Tubo-ovarian abscess: Difference between revisions
| Line 32: | Line 32: | ||
*OB/GYN consult for possible 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=== | ===Outpatient=== | ||
Revision as of 23:11, 6 October 2018
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
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
- 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[2]
- WBC > 16,000
- TOA size > 5.2 cm
Outpatient
- Ceftriaxone 250mg IM once PLUS doxycycline 100mg PO BID x14 days
- Add metronidazole 500mg 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 100mg q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg QD 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