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]

  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]

• Anorexia

  Presentation Five days lower abdominal pain with anorexia, nausea, constipation. Patient Data Age: 37 Gender: Female A normal appearing anteverted, anti-flexed uterus is present. Endometrial stripe measures 4mm. Both ovaries are identified. [radiopaedia.org]

  ◀ Tubo-Ovarian Complex : 30 year old female experiencing lower abdominal pain for 5/7’s with associated nausea, anorexia and constipation. Suprapubic tenderness on examination. [you-green.com]

  Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Stephen Alerhand, MD (@SAlerhand) Case #1 12 year-old girl presents with five days of right lower quadrant abdominal pain, anorexia [emdocs.net]

  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]

• Pneumonia

  The bacteria were gram-positive, lancet-shaped diplococci characteristic of Streptococcus pneumoniae. Immunoperoxidase stains confirmed the identification of the organism as S pneumoniae. [ncbi.nlm.nih.gov]

  In the bacterial culture, K. pneumoniae and E. coli were grown. The patient was treated with sensitive antibiotics and recovered from her disease. [e-cep.org]

• Abdominal Pain

  We conclude that physicians should consider the diagnosis of tubo-ovarian abscess in the differential diagnosis of abdominal pain, fever and leukocytosis after ovum retrieval and transcervical embryo transfer for IVF treatment. [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]

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

  A TOA should be considered in the differential diagnosis of pelvic masses in previously healthy pediatric patients regardless of their sexual activity. [jhu.pure.elsevier.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]

• Hypotension

  A 53-year-old postmenopausal woman was transferred to our emergency department for drowsiness, hypotension, and lower abdominal discomfort. [ncbi.nlm.nih.gov]

  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]

  Fluid replacement to correct hypotension, and intensive-care monitoring is required. [glowm.com]

  Severe sepsis Septic shock Temperature >38°C or <36°C SIRS + lactic acidosis or hypotension Severe sepsis + hypotension (despite adequate fluid resuscitation) Heart rate >90 bpm Respiratory rate >20 or PaCO2 <32 mmHg WCC >12 or <4 a Two or more. [obgyn.onlinelibrary.wiley.com]

• Pelvic Pain

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

  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. [cdemcurriculum.com]

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

  pain in a female, and PID may be found incidentally. [emedicine.medscape.com]

• Adnexal Tenderness

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

• 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. [merckmanuals.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]

  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]

• Ovarian Pain

  Pain in the ovaries can either be acute or chronic. 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. [webmd.com]

  Ovarian pain sometimes occurs when the embryo develops outside the uterus in the fallopian tube. However, before the fallopian tubes fall, ectopic pregnancy causes pain - usually stronger on one side of the lower abdomen. [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]

• Ovarian Mass

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

  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]

  A laparotomy, carried out for suspected sub torsion of a right ovarian mass, discovered a right TOA of about 7cm diameter. The appendix was grossly normal. [ispub.com]

  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]

• Neutrophilia

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

  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]

• Leukocytosis

  We conclude that physicians should consider the diagnosis of tubo-ovarian abscess in the differential diagnosis of abdominal pain, fever and leukocytosis after ovum retrieval and transcervical embryo transfer for IVF treatment. [ncbi.nlm.nih.gov]

  After two weeks of antibiotic treatment, leukocytosis, pyuria, and sepsis resolved, but intermittent fever lasted along with pelvic tenderness. [bmcwomenshealth.biomedcentral.com]

Tuboovarian abscess is a rare complication of IVF treatment, which can be lethal on rupture. [ncbi.nlm.nih.gov]

It should not be construed as dictating an exclusive course of treatment or procedure to be followed. [exxcellence.org]

[…] laparoscopic salpingectomy or salpingo-oophorectomy (ablative treatment). [laparoscopyhospital.com]

prognosis group (n = 87). [ncbi.nlm.nih.gov]

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]

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]

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. [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]

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

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

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]

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]

Further Reading: Center for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR 2015; 64(RR-3);1-137. Visit: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Gjelland K, Ekerhovd E, Granberg S. [exxcellence.org]

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]

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.