Gonorrheal Salpingitis

Gonorrheal Salpingitis Views on Treatment and Prognosis ERIK HEDBERG, M.D., and AKE ANBERG, M.D.

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N SPITE OF NEWER FORMS OF THERAPY, the gonorrheal-salpingitis patient still represents a considerable part of the gynecologic clientele. The disease has always been of great importance to the gynecologist not only because of its long-standing course and deficient healing but also because of the sequelae that result in surgery and sterility. During the last decades, as a result of chemotherapeutic and antibiotic agents, the prognosis for the gonorrheal-salpingitis patient has undergone a considelable change. This improved prognosis applies not only to overcoming the acute stage of the disease but especially to its most serious sequela, sterility. In the beginning of the present century, conception after bilateral gonorrheal salpingitis was considered to be exceptional. After the introduction of antibiotics and chemotherapy, a more optimistic attitude has been adopted. But, although we now possess specific and highly effective remedies to master the gonorrheal infection, the results of our treatment are still far from satisfactory. Too many factors outside our scope contribute to destroy an effective therapy. The effect of the therapy, to a great extent, depends upon the time of admission. If treatment is started at an early stage, the disease can be checked and the occurrence of inflammatory adnexal swelling effectively prevented. In the later stages of the disease, the possibilities of an effective antibiotic treatment are limited. During the last several years, a combined use of antibiotics and corticosteroids has been applied in the treatment of salpingitis. 1 , 4, 5 This combination has been used to prevent the reactive tissue changes due to inflammation of the adnexa and to effect anatomic and functional restitution. The preliminary results of this treatment have been favorable in combating the acute attack of the disease and its long-standing effects. The possibilities of evaluating the effect of different therapeutic agents on acute salpingitis are limited. A term pregnancy, of course, confirms functional restitution; but, in the normal woman, fertility depends upon several

From the Department of Obstetrics and Gynecology, University of Gothenburg, Sweden.

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factors-civil status, voluntary sterility, condition of the cervix, quality of the spenn, etc. A more adequate and direct method of studying the condition of the tubes is by hysterosalpingography. To our knowledge, no extensive followup studies with salpingography after gonorrheal salpingitis have been published. In 1958, the authors published the results of hysterosalpingography after gonorrheal salpingitis in 30 cases. Bilateral tubal patency was found in 17 cases. 3 The aim of the present investigation is to show, by means of hysterosalpingography, the condition of the tubes after gonorrheal salpingitis treated with antibiotics and a combination of antibiotics and corticosteroids. It was also considered of interest to show whether combined treatment with antibiotics and corticosteroids is more effective than treatment with antibiotics alone. CASE MATERIAL

The series consisted of 200 patients with acute gonorrheal salpingitis who were treated at the Department during 1956-1962. Only those patients were included whose past history, objective findings at the examination, and course of the disease made the diagnosis of salpingitis definite. In all cases, there were positive cultures of gonococci from the cervix. This was accepted as proof that the salpingitis was caused by the same organism. All chronic cases and relapses were excluded. TREATMENT

Our methods of treating the acute gonorrheal salpingitis do not differ from those generally recognized. The treatment has been conservative in all cases. Hospitalization with bedrest has been compulsory until the temperature and sedimentation rate have become nonnal and, if possible, the positive findings on palpation have disappeared. In regard to the specific antibiotic therapy, it is generally found that the effect of the therapy depends upon the interval hetween onset of symptoms and initial treatment. To reduce this important time factor, the following methods have been adopted. In every case of suspected salpingitis, smears for culture of gonococci are taken from cervix, urethra, and rectum on three separate occasions during the first 24 hr. Without waiting for the result of the cultures, antibiotic therapy was started in every case. In many cases, the antibiotic therapy may have been unnecessary, the cultures being negative; however, the advantage of starting the antibiotic therapy as early as possible in cases of manifest gonorrheal salpingitis was considered great enough to justify these methods of treatment.

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In 130 cases of gonorrheal salpingitis, the treatment consisted of 800,000 I. U. of Astracillin" (benzyl-penicillin-procain benzyl-penicillin-sodium 3:1) daily for 7 days. In 70 cases, a combined treatment with antibiotics and corticosteroids was given. The corticosteroid dosage was 5 mg. Deltacortril t (prednisolone). The tablets were given as follows: on the first 3 days of treatment, the patient was given 3 tablets daily; on the fourth day, 2 tablets; and on the fifth day, 1 tablet. The antibiotic therapy was administered similarly. New smears were examined immediately after termination of treatment and then each week during hospitalization. If, despite treatment, the culture remained positive, the course of treatment was repeated. All cases of gonorrheal salpingitis reported have been examined by means of salpingography before patient discharge. All patients had been given an adequate course of treatment before this examination, were afebrile with a normal sedimentation rate, and were subjectively free of symptoms. A few days before and after salpingography, antibiotics were given prophylactically. In no case were complications experienced in connection with the examination.

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RESULTS

Hysterosalpingography on the 200 patients with gonorrheal salpingitis treated with penicillin or a combination of penicillin and prednisolone showed: 105 patients with bilaterally normal tubes, 57 patients with unilaterally normal tubes, and 38 with bilaterally closed tubes. Salpingography revealed normal tubes on one or both sides in about 80% of treated gonorrheal-salpingitis cases. Our definition of a roentgenologically normal tube includes normal patency, normal width of the tube, and a free distribution of the contrast medium in the pouch of Douglas. The great importance of the time factor for the prognosis of the gonorrheal salpingitis is demonstrated in the statistics, which show the relationship between duration of the disease before admission and the condition of the tubes at salpingography after treatment. In 113 patients with 1-6 days' duration of disease before admission, 98 cases (87%) had unilaterally or bilaterally normal tubes. In the 87 cases with 7 or more days of disease duration, 64 (74%) had unilaterally or bilaterally normal tubes. The difference between the two groups regarding tubal patency is highly significant (t = 6.21; t = 3.3OXxx ). It has been of special interest to compare the results of salpingography in * Astra, Sweden. tPfizer, U.S.A.

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cases treated with penicillin and prednisolone with those treated with penicillin only. Hysterosalpingography after treatment shows that, of 130 patients treated only with penicillin, bilaterally normal tubes were present in 65, unilaterally normal tubes in 36 (combined total, 78%). Fifty-one per cent of these patients complained of symptoms for more than 6 days prior to admission. Of the 70 treated with penicillin and prednisolone, 40 showed bilaterally normal tubes, and 21 showed unilaterally normal tubes (combined total, 87%). Of this group, 30% complained of symptoms for more than 6 days prior to admission. It is evident that, with the preparations and doses used in this investigation, the combined treatment with penicillin and prednisolone gives better results than the treatment with penicillin only. The difference is highly significant (t = 7.26; t = 3.30 XXX ) .

DISCUSSION

The aim in treatment of acute salpingitis should be to check the acute attack rapidly and effectively, and especially to prevent the injurious longterm effects of the disease. No doubt, the introduction of modern antibiotics has brought us nearer to this ideal. If treatment is started at an early stage, the occurrence of inHammatory adnexal swelling can be prevented. Unfortunately, these perfect conditions for the therapy rarely occur. In the later stages of the disease, the possibilities of effective antibiotic treatment are considerably reduced. It has been shown that the concentration of an antibiotic agent in the wall of a pyosalpinx or in the pus of an abscess is too low to achieve a good bacteriostatic or bactericidal effect. In these cases, there is a greater risk that resistant bacterial strains will develop.2 To bypass this difficulty, and to prevent the reactive tissue changes due to inHammation, the anti proliferative and antiexudative properties of the corticosteroids have been used in the treatment of salpingitis. A combination of antibiotics with corticosteroids may thus result in a better reponse to the antibiotic agent and contribute to the anatomic and functional restoration of the tubes. The present investigation points to the advantages of such a combined therapy. Future possibilities of improving the prognosis of acute gonorrheal salpingitis will, to a great extent, depend upon the interval between onset of the disease and initial treatment. The responsibility for this will rest with many, but the patient herself is responsible for her future. If, by authoritative information, women could be persuaded to consult their physician immediately when any lower abdominal symptoms are noticed, much would· be gained in obtaining ideal conditions for treatment and the prognosis would thereby be improved.

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SUMMARY A series of 200 patients with acute gonorrheal salpingitis treated at the Department between 1956 and 1962 is discussed. In 130 cases the treatment consisted only of penicillin; in 70 cases, of a combination of penicillin and prednisolone. All cases were examined by means of hysterosalpingography before being discharged. In about 80%, salpingography showed normal patency of one or both tubes after treatment of gonorrheal salpingitis. The effect of therapy greatly depends upon the interval between onset of symptoms and initial treatment. The effect of a combined treatment with penicillin and corticosteroids was better than with penicillin only. University of Gothenburg Department of Obstetrics and Gynaecology Sahlgrenska S;ukhuset Gothenburg SV, Sweden

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