Case Presentation

A 56-year-old African menopausal woman who had given birth multiple times visited the emergency department due to persistent high-grade fever, pain in the right side of her abdomen, and severe lower urinary tract symptoms.

During the physical examination, she displayed mild distress as a result of the pain. Her vital signs showed her blood pressure to be 100/56 mmHg, her heart rate was 120 beats per minute, her body temperature was 39.4 °C, her respiratory rate was 22 breaths per minute, and her oxygen saturation level was 95% in the room air. Doctors conducted an abdominal examination, her abdomen was soft, and she had mild diffuse tenderness throughout the abdomen. The tenderness was increased in the right renal angle. However, there were no signs of guarding or rigidity. All other physical examinations appeared normal.

Investigations

Blood tests revealed an elevated white blood cell count of 18.7 × 103/dl, mild anaemia, and a creatinine level of 7 mg/l. The level of C-reactive protein (CRP) was significantly high at 294.6 mg/l. The urinalysis showed the presence of both blood and pus, and the urine culture confirmed the growth of more than 105 E. coli. Doctors also ordered a contrast-enhanced computed tomography (CT) scan of her abdomen and pelvis.

The CT scan indicated that her right ureter and kidney were dilated, and there was inflammation in the fat surrounding her right kidney. Doctors observed multiple areas of infection in her kidneys. Additionally, the CT scan revealed the presence of a mass near her right fallopian tube with complex internal fluid and thick walls. This mass was putting pressure on the right ureter. An ultrasound examination confirmed the existence of an irregular cystic mass with a thickened wall, measuring 6 cm. The appearance of a “cogwheel sign” on the ultrasound indicated that the mass was likely a pyosalpinx. Furthermore, tests for Chlamydia trachomatis, Neisseria gonorrhoeae, reactive plasmin reagin, and human immunodeficiency virus were all negative.

Management: Pyosalpinx

The patient’s treatment involved a combination of ceftriaxone, metronidazole, and doxycycline, along with paracetamol for pain relief. Doctors inserted a ureteric stent to improve urine flow. Doctors used the transvaginal ultrasound to guide the placement of an ultrasound probe and then inserted an 18-gauge needle into the fluid collection, and aspirated 50 ml of fluid.

The culture of the fluid indicated the presence of multiple types of bacteria. The tests for Chlamydia trachomatis and Neisseria gonorrhoeae were negative, and further investigations ruled out tuberculosis. They discharged the patient after three days and prescribed a ten-day course of oral amoxicillin. At a follow-up appointment two months later, she reported feeling well and had no symptoms.

Discussion: Pyosalpinx

Pyosalpinx and tubo-ovarian abscesses are frequently associated with pelvic inflammatory disease and are caused by sexually transmitted infections. These conditions more commonly affect young women and are rarely found in older women, although there have been some reported cases. Pyosalpinx can present with minimal symptoms or remain asymptomatic. Less than half of the women with pyosalpinx experience fever and chills. Other symptoms may include nausea, abnormal vaginal discharge, and vaginal bleeding. About 15-30% may also experience urinary symptoms.

During a physical examination, tenderness over the adnexal region may be observed, with or without guarding or rebound tenderness. The absence of symptoms and signs during the physical examination can delay an accurate diagnosis. Biological factors can contribute to infection development in sexually inactive females, such as decreased levels of protective antibodies, cervical ectopy, increased cervical mucus permeability, and changes in vaginal flora.

Transvaginal ultrasound is the initial imaging method of choice for diagnosing pyosalpinx due to its cost-effectiveness and ability to provide detailed visualization of pelvic structures. In emergency cases, doctors often order abdominopelvic computed tomography with contrast. Magnetic resonance imaging (MRI) is another useful method for examining and diagnosing gynaecological conditions in both elderly and young women.

Early diagnosis of pyosalpinx can be challenging due to its rarity and overlap of symptoms with other causes of acute abdominal pain, such as appendicitis, cystitis, gastroenteritis, pyelonephritis, and peritonitis. Treatment for pyosalpinx involves antibiotic therapy as soon as possible. The treatment approach varies from conservative management with intravenous antibiotics to laparoscopic aspiration, image-guided aspiration or drainage, laparoscopic salpingostomy, or salpingectomy. In most cases, antibiotics alone are enough to treat pyosalpinx. However, for collections greater than 3-4 cm, drainage should be performed to reduce the risk of complications and treatment failure.