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Tubo-Ovarian Abscess

Abscess Tubo Ovarian

Tubo-ovarian abscesses (TOA) are localized collections of pus in the ovaries, salpinges or other organs of the female genital system, due to pelvic inflammatory disease. They constitute a potentially serious medical condition and require treatment with antibiotics in order to prevent their rupture and subsequent septic shock. Diagnosis is usually achieved via various imaging modalities, including radiographs, ultrasonographic scans, magnetic resonance imaging scan (MRI) and a computerized tomography scan (CT).


Presentation

Women under the age of 25 years, who are sexually active, are the most common patients affected by a TOA. The clinical presentation varies, but the most frequently reported symptoms include pain in the lower region of the abdomen or pelvis, vaginal discharge, and fever. The pain tends to arise after menstruation has terminated, it is described by the patients as dull and cramp-like and is exacerbated by exercise or sexual intercourse; it also tends to disappear after a week. Fever is usually around 38° C and in cases of advanced disease, it may be accompanied by nausea and vomiting. Tubo-ovarian abscesses develop on the grounds of pelvic inflammatory disease (PID) in the vast majority of cases, with rare occurrences diagnosed without PID or in women who are not sexually active [1] [2].

Upon palpation, patients affected by a TOA usually report adnexal tenderness, that is unilateral. The finding of rebound tenderness suggests a potential peritonitis and is a sign of severe disease that requires immediate surgical intervention; Fitz-Hugh-Curtis syndrome is another potential complication [3] [4] [5] [6] [7]. In general, both PID and a TOA present with identical symptomatology; however, in a TOA case, the abscess can be identified by means of ultrasonography, plain radiograph or a magnetic resonance imaging scan.

Given the fact that tubo-ovarian abscesses develop on the grounds of pelvic inflammatory disease and can be complicated with sepsis upon their rupture, the Centre of Disease Control stipulates that antibiotics should be empirically administered for pelvic inflammatory disease, in patients who:

  • Are high-risk patients for sexually transmitted diseases
  • Present with pelvic or lower abdominal pain
  • Have a disease that cannot be identified as non-PID
  • Present with cervical, uterine or adnexal tenderness (one required)
Fever
  • Laparoscopy was done because of sustained fever, and an ovarian abscess was found. Laparoscopic salpingo-oophorectomy was performed. The patient was discharged 5 days later and oral clindamycin was prescribed.[ncbi.nlm.nih.gov]
  • CASE: A 30-year-old diabetic Chinese woman was transferred for diffused abdominal pain, mild fever, nausea, and low-grade fever for 5 days. The sonography revealed a 5-cm adnexal mass. The chest X-rays revealed the pneumoperitoneum.[ncbi.nlm.nih.gov]
  • A tubo-ovarian abscess is a rare complication of enteric fever. BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.[ncbi.nlm.nih.gov]
  • Significant differences between patients with TOA and PID were found with regard to the patients' age (39.3years vs 33.1years; P 0.04), educational level (only elementary, 13 [50%] vs 5 [19%]; P 0.14), presentation with fever (23 [88%] vs 16 [62%]; P[ncbi.nlm.nih.gov]
  • Multivariate analyses demonstrated that an abscess larger than 6.5 cm in size (P 0.027), fever at admission (P CONCLUSION: Although increased TOA size, fever at admission, and parity were associated with increased odds of patients with TOA requiring surgical[ncbi.nlm.nih.gov]
Malaise
  • Malaise. Tests to Diagnose Tubo-Ovarian Abscess History and physical exam. Pelvic exam. VDRL blood test. Complete blood count. Chlamydia & gonorrhea culture. Pelvic ultrasound. CT scan of the pelvis. MRI of the abdomen. PAP smear.[epainassist.com]
  • Pain is associated with systemic symptoms such as high fever, vomiting, malaise, headache etc. In most cases a mass can be felt through vaginal examination. An enlarged abscess can be felt even from outer aspect of pelvis.[tandurust.com]
  • Additionally, 60-80% may complain of systemic symptoms like fever, leukocytosis, weakness, malaise, etc. In most cases, a palpable mass is present on gynecological examination.[simple-remedies.com]
  • Patients may also present with fever, nausea, vomiting and general malaise, but this is variable and may range from minimally symptomatic to toxic appearing.[cdemcurriculum.com]
Fatigue
  • Fatigue. Malaise. Tests to Diagnose Tubo-Ovarian Abscess History and physical exam. Pelvic exam. VDRL blood test. Complete blood count. Chlamydia & gonorrhea culture. Pelvic ultrasound. CT scan of the pelvis. MRI of the abdomen. PAP smear.[epainassist.com]
  • Pain or ache in your abdomen or pelvis, or pain that worsens with activity or during sex Tender area in your lower abdomen Heavy monthly periods, spotting, or vaginal bleeding between periods Vaginal discharge Nausea or vomiting Lower back pain Fatigue[drugs.com]
Pseudotumor
  • CONCLUSIONS: DW-MRI is superior to MRI in the assessment of TOA mimicking ovarian malignancy, and the ADC values aid in discriminating the pseudotumor area of TOA from the solid portion of ovarian malignancy.[ncbi.nlm.nih.gov]
Abdominal Pain
  • TOA should be considered in the differential diagnosis of females with abdominal pain and adnexal mass whether sexual activity is present or not.[ncbi.nlm.nih.gov]
  • Given the severity of outcomes following TOA, this pathology should be considered in the differential diagnosis of virginal adolescents who present with fever and abdominal pain.[ncbi.nlm.nih.gov]
  • PID in virgin women is rare, but it should be considered in all women with abdominal pain, regardless of sexual history.[ncbi.nlm.nih.gov]
  • Eventual investigation of the patient's abdominal pain, initially attributed to vasculitis involving the gastrointestinal tract, revealed a left tubo-ovarian abscess caused by Morganella morganii.[ncbi.nlm.nih.gov]
  • Abstract A 32-year-old pregnant woman presented to the hospital with abdominal pain and minimal vaginal bleeding.[ncbi.nlm.nih.gov]
Pelvic Mass
  • Actually all these three cases presented as tubo-ovarian abscess because of the existence of tender pelvic mass.[ncbi.nlm.nih.gov]
  • A virginal adolescent female with no prior medical history presented with a large pelvic mass which proved to be a TOA. An exploratory laparotomy was eventually required to establish the diagnosis.[ncbi.nlm.nih.gov]
  • We conclude that the characteristics of CT findings that may be suggestive of TOA are peripherally enhancing low-density pelvic mass, anterior displacement of the round ligament, and, especially, the presence of satellite lesions adjacent to main masses[ncbi.nlm.nih.gov]
  • We present a case of 19-year-old sexually inactive girl who presented with abdominal pain and pelvic mass resembling ovarian tumor. Unilateral tubo-ovarian abscess with extensive bowel adhesions was determined at laparotomy.[ncbi.nlm.nih.gov]
  • A pelvic mass, supposedly originating from the ovary, was detected in a 13-year-old sexually inactive girl suffering from abdominal pain and menstrual disorder.[ncbi.nlm.nih.gov]
Left Lower Quadrant Pain
  • A 37-year-old female with acute onset left lower quadrant pain. Gray-scale (A) and color (B) sonograms of ovarian torsion show an enlarged ovary with prominent peripherally located follicles.[doi.org]
Right Lower Quadrant Tenderness
  • On physical examination, the patient is febrile to 102.4 F, abdominal exam reveals right lower quadrant tenderness and labs are significant for WBC of 13,000.[emdocs.net]
Tachycardia
  • Symptoms of TOA rupture include signs of sepsis (hypotension, tachycardia, tachypnea) as well as an acute abdominal examination (rebound / guarding). Reported rate of rupture is approximately 15%.[visualdx.com]
Encephalopathy
  • Patient's medical history was complicated by mitochondrial neurogastrointestinal encephalopathy (MNGIE). Upon her admission to the hospital, an exploratory laparoscopy was performed. Intraoperative findings revealed a ruptured right-sided TOA.[ncbi.nlm.nih.gov]
Pelvic Pain
  • This was a retrospective review of non-pregnant ED patients presenting with pelvic pain who were diagnosed with TOA using bedside transvaginal US.[ncbi.nlm.nih.gov]
  • Abstract A 57-y-old woman presented with recurrent abdominal and pelvic pain of 6 months' duration with low-grade fever. A computed tomographic scan indicated an ovarian tumor. Laparotomy revealed a pelvic abscess.[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment are essential to prevent further sequela including infertility, ectopic pregnancy, and chronic pelvic pain.[ncbi.nlm.nih.gov]
  • The majority of the public health impact from PID comes from its attributable long-term sequelae, including tubal-factor infertility, ectopic pregnancy, and chronic pelvic pain. Tubo-ovarian abscess (TOA) represents a severe form of PID.[ncbi.nlm.nih.gov]
  • The complications of PID include pyosalpinx and tubo-ovarian abscess, infertility or ectopic pregnancy, and chronic pelvic pain of varying degrees. These sequelae underscore the importance of prompt diagnosis.[ncbi.nlm.nih.gov]
Adnexal Tenderness
  • Upon palpation, patients affected by a TOA usually report adnexal tenderness, that is unilateral.[symptoma.com]
  • All had lower abdominal tenderness and 9 (45%) had cervical motion or adnexal tenderness.[ncbi.nlm.nih.gov]
  • 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.[cdemcurriculum.com]
  • Physical examination will be positive for abdominal and/or adnexal tenderness and potentially show cervical motion tenderness as well. A pelvic mass will present on imaging. Rupture is a surgical emergency.[visualdx.com]
Dyspareunia
  • Symptoms experienced included pain, which was exacerbated by walking, and mild deep dyspareunia. Abdominal and pelvic examinations revealed pain in the left iliac fossa, cervical excitation tenderness, and an ill-defined left adnexal mass.[ncbi.nlm.nih.gov]
  • Sequelae of PID * ectopic pregnancy * infertility * chronic pelvic pain * dyspareunia * pelvic adhesions * recurrent PID * tubo-ovarian abscess a patient has tubo-ovarian abscess or a weakened immune system 5% Table 5: Differential diagnosis of an adnexal[medical-dictionary.thefreedictionary.com]
  • Other symptoms include vaginal discharge, vaginal bleeding, dyspareunia, urinary discomfort, fever, nausea, and vomiting. Peritoneal signs may be present. Occasionally, symptoms are minimal. An exquisitely tender unilateral mass may suggest TOA.[accessemergencymedicine.mhmedical.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.[cdemcurriculum.com]
Right Adnexal Tenderness
  • Digital vaginal examination revealed a median, long, closed cervix with cervical excitation tenderness; a bulky uterus of about 14 weeks gestation and a right adnexal tenderness.[ispub.com]
  • A 34-year-old female with right adnexal tenderness.[doi.org]

Workup

A tubo-ovarian abscess can be diagnosed using various imaging modalities, such as ultrasonography (US), MRI, plain radiographs and a CT scan. Should the aforementioned imaging modalities fail to definitively depict a tubo-ovarian abscess, laparoscopy can also help to diagnose the abscess.

Physicians many times differentiate between a tubo-ovarian abscess and a tubo-ovarian complex. The former occurs when the ovary and fallopian tube are clearly discernible via imaging modalities, something that does not apply in the case of a tubo-ovarian complex. As far as radiographs are concerned, they are usually non-specific but may illustrate masses, reduced concentration of fat in the pelvic area and the radiographic picture of paralytic ileus. A transabdominal or endovaginal ultrasound is the imaging modality of choice for the diagnosis of a TOA and can clearly illustrate abdominal masses and debris that are usually bilateral. Ultrasonography is also opted for due to its low cost, high sensitivity and lack of ionizing radiation exposure [8]. Lastly, a CT scan is used to define the extent of the condition and an MRI scan can be useful when ultrasonography fails to illustrate an abscess.

Pneumoperitoneum
  • Pneumoperitoneum is often associated with the bowel perforation. We reported one case with TOA and pneumoperitoneum that have been mistaken for a perforated bowel with concomitant adnexal mass.[ncbi.nlm.nih.gov]
Thrombocytosis
  • Blood examination revealed there to be marked elevation of the platelets (thrombocytosis) on some occasions. It was then realised that there was correlation between the platelet levels and serum potassium values.[ncbi.nlm.nih.gov]
Ovarian Mass
  • Additionally, bilateral complex masses are present; this finding is compatible with tubo-ovarian masses.[emedicine.medscape.com]
  • Ovarian torsion resulting from a large ovarian mass. A. Gray-scale sonogram from a 19-year-old female with acute onset right pelvic pain shows partial visualization of a very large, complex right ovarian mass.[doi.org]

Treatment

  • The USG-guided drainage was less invasive with fewer complications and should be the preferred surgical treatment.[ncbi.nlm.nih.gov]
  • This study was aimed at investigating the clinical characteristics and treatment outcomes in patients with TOA at a tertiary care hospital in Taiwan.[ncbi.nlm.nih.gov]
  • No correlation was present between ultrasonographic TOA morphology and patients requiring surgical treatment (all P 0.05).[ncbi.nlm.nih.gov]
  • CONCLUSION: The combined use of the sonographic TOA diameter and laboratory parameters (ESR and CRP level) can aid clinical treatment decisions and improve the prediction of the outcome of medical TOA treatment. 2013.[ncbi.nlm.nih.gov]
  • This case suggests that a preconception evaluation and treatment for such conditions should be considered for women undergoing treatment for infertility.[ncbi.nlm.nih.gov]

Prognosis

  • prognosis group (n 87).[ncbi.nlm.nih.gov]
  • 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]
  • Public health efforts implemented in Scandinavia to decrease the prevalence of STIs have been quite effective in reducing the incidence of PID. [47, 48] Prognosis PID has 3 principal complications, as follows: Chronic pelvic pain Infertility Ectopic pregnancy[emedicine.com]

Etiology

  • Abstract Bacteroides gracilis infections are very rare and have always been reported to have a polymicrobial etiology. The majority of these infections occur in the head and neck areas, the pleuropulmonary system, and the abdominal cavity.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To study the microbial etiology of tubo-ovarian abscess (TOA). METHODS: We recruited 11 women in Nairobi, Kenya who failed antibiotic therapy alone and required surgical drainage of a presumptive TOA.[ncbi.nlm.nih.gov]
  • With only the organism, Streptococcus viridians, isolated in her cultures, an etiology of direct ascension from the lower genitourinary tract is implicated.[ncbi.nlm.nih.gov]
  • With these limitations of our case report, we could not establish if Enterobius vermicularis was the sole etiologic agent of this patient's tubo-ovarian abscess .[medical-dictionary.thefreedictionary.com]
  • Etiology for TOA development following a sexually transmitted infection involves ascending spread of disease to the level of the fallopian tubes / peritoneal cavity.[visualdx.com]

Epidemiology

  • OBJECTIVE: To assess retrospectively if there is a trend of change in the epidemiology of tubo-ovarian abscess (TOA) and to define the epidemiologic, clinical and laboratory risk factors associated with failed response to conservative antibiotic therapy[ncbi.nlm.nih.gov]
  • Both groups were compared in terms of laboratory, clinical, and epidemiological parameters. RESULTS: Of 73 patients admitted with the diagnosis of PID, 44 (60.3 %) were found to have TOA, and 29 (39.7 %) were not found.[ncbi.nlm.nih.gov]
  • The epidemiology of TOA is closely related to that of pelvic inflammatory disease which is estimated to one million people yearly.[en.wikipedia.org]
  • Epidemiology, Clinical Manifestations, and Diagnosis of Tuboovarian Abscess.” Epidemiology, Clinical Manifestations, and Diagnosis of Tuboovarian Abscess . UpToDate, n.d. Web. 15 June 2015. 2) Beigi, Richard H., MD.[emdocs.net]
  • Atlanta, GA 30333, USA 800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC-INFO Self-Study STD Modules for Clinicians - Pelvic Inflammatory Disease (PID) Epidemiology Introduction Pelvic inflammatory disease (PID) is a clinical syndrome in women[www2a.cdc.gov]
Sex distribution
Age distribution

Pathophysiology

  • Taylor et al. warn about the possible connection between IUD presence and the formation of unilateral tubo-ovarian abscess, though the pathophysiology of the relation is not understood.[popline.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]
  • 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]

Prevention

  • Early diagnosis and treatment are essential to prevent future sequelae causing infertility. Laparoscopic surgery which minimises postoperative complications should be the first option in the treatment of TOA.[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment are essential to prevent further sequela including infertility, ectopic pregnancy, and chronic pelvic pain.[ncbi.nlm.nih.gov]
  • Early recognition of a tubo-ovarian abscess is important in order to prevent the associated morbidity and mortality. This condition has the propensity to mimic a neoplasm.[ncbi.nlm.nih.gov]
  • Therefore, aggressive treatment of BV in patients with known advanced-stage endometriosis may be considered to prevent superinfected endometriomas.[ncbi.nlm.nih.gov]
  • Based on this case, tubal occlusion by induced fibrosis may not be a sufficient obstacle in preventing ascending pelvic infections.[ncbi.nlm.nih.gov]

References

Article

  1. Goodwin K, Fleming N, Dumont T. Tubo-ovarian abscess in virginal adolescent females: a case report and review of the literature. J Pediatr Adolesc Gynecol. 2013 Aug;26(4):e99-102.
  2. Ho JW, Angstetra D, Loong R, Fleming T. Tuboovarian abscess as primary presentation for imperforate hymen. Case Rep Obstet Gynecol. 2014;2014:142039.
  3. Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983 Sep-Oct;5(5):876-84.
  4. Rivlin ME, Hunt JA. Ruptured tuboovarian abscess. Is hysterectomy necessary?. Obstet Gynecol. 1977 Nov; 50 (5):518-22.
  5. Laohaburanakit P, Treevijitsilp P, Tantawichian T, Bunyavejchevin S. Ruptured tuboovarian abscess in late pregnancy. A case report. J Reprod Med. 1999 Jun; 44 (6):551-5.
  6. De Temmerman G, Villeirs GM, Verstraete KL. Ruptured tuboovarian abscess causing peritonitis in a postmenopausal woman. A difficult diagnosis on imaging. JBR-BTR. 2003 Mar-Apr; 86 (2):72-3.
  7. Powers K, Lazarou G, Greston WM, Mikhail M. Rupture of a tuboovarian abscess into the anterior abdominal wall: a case report. J Reprod Med. 2007 Mar; 52 (3):235-7.
  8. Dupuis CS, Kim YH. Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women. Ultrasonography. 2015 34 (4): 258–267.

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Last updated: 2018-06-22 03:11