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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)
Entire body system
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]
- The triad of fever, leukocytosis, and diarrhea was positively related to the presence of TOA. The triad of fever, leukocytosis, and diarrhea should alert clinicians to the possibility of TOA formation in patients with PID.[ncbi.nlm.nih.gov]
- A tubo-ovarian abscess is a rare complication of enteric fever.[ncbi.nlm.nih.gov]
- 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]
- Although increased TOA size, fever at admission, and parity were associated with increased odds of patients with TOA requiring surgical treatment, ultrasonographic TOA morphology was not.[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]
- 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]
- 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]
- 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]
Patient Appears Acutely Ill
- Patients appear acutely ill, and fever is common. Physical examination reveals skin changes that progress from an erythema to a blue-grey discoloration. Bullous changes in the skin may be present in advanced disease.[glowm.com]
Gastrointestinal
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]
- A 24-year-old woman having two children using an intrauterine contraceptive device was admitted with lower abdominal pain and fever. On clinical and radiographic examination revealed a 7x6 cm multi-loculated cystic mass in the lower abdomen.[ncbi.nlm.nih.gov]
Pelvic Mass
- A TOA should be considered in the differential diagnosis of pelvic masses in previously healthy pediatric patients regardless of their sexual activity.[ncbi.nlm.nih.gov]
- Actually all these three cases presented as tubo-ovarian abscess because of the existence of tender pelvic mass.[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]
Chronic Abdominal Pain
- abdominal pain, ectopic pregnancy, and infertility. 7 It has been demonstrated that no single subjective complaint, physical examination finding, or laboratory test is highly sensitive or specific for the diagnosis of PID.[dovepress.com]
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]
Cardiovascular
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]
- S, a 30-year-old nulliparous lady presented with fever (102 – 1030 F), tachycardia (pulse 126 per min), pain abdomen and vomiting following oocyte retrieval.[redorbit.com]
- A physical examination showed a high-grade fever (39 C), tachycardia (pulse rate of 112 beats per minute), tachypnea (respiratory rate of 26 per minute), and a blood pressure of 110/60mmHg.[jmedicalcasereports.com]
Urogenital
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]
- 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
- 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]
- Mucopurulent (green or yellow) discharge on speculum examination and acute cervical motion tenderness, uterine or adnexal tenderness are indicative for PID and TOA.[clinicaladvisor.com]
Dyspareunia
- 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]
- Presentation A 36 year old woman presented to the ER with sharp left sided pelvic pain and dyspareunia. Caption: Transverse transvaginal scan Description: The uterus appears normal.[sonoworld.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]
Imperforate Hymen
- "Tuboovarian Abscess as Primary Presentation for Imperforate Hymen". Case Reports in Obstetrics and Gynecology . 2014 : 1–3. doi : 10.1155/2014/142039 . ISSN 2090-6684 . a b Dupuis, Carolyn S.; Kim, Young H. (2015).[en.wikipedia.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.
X-ray
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]
- The abdomen was entered with three 5mm ports and pneumoperitoneum was created. There were mental adhesions to anterior abdominal wall, bowel adhesions to posterior surface of uterus and bladder adhesions to fund us of uterus.[bioaccent.org]
Pulmonary Infiltrate
- Common clinical manifestations of aspergillosis in renal transplant recipients are fever and pulmonary infiltrates, but involvement of the reproductive system is rare.[ncbi.nlm.nih.gov]
Ultrasound
Ovarian Mass
- Ultrasound showed right tubo-ovarian mass of eight centimeters size. We believe that the tubo ovarian mass had developed secondary to the intrauterine device.[bioaccent.org]
- One of the most common causes of a tubo-ovarian mass in a reproductive age group is usually a sequelae of sexually transmitted diseases.[1] However here we present a case of a tubo-ovarian mass that on exploration turned out to be a case of tubercular[jpgo.org]
- Sonologist gave a differential diagnosis of appendicular mass or tubo-ovarian mass.[gynecendoscopy.org]
Treatment
- No correlation was present between ultrasonographic TOA morphology and patients requiring surgical treatment (all P 0.05).[ncbi.nlm.nih.gov]
- There were no complications in the USG-guided drainage surgical treatment group. The TOA size, complex multi-cystic mass image, CRP, and ESR are useful indicators as to whether surgical treatment is required for the management of TOA.[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]
- 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.[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]
- 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]
- 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]
Etiology
- 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]
- 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]
- To study the microbial etiology of tubo-ovarian abscess (TOA). We recruited 11 women in Nairobi, Kenya who failed antibiotic therapy alone and required surgical drainage of a presumptive TOA.[ncbi.nlm.nih.gov]
- Fusobacterium necrophorum subspecies funduliforme , a normal flora found mainly in the oral cavity, appears to be the etiologic organism.[jmedicalcasereports.com]
Epidemiology
- 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]
- "PID Epidemiology" . Center for Disease Control . Retrieved 2015-05-21 . External links [ edit ][en.wikipedia.org]
- Both groups were compared in terms of laboratory, clinical, and epidemiological parameters. 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]
- “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]
- 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]
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]
- The post-partum period appears to be the least likely time to develop a TOA because ascending infection, which is the major pathophysiology in developing PIDs in most women, rarely occurs during this phase.[jmedicalcasereports.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
- 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.
- Ho JW, Angstetra D, Loong R, Fleming T. Tuboovarian abscess as primary presentation for imperforate hymen. Case Rep Obstet Gynecol. 2014;2014:142039.
- Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983 Sep-Oct;5(5):876-84.
- Rivlin ME, Hunt JA. Ruptured tuboovarian abscess. Is hysterectomy necessary?. Obstet Gynecol. 1977 Nov; 50 (5):518-22.
- 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.
- 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.
- 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.
- Dupuis CS, Kim YH. Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women. Ultrasonography. 2015 34 (4): 258–267.