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]

  She has had a persistent fever of 39.4 (103) despite three days of appropriate antibiotics covering both aerobes and anaerobes. She had normal lochial flow. [medbullets.com]

  PHYSICAL FINDINGS & CLINICAL PRESENTATION • Abdominal or pelvic pain (90%) • Fever or chills (50%) • Abnormal bleeding (21%) • Vaginal discharge (28%) • Nausea (26%) • Up to 60% to 80% present in the absence of fever or leukocytosis; lack of these findings [encyclopedia.lubopitko-bg.com]

• 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]

• 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]

  In light of worsening and shifting abdominal pain, the diagnosis of appendicitis was reconsidered and exploratory laparotomy recommended. [meddean.luc.edu]

• 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]

  Features are non-specific and may include: soft tissue density mass loss of normal pelvic fat planes an adynamic ileus may be present Ultrasound Transabdominal and endovaginal ultrasound are the preferred initial imaging investigations. [radiopaedia.org]

  Laparotomy showed a double-lobed retrouterine pelvic mass of 10x7x5cm and solid-cystic appearance. It was attached to the pelvic walls, the posterior side of the uterus, the pouch of Douglas, and the anterior surface of the sigmoid rectum. [revistas.unal.edu.co]

  The clinical diagnosis is generally based on the findings of fever and a palpable adnexal or pelvic mass. This mass may be distinctly palpable and fluctuant or less distinct and characterized by a “fullness” noted during bimanual pelvic examination. [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]

  The most common physical exam findings are bilateral adnexal tenderness and purulent cervical discharge. 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

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

  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]

• 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]

  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]

  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]

  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

  RESULT(S): The CT scan revealed several large, multiloculated pelvic and tuboovarian abscesses. The patient defervesced after 6 days of intravenous antibiotics, but the pelvic pain did not improve. [ncbi.nlm.nih.gov]

  Determine which women with PID require hospitalization Initial Actions and Primary Survey When a woman of reproductive age presents with vaginal discharge or pelvic pain, a pelvic exam and pregnancy test should always be performed. [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]

  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]

  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]

• Adnexal Mass

  Contrasted magnetic resonance imaging (MRI) was requested, finding right adnexal mass compatible with simple cyst and left adnexal mass with solid and cystic component of 152x120x103mm; the solid zone had low signal on T2, without enhancement or restriction [revistas.unal.edu.co]

  or suspicion of rupture) • Poor response to medical therapy in those with adnexal masses >8 cm, bilateral disease, or immunocompromise • Antibiotic combinations: 1. [encyclopedia.lubopitko-bg.com]

  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]

  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]

• 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]

• Neutrophilia

  Acute abdominal symptoms, radiological finding of small bowel PI with massive PMVG, severe neutrophilia, and high serum lactate forced us to perform exploratory laparotomy, from which it was observed a diffuse band-like pneumatosis of all the small bowel [giornalechirurgia.it]

  In the present case, TOA explains the leukocytosis with neutrophilia presented by the patient, as well as the unquantified fever, since no persistent or recurrent urinary tract infection was demonstrated. [revistas.unal.edu.co]

• Ovarian Mass

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

  Combining a second generation multivariate index assay with ovarian imaging improves the preoperative assessment of an adnexal mass. [revistas.unal.edu.co]

LIMITATIONS: The small number of patients and the absence of a comparative treatment group. [ncbi.nlm.nih.gov]

Conclusion: As treatment with antibiotics alone was ineffective in almost all cases, surgical treatment was required. Drainage might be the first-choice treatment for pelvic abscess to avoid invasive surgery. 1. [file.scirp.org]

Prognosis of pelvic inflammatory disease The prognosis of PID depends mostly on the awareness of adolescents to look for timely health care and to prevent future episodes of sexually-transmitted infections. [news-medical.net]

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]

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]

There are four categories based on etiologic factors: • Ascending infection, spreading from cervix through endometrial cavity to adnexa, forming a tuboovarian complex • Infection occurring in the puerperium, which spreads to the adnexa from the endometrium [encyclopedia.lubopitko-bg.com]

Etiology Some of the causes include: pelvic inflammatory disease ( tubo-ovarian abscess ) iatrogenic e.g. post surgical inflammatory bowel disease pelvic actinomycosis infection diverticulitis Presenting complaints are varied and include pelvic or low [radiopaedia.org]

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]

[…] via hematogenous or lymphatic route • Abscess complicating pelvic surgery • Involvement of the pelvic viscera secondary to spread from contiguous organs, such as appendicitis or diverticulitis SYNONYMS Tuboovarian abscess (TOA) Vaginal cuff abscess EPIDEMIOLOGY [encyclopedia.lubopitko-bg.com]

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]

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]

Carolina O Nastri (2010) ovarian hyper stimulation syndrome: pathophysiology and prevention. [omicsgroup.org]

Associated pathophysiologic effects may become life threatening or lead to extended periods of morbidity with prolonged hospitalization. [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]

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]

Surgical removal to prevent such complications can be considered, balanced against the high operative risks. [ncbi.nlm.nih.gov]

Aggressive antibiotic therapy to treat peritonitis or to prevent it from occurring. [simple-remedies.com]

The end-goal is to adequately treat the infection, minimize tubal damage and prevent adhesions, avoiding in turn looming sequelae of tubal damage. [news-medical.net]

1. Benigno BB. Medical and surgical management of the pelvic abscess. Clini Obstet Gynecol. 1981 Dec;24(4): 1187-97
2. Richards RJ. Management of abdominal and pelvic abscess in Crohn's disease. World J Gastrointest Endosc. 2011 Nov 16; 3(11):209-12.
3. Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorectal Dis. 1994;9:158–162.
4. 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.
5. 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.
6. Fleshman JW. Pyogenic complications of Crohn's disease, evaluation, and management. J Gastrointest Surg. 2008;12:2160–2163.
7. 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.
8. 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.
9. 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
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.
11. 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.