Tubo-ovarian abscess: Difference between revisions

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==Background==
==Background==
*Typically a complication of PID, though inflammatory bowel, appendicitis, and hematologic nidi have been reported  
*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
*Mortality if not ruptured: <1% if treated; 2-4% if untreated
*Risk factors:
**Multiple sex partners
**Age 15-25 years old
**Prior history of PID
**IUD
**HIV infection
*Infections are often polymicrobial
*Infections are often polymicrobial
**Common organisms: Escherichia coli, aerobic streptococci, Bacteroides fragilis, Prevotella, Peptostreptococcus
**Common organisms: [[Escherichia coli]], aerobic streptococci, [[Bacteroides fragilis]], Prevotella, Peptostreptococcus
**N. gonorrhoeae and C. trachomatis are rarely culprit organisms
**[[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<ref>https://www.cdc.gov/std/tg2015/pid.htm</ref>)
*[[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  
*Suspect in pt who does not respond after 72hr of treatment for [[PID]]
*Suspect in patient who does not respond after 72hr of treatment for [[PID]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Pelvic pain DDX}}
{{Pelvic pain DDX}}


==Workup==
==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
*TVUS (Sn 75-82%)
*Transvaginal pelvic ultrasound (Sn 75-82%)
:or
*CT pelvis (Sn 78-100%) - preferred in patients in whom associated GI pathology must be excluded
*CT pelvis (Sn 78-100%)
**Preferred with 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


===Outpatient===
{{PID antibiotics}}
*[[Ceftriaxone]] 250 mg IM once PLUS [[doxycycline]] 100 mg PO BID x14 days
*Add [[metronidazole]] 500 mg PO BID x14 days if suspicion of bacterial [[vaginitis]] or gyn instrumentation in preceding 2-3 wks
 
=== Inpatient ===
*[[Cefoxitin]] 2gm IV q6hr OR [[cefotetan]] 2gm IV q12hr) + [[doxycycline]] PO or IV 100 mg q12hr OR
*[[Clindamycin]] 900mg IV q8h + [[gentamicin]] 2mg/kg QD OR
*[[Ampicillin-sulbactam]] 3gm IV q6hr + [[doxycycline]] 100mg IV/PO q12hr


==Disposition==
==Disposition==
*Admission
*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==
==See Also==

Latest revision as of 16:51, 27 May 2021

Background

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

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

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
  • 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

Inpatient Antibiotic Options

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

  1. ↑ https://www.cdc.gov/std/tg2015/pid.htm
  2. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  3. ↑ Huma F et al. Inpatient Management of Tubo-Ovarian Abscesses: What Is the Threshold of Parenteral Antibiotic Treatment Failure? Obstetrics & Gynecology: May 2015
  4. ↑ 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.
  5. ↑ Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  6. ↑ 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
  7. ↑ 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
  8. ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  9. ↑ 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
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