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Antibodies to Chlamydia trachomatis in acute salpingitis.
Recent isolation studies have shown Chlamydia trachomatis to be an important aetiological agent in acute salpingitis in women. The present serological study indicates that C. trachomatis is the probable aetiological agent in two-thirds of 143 women with pelvic inflammatory disease (PID). In general, high levels of chlamydial antibody were found in sera and fluids aspirated from the pouch of Douglas and such antibody titres were shown to correlate with the severity of clinically graded tubal inflammation.
Sonographic morphology of the normal menstrual cycle.
Sequential gray-scale sonograms were obtained during 20 menstrual cycles in 16 normal female volunteers. Hormonal and physical parameters of an ovulatory cycle were correlated with morphological changes in the ovaries, uterus, and cul-de-sac as seen on the sonogram. Ovarian cysts of two sizes were observed, corresponding chronologically and morphologically to Graafian follicles and corpora lutea. Small amounts of free pelvic fluid were demonstrated in many women at ovulation. A characteristic uterine appearance is seen prior to menstruation and is related to hormonal influences on the uterus. These findings emphasize the importance of recognizing normal physiological changes when interpreting gynecologic sonograms.
Gastrointestinal tract involvement by gynecologic diseases.
Involvement of the gastrointestinal tract by gynecologic disease processes-endometriosis, gynecologic neoplasms, inflammatory processes, and complications from radiation therapy or surgery for gynecologic tumors-may mimic primary gastrointestinal carcinoma on radiologic images. Endometriosis most often involves the anterior wall of the rectosigmoid colon, adjacent to the pouch of Douglas, and typically produces extrinsic mass effect on the serosa, with the overlying mucosa left intact. Direct extension of ovarian cancer to the colon through the subperitoneal space produces mass effect with serosal spiculation, tethering, and fixation; annular constriction; or partial or complete obstruction. Intraperitoneal seeding of ovarian carcinoma most frequently involves the colon and is seen as extrinsic masses, often with serosal spiculation and tethering. Cervical carcinoma, which most commonly spreads by direct invasion of the pelvic side wall and adjacent structures, produces serosal spiculation and circumferential narrowing. Benign ovarian or uterine tumors are purely extrinsic and have a smooth interface with the colonic wall. Tubo-ovarian abscesses are difficult to differentiate from cystic ovarian neoplasms or endometriomas. Radiation colitis causes narrowing of the rectum with intact mucosa and can be differentiated from recurrent tumor, unlike radiation-induced injury of the small bowel, which may be difficult to distinguish. Surgical adhesions produce a discrete transition point between dilated bowel proximally and nondilated distal bowel. Familiarity with the varied patterns of gastrointestinal tract involvement is important for accurate interpretation of imaging studies.
Posterior cul-de-sac obliteration associated with endometriosis: MR imaging evaluation.
PURPOSE: To retrospectively evaluate the accuracy of magnetic resonance (MR) imaging in depicting posterior cul-de-sac obliteration in patients with endometriosis. MATERIALS AND METHODS: Institutional review board approval was not required for this retrospective study, but informed consent was obtained from all patients. MR images obtained between January 1989 and December 2000 in 57 women (mean age, 39 years; age range, 26-52 years) with histologically confirmed endometriosis were retrospectively evaluated by four radiologists independently. All patients underwent laparotomy or laparoscopy less than 1 month after MR imaging. MR images were evaluated for the presence and location of endometrial implants and adhesions. MR images were also scored for the presence of five findings: retroflexed uterus, elevated posterior vaginal fornix, intestinal tethering or tethered appearance of rectum in direction of uterus, faint strands between uterus and intestine, and fibrotic plaque or nodule covering serosal surface of the uterus. Interobserver agreement for each of the five findings and for the overall diagnosis of cul-de-sac obliteration was calculated. Sensitivity, specificity, accuracy, positive and negative predictive values, and kappa statistics were determined. RESULTS: Laparotomy or laparoscopy revealed posterior cul-de-sac obliteration in 30 patients. Overall, the four radiologists had mean accuracies of 89.0% and 76.3% for diagnosing endometrial implants and adhesions, respectively, at MR imaging. Overall, the radiologists achieved mean sensitivity, specificity, accuracy, and positive and negative predictive values of 68.4%, 76.0%, 71.9%, 76.6%, and 68.5%, respectively, in diagnosing posterior cul-de-sac obliteration. The best accuracy (mean value, 64.5%) was obtained with the finding of fibrotic plaque in the uterine serosal surface. Readers agreed on the observations 63.2%-91.2% of the time. For the impression of the presence or absence of posterior cul-de-sac obliteration, interobserver agreement varied between substantial and moderate: Mean interobserver agreement was 78.4% (range, 70.2%-84.2%), and mean kappa was 0.57 (range, 0.40-0.67). Mean accuracy of MR imaging for diagnosing posterior cul-de-sac obliteration was 71.9%. CONCLUSION: These results suggest that use of the described MR imaging findings may enable diagnosis of posterior cul-de-sac obliteration.
Echogenic clot: a useful sign of pelvic hemoperitoneum.
The sonograms of 34 patients with surgically proved pelvic hemoperitoneum were reviewed. In 15 of these patients clotted blood was found at surgery in the pelvis or cul-de-sac. In nine of these patients (60%), ultrasound demonstrated echogenic fluid collections or "masses" with an echogenicity equal to or greater than the uterus. Because anechoic fluid in the pelvis is a nonspecific finding, awareness that clotted blood can be highly echogenic may be of considerable value in the differential diagnosis of pelvic fluid collections. The limitations and pitfalls in interpreting this finding are discussed.
Peritoneal implants from ovarian tumors: CT findings.
Metastatic peritoneal implants were assessed preoperatively with computed tomography (CT) in 38 patients with ovarian tumors. In the 106 biopsy specimens of gross peritoneal implants and the 118 random biopsy specimens obtained from these patients, metastatic deposits were detected in 27 of 38 (71%) patients and in 104 biopsy sites. CT depicted metastatic lesions in 17 of 27 (63%) patients and in 63 of 104 (61%) biopsy sites. The three sites most commonly involved were the right subphrenic region, the greater omentum, and the pouch of Douglas. The usefulness of CT in detecting lesions depended mainly on the location of the implant and the presence of adjacent ascites, rather than on lesion size.
US of the peritoneum.
Familiarity with the pathophysiology of peritoneal disease is the basis of successful ultrasound (US) study of the peritoneum. The pouch of Douglas, diaphragmatic surfaces, the paracolic gutters, and the regions of the mesentery and omentum should receive careful scrutiny in the patient at risk for a peritoneal disease process. An optimal US technique requires assessment of the entire peritoneum with a transducer selected to reflect the depth of the region of interest. US may demonstrate minute quantities of free intraperitoneal fluid and is therefore capable of providing sensitive quantitative information about ascites. Qualitative information may also be inferred, as blood, pus, and neoplastic cells demonstrate correlation with particulate ascites on gray-scale US scans. Peritoneal nodules, plaques, and thickening may be detected on the visceral or parietal peritoneal surfaces, especially when high-frequency probes are used. Transvaginal study in women increases the sensitivity of US for detection of peritoneal disease. In women who have unexplained sepsis or are at risk for carcinomatosis, transvaginal scanning should routinely be added to the regular abdominal and pelvic studies regardless of the findings of those studies. Peritoneal carcinomatosis, primary peritoneal neoplasms, pseudomyxoma peritonei, and peritonitis have characteristic appearances at US.
Is endometriosis really associated with pain?
To address the contrasting findings regarding how pain is related to endometriosis, the relationship between pain and stage of endometriosis was dissected differently by the chief complaint to eliminate selection biases. A total of 1,092 women with endometriosis were classified into two groups depending on their chief complaint, i.e., infertility (infertility group; n = 476) or pain (pain group; n = 616). The correlations between disease stage and various types of pain were analyzed differently in each group. The frequencies of chronic pelvic pain and dyspareunia increased with disease stage either in the infertility group, in the pain group or in the aggregate. On the other hand, no significant relation between the severity of dysmenorrhea and disease stage was observed in the aggregate. Interestingly, a parallel increase in the severity of dysmenorrhea with disease stage was observed in the infertility group, but not in the pain group. In view of selection biases involved in analyzing endometriosis associated with pain, these results could be seen to support the contention that chronic pelvic pain, dyspareunia and dysmenorrhea are in fact related to the extent of endometriosis.
Suppurative adnexal infections report on 830 patients treated in 1947-61.
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Hydrotubation for diagnosing carcinoma in situ of the fallopian tube. A case report.
BACKGROUND: Primary adenocarcinoma of the fallopian tube is rare and not diagnosed until at an advanced stage. We present a case of carcinoma in situ of the fallopian tube in which cytologic examination obtained by hydrotubation facilitated the diagnosis. CASE: A 55-year-old woman presented to Yamaguchi Red Cross Hospital for uterine cancer screening. Endometrial brush cytology revealed adenocarcinoma cells, but endometrial curettage showed no abnormal findings. We performed hydrotubation, collecting abdominal fluid by culdocentesis for cytology. The smear test showed adenocarcinoma with cells similar to those obtained by endometrial brush cytology. Laparotomy showed no abnormalities in the abdominal cavity, and pelvic washing cytology was negative. Based on the positive cytology found by hydrotubation, we performed a hysterectomy and bilateral salpingo-oophorectomy. Postsurgical histology revealed adenocarcinoma in situ of the fallopian tube. CONCLUSION: The present case suggests that cytologic examination obtained by hydrotubation may be useful in diagnosing early tubal cancer.
Bowel prolapse and gangrene following vaginal vault perforation: an example of the menace of criminal abortion in Nigeria.
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Silent upper genital tract chlamydial infection and disease in women.
To find what proportion of women with endocervical Chlamydia trachomatis infection had asymptomatic infection of the upper genital tract, 10 women with neither gonorrhoea nor signs, symptoms or a past history of pelvic inflammatory disease were laparoscoped. Swabs from the fimbriae and pouch of Douglas were tested for C. trachomatis by tissue culture, enzyme immunoassay, direct fluorescent antibody and polymerase chain reaction techniques. Four of the women had an upper genital tract chlamydial infection. Neither laparoscopic appearances, menstrual phase, interval since last intercourse, partner change nor other coincidental genital infection was associated with the upper genital tract spread. These findings suggest that careful investigation, immediate treatment and contact tracing are mandatory when asymptomatic endocervical chlamydial infection is discovered.
Herniography in atypical inguinal hernia.
In patients with unclear groin pain herniography has revealed hernia in 36% of the patients with a normal physical examination. Most of the hernias detected on herniography are of indirect, direct or femoral type. The former two are found predominantly among men and the latter among women. These types of hernia are defined herniographically according to their location and shape. Whether or not a hernia is present is usually obvious although small hernias may be obscured by pelvic bone and contrast medium in the inguinal fossae and pouch of Douglas. In most patients the hernias are conspicuous and easy to classify correctly. Problems may, however, arise in the precise definition of some types of hernia. In this respect positive contrast herniography contributes to the pre-operative evaluation in patients with inguinal hernia. The aim of the present report is to describe some less well-known herniographic findings. The clinical impact of the particular findings is discussed.
Malignant stromal tumour of the rectum: findings at endorectal ultrasound and MRI.
This case report describes the findings on endorectal ultrasound and MRI in a patient with a giant malignant stromal tumour of the rectum. A review of imaging characteristics and histopathological findings as described in the literature is presented.
Sperm transport in the human female reproductive tract in relation to semen analysis characteristics and time of ovulation.
Laparoscopic sperm recovery from the pouch of Douglas and tubal fimbriae was performed in 64 infertile couples. Spermatozoa were recovered from 16/35 couples investigated after AIH, and from 13/29 couples post coitum. The method of insemination had no effect on the result, which was positive in 45.3% of all couples, although AIH did result in significantly larger numbers of peritoneal spermatozoa. The number of peritoneal spermatozoa did not show any direct correlation with the number inseminated, but there were reductions along the tract of 5.83 (+/- 1.4 s.d.) orders of magnitude for total sperm count, and 5.52 (+/- 1.21 s.d.) for the number of motile spermatozoa. Only sperm motility had a significant influence on the success of sperm transport; spermatozoa were recovered from patients with sperm densities as low as 3.0 and 3.5 x 10(6)/ml, but with 56 and 44% motile spermatozoa. No influence of cycle day within the range +/- 4 days of ovulation on sperm transport was found. In 45 couples, routine semen analyses were apparently completely normal, but the incidence of sperm recovery was still only 49% (22/45), suggesting that a failure of sperm transport may have been a significant causative factor in their infertility.
The cul-de-sac packing method with a metreurynter in gynecologic gasless laparoscopy.
Laparoscopic surgery has inherent restrictions with respect to the operative field of view and the range of surgical manipulation. Of the two procedures which secure sufficient operative space, the operative view of the gasless method is inferior to that of a pneumoperitoneum. In order to gain greater surgical visualization in gynecological gasless laparoscopy, the authors devised the cul-de-sac packing method employing a metreurynter, an instrument familiar to obstetricians in Japan. A metreurynter was lead into the cul-de-sac, and was inflated with saline, which resulted in the adnexae being raised up. This method was performed in three patients whose preoperative diagnoses were unknown infertility, ovarian cyst, and ectopic pregnancy, respectively. In all cases this method was able to keep the bowels out of the cul-de-sac space. In the first case, we were able to perform a tubal patency test under tension-free conditions, while at the same time bilateral tubal information could be obtained in a single view. In the latter two cases the adnexal lesions were maintained at an inspectional position throughout the operation without the necessity of being held by forceps to prevent them from falling down into the cul-de-sac space. No complications occurred in our three cases. This method will not be useful for patients whose cul-de-sac space is closed due to adhesions. However, except in such cases, this technique supplies a good operative view while being simple, safe, and inexpensive. Furthermore, this method supports gentler and less traumatic manipulation throughout the operation.
Distribution of intra-abdominal malignant seeding: dependency on dynamics of flow of ascitic fluid.
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