Tubo-ovarian abscess: Difference between revisions
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*Age 15-25 years old | *Age 15-25 years old | ||
*Prior history of [[PID]] | *Prior history of [[PID]] | ||
*IUD | *[[IUD]] (within 21 days of insertion<ref>https://www.cdc.gov/std/tg2015/pid.htm</ref>) | ||
*[[HIV]] infection | *[[HIV]] infection | ||
==Clinical Features== | ==Clinical Features== | ||
*+/-[[Fever]] | *+/-[[Fever]] | ||
*Vaginal discharge | *[[Vaginal discharge]] | ||
*Dyspareunia | *Dyspareunia | ||
*Disproportionate unilateral adnexal tenderness or adnexal mass or fullness | *Disproportionate unilateral adnexal tenderness or adnexal mass or fullness | ||
| Line 24: | Line 24: | ||
==Evaluation== | ==Evaluation== | ||
[[File:PMC4603210 usg-15013-f11.png|thumb|Dilated, complex, fluid-filled tubular structure is consistent with hydro/pyosalpinx (A, B). Short-axis image (C) demonstrates the “cog-wheel” pattern of the endosalpingeal folds, indicative of tubal inflammation in pelvic inflammatory disease with a pyosalpinx or a hydrosalpinx. (arrows).]] | |||
*CBC | *CBC | ||
*ESR/CRP | *ESR/CRP | ||
*Transvaginal pelvic ultrasound (Sn 75-82%) | *Transvaginal pelvic ultrasound (Sn 75-82%) | ||
*CT pelvis (Sn 78-100%) - preferred in patients in whom associated GI pathology must be excluded | *CT pelvis (Sn 78-100%) - preferred in patients in whom associated GI pathology must be excluded | ||
==Management== | ==Management== | ||
*OB/GYN consult | ===Operative Drainage=== | ||
*OB/GYN consult for possible operative drainage | |||
*Majority (60-80%) resolve with [[antibiotics]] alone | *Majority (60-80%) resolve with [[antibiotics]] alone | ||
*Predictors of antibiotic treatment failure and possible indications for IR drainage upon admission to Ob<ref>Huma F et al. Inpatient Management of Tubo-Ovarian Abscesses: What Is the Threshold of Parenteral Antibiotic Treatment Failure? Obstetrics & Gynecology: May 2015</ref> | |||
**WBC > 16,000 | |||
**TOA size > 5.2 cm | |||
{{PID antibiotics}} | |||
==Disposition== | ==Disposition== | ||
*Decision should be made in conjunction with gynecological colleague | *Decision should be made in conjunction with gynecological colleague | ||
* Patient with fevers, elevated WBC, abscess greater than 5 cm, or systemic toxicity demand admission | *Patient with fevers, elevated WBC, abscess greater than 5 cm, or systemic toxicity demand admission | ||
* Hemodynamically stable, afebrile patients with a relatively small [[abscess]] can be safely discharged with close gynecological follow up on antibiotics | *Hemodynamically stable, afebrile patients with a relatively small [[abscess]] can be safely discharged with close gynecological follow up on antibiotics | ||
==See Also== | ==See Also== | ||
Latest revision as of 16:51, 27 May 2021
Background
- Typically a complication of PID, although inflammatory bowel, appendicitis, and hematologic nidius have been reported
- Mortality if not ruptured: <1% if treated; 2-4% if untreated
- Infections are often polymicrobial
- Common organisms: Escherichia coli, aerobic streptococci, Bacteroides fragilis, Prevotella, Peptostreptococcus
- N. gonorrhoeae and C. trachomatis are rarely culprit organisms
Risk factors
- Multiple sex partners
- Age 15-25 years old
- Prior history of PID
- IUD (within 21 days of insertion[1])
- HIV infection
Clinical Features
- +/-Fever
- Vaginal discharge
- Dyspareunia
- Disproportionate unilateral adnexal tenderness or adnexal mass or fullness
- Suspect in patient who does not respond after 72hr of treatment for PID
Differential Diagnosis
Acute Pelvic Pain
Gynecologic/Obstetric
- Normal variants may be noted on exam but generally do not cause pain or other symptoms
- Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
- Cervical Ectropion: Edothelial cells on the exterior of the cervix
- Parous cervix: The is no longer round but may have multiple shapes after birth
- Pregnancy-related
- Ectopic pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Pelvic organ prolapse
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
Evaluation
- CBC
- ESR/CRP
- Transvaginal pelvic ultrasound (Sn 75-82%)
- CT pelvis (Sn 78-100%) - preferred in patients in whom associated GI pathology must be excluded
Management
Operative Drainage
- OB/GYN consult for possible operative drainage
- Majority (60-80%) resolve with antibiotics alone
- Predictors of antibiotic treatment failure and possible indications for IR drainage upon admission to Ob[3]
- WBC > 16,000
- TOA size > 5.2 cm
Antibiotics
- No sexual activity for 2 weeks;
- Treat all partners who had sex with patient during previous 60 days prior to symptom onset
Outpatient Antibiotic Options
- Ceftriaxone 500mg IM (1g if >150kg)[4][5] x1 + doxycycline 100mg PO BID x14d + metronidazole 500mg PO BID x14d [6][7]
- Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose[10] + Doxycycline 100 mg PO BID x 14 days + metronidazole
Inpatient Antibiotic Options
- Recommended[11]: Ceftriaxone 1gm IV q24hr OR Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr + Metronidazole 500mg IV or PO Q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg loading -> 1.5 mg/kg q8hr IV OR
- Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
Disposition
- Decision should be made in conjunction with gynecological colleague
- Patient with fevers, elevated WBC, abscess greater than 5 cm, or systemic toxicity demand admission
- Hemodynamically stable, afebrile patients with a relatively small abscess can be safely discharged with close gynecological follow up on antibiotics
See Also
References
- ↑ https://www.cdc.gov/std/tg2015/pid.htm
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Huma F et al. Inpatient Management of Tubo-Ovarian Abscesses: What Is the Threshold of Parenteral Antibiotic Treatment Failure? Obstetrics & Gynecology: May 2015
- ↑ Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
- ↑ Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
- ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon