Laparoscopic Diagnosis of Chlamydial Pelvic Inflammatory Disease Discussion
Chlamydia Trachomatis and Pelvic Inflammatory Disease C. trachomatis can be isolated from the urethra, cervix, endometrium, Fallopian tubes16
and liver peritoneum of women. Prevalence rates of
C. trachomatis is the major aetiological agent of PID. There is no evidence to answer the question of how long C. trachomatis can remain in human tissue without treatment, since this micro-organism can be eliminated by the host immune system or even spontaneously.17
C. trachomatis infection in asymptomatic women range from 2–17 % depending on the screening setting, population, targeted test group and country.9
Previous estimates of the rates of complications following cervical infection (e.g., PID, ectopic pregnancy, tubal factor infertility) were based on selected high-risk populations and case-control studies, with an implied major potential bias.9
Figure 1: EndoSwab®, Disposable Plastic Calcium Alginate Swab Holder
Revised estimates are based on
hospital and general practice discharge registries. However, complication rates following C. trachomatis infection that are based on population registries are about 100 times less high than previously estimated from the literature.6
Undoubtedly, the reproductive
morbidity following PID is high; e.g., with C. trachomatis antibody titres as a surrogate marker, the relative risk of ectopic pregnancy is 6 and the relative risk of tubal factor infertility is 14.17
The prevalence of chlamydial infection in Europe has increased in the past 10 years, reflecting greater public awareness and improved testing opportunities. Consequently, the ECDC has started to evaluate and propose C. trachomatis control activities throughout the European Union. There are over 30 guidelines regarding the screening, diagnosis and treatment of C. trachomatis infection available in Europe, most of them published by nationally recognised professional societies, but they are not always endorsed by government entities or other health authorities.8
Another probably underestimated problem is the subjective factor at laparoscopy: inter- and intra-observer agreement ranges from poor to fair, mainly for registrars but also for senior physicians.20
The accuracy of the clinical diagnosis of PID in patients with pelvic pain differs according to clinical setting and extent of laparoscopy use. In the 1,247 Erfurt study patients, the percentage of laparoscopically diagnosed acute salpingitis and/or PID was as low as 29.1 %, with a broad spectrum of differential diagnoses. However, in other large studies of women with clinically suspected forms of PID, the confirmation rate was higher, at 65 % (n=814), 46 % (n=223) and 54 % (n=736).18,19
This is probably also true of the Erfurt data, considering they were collected over a long period of time.
this compares with 15.2 % out of 363 in the Erfurt study. The isolation rate of positive peritoneal specimen was 9 % of 372 women with salpingitis who underwent laparoscopy and 39 % of 75 women known to be C. trachomatis-positive at the cervix.17
The
isolation rates in the Erfurt study were 28.4 % at all locations and 41.8 % for C. trachomatis intraperitoneally in cervix-positive women. C. trachomatis appears to remain in the Fallopian tubes for longer than the acute disease is evident. C. trachomatis was isolated in cases of so-called chronic disease3,21 normal appearing oviducts.3,22
as well as occasionally from The cervical status in this situation was not consistently reported. On the other hand, in the Erfurt study, in EUROPEAN OBSTETRICS & GYNAECOLOGY
According to Paavonen et al., C. trachomatis was isolated from the cervix in 29 % of women (range 5–51 %) out of a total of 1,528 women with PID;17
47 (45,6 %) of all 103 C. trachomatis-positive patients, C. trachomatis was exclusively present in the Fallopian tubes!
Experimental infection of the cervix and/or Fallopian tubes with C. trachomatis can produce salpingitis in primates.23
For example,
a single inoculation of the cervix or oviducts leads to acute inflammation for a few days, after which C. trachomatis is no longer recorded; however, repeat infection results in severe tubal damage
11
Figure 2: Chlamydial Salpingitis and Laparoscopic Collection of Tubal Swab Specimen
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