Pelvic Abscess

Pelvis Abscess

A pelvic abscess is loculated purulent material in the pelvic cavity and develops as a complication of either gastrointestinal or urogenital infection or surgical procedures. It can present with mild symptoms or life-threatening peritonitis. Imaging studies help to diagnose the condition while microbiological studies are required to identify the causative organism.

Presentation

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.

Entire body system

Fever

Physicians should consider a diagnosis of tuboovarian abscess in a patient reporting fever and pelvic pain after IVF and embryo transfer.[ncbi.nlm.nih.gov]
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]
A 43-year-old woman developed fever, abdominal pain, and abdominal distention following a total abdominal hysterectomy and right salpingo-oophorectomy. Empirical treatment with broad-spectrum antimicrobial agents was not successful.[ncbi.nlm.nih.gov]
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]
A 20-month-old previously healthy boy presented for evaluation of limping and history of fever. The physical examination was suggestive of transient synovitis.[ncbi.nlm.nih.gov]

Gastrointestinal

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]
A 43-year-old woman developed fever, abdominal pain, and abdominal distention following a total abdominal hysterectomy and right salpingo-oophorectomy. Empirical treatment with broad-spectrum antimicrobial agents was not successful.[ncbi.nlm.nih.gov]
In all cases, a pelvic mass and abdominal pain constituted the referral signs and symptoms. All women received an initial antibiotic regimen comprising penicillin (24 mU/day), clindamycin (900 mg/day) and gentamycin (240 mg/day) in divided doses.[ncbi.nlm.nih.gov]
Subsequently, the patient complained of lower abdominal pain and had persistent fever. Enhanced computed tomography revealed pelvic abscesses.[jmmcr.microbiologyresearch.org]

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]
., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after initiation of therapy.[cdc.gov]

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]
In all cases, a pelvic mass and abdominal pain constituted the referral signs and symptoms. All women received an initial antibiotic regimen comprising penicillin (24 mU/day), clindamycin (900 mg/day) and gentamycin (240 mg/day) in divided doses.[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]

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]

Cardiovascular

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]
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]

Musculoskeletal

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]

Urogenital

Pelvic Pain

Physicians should consider a diagnosis of tuboovarian abscess in a patient reporting fever and pelvic pain after IVF and embryo transfer.[ncbi.nlm.nih.gov]
For patients with unusual postpartum pelvic pain, uterine rupture should be considered as one of the possible etiologic factors, and prompt survey should be performed. Laparoscopic intervention may be valuable in such situations.[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]
[…] 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]
Salpingitis was considered mild PID, whereas pyosalpinx and TOA were considered severe PID.[laparoscopyhospital.com]
[…] 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]
N70.0 Acute salpingitis and oophoritis N70.1 Chronic salpingitis and oophoritis Hydrosalpinx N70.9 Salpingitis and oophoritis, unspecified N71 Inflammatory disease of uterus, except cervix Includes: endo(myo)metritis metritis myometritis pyometra uterine[apps.who.int]

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]
., abnormal bleeding, dyspareunia, and vaginal discharge).[cdc.gov]

Adnexal Mass

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]

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]

Workup

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

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]

Ultrasound

Ovarian Mass

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

Treatment

Given the morbidity and mortality associated with these infections, aggressive treatment with amphotericin B and drainage of abscesses is warranted.[ncbi.nlm.nih.gov]
The small number of patients and the absence of a comparative treatment group.[ncbi.nlm.nih.gov]
We report the unique occurrence and treatment of spontaneous multiple insufficiency fractures after sepsis in a patient with rheumatoid arthritis (RA). The patient was a 53-year-old woman with a 13-year history of RA.[ncbi.nlm.nih.gov]
Patients with ovarian endometrioma and received IVF-ET treatment were retrospectively classified into two groups according to the difference of vaginal douching solution immediately before oocyte retrieval.[ncbi.nlm.nih.gov]
Percutaneous imaging-guided drainage is the first-line treatment for infected or symptomatic fluid collections in the abdomen and pelvis, in the absence of indications for immediate surgery.[ncbi.nlm.nih.gov]

Prognosis

Treatment and prognosis Percutaneous abscess drainage which is the standard treatment for abdominal and pelvic abscesses in the absence of an acute surgical abdomen. Broad-spectrum antibiotic therapy is given concurrently.[radiopaedia.org]
Prognosis The prognosis will depend on the aetiology of the abscess, underlying well-being of the patient and the speed of diagnosis and effective management. An abscess may sometimes drain spontaneously into the rectum.[patient.info]
Definitive diagnosis is important for prompt treatment and improved prognosis. Medical diagnoses that need to be ruled out include pelvic inflammatory disease, appendicitis, diverticulitis, generalized peritonitis, and septic abortion.[simple-remedies.com]
Gastrointestinal stromal tumors: Review on morphology, molecular pathology, prognosis, and differential diagnosis. Arch Pathol Lab Med 2006;130:1466-78. 8. Sandrasegaran K, Rajesh A, Rydberg J, Rushing DA, Akisik FM, Henley JD.[mjmsr.net]
A person would have to come in immediately to be treated,” said Samadi, while noting that he has not treated Chavez and, therefore, could not be sure of the leader's prognosis.[foxnews.com]

Etiology

After completion of this article, the reader will be able to understand the nonsurgical alternatives for the drainage of intraabdominal abscesses, the possible etiologies of intraabdominal abscess formation in the pregnant population, and the various[ncbi.nlm.nih.gov]
For patients with unusual postpartum pelvic pain, uterine rupture should be considered as one of the possible etiologic factors, and prompt survey should be performed. Laparoscopic intervention may be valuable in such situations.[ncbi.nlm.nih.gov]
Abscess characteristics (etiology, number, size, intrastructure, microbiological content, presence of fistula), patient demographics (age, sex, presence of malignancy, primary disease, antibiotic treatments), procedure-related factors (guidance method[ncbi.nlm.nih.gov]
There were calicified mesenteric and iliac lymph nodes suggesting a tubercular etiology.[atmph.org]

Epidemiology

In this case it is an inflammatory mass which involves the ovary and Fallopian tube. [ 1 , 2 ] Epidemiology Uncommon. Predisposing factors include Crohn's disease, diabetes mellitus, immunodeficiency and pregnancy.[patient.info]
It is hoped that with a better understanding of the epidemiology of PID and with the advent of improved diagnostic and therapeutic modalities for early genital tract infection, a pelvic abscess will eventually become a great rarity on gynecology services[ncbi.nlm.nih.gov]
Direct extension of infection from adjacent viscera and uterine instrumentation are more important risk factors in postmenopausal PID. [32] Epidemiology Annually, approximately 1 million women develop PID. [ 1 ] PID is most commonly seen in young women[emedicine.medscape.com]
Retrieved February 21, 2015 . a b "Self-Study STD Modules for Clinicians — Pelvic Inflammatory Disease (PID) Next Centers for Disease Control and Prevention Your Online Source for Credible Health Information CDC Home Footer Separator Rectangle Epidemiology[en.wikipedia.org]
The PPV of a clinical diagnosis of acute PID depends on the epidemiologic characteristics of the population, with higher PPVs among sexually active young women (particularly adolescents), patients attending STD clinics, and those who live in other settings[cdc.gov]

Sex distribution

Age distribution

Pathophysiology

Carolina O Nastri (2010) ovarian hyper stimulation syndrome: pathophysiology and prevention.[omicsgroup.org]
Pathophysiology PID is a complex polymicrobial disease that is due to the ascending spread of pathogens from the cervix or vagina, most commonly Chlamydia trachomatis or Neisseria gonorrhoeae (60-75%) , which then spreads into the endometrium, fallopian[emedicine.medscape.com]
Return to Pathophysiology Return to Atypical Clinical Presentation (C) Return to Primary Treatment Return to CT Findings Case 8 Perforated appendicitis with generalized peritonitis and multiple abscesses. 14 year old girl presented with one week history[meddean.luc.edu]
Pathophysiology of TOA Ascending bacterial infection originating in the uterus Extending to the fallopian tube and broad ligament Acute supprative salpingitis, salpingo-oophoritis, pyosalpinx Tuboovarian complex or tuboovarian abscess [7].[laparoscopyhospital.com]
The pathophysiology of SPT is outlined by Virchow's triad: Venous stasis Injury to the vascular epithelium A hypercoagulable state These factors explain why SPT is almost always a puerperal event that is most commonly diagnosed after postcesarean endomyometritis[glowm.com]

Prevention

Surgical removal to prevent such complications can be considered, balanced against the high operative risks.[ncbi.nlm.nih.gov]
Vaginal douching with aqueous povidone iodine followed by normal saline irrigation immediately before oocyte retrieval is effective in preventing the pelvic infection without compromising the outcome of IVF treatment.[ncbi.nlm.nih.gov]
Prophylactic IV cefazolin does not seem to prevent this complication.[ncbi.nlm.nih.gov]
Although her course after treatment was satisfactory during the study period, we recommend taking repetitive radiographs to detect insufficiency fracture for RA patients with continuing pain and reducing the corticosteroid dose to prevent infection and[ncbi.nlm.nih.gov]
Aggressive antibiotic therapy to treat peritonitis or to prevent it from occurring.[simple-remedies.com]

References

Article

Benigno BB. Medical and surgical management of the pelvic abscess. Clini Obstet Gynecol. 1981 Dec;24(4): 1187-97
Richards RJ. Management of abdominal and pelvic abscess in Crohn's disease. World J Gastrointest Endosc. 2011 Nov 16; 3(11):209-12.
Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorectal Dis. 1994;9:158–162.
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt) 2010;11:79–109.
Dala-Ali BM, Lloyd MA, Janipireddy SB, Atkinson HD. A case report of a septic hip secondary to a psoas abscess. J Orthop Surg Res. 2010;5:70.
Fleshman JW. Pyogenic complications of Crohn's disease, evaluation, and management. J Gastrointest Surg. 2008;12:2160–2163.
Georgopoulos F, Mylonaki M, Malgarinos G, et al. Intraabdominal abscesses in patients with Crohn’s disease: Clinical data and therapeutic manipulations in 17 cases of a single hospital setting. Annals of Gastroenterology. 2008;21:188–192.
Gutierrez A, Lee H, Sands BE. Outcome of surgical versus percutaneous drainage of abdominal and pelvic abscesses in Crohn's disease. Am J Gastroenterol. 2006;101:2283–2289.
Macari M, Megibow AJ, Balthazar EJ. A pattern approach to the abnormal small bowel: observations at MDCT and CT enterography. AJR Am J Roentgenol. 2007;188:1344–1355
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.
Kim HC, Yang DM, Lee CM, et al. Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels. Br J Radiol. 2011 Dec; 84(1008):1115-20.

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Last updated: 2018-06-22 10:07