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]

  Fever and chills, vaginal discharge, nausea and abnormal vaginal bleeding accompany this. [redorbit.com]

• 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]

  In Crohn's disease, abscesses may occur either spontaneously or as a complication of surgery. [ 3 ] Presentation Systemic features of toxicity: fever, malaise, anorexia, nausea, vomiting, pyrexia. [patient.info]

• 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]

• 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]

  Diagnostic uncertainty is common in adolescent females with lower abdominal pain, particularly when right-sided, as the pain is difficult to distinguish from that caused by appendicitis, ureteral stones, cystitis, or ovarian torsion. [jahonline.org]

• 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]

  Using CA-125 measurements alone has limited value in differentiating benign from malignant pelvic masses [1]. [ijcasereportsandimages.com]

• 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]

• Chronic Abdominal Pain

  In addition, patients who presented with abdominal pain were more likely to have a shorter duration of antibiotic treatment (P-value =0.015) when compared with those who had no pain on admission. [dovepress.com]

• 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]

  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]

  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]

• 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 24-year-old female with left pelvic pain. [doi.org]

• Adnexal Tenderness

  Upon palpation, patients affected by a TOA usually report adnexal tenderness, that is unilateral. [symptoma.com]

  uterine tenderness, or adnexal tenderness. [emdocs.net]

  On exam, you note that she is tender in bilateral lower quadrants, right greater than left. On pelvic exam, you note purulent discharge from the cervix and severe bilateral adnexal tenderness to palpation. [saem.org]

  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]

• 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]

  Occasionally, dyspareunia or dysuria occurs. Many women with inflammation that is severe enough to cause scarring have minimal or no symptoms. [msdmanuals.com]

• Imperforate Hymen

  Imperforate hymen represents the extreme in the spectrum of hymenal embryological variations. The archetypal presentation in the adolescent patient is that of cyclical abdominopelvic pain in the presence of amenorrhoea. [ncbi.nlm.nih.gov]

  "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. PMC 4009186. PMID 24822139. ^ a b Dupuis, Carolyn S.; Kim, Young H. (2015). [en.wikipedia.org]

• 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]

  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]

  A 34-year-old female with right adnexal tenderness. [doi.org]

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]

• Neutrophilia

  There is usually elevation of the inflammatory serum parameters, such as leucocytosis with neutrophilia and elevated C-reactive protein (CRP). [clinmedjournals.org]

• 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]

  Abstract A tubo-ovarian mass/ abscess is a mass involving the ovaries, fallopian tubes and sometimes the adjacent pelvic organs (bladder/ bowel). [jpgo.org]

  Some differentiate between: tubo-ovarian "abscess": ovary and tube cannot be separately distinguished within the inflammatory mass tubo-ovarian "complex": if the tube and ovary are separately discernible structures within the inflammatory mass Plain radiograph [radiopaedia.org]

  […] uterine leiomyoma Retain product of conception (RPOC) Retained products of conception Right ovarian mass – dermoid Right ovarian torsion Rupturing ectopic pregnancy Second And Third Trimester Subseptate uterus Succenturiate lobe of placenta Threatened [play.google.com]

• Eikenella

  […] constellatus + cocci [8][10] Prevotella bivia + bacillus [10] Fusobacterium nucleatum + bacillus [10] Enterococcus faecium + cocci [10] Actinomyces neuii + bacillus X [10] Lactobacillus delbrueckii + bacillus [10] Streptococcus intermedius + cocci [8][10] Eikenella [en.wikipedia.org]

The USG-guided drainage was less invasive with fewer complications and should be the preferred surgical treatment. [ncbi.nlm.nih.gov]

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]

With only the organism, Streptococcus viridians, isolated in her cultures, an etiology of direct ascension from the lower genitourinary tract is implicated. [jhu.pure.elsevier.com]

Fusobacterium necrophorum subspecies funduliforme, a normal flora found mainly in the oral cavity, appears to be the etiologic organism. [jmedicalcasereports.com]

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]

ISBN 9780323069861. ^ https://www.cdc.gov/std/treatment/2010/pid.htm ^ "PID Epidemiology". Center for Disease Control. Retrieved 2015-05-21. [en.wikipedia.org]

Eschenbach DA: Epidemiology and diagnosis of acute pelvic inflammatory disease. Obstet Gynecol 1980;55(suppl 5):142–153. [karger.com]

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 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]

Early diagnosis and treatment are essential to prevent further sequela including infertility, ectopic pregnancy, and chronic pelvic pain. [ncbi.nlm.nih.gov]

Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. Centers for Disease Control and Prevention. MMWR Recomm Rep 1993;42:1-39. [doi.org]

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2. Ho JW, Angstetra D, Loong R, Fleming T. Tuboovarian abscess as primary presentation for imperforate hymen. Case Rep Obstet Gynecol. 2014;2014:142039.
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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.