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]

• 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. [saem.org]

• 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]

  These can include inflamed skin, nausea, diarrhea, and fatigue. Radiation is not often used to treat ovarian cancer. Learn more about the types of ovarian tumors. [webmd.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]

• Sulfur Granules

  Pathologically, an actinomycotic tubo-ovarian abscess with sulfur granules was disclosed. [ncbi.nlm.nih.gov]

  The presence of sulfur granules at pathologic examination is important in diagnosing this infection, as well as multiple Gram-positive branching hyphae (,9–,11). [pubs.rsna.org]

• Recurrent Urinary Tract Infection

  The TOA in our second case was attributed to a combination of obesity, constipation, recurrent urinary tract infections, and poor hygiene. [ncbi.nlm.nih.gov]

  urinary tract infection,[7] or infection by rare organisms.[1] Up to 95% of cases present with abdominal pain, while other complaints are palpable adnexal mass, cervical motion tenderness, fevers or vaginal discharge.[4] Our patient only had abdominal [jpgo.org]

• 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]

• 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]

• 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]

• 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]

• 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.biomedcentral.com]

• 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]

• 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]

  On pelvic exam, you note purulent discharge from the cervix and severe bilateral adnexal tenderness to palpation. The patient is concerned and asks, “What do you think the problem is Doc?” [saem.org]

• Dyspareunia

  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]

  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. [saem.org]

• Right Adnexal Tenderness

  Exam is significant for cervical friability and white cervical discharge, as well as cervical motion and right adnexal tenderness. Pelvic ultrasound is performed showing a 4 cm mass near the right ovary. [emdocs.net]

  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]

• Ovarian Pain

  Acute ovarian pain comes on quickly (over a few minutes or days) and goes away in a short period of time. Chronic ovarian pain usually starts more gradually. Then it last for several months or longer. Ovarian pain may be continuous. [webmd.com]

  Ovarian pain in early pregnancy is due to the fact that the uterus expands, stretching, adapting to new conditions. The body also has to adapt to the new hormonal and embryonic situation. [infoassay.ru]

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]

  A case of tubo-ovarian abscess (TOA) presenting with pneumoperitoneum is unusual. Very few cases have been reported where the pneumoperitoneum is caused by an abscess involving the adnexa. [unboundmedicine.com]

  PID, STIs 4 2020 Pneumoperitoneum secondary to tubo-ovarian abscess: A case report. CT 5 2019 A tubo-ovarian abscess mimicking an appendiceal abscess: a rare presentation of Streptococcus agalactiae. [allie.dbcls.jp]

  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]

• 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]

  masses, and peritoneal and serosal thickening and enhancement. [radiopaedia.org]

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.