A pelvic abscess represents the penultimate stage of a pelvic cavity infection [1]. It can occur spontaneously in Crohn's disease [2] but is usually secondary to infections and surgeries in the abdominopelvic region. Acute diverticulitis with perforation of the colon has been reported to be the commonest cause of pelvic abscess [3] while other causes are a pelvic inflammatory disease (PID), obstetric/ prostate/ colon surgeries, Crohn's disease and appendicitis. Risk factors for pelvic abscess include diabetes mellitus, immunodeficiencies, malignancies, and pregnancies.

Although immunosuppressed patients and the elderly present few or no symptoms [4], most patients present with constitutional symptoms of anorexia, high-grade fever, asthenia, nausea, and vomiting. Irritation of the peritoneum or neighboring organs can cause bilateral lower quadrant abdominal pain, diarrhea, prostration, increased frequency of urination, dysuria, foul-smelling vaginal discharge, vaginal bleeding, and dyspareunia. Non-specific flank pain or limp may be the initial presentation in cases with involvement of the psoas muscle by a pelvic abscess [5].

If the abscess ruptures, then clinical features of peritonitis such as severe abdominal guarding and rigidity are noted. Fistulous tracts leading from the abscess cavity into the affected part of the intestine [6] occur in patients with Crohn's disease and this is associated with severe abdominal pain and a palpable swelling [7]. One-third of these patients also have rebound tenderness [8].

Unless diagnosed and treated emergently, a ruptured pelvic abscess with peritonitis can be life-threatening.

• Fever

  Physicians should consider a diagnosis of tuboovarian abscess in a patient reporting fever and pelvic pain after IVF and embryo transfer. Published by Elsevier Inc. [ncbi.nlm.nih.gov]

• Fatigue

  Other symptoms may also arise, including fever, nausea, fatigue, vomiting, difficulty passing a stool, pus in the stools and a high temperature. Such symptoms should prompt medical practitioners to suspect an infection. [glynns.co.uk]

• Intermittent Fever

  We present an unusual occurrence in which office Pipelle endometrial sampling in a perimenopausal patient was complicated 10 days later by lower abdominal pain and intermittent fever. [ncbi.nlm.nih.gov]

• Pharyngitis

  Arcanobacterium haemolyticum has usually been isolated in cases of pharyngitis and wound infections. Rarely it has been reported to cause deep tissue infections. [ncbi.nlm.nih.gov]

• Abdominal Pain

  Fistulous tracts leading from the abscess cavity into the affected part of the intestine occur in patients with Crohn's disease and this is associated with severe abdominal pain and a palpable swelling. [symptoma.com]

  We present an unusual occurrence in which office Pipelle endometrial sampling in a perimenopausal patient was complicated 10 days later by lower abdominal pain and intermittent fever. [ncbi.nlm.nih.gov]

  Clinical evaluation proved abdominal pain on palpation without fever. Serum levels of C-reactive protein were significantly elevated reaching the plateau of 320,943. [omicsgroup.org]

• Pelvic Mass

  We describe a patient in whom the diagnosis of a pelvic mass was made by sonography and MRI at 25 weeks' gestation. At laparotomy, a pelvic abscess was partially resected and drained. [ncbi.nlm.nih.gov]

  Typically seen as thick-walled fluid-filled pelvic mass(es) 12 T1: abscess contents typically hypointense T2: abscess contents typically heterogeneous signal or hyper-intense Treatment and prognosis Initial treatment can be with antibiotic therapy. [radiopaedia.org]

  Ultrasound (US) is the first method of choice to evaluate a pelvic mass thought to be an abscess. It easily differentiates between fluid-containing and solid lesions. Pus collections have fine internal echoes of differing sizes. [glowm.com]

• Abdominal Tenderness

  Systemic Symptoms Include: Fever Body malaise Nausea Vomiting Anorexia Localized Symptoms: Abdominal pain Abdominal tenderness Diarrhea Rectal mucous discharges Urinary frequency Dysuria Tender pelvic peritoneum upon pelvic examination. [simple-remedies.com]

  Cervical motion, uterine, and lower abdominal tenderness may also be present. [saem.org]

  Physical exam findings in PID often include the following: a temperature greater than 101 F (38.3 C); abnormal vaginal discharge ; lower abdominal tenderness when exterior pressure is applied; tenderness when the cervix is moved (during a bimanual or [emedicinehealth.com]

  Physical examination revealed diffuse abdominal tenderness. Clinical considerations included duodenal hematoma and appendicitis. [meddean.luc.edu]

• Suprapubic Pain

  She was discharged from hospital on day six post operationbut presented again to the same hospital emergency room after two days complaining of moderate suprapubic pain, distension and dysuria. Physical examination was unremarkable. [ommegaonline.org]

  The patient had pyuria, suprapubic pain and leukocytosis at that time. Radiopharmaceutical: .459 mCi In-111 labeled autologous leukocytes i.v. [gamma.wustl.edu]

• Right Lower Quadrant Tenderness

  She now presents three days after the initial CT with nausea, vomiting, fever, and right lower quadrant tenderness. Repeat CT examination was obtained, shown below. Figure 1. [meddean.luc.edu]

• Tachycardia

  Pelvic and abdominal pain which is bilateral and aggravated by motion and intercourse, and fever possibly exceeding 103 degrees fahrenheit with leucocytosis, tachycardia, and prostration are the most common symptoms of pelvic abscess. [ncbi.nlm.nih.gov]

  Alternatives: ampicillin sulbactam 3 g IV q6h or cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h plus doxycyline 100 mg IV q12h • During medical management, high index of suspicion for acute rupture, such as acute worsening of abdominal pain or new-onset tachycardia [encyclopedia.lubopitko-bg.com]

  Her vital signs revealed a temperature of 38.1 C with resting tachycardia, stable blood pressure and respiratory rate. Pertinent physical exam findings included normal breast andlower limbs. [ommegaonline.org]

  With generalised peritonitis, the patient is very unwell, with marked fever, tachycardia and dehydration. There is diffuse abdominal pain, exacerbated by even the slightest movement. [surgwiki.com]

  Although tachycardia is common with fever and a pulse of greater than 90 beats/min qualifies as one of the criteria for sepsis. [glowm.com]

• Low Back Pain

  Nonspecific symptoms such as low back pain and fever delayed diagnosis, which may have led to secondary fractures. [ncbi.nlm.nih.gov]

  back pain accompanied by fever and leukocytosis. [radiopaedia.org]

• Hip Pain

  Fever and hip pain developed abruptly 1 week later when she was ready for discharge from hospital. Magnetic resonance imaging (MRI) of the pelvis disclosed an intramuscular abscess. [ncbi.nlm.nih.gov]

• Pelvic Pain

  Physicians should consider a diagnosis of tuboovarian abscess in a patient reporting fever and pelvic pain after IVF and embryo transfer. Published by Elsevier Inc. [ncbi.nlm.nih.gov]

  If the patient is pregnant, other causes of pelvic pain such as ectopic pregnancy should be considered since PID is less likely in pregnancy. If PID does occur in pregnancy, it is most common in the first 12 weeks of pregnancy. [saem.org]

  pain in a female, and PID may be found incidentally. [emedicine.medscape.com]

  This can even develop to ectopic pregnancy or chronic pelvic pain and even death. Preventing the attack of the disease is very important for female health. [home-remedies-for-you.com]

• Salpingitis

  The impression was of rare pelvic inflammatory disease in pregnancy, which developed into right tubo-ovarian abscess with acute salpingitis post partum. [casereports.bmj.com]

  Salpingitis was considered mild PID, whereas pyosalpinx and TOA were considered severe PID. [laparoscopyhospital.com]

  […] pel·vic ab·scess an abscess in the pelvic peritoneal cavity, developing as a complication of diffuse peritonitis or of localized peritonitis associated with abdominal or pelvic inflammatory disease, such as salpingitis; the pus frequently collects in [medical-dictionary.thefreedictionary.com]

  […] is the long-term sequelae of chronic pelvic pain, infertility, and ectopic pregnancy due to scarring and adhesions that burden the healthcare system in an adverse manner. [3, 4, 5] It encompasses a broad category of diseases, including endometritis, salpingitis [emedicine.medscape.com]

  Mixed flora of anaerobes, aerobes, and facultative anaerobes, such as E. coli, B. fragilis, Prevotella species, aerobic streptococci, Peptococcus, and Peptostreptococcus • N. gonorrhoeae and Chlamydia are the major etiologic factors in cervicitis and salpingitis [encyclopedia.lubopitko-bg.com]

• Adnexal Mass

  48 to 72 hr of therapy, with persistent fever or leukocytosis, increasing size of mass, or suspicion of rupture) • Poor response to medical therapy in those with adnexal masses 8 cm, bilateral disease, or immunocompromise • Antibiotic combinations: [encyclopedia.lubopitko-bg.com]

  A palpable adnexal mass may be seen in complicated PID with TOA. [emedicine.medscape.com]

  Bimanual examination revealed no adnexal mass or tenderness, no cervical excitation. Larger amounts of pussy fluid exuded from the vagina. [ommegaonline.org]

  Findings may include: multilocular complex retro-uterine/adnexal mass debris, septations, and irregular thick walls commonly bilateral echogenic debris within the pelvis CT Can be a helpful adjunct to ultrasound especially in determining the extent of [radiopaedia.org]

  In the diagnosis of intra-abdominal conditions, magnetic resonance imaging (MRI) has been widely accepted, although MRI has been used rarely in the imaging of adnexal masses and gynecologic infections. [laparoscopyhospital.com]

• Dyspareunia

  Irritation of the peritoneum or neighboring organs can cause bilateral lower quadrant abdominal pain, diarrhea, prostration, increased frequency of urination, dysuria, foul-smelling vaginal discharge, vaginal bleeding, and dyspareunia. [symptoma.com]

  The complications of PID include chronic pelvic pain, dyspareunia, infertility, ectopic pregnancy, TOA and Fitz-Hugh-Curtis syndrome. Women with a previous episode of PID are 12-15 % more likely to have an ectopic pregnancy. [saem.org]

  The patient did report dyspareunia at the 1-year follow-up. Fig. 1 From patient #3. A sagittal midline image from the initial oral and intravenous contrast-enhanced CT. [link.springer.com]

• Urinary Incontinence

  Manufacturers have adamant about changing the mesh composition rather than finding a more natural and less toxic remedy for SUI (stress urinary incontinence) and POP (pelvic organ prolapse). [pelvicmeshownersguide.com]

Clinical suspicion, a thorough history, along with pelvic and rectal examination help to recognize pelvic abscesses in a majority of the patients [4]. Bimanual palpation may elicit tenderness in either the cul-de-sac or adnexal region in pelvic abscess secondary to PID.

Routine laboratory tests such as a complete blood count and inflammatory markers may reveal leukocytosis and elevated erythrocyte sedimentation rate. Serological tests for autoimmune conditions, syphilis, and human immunodeficiency virus are performed based on clinical findings. A cervical swab is required to identify chlamydial or gonorrheal infection while urinalysis may detect pus cells.

The gold standard test for diagnosing a pelvic abscess is an abdominopelvic ultrasonogram which (US) is performed initially as it can differentiate between an abscess and appendicitis while a transvaginal ultrasound, in cases with PID, helps to confirm and localize the abscess.

Computed tomography (CT) with contrast or magnetic resonance imaging (MRI) are indicated in post-operative patients or patients with Crohn's disease or malignancies suspected to have enteric fistulae. CT with contrast (enterography) provides information regarding the severity of bowel inflammation and a concomitant fistula [9].

Imaging may show a thickened abscess wall in a chronic abscess [10] or an ill-defined border in case of a mass or a phlegmon [11]. US guided or CT guided aspiration of the purulent material from the pelvic abscess should be sent for microbiological staining, culture, and antibiotic sensitivity testing in all cases.

• X-Ray Abnormal

  Abscesses near the diaphragm may result in chest x-ray abnormalities such as ipsilateral pleural effusion, elevated or immobile hemidiaphragm, lower lobe infiltrates, and atelectasis. CBC and blood cultures should be done. [msdmanuals.com]

• Ovarian Mass

  Additionally, bilateral complex masses are present; this finding is compatible with tubo-ovarian masses. [emedicine.medscape.com]

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10. Clayton J. Radiologic considerations in pelvic and intra-abdominal infections. In Pastorek JG III (ed): Obstetric and Gynecologic Infectious Disease. New York, Raven Press, 1994.
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