis, M. hominis and U. urealyticum, it is clearly necessary to perform screening for all three microorganisms among all women of reproductive age but especially those who are infertile.

[Prevention of eventration in diffuse suppurative processes in small pelvis]

The study was devoted to the problem of postoperative eventrations in gynaecological practice. Coaptation removable sutures were applied in order to prevent similar complications. Operations were performed in the cases of desolate condition of purulent disease of the uterus and uterine appendages with diffuse suppurative peritonitis. An advanced operative technique of suturing through all layers of abdominal wall demonstrated its high efficacy. No one patient (from 39) had the eventration or wound abscess.

[Related factors associated with pelvic adhesion and its influence on fallopian tube recanalization in infertile patients]

OBJECTIVE

To investigate factors with pelvic adhesions and the effect of different degrees pelvic adhesions on fallopian tube recanalization in infertile patients.

METHODS

Total of 527 infertile patients undergoing hysteroscopy and laparoscopic surgery in Affiliated Hospital of Chinese People's Armed Police Forces Logistics College were studied retrospectively. According to the extent of pelvic adhesions, tubal umbrella adhesions and atresia, 377 cases were classified into adhesion groups, including 73 cases in grade I, 221 cases in grade II, 75 cases in grade III and 8 cases in grade IV based on adhesion score. The 150 cases with no obvious pelvic adhesion were matched as control group. Among 8 cases with grade IV ahesion were exluded from ahesion group the relationship between pelvic adhesions and related history, abdominal lesions, tubal patency and the prognosis were studied.

RESULTS

(1) Related factors: the frequency of pelvic adhesion and more than 7 years of infertility of 23.9% (88/369) in adhesion group were significantly higher than 12.0% (18/150) in control groups. (2) HISTORY: compared with the control group (12.7%, 19/150; 28.7%, 43/150; 11.3%, 17/150; 12.0%, 18/150; 17.3%, 26/150), patients with pelvic adhesions present more incidence abortion (23.6%, 87/369), uterine cavity operation (38.2%, 141/369), ectopic pregnancy (20.9%, 77/369), pelvic inflammatory disease (25.5%, 94/369) and abdominopelvic surgery (31.4%, 116/369). (3) Endoscopy exploration: the incidence of hydrosalpinx (24.7%, 91/369), tube distorted (15.7%, 58/369) and salpingostomy (72.9%, 269/369) in adhesion group were higher than those in control group (2.0%, 3/150; 4.0%, 6/150; 12.0%, 18/150), but relatively lower incidence of pelvic endometriosis lesions (5.7%, 21/369) and mesosalpinx cysts (16.3%, 60/369) than those in control group (16.0%, 24/150; 30.0%, 45/150). The rate of proximal tubal recanalization (59.5%, 91/153) in adhesion group was lower than 75.4% (52/69) in control group. However, the rate of distant tubal recanalization of 84.4%, (281/333) in adhesion group and; 13/15 in control group didn't show statistical difference. (4) PROGNOSIS: the rate of ectopic pregnancy of 9.7% (29/299) in adhesion group was significantly higher than 3.1% (4/128) in control group. Among cases with grade III adhesion exhibited the highest rate of ectopic pregnancy (13.0%, 7/54; OR = 4.62, 95%CI: 1.29 - 16.50). (5) Multivariate analysis: it was found that more than two drug abortions (OR = 3.29, 95%CI: 1.34 - 8.07), pelvic and(or) abdominal surgery history (OR = 2.20, 95%CI: 1.35 - 3.57) and pelvic inflammatory disease history (OR = 1.54, 95%CI: 1.21 - 1.97) were risk factors with pelvic adhesions.

CONCLUSION

More than or equal to two drug abortion history, pelvic inflammatory disease and pelvic and abdominal surgery damage were important factors for pelvic adhesions of infertility patients, which may decrease the possibility of proximal tubal recanalization and increase ectopic pregnancy risk.

[Chlamydia and infertility]

Chlamydia trachomatis has for long been considered to be a major contributor to tubal infertility. However, the scientific evidence based on human clinical research is weak. C. trachomatis is associated with pelvic inflammatory disease, and pelvic inflammatory disease is associated with tubal infertility. But no interventional trial nor well-conducted study or large cohort study has assessed the risk of infertility given an undiagnosed or untreated genital chlamydial infection. We suggest that the many well established registers in Denmark serve to further elucidate the evidence.

Acute gonococcal Fitz-Hugh-Curtis syndrome: a case report

A case of acute Fitz-Hugh-Curtis syndrome in a young woman with purulent peritonitis and acute purulent appendicitis and oophoritis is presented. Open emergency appendectomy was performed and peritoneal pus was drained. Neisseria gonorrhoeae was cultured from the peritoneal pus. The hepatic enzymes were found to be raised. The patient was successfully managed and is asymptomatic after three months follow-up. To our knowledge, this is the first case of Fitz-Hugh-Curtis syndrome reported from Kuwait.

Mycoplasma genitalium: should we treat and how?

Mycoplasma genitalium is associated with acute and chronic urethritis in men. Existing data on infection in women are limited and inconsistent but suggest that M. genitalium is associated with urethritis, cervicitis, pelvic inflammatory disease, and possibly female infertility. Data are inconclusive regarding the role of M. genitalium in adverse pregnancy outcomes and ectopic pregnancy. Available data suggest that azithromycin is superior to doxycycline in treating M. genitalium infection. However, azithromycin-resistant infections have been reported in 3 continents, and the proportion of azithromycin-resistant M. genitalium infection is unknown. Moxifloxacin is the only drug that currently seems to uniformly eradicate M. genitalium. Detection of M. genitalium is hampered by the absence of a commercially available diagnostic test. Persons with persistent pelvic inflammatory disease or clinically significant persistent urethritis or cervicitis should be tested for M. genitalium, if possible. Infected persons who have not previously received azithromycin should receive that drug. Persons in whom azithromycin therapy fails should be treated with moxifloxicin.