Tubo-ovarian abscess

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)
• 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

• 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
  • Cervial 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
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• 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

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

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

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
  • 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) x1 + doxycycline 100mg PO BID x14d + metronidazole 500mg PO BID x14d
  • Metronidazole
    • Recommended for empiric treatment of PID by the CDC
    • Recommended empirically by European guidelines
• Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose + Doxycycline 100 mg PO BID x 14 days + metronidazole

Inpatient Antibiotic Options

• Recommended: 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

• PID