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Tubo-Ovarian Abscess

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Tubo-Ovarian Abscess, Tuboovarian Abscess

  • See Also
  1. Pelvic Inflammatory Disease
  2. Sexually Transmitted Infection
  • Epidemiology
  1. Complicates 17-20% of Pelvic Inflammatory Disease cases (esp. if delayed treatment)
  2. Most common age 15 to 40 years old
  • Pathophysiology
  1. See Pelvic Inflammatory Disease
  2. Infectious, inflammatory mass involving the ovary and fallopian tube
  3. Infection may spread more broadly to involve other pelvic organs, as well as the bowel and Bladder
  • Risk Factors
  1. See Pelvic Inflammatory Disease
  2. Delayed treatment of Pelvic Inflammatory Disease (or incomplete treatment)
  3. Recent genitourinary procedures (e.g. hysteroscopy, abdominal or pelvic surgery)
  4. Diabetes Mellitus
  5. Immunocompromised state (e.g. HIV Infection)
  6. Inflammatory Bowel Disease
  7. Chronic Bacterial Infections (e.g. Salmonella typhi, Brucellosis)
  • Causes
  • Sources
  1. Ascending Infection (most common)
    1. Sexually Transmitted Infection
    2. Pelvic Inflammatory Disease
    3. Vaginal flora
  2. Other sources
    1. Gastrointestinal infection spread (e.g. Appendicitis, Diverticulitis)
    2. Inflammatory Bowel Disease
    3. Urinary tract spread (e.g. Pyelonephritis)
    4. Pelvic organ cancer
      1. Underlying malignancy is found in up to 50% of postmenopausal patients with Tuboovarian Abscess
  • Causes
  • Infections
  1. See Pelvic Inflammatory Disease
  2. Most common (Sexually Transmitted Infections)
    1. Gonorrhea
    2. Chlamydia trachomatis
    3. Trichomoniasis
  3. Other organisms
    1. Escherichia coli (common)
    2. Bacteroides fragilis
    3. Prevotella species
    4. Anaerobic streptococcal species
  4. Immunocompromised state
    1. Candida
    2. Mycobacterium tuberculosis
    3. Pasteurella
    4. Streptococcus Pneumoniae
  5. Intrauterine Device
    1. Actinomyces israeli (covered by typical PID regimens)
  • Symptoms
  1. Lower Abdominal Pain (90%)
  2. Fever (>50%)
    1. Much more common in Tubo-Ovarian Abscess than in Pelvic Inflammatory Disease
  3. Chills (50%)
  4. Nausea (25%)
  5. Vaginal Discharge or Vaginal Bleeding (25%)
  6. Flank Pain (if ureteral obstruction with Hydronephrosis)
  • Signs
  1. Ill or toxic appearance
  2. Mucopurulent cervical discharge
  3. Cervical motion tenderness
  4. Significant Adnexal tenderness
  5. Palpated Adnexal Mass (40% of cases)
  • Labs
  1. See Pelvic Inflammatory Disease
  2. Complete Blood Count
    1. Leukocytosis (77% of cases)
  • Imaging
  1. Transvaginal Ultrasound
    1. Test Sensitivity 75 to 90%
    2. Complex Adnexal Mass with thick walls and increased echogenic contents
    3. Complex free fluid in the pouch of douglas
  2. CT Abdomen and Pelvis with IV contrast
    1. Preferred in non-pregnant patients with broader involvement, wider differential or toxic appearance
    2. Test Sensitivity 90-95% with modern CT
    3. Consider Oral Contrast in some cases (consult radiology)
    4. Multiloculated, rim-enhancing, thick-walled Adnexal Mass, and contents with increased fluid density
    5. Thickened fluid filled fallopian tubes with incomplete septae (50% of cases)
    6. Contiguous inflammation (e.g. bowel wall thickening, fat stranding)
  • Management
  1. See Pelvic Inflammatory Disease
  2. Admit all patients with Tubo-Ovarian Abscess
  3. Early gynecology Consultation
  4. Antibiotics
    1. Initial IV Antibiotics are transitioned to 14 days of oral Antibiotics
    2. Preferred Regimens
      1. Doxycycline 100 mg every 12 hours AND
      2. Choose one beta lactam (Cephalosporin or Penicillin)
        1. Ceftriaxone 1 g IV every 24 hours AND Metronidazole 500 mg IV every 12 hours OR
        2. Cefotetan 2 g IV every 12 hours OR
        3. Cefoxitin 2 g every 6 hours OR
        4. Ampicillin-Sulbactacm (Unasyn) 3 g IV every 6 hours
    3. Regimens for Severe Penicillin Allergy
      1. Clindamycin 900 mg IV every 8 hours AND
      2. Gentamicin
  5. Management varies by abscess size
    1. Abscess 4-6 cm diameter
      1. Resolve with Antibiotics alone 85% of the time
    2. Abscess >10 cm (or abscess rupture) typically require surgical management
      1. Laparoscopy or percutaneous drainage required in 60% of abscess >10 cm
  6. Management of specific associated conditions
    1. See Pelvic Inflammatory Disease for concerns in HIV, pregnancy and patients with IUD
  • Complications
  1. See Pelvic Inflammatory Disease
  2. Acute
    1. Sepsis (20%)
    2. Tubo-Ovarian Abscess rupture (15%)
  3. Chronic
    1. Chronic Pelvic Pain
    2. Infertility
  • Prognosis
  1. Mortality 4% in Sepsis or abscess rupture (otherwise mortality is much lower)
  • References
  1. Long and Werner in Swadron (2023) EM:Rap 23(9)
  2. Martin and Khoujah (2023) Crit Dec Emerg Med 37(10): 22-9
  3. Bridwell (2022) Am J Emerg Med 57:70-5 +PMID: 35525160 [PubMed]
  4. Kairys (2023) Tubo-Ovarian Abscess, StatPearls, Treasure Island, FL [PubMed]
    1. https://www.ncbi.nlm.nih.gov/books/NBK448125/