Pelvic Inflammatory Disease

Transcription

1 Pelvic Inflammatory Disease JUDYTHE TORRINGTON, RNC A dramatic increase in the incidence of pelvic inflammatory disease in recent years has led to a parallel increase in consequent infertility. The economic and psychologic costs of infection and infertility are severe and preventable. The author reviews and outlines current diagnostic and therapeutic recommendations that are now being used to prevent infectious morbidity. A brief review of the indications, techniques, and prospects for surgical correction of tubal disease and pelvic adhesions is also presented. A consequence of changing sexual mores in the last two generations has been a dramatic increase in pelvic inflammatory disease (PID) and subsequent infertility. More than one million cases of gonorrhea were reported in the United States in 1978, and this was estimated to be only 50% of the actual cases. The yearly incidence of pelvic inflammatory disease is one percent of all women of childbearing age but is at least twice as high in teenagers and women in their early 20s. Westrom outlined the dramatic consequences of the epidemic of pelvic inflammatory disease in the last 25 years. The incidence of pelvic inflammatory disease parallels the prevalence of all sexually transmitted diseases and is magnified by the increased use of intrauterine contraceptive devices and therapeutic abortion in the sexual-revolution generation. Postinfectious tubal damage is an etiologic factor in one-third of female infer ti lit^.^ Westrom estimates that, annually, about 25,000 ectopic pregnancies can be attrib- uted to the damage of pelvic inflammatory disease. He further states that infertility secondary to pelvic inflammatory disease has nearly doubled in the last 20 years.2 Droegemueller has reviewed the disastrous economic impact of pelvic inflammatory disease and estimates it to be $2.5 billion annually. This is the cost of an estimated two million outpatient visits and 250,000 hospital admissions for pelvic inflammatory disease annually. Tuba1 factors are said to be responsible for 35 percent of the infertility experienced by 10 to 15 percent of all couples. One acute episode of salpingitis will render about 20 percent of patients infertile.3 This is a dramatic reduction from a 75% sterility rate experienced by victims of pelvic inflammatory disease in the 1960s and is largely the result of earlier diagnosis and improved antibiotic regimens. The last decade has seen an unprecedented effort to improve methods of surgical treatment for infertility secondary to pelvic in- flammatory disease. Adoption of microsurgical techniques with emphasis on finer nonreactive suture materials, meticulous hemostasis, and adjuvant measures designed to reduce the incidence and extent of postoperative adhesions has been rapid.4 These measures have undoubtedly improved the prospects for fertility in victims of pelvic inflammatory disease but may have contributed to an increasing rate of ectopic pregnancies arising in tubes either partially damaged by infection or whose integrity and function have been compromised by reparative surgery. CONTRIBUTING FACTORS Few would question that the sexual revolution has had a profound effect on the nation s fertility. Precise comparative figures are difficult to obtain because data from the preantibiotic era are sparse. The presexual-revolution generation s methods of contraception (i.e., diaphragm and condoms) were relative barriers to ascending infections in the female Novernber/December 1985 JOGNN (Supplement) 21s

2 genital tract. A trend toward earlier age at onset of intercourse, at a time when the final maturation of the squamous epithelium of the cervix has yet to occur, may be responsible for an increased susceptibility to pathogens in the younger age group (and perhaps for the increased incidence of cervical neoplasia seen in this age group as well). Sweet et a/. state that the most striking risk factor associated with salpingitis is the number of sexual partner^.^ Sweet et a/. noted that users of intrauterine contraceptive devices have a higher rate of salpingitis. Westrom s data indicate that teenagers experience a one and one-half to two percent risk of developing salpingitis yearly, an incidence at least twice that of patients in their 20s. Whether this is a result of increased susceptibility or of increased exposure rates is unknown. Some authorities speculate that younger women are less likely to have specific antibodies against various serotypes of chlamydia and gonococci. Thus, the development of antibodies may explain the marked drop in the incidence of salpingitis with increasing age. An alternative and not mutually exclusive explanation is proposed by Eliasson, who found that 15-yearold girls having intercourse regularly were more than twice as likely to have four or more partners in a year than their 18-year-old counterparts (50% versus 20%).6 Equally confusing, but nonetheless important, is the controversy surrounding the incidence of pelvic inflammatory disease and subsequent infertility secondary to the use of the intrauterine device. Toth states that the nulligravid intrauterine device users have a seven to tenfold higher chance of developing pelvic inflammatory disease than control groups of women using other birth control methods7 Toth reviewed experimental evi- dence showing that bacteria, commonly isolated from the seminal fluid of asymptomatic men, can attach themselves to moving spermatozoa and ascend through the ovulatory-phase cervical mucus of intrauterine device users. Several authorities have debated the relative importance of the intrauterine device-string acting as a wick and providing access for pathogens to the endometrial cavity and fallopian tubes. The Dalkon@ shield in particular, because of its multifilament tail construction, has been singled out in this regard. Edelman, et al. have disputed this association, proposing that cited differences in pelvic inflammatory disease among intrauterine device users versus control groups are due to a relative lack of protection against pelvic inflammatory disease as compared with that afforded by barrier methods and oral contraceptives, as well as a possible increased exposure to pathogens among intrauterine device users8 This is not an unreasonable assumption in that clinicians may suggest an intrauterine device for a nulliparous teenager only after careful assessment has determined that user-oriented methods such as condom, diaphragm, or birth control pills are unlikely to be used. Iatrogenic causes of pelvic inflammatory disease-related infertility are probably of minor import but deserve mention because they are potentially preventable. These causes include infections introduced at the time of therapeutic abortion, cesarean section, hysterosalpingography, and other procedures that allow access of bacteria into the cervical canal and endometrial cavity. Westrom cites an incidence of one-half percent of acute salpingitis within three weeks of legal therapeutic abortion procedures. While this is undoubtedly a miniscule percentage of infectious complications compared with that encountered in the days of illegal abortion, if one million legal abortions are being performed annually in the United States, about 5000 cases of salpingitis might be expected each year (and 1000 will subsequently have infertility). In an attempt to reduce this rate, many abortion clinics now provide a five-day prophylactic course of tetracycline the rap^.^ The incidence of infection secondary to hysterosalpingography is less clear. Pittaway et a/. were able to reduce the incidence of post-hysterosalpingography salpingitis in women with pre-existing tubal disease to zero percent by prescribing doxycycline. Most infertility experts do not advocate the routine use of prophylactic antibiotics before hysterosalpingography in women without a prior history of salpingitis, although most would advocate antibiotics when prior tubal damage is known or suspected. Such a recommendation is based on the assumption that prior tubal damage renders the tubes more susceptible to other pathogens, particularly anaerobic organisms. In the last 10 years, the increase in the use of prophylactic antibiotics during cesarean section has been dramatic. Although initially reserved for patients with obvious risk factors such as prolonged ruptured membranes, obvious amnionitis, anemia, or obesity, use has now been extended to nearly all cesarean operations. Reducing the incidence of postcesarean febrile morbidity has probably reduced the incidence of secondary infertility as well. Because the use of prophylactic antibiotics is a recent phenomenon, precise statistics about its effect on subsequent fertility are not yet available. DIAGNOSIS In the past, the diagnosis of salpingitis and pelvic inflammatory disease were often delayed while 22s Novernber/Decernber 1985 JOGNN (Supplement)

3 physicians waited for the classical criteria of fever, adnexal tenderness, and leukocytosis. If the incidence of post-pelvic inflammatory disease infertility is to be reduced to a minimum, earlier diagnosis and treatment must be emphasized. The illuminating laparoscopy study of acute salpingitis by Jacobsen and Westrom revealed that only 40% of laparoscopically verified pelvic inflammatory disease patients were febrile (rectal temperature greater than 38OC). Thus, fever is not seen in the majority of women presenting with subsequently proven pelvic inflammatory disease. Gonorrheaassociated pelvic inflammatory disease is far more prone to present with fever than the less-symptomatic infections secondary to C. trachomatis and mycoplasma. The gradual onset of dull, bilateral lower abdominal pain (Table l), often accompanied by symptoms of urethritis, should alert the clinician to the possibility of pelvic inflammatory disease. Patients with proven pelvic inflammatory disease invariably have a marked increase in the number of inflammatory cells seen in the vaginal secretions. A wet smear and culture should be obtained from the endocervix of any patient presenting with lower abdominal pain. A normal smear with mature vaginal epithelial cells and rod-shaped bacteria (lactobacil- Iae) virtually rules out pelvic inflammatory disease, since virtually all proven pelvic inflammatory disease cases exhibit signs of infection, especially a predominance of inflammatory cells, coccoid bacteria, and trichomonads. Westrom proposes that peritoneal fluid be obtained by cul-de-sac puncture because the white blood cell count in this fluid generally exceeds 30,000 in pelvic inflammatory disease cases and is usually less than 1000 in women without pelvic infections. Table 1. Signs and Symptoms of Pelvic Inflammatory Disease Pain Fever Leukocytosis Sign Cervico-vaginal wet smear Adnexal masses Symptoms Dull, subacute at onset, progressing to diffuse and debilitating bilateral lower abdominbal rebound tenderness Present in a minority of patients at onset but increases with duration and severity, especially in cases of gonococcal origin Present in 66% at onset Marked inflammatory response in nearly 100% of cases Palpable swelling in 50% A high percentage of pelvic inflammatory disease develops during or shortly after a menstrual period that is often heavier and longer than usual. This is consistent with the theory that pathogens, especially the gonococcus, gain access to the fallopian tubes by ascending through the endometrial cavity at the time of menstruation. The degree and duration of pelvic pain can be misleading. A patient does not need to demonstrate the classic chandelier sign of exquisite pelvic tenderness from motion of the cervix. BACTERIOLOGY The three bacteria generally thought to be most commonly isolated from infected fallopian tubes and pelvic abscesses are Neissera gonorrhoeae, Chlamydia trachomatis, and Mycoplasma hominis-all of them sexually transmitted organisms. In addition, a plethora of aerobic and anaerobic organisms have been isolated from patients with pelvic inflammatory disease. Most all have been identified from time to time as part of the normal vaginal flora. These same bacteria are frequently recovered from the seminal fluid. Toth s study of 430 males showed that while asymptomatic and fertile males had moderate incidence of bacteriospermia, significantly higher levels were recov- ered from men with a past history of genital tract infection, infertile marriages, and wives with pelvic infections. Formerly, health-care providers were taught that the initial episode of pelvic inflammatory disease was always due to Neissera gonorrhoeae and that appropriate initial therapy must include penicillin, ampicillin, or another antibiotic capable of dealing with this organism. A broader-spectrum antibiotic such as tetracycline was reserved for persistent or recurrent infections. Laparoscopically recovered isolates have dispelled this formerly held view. Health-care professionals now recognize that less than one-half of all pelvic inflammatory disease cases are due to gonorrhea alone. Chlamydia trachomatis is being recovered on an increasingly frequent basis. Westrom reported that more than one-half of the pelvic inflammatory disease cases in women under 25 years of age are due to Chlamydia. The Centers for Disease Control report that chlamydia is now the most prevalent sexually transmitted disease in the United States. The indolent nature of chlamydial salpingitis needs to be emphasized. Chlamydia1 infections are less apt to cause systemic symptoms such as fever and rebound tenderness. Patients harboring chlamydia organisms may sustain damage to the tuba1 endothelium Novernber/Decernber 1985 JOGNN {Supplement) 23s

4 Table 2. Centers for Disease Control Protocol for Outpatient Treatment of PID 1) Cefoxitin 2 g IM or Ampicillin 3.5 g PO or Amoxicillin 3 g PO or Aqueous Procaine Penicillin G, 4.8 million U IM plus 2) plus 3) Probenecid 1 g PO Doxycycline 100 mg PO bid X 10d or experience extensive tuboovarian adhesions over a prolonged period before their symptoms are severe enough to attract attention. For these reasons, current antibiotic therapies recommended by the Centers for Disease Control have included antibiotics such as doxycycline, which have excellent activity against both chlamydia and mycoplasma. Sweet et al. have demonstrated that, contrary to traditional teaching, the highest recovery of all organisms, whether aerobes or anaerobes, occurs in the earliest stage of the disease. The majority of women have mixed bacterial infections at the onset. On this basis, some authorities recommend triple antibiotic coverage in any patient with infection serious enough to merit hospitalization on the grounds that only such therapy will prevent the progression toward anaerobic tubo-ovarian abscess formation, with grave implications for fertilit~. ~ Table 3. Recommended Treatment of Sexual Partners of Patients with Pelvic Inflammatory Disease (from protocols of the Centers for Disease Control) Doxycycline 100 rng PO bid X one wk or Tetracycline 500 mg PO qid X one wk or Erythromycin 500 mg PO qid X one wk TREATMENT A current therapy of pelvic inflammatory disease must be based more on a recognition of the polymicrobial nature of such infections than the initial severity of the disorder, past history of the patient, or preliminary evidence that the infection is due to a single organism (i.e., finding gram-negative, intracellular diplococci, monoclonal antibody detection of gonorrhea, or fluorescent antibody-positive for C. trachornatis). Laparoscopic studies show poor correlation between endocervical isolates and materials taken from the fallopian tubes or cul-de-sac. The main thrust of medial therapy must be both to ameliorate the presenting symptom of pain and reduce or eliminate the sequellae of infection, especially infertility, ectopic pregnancy, and chronic pelvic pain. This is the rationale behind the therapeutic recommendation of the Centers for Disease Control for outpatient treatment of pelvic inflammatory disease (Table 2). Cefoxitin (or an equivalent cephalosporin), included because of its activity against penicillinase-producing gonorrhea, would be the agent of choice in areas where resistant strains of N. gonorrhoeae occur. Since cefoxitin is expensive, most clinicians selectively prescribe it. Evaluation of the patient s male sexual partner is often overlooked. This is a serious omission because many of these males may be asymptomatic carriers of N. gonorrhoeae or C. trachornatis and may re-infect their partners. Ideally, these males should be examined and cultured. A more pragmatic approach, which may be the clinician s only option, is to treat the sexual partner as outlined in Table 3. Each of these medications will treat most strains of N. gonorrhoeae and C. trachornatis. Two important aspects of clinical evaluation are paramount to the patient s immediate and ultimate well-being. First, the presenting complaint is nearly always pelvic pain. After careful evaluation of a patient s presenting signs and symptoms, if no other satisfactory explanation exists, the patient must be assumed to have early pelvic inflammatory disease and treated accordingly. Undoubtedly, especially in patients with rather obscure complaints, pelvic inflammatory disease will be overdiagnosed. On the other hand, failure to treat early and effectively may have disastrous consequences. Clinicians would do well to adopt the maxim, When in doubt, treat. The second maxim, When in doubt, admit and treat, should also be adopted. The decision to treat on an inpatient basis is the second important and often difficult clinical decision. Clinicians are opting for inpatient therapy with increasing frequency based on the as-yet unproven assumption that administration of parenteral antibiotics with a broad spectrum at a high dosage will result in more prompt control of infection and reduce the chances of tuba1 damage, abscess formation, and pelvic adhesions.. The patient with suspected tuboovarian abscess must be admitted. The presence of upper-quadrant peritonitis is evidence that purulent material has already escaped the confines of the fallopian tube and, like tubo-ovarian abscess, is potentially life-threatening. Severe gastrointestinal symptoms are equally ominous. The clinician must assume that purulent material is present in the peritoneal cavity in the face of such symptoms. The inability to tolerate oral medications requires hospitalization for intravenous antibiotics lest the patient s symptoms worsen dramatically in a relatively short time. There is an understandable tendency to attempt 24s November/Decernber 1985 JOCNN (Supplement)

5 outpatient treatment with antiemetics in such patients, but the adverse alternatives do not justify such a clinical risk. Pelvic inflammatory disease co-existing with pregnancy is rarely encountered but should always be treated on an inpatient basis because the risk of abortion secondary to the infectious process is great.i3 Automatic hospitalization of pelvic inflammatory disease patients who have an intrauterine device is controversial. This recommendation is based on the assumption that intrauterine devices are associated with a higher percentage of anaerobic infections that are better treated with intravenous antibiotics. Also, the early symptoms of pelvic inflammatory disease may be mistakenly thought to be secondary to the intrauterine device. Such patients may seek medical attention only after their infection has become relatively advanced. Admitting all nulliparous patients is equally controversial but based on the premise that compromised fertility would be more disastrous to this patient than for multiparous patients. Obviously, many multiparous patients would object to this conclusion. The patient with moderately severe symptoms, in whom the diagnosis is questionable, deserves hospitalization for much the same reason as the patient who fails to respond to outpatient treatment after 48 to 72 hours. All outpatients should be examined after 48 hours because the danger of undiagnosed ectopic pregnancy, appendicitis, or other surgical conditions is ever present. Swedish gynecologists such as Westrom have taken the lead in proposing that all cases of pelvic inflammatory disease be confirmed by diagnostic laparoscopy. This approach has considerable merit and is being adopted by many medical centers in the United States. In Jacobsen and Westrom s study, involving nearly Table 4. Recommended Alternative Protocols for Inpatient Therapy of Pelvic Inflammatory Disease Protocol I. Intravenous therapy Doxycycline 100 mg IV bid and Cefoxitin 2 g IV qid Follow-up oral therapy Doxycycline 100 mg bid X 10 days 11. Intravenous therapy Clindamycin 600 mg IV qid and Tobramycin or gentamicin 2 mg/kg IV initially, and 1.5 mg/kg IV tid thereafter Follow-up oral therapy Clindamycin 450 mg qid X 10 days Ill. Intravenous therapy Doxycycline 100 mg IV bid and Metronidazole 1 g IV bid Follow-up oral therapy Doxycycline 100 mg PO bid and Metronidazole 1 g PO bid 3000 laparoscopies in women with acute lower abdominal pain and objective signs of a lower genital tract infection, 65% of patients were found to have acute salpingitis and 23% had normal pelvic findings. Twelve percent of the women had other pelvic pathology responsible for their pain; in one-half of these patients (6.6% of the total), appendicitis or ectopic pregnancy was diagnosed. A cost-benefit analysis of subjecting all patients with suspected pelvic inflammatory disease to diagnostic laparoscopy has not yet been performed. Currently, most clinicians assume that the financial cost of routine laparoscopy precludes its universal application. Still, the prudent clinician is fully justified in using diagnostic laparoscopy whenever the diagnosis is in question or when the patient Comments Provides excellent coverage against penicillinase-producing N. gonorrhoeae, and Chlamydia but less effective against anaerobes and abscesses Better coverage against anaerobes in patients with pelvic abscess, although less active against Chlamydia and A!. gonorrhoeae Excellent coverage against Chlamydia and anaerobes but poor activity against some strains of N. gonorrhoeae and Enterobacter fails to respond to accepted therapy in a reasonable time. The therapeutic recommendations of the Centers for Disease Control for inpatient treatment of acute pelvic inflammatory disease are listed in Table 4. These antibiotic combinations have been chosen with the knowledge that acute pelvic inflammatory disease is a polymicrobial infection dominated by Neisseria gonorrhoeae, Chlamydia trachomatis, and mixed anaerobes. All three protocols provide coverage against N. gonorrhoeae and Chlamydia, but Protocols I1 and Ill might be selected when abscess formation with anaerobes is suspected. In general, intravenous antibiotics are given for at least four days and continued for at least 48 hours after the patient has become afebrile. Thereafter, the patient is switched to oral November/December 1985 JOCNN [Supplement) 25s

6 Figure 1. Sites of tuba1 disease involvement and correction procedures. medications that are continued for another 10 days. SURGICAL TREATMENT In the past 20 years, dramatic changes have occurred in the hospital management of patients with suspected pelvic inflammatory disease. In a former era, gynecologic services were filled with patients receiving combinations of intravenous penicillin, streptomycin, and chloramphenicol while clinician and patient alike waited expectantly, often for several weeks, for a pelvic abscess to point. Such abscesses occasionally drained spontaneously through the rectum or vagina but more often were drained surgically through a posterior colpotomy incision. Cultures of the abscess contents were often reported as sterile because older bacteriologic methods were unable to detect Chlamydia or anaerobic bacteria. If an abscess or pelvic mass persisted or if continuing signs of sepsis despite intravenous antibiotics exhibited, the patient was subjected to laparotomy, which often eventuated in a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Such drastic surgical therapy was justified at that time by the dismal subsequent reproductive record of most patients who did not have surgery and by the impressively high rate of chronic pelvic pain and ectopic pregnancies that plagued the pelvic inflammatory disease victim. As with many other areas of obstetrics and gynecology, the surgical management of patients with acute pelvic inflammatory disease has undergone a radical change. Broad-spectrum antibiotic therapy has minimized the tendency toward anaerobic pelvic abscess formation, and only a small minority of patients will require surgery for a ruptured tubo-ovarian abscess or for a pelvic mass or abscess which fails to resolve after appropriate medical therapy. The patient who presents with an acute abdomen (a rigid, board-like abdomen with rebound tenderness) is often difficult to differentiate from the patient with pelvic inflammatory disease. Such a presentation may well be due to a ruptured or leaking pelvic abscess, and immediate surgical intervention is justified. In many cases, a ruptured appendix or ectopic pregnancy may be detected and treated; in others, a ruptured or leaking tubo-ovarian abscess is encountered, and the patient may respond to unilateral salpingo-oophorectomy. Unilateral abscesses are being encountered with increasing frequency. If the contralateral adnexa is inflamed but there is no abscess formation, there is probably no need to remove it or the uterus.' In such cases, the potential prospect of fertility is retained, either through surgical reconstruction or in vitro fertilization. The prospect of widespread adoption of in uitro fertilization poses a new dilemma for the surgeon because in uitro fertilization demands the retention of at least the uterus and one ovary. In the past, if both tubes were irreparably damaged, there was little justification for conservation of any of the pelvic reproductive structures. The final decision to retain or remove specific structures must be individualized for each patient at the time of laparotomy. Failure to respond to currently recommended antibiotic regimens after 72 hours is another indication for laparoscopy or laparotomy. One assumes that an abscess is present and needs to be drained or removed in such patients. The persistence of an adnexal mass in a patient who is otherwise responding satisfactorily to antibiotic treatment is not an indication for immediate operative intervention. These patients may be followed for several weeks and if the mass persists more than six weeks after therapy, it can then be removed. Occasionally, an enlarging or persistent mass is found to be a hydrosalpinx, ovarian neoplasm, or benign ovarian cyst. In these cases, surgery is best postponed until the patient has recovered from the initial acute infection. POST-PELVIC INFLAMMATORY DISEASE TUBAL DISEASE In the late 1960s, a diagnosis of acute pelvic inflammatory disease had grave implications for future fertility. As high as 85% of patients with this diagnosis were rendered permanently sterile. If fertility was retained, such patients were at higher-than-usual risk for ectopic pregnancy and repeated episodes of pelvic inflammatory disease. With contemporary tendencies toward early diagnosis, and early treatment with broad-spectrum antibiotic coverage, the outlook for fertility has been vastly improved. Nevertheless, at least 15 to 25% of patients so affected will be rendered infertile. Many such patients can be restored to fertility, depending on the degree and location of damage to the adnexal structures. Figure 1 depicts the typical areas of involvement and lists the 26s November/December 1985 JOCNN (Supplement)

7 procedures that are currently used for correction of the compromised structures. The damage site of pelvic inflammatory disease is unpredictable: it may compromise and close the tube at the distal or proximal ends or in any intervening segment. Fortunately, because of early diagnosis and treatment, many patients sustain damage at only one site, most commonly the fimbriated end of the tube. Thus, the most common surgical corrective procedures are reconstruction of the fimbriated end of the tube (fimbrioplasty) or, in cases of severe hydrosalpinx with virtual disappearance of the fimbria, the fashioning of a new distal tubal opening (salpingostomy) (Figure 2). Somewhat less commonly, blockage of the tube occurs at the utero-tuba1 junction. Surgical corrective measures at this site include excision of the blocked segment of tube and reconnection to the uterus (tubo-cornual anastomosis) or excision of the blocked portion of tube and reimplantation of the remaining tube into a new uterine opening (utero-tuba1 implantation) (Figure 3). This latter operation is often selected if the intramural portion of the tube, (which extends into the uterine myometrium) has become occluded. Less often, an isolated tubal blockage is found in the intervening midportion of the tube. This may be amenable to excision of the blocked segment followed by anastomosis of the remaining tubal segments. Occasionally, such anastomosis surgery is technically difficult because of marked differences in the diameters of the remaining tubal segments. If multiple areas of blockage have been sustained, surgical correction will probably not be successful and is usually not attempted. The division and removal of periadnexal and peri-ovarian adhesions (salpingo-ovariolysis) is fre- quently necessary in conjunction with one of the other types of surgery. In general, the more extensive the adhesions, the less favorable the prognosis because extensive surgical lysis invariably leaves areas of denuded epithelium that are always susceptible to adhesion reformation. Nevertheless, lysis of tubo-ovarian adhesions is an essential and integral part of infertility surgery and adhesion formation might be minimized with adjuvant measures. Swolin,14 Gomel,15 and Winston" were pioneers in the introduction of microsurgical techniques into reconstructive infertility surgery in the last 10 years. They have championed a number of new concepts, instruments, and techniques that have been associated with significantly higher success rates in recent years. Many patients have been forced to turn to surgical correction because of the recent lack of infants available for adoption. An increased surgical case load has prompted a wider search for improved materials and methods. Numerous courses in microsurgery, textbooks, and other instructional opportunities have become available recently. The first documented tuboplastic procedure was performed by Schroder in Until the mid- 1960s, tubal surgery had a limited role in the correction of infertility and was usually confined to simple lysis of adhesions and fimbrioplasty. Few surgeons were skilled enough or had the patient load or patience to become skilled in tubal anastomosis or tubal implantation techniques. Swolin introduced the modern concepts of microsurgical correction of tubal disease in He and Gomel15 have outlined and elucidated the principles of microsurgery (Table 5). They have taught that the concept of microsurgery is a broad one that emphasizes gentle and atraumatic tis- Table 5. Principles of Microsurgery Magnification Hernostasis Irrigation Atraumatic technique Complete excision of pathologic tissues Precise realignment of tissue planes Reperitonealization sue handling, meticulous hemostasis and constant irrigation, the use of delicate instruments and fine nonreactive sutures, and precise tissue dissection and tissue reapproximation. Swolin and Come1 have insisted that the major cause of adhesion formation is trauma (bacterial, thermal, chemical, or mechanical). The ensuing inflammatory reaction leads to fibrin deposition and subsequent adhesion formation. Thus, the primary aim of infertility surgery is to minimize trauma. Gloves and instruments are rinsed and wiped before surgery to avoid contamination of the operative area with talc or other adhesion-promoting substances. Exposed peritoneal surfaces are continually kept moist with irrigating solutions containing heparin. Hemostasis with needle electrodes helps to minimize tissue destruction,and adhesions. Fine 8-0 synthetic suture materials that are visible only under magnification are used to minimize tissue reaction. Strict adherence to these principles of microsurgery, even in the absence of magnification devices, has undoubtedly improved the outcome of all fertility surgery. PREOPERATIVE EVALUATION Patients being considered for tubal reconstruction procedures must be otherwise normal or have infertility factors amenable to therapy (such as ovulatory dysfunction or a willingness to undergo donor insemination). The normal, preoperative evaluation November/Decernber 1985 JOCNN (Supplement) 27s

8 ~~~ includes a semen analysis, postcoital testing, midluteal phase progesterone values, endometrial biopsy, and hysterosalpingography. The most important preoperative evaluative step is a diagnostic laparoscopy. At times, when tubal patency has previously been demonstrated by hysterosalpingography, lysis of adhesions and even fimbrioplasty are possible at the time of laparoscopy. In most cases, however, the laparoscopy is employed to assess the degree of tubal damage and to afford a prognosis when the type of surgery is discussed with the patient preoperatively. Laparoscopy affords an opportunity to reassess the state of tubal patency by transcervical injection of indigo-carmine or methylene blue dye (chromopertubation) especially if a substantial time interval has elapsed since the performance of the hysterosalpingography. Hysteroscopy is used by some microsurgeons preoperatively to provide visualization of the first millimeters of the intramural tubal segment. This technique is occasionally useful in detecting endometrial polyps and intrauterine adhesions. NURSING ASPECTS Knowledge of the pathophysiology, clinical presentation, treatment, and surgical sequelae of pelvic inflammatory disease is essential to the nurse in a variety of practice roles. Depending on the specific clinical setting, the nursing diagnosis may deal with prevention of pelvic inflammatory disease, treatment of the acute episode, or surgical repair of the postinfectious damage. The contraceptive counselor may be a public health nurse, a family planning nurse practitioner, or a nurse clinician in an outpatient clinic setting. Here, the preventive role is stressed. Patients at high risk for pelvic inflammatory disease-very young, low socioeconomic status, prior history of pelvic infection-may be educated about the relative risk of pelvic inflammatory disease when using each specific contraceptive method. For example, the nurse might discourage the patient from using an intrauterine device and encourage the use of oral contraceptives, which appears to reduce the risk. However, recent evidence from the Centers for Disease Control suggests that chlamydia1 infections may be prompted by the relative thin endometrium produced by oral contraceptives. The contraceptive counselor may also have an opportunity to acquaint the patient with the early symptoms of pelvic inflammatory disease. Early recognition of symptoms will lead to early diagnosis and treatment and a better final prognosis. Nurse clinicians and nurse practitioners in outpatient clinics are often the first to screen women who are experiencing early pelvic inflammatory disease symptoms. The promptness of diagnosis and referral for treatment or initiation of treatment under established protocols for pelvic inflammatory disease has important consequences for fertility. The nurse s clinical knowledge about the symptomatology and treatment of pelvic inflammatory disease may be pivotal in this regard. The nurse clinician s role in the infertility clinic setting has undergone dramatic changes in recent years. In some practices, the role is largely technical, dealing with performance of postcoital tests, ultrasonographic monitoring of ovulation, assessment of ovulation through basal body temperature chart inspection, artificial insemination, and other outpatient procedures. In other practice settings, the nurse s role may involve a greater educational and counseling component. Patients who are reluctant or embarrassed to ask a busy physician questions about their diagnosis and treatment are often eager to obtain detailed information from a nurse they perceive to be more accessible. Preoperative counseling and reassurance by the nurse member of the team may be the most important and informative professional contact made by a team member. In other circumstances, a similar role is filled by the inpatient gynecology nurse clinician, who must also be able to explain the rationale for certain postoperative medications such as steroids and promethazine for procedures like hydrotubation. An increasing number of operating room nurses are becoming expert surgical assistants for tubal microsurgical procedures. This nursing role demands familiarity with the surgical principles behind microsurgical techniques and the persistent emphasis being placed on gentle tissue handling to prevent abrasion, moist operative field and constant irrigation, and meticulous hemostasis. Many microsurgeons have found it advantageous to employ a full-time operating room nurse specialist as their principal assistant. ~~ SPECIFIC SURGICAL TECHNIQUES Salpingolysis and Ovariolysis Salpingolysis and ovariolysis refers to the separation and complete removal of peri-tuba1 and periovarian adhesions. Adhesions may cover the ovarian surface or prevent the normal interaction of the fimbriated end of the tube with the ovarian surface. Adhesions must be completely removed, usually before repair of other tubal pathology is attempted. Using appro- 28s November/December 1985 JOGNN (Supplement)

9 priate magnification devices (operating microscope, loupes, or other devices), adhesions are stretched and divided with a microelectrode close to the peritoneum. Dissection includes removal of the adhesive tissue from its attachment to the tubes and ovary. The surgeon and surgical assistants take great pains to avoid producing further adhesions through abrasion of serosal surfaces, rough handling of instruments and sponges, or drying of tissues. Meticulous technique is the keystone to avoiding further adhesions. To avoid readhesion of recently separated surfaces, many surgeons perform a uterine suspension at the conclusion of the procedure. The operative site is irrigated to rid the pelvis of fibrin-containing clots. Finally, high-molecular-weight 32% dextran 70 solution is sometimes added to the pelvis. This hypertonic solution may induce a temporary formation of ascites, which causes the newly freed adnexal structures to float in the solution until the patient s own mesothelial cells, floating in the abdominal cavity, have had a chance to reperitonize the raw surfaces. Although animal studies appear to show reduction of adhesion formation associated with its use,17 no well-controlled, double-blind study has been conducted that clearly shows dextran to be efficacious. Allergic reactions and at least one operative mortality have been attributed to the use of this dextran preparation.i8 Some surgeons give intraoperative and postoperative dexamethasone and promethazine (the socalled Garcia regimen). This corticosteroid-antihistamine combination is believed by some to reduce the initial inflammatory response. lntraoperative and postoperative broad-spectrum antibiotics are also given by many surgeons, especially in the repair of pelvic inflammatory disease-induced injuries. Salpingostom y Salpingostomy is the surgical reopening of the occluded fimbrial end of a fallopian tube (Figure 2). Preoperatively, the tube is usually distended in the form of a hydrosalpinx. The surgeon inserts a transcervical pediatric Foley catheter into the uterus just before laparotomy. The tube is then distended with dilute dye solution. If proximal tubal occlusion is not found, the distal tube becomes distended with dye. On close observation, a series of avascular lines extending in a stellate pattern from a centerpoint of the distal end of the tube can be seen. Superficial linear incisions are made along these stellate lines with a microelectrode. At some point, if the fimbrial tissues are viable but buried beneath the upper layer of the overlying scar tissue, the fimbria will evert and blossom out into the surgically created opening. If little or no fimbrial tissue remains, the incision is continued until the tube is completely opened. In either case, three or four sutures of fine, nonreactive material are used to secure and maintain the reopened ostia in an everted position (Figure 2). In cases where the fimbriated end of the tube is only partially closed and portions of the fimbria are still visible, a similar process is conducted using the same meticulous techniques of dissection and hemostasis. In such cases, the procedure would be more properly termed fimbrioplasty or fimbriolysis. When the tube has been greatly dilated with a chronic hydrosalpinx and when the distal tube is densely adherent to the ovarian surface, dissection to free the tube from the ovary may leave only a Figure 2. Salpingostorny. thinned-out segment of dilated distal tube devoid of mucosal elements. In such a case, the only realistic surgical alternative may be excision of the useless distal tissues and the creation of a new tubal ostium at a point where the mucosal surface is relatively normal. A new opening is created by the turning back or everting of the mucosal surface on itself and suturing the recently cut edges back on to the serosal surface of the tube. The result is a shortened fallopian tube with a less-than-physiologic ovum pick-up mechanism. An occasional pregnancy may nevertheless be seen following such a procedure. Given the increasingly successful results of in uitro fertilization, such a surgical solution may not be advocated in the future. Anastomosis for Cornual Occlusion The traditional treatment of cornual occlusion involved implantation of the patent segment of fallopian tube into a new uterine incision created by a boring or drilling procedure. The patent distal tube is brought through this hole and sutured to the inner endometrial surface. Since the advent of microsurgical techniques, in many cases of cornual tubal oc- Novernber/Decernber 1985 JOGNN (Supplement) 29s

10 Figure 3. Tubo-uterine anastomosis. clusion, the intramural portion of the tube is patent. In most cases, the blocked segment of proximal tube can be easily excised and the patent distal segment reattached to the uterus. Although this junction of the tube and uterus is highly vascular, bleeding can be minimized by preoperative injection of vasopressin into the area (Figure 3). After ascertaining patency of the intramural portion of tube by injection of dye through the transcervical catheter, an end-to-end anastomosis is performed. First, the muscularis layer is approximated with interrupted 8-0 nonabsorbable sutures. Care is taken that no suture invades the inner mucosal layer. The last step involves approximating the serosal layer with interrupted 8-0 sutures. Reliable figures are not available for the percentage of patients who will have a term pregnancy after these procedures because the results are governed by the state of preoperative pathology as well as the surgeon s skill. In cases of simple fimbrioplasty, salpingolysis, or ovariolysis, a successful outcome may be expected in a high percentage of cases. On the other hand, when salpingostomy is performed in the face of complete tubal occclusion and hydrosalpinx, at best only a 30% term pregnancy rate can be expected, accompanied by a nine percent incidence of ectopic pregnan~y.~ In the case of tubo-cornual anastomosis or isolated cornual occlusions, the results are considerably better. Gome1 has cited a term pregnancy rate of 56%,4 a result more than twice as good as his series using tubal implantation. If the results of in uitro fertilization continue to improve and approach a 50 percent success rate for each attempt, infertility surgeons will need to reassess carefully their own results before recommending a surgery that carries a higher morbidity and lower success rate than in uitro fertilization. This is especially true if the surgeon contemplates a second operation for fallopian tube repair on the same patient. In many cases, even if in uifro fertilization is selected initially, an open pelvic procedure may be necessary to free the ovaries and provide access for ovum retrieval. In such cases, the remaining pelvic structures should be returned to a normal state of function at the same operation, if possible. Nothing is lost by such an approach, and the results may well make a subsequent in uifro fertilization attempt superfluous. ADJUNCTIVE MEASURES A wide variety of therapeutic agents have been employed to reduce postoperative adhesion formation. Before the recognition that tissue trauma and fibrin deposition were the key elements in adhesion formation, the main thrust of pharmacologic intervention was the use of such diverse agents as vitreous of calf s eye, fetal membranes, vasoline, lanolin, and other oily substances that would effect a mechanical separation of the traumatized surfaces. Currently, most microsurgeons employ a few adjuncts that appear to have reduced the incidence of adhesions in wellcontrolled studies (Table 6). SUMMARY Despite an epidemic of sexually transmitted pelvic inflammatory disease in the last two decades, a concomitant improvement in the early diagnosis and rational anti- Table 6. Adjunctive Medications and Techniques in Infertility Surgery Medication or Technique Heparin Antihistamines Promethazine Corticosteroids Hydrocortisone Dexamethasone Prostaglandin inhibitors Oxyphenbutazone Ibuprofen Prophylactic antibiotics 32% dextran 70 (Hyskona) Second-look laparoscopy Rationale Prevent clot formation and subsequent fibrin deposition on traumatized tissues. Reduce the initial inflammatory response (vessel dilation, increased tissue permeability, and exudate formation) Inhibit and prevent the inflammatory response and fibroblast proliferation Inhibition of prostaglandin-mediated vasodilation and fluid transition Reduce adhesions formed in response to tissue infection Promote mechanical separation of injured surfaces through formation of temporary ascites in peritoneal cavity Offers opportunity to separate thin, avascular adhesions before they have become thick and vascular 30s November/December 1985 JOCNN (Supplemenl)

11 biotic treatment of pelvic inflammatory disease has lessened the degree of an adverse infectious sequela and provided an opportunity for reparative fertility surgery in a higher percentage of cases. Advances in microsurgical techniques, especially an emphasis on methods that promote the restoration of normal anatomy without a significant degree of postoperative adhesion formation, have improved the prognosis substantially. Continuing improvement in the field of in uitro fertilization and embryo transfer will also be beneficial to pelvic inflammatory disease patients. However, the relative place of in uitro fertilization/embryo transfer and microsurgery for infertility will not be established for several years. REFERENCES Droegemueller W. Pelvic inflammatory disease. Drug Therapy: 1984; 14:31. Westrom L. Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Obstet Gynecol 1980;138:880. Hedberg E, Speyz SO. Acute sal- pingitis. Views on prognosis and treatment. Acta Obstet Gynecol Scand 1958;37: Gomel V. Microsurgery in female infertility. Boston: Little, Brown and Co, Sweet RL, Yonekura ML, Hill G, Gibbs RS, Eschenbach DA. Appropriate use of antibiotics in serious obstetric and gynecologic infections. Am J Obstet Gynecol 1983; 146: Eliasson RM. Konsdifferenser i sexuellt beteende och attityder till sexualitet. Thesis, Institute of Sociology, University of Lund, Sweden, Toth A. Alternative causes of pelvic inflammatory disease. J Reprod Med 1983;28:669 (supplement). 8. Edelman DA, Berger GS, Keith L. Intrauterine devices and their complications. Boston: GK Hall, Lande V, Lewit S. Administrative, counseling and Medical in national abortion federation facilities. Fam Plann Perspect 1982;14: Pittaway DE, Winfield AC, Maxson W, Daniel1 J, Herbert C, Wentz AC. Prevention of acute pelvic inflammatory disease after hysterosalpingography: efficacy of doxycycline prophylaxis. Am J Obstet Gynecol 1983;147: Jacobson L, Westrom L. Objectivized diagnosis of acute pelvic inflammatory disease. Am J Obstet Gynecol 1969;105: Sweet RL, Draper DL, Hadley WK. Etiology of acute salpingitis: Influence of episode number and duration of symptoms. Obstet Gynecol 1981;58: Sarrell PM, Pruett SA. Symptomatic gonorrhea during pregnancy. Obstet Gynecol 1968;32: Swolin K. 50 fertilatats operation: Tiel I und It. Acta Obstet Gynecol Scand 1967;46: Gomel V. Tuba1 reanastomosis by microsurgery. Fertil Steril 1977;28: Winston RML. Microsurgical tubocornual anastomosis for reversal of sterilization. Lancet 1977;1: Neuwirth RS, Khalaf SM. Effect of thirty-two percent dextran 70 on peritoneal adhesion formation. Am J Obstet Gynecol 1975;121: Utian WH, Goldfarb JM, Starks GC. Role of dextran 70 in microtubal surgery. Fertil Steril 1979;31: Monif GRG. The staging of acute salpingitis and its therapeutic ramifications. J Reprod Med 1983 (Supp1);28: Washington AE, Goves, Schachter J, Sweet RL. Oral contraceptives, Chlamydia trachomatis infection, and pelvic inflammatory disease. JAMA 1985;253:2246. Address for correspondence: Judythe Torrington, RNC, Eastowne Ob/Gyn and Infertility, 700 Eastowne Drive, Suite 200, Chapel Hill, NC November/December 1985 JOGNN (Supplement) 31s