Tubo-ovarian abscess

I. What every physician needs to know.

Tubo-ovarian abscess (TOA) is an inflammatory mass found in the fallopian tube, ovary and adjacent pelvic organs. TOAs occur in about 15% of women with pelvic inflammatory disease (PID) with 100,000 admissions per year in the United States.

A tubo-ovarian abscess usually presents in young women with an upper genital tract infection as a severe complication of PID or from local spread of an inflammatory disease of the bowel or adnexal surgery. They tend to be polymicrobial infections with both aerobic and anaerobic bacteria. The most common organisms include Escherichia coli, Streptococci, Bacteroides fragilis, and Prevotella. Intrauterine devices are associated with Actinomyces israelli. Interestingly, both N. gonorrhea and C. trachomatis are rarely isolated from a TOA.

Tubo-ovarian abscess is a life-threatening condition that can present with sepsis and shock if rupture occurs. The classic treatment historically was hysterectomy with bilateral adnexectomy that produced high cure rates but resulted in young women without reproductive potential. Modern therapy now includes a trial of broad spectrum antibiotics if the patient is stable and the abscess is less than 9 cm. However, one-fourth of patients will still require surgical treatment. If the patient is not stable, then surgical intervention either with minimally-invasive ultrasound or computed tomography (CT)-guided drainage or laparoscopy/laparotomy is required. Long term complications include infertility, ectopic pregnancy, ovarian vein thrombosis, pelvic thrombophlebitis and chronic pelvic pain.

II. Diagnostic Confirmation: Are you sure your patient has a Tubo-Ovarian Abscess?

Diagnostic confirmation of a TOA is made by direct visualization on imaging studies or laparoscopy, and drainage of the mass showing purulent material.

A. History Part I: Pattern Recognition:

The typical symptoms include the sudden onset of lower abdominal pain, chills, dyspareunia, fever and vaginal discharge. Other symptoms that have been reported include nausea, vomiting and abnormal vaginal bleeding. However, PID can present in a similar manner. Pain that is severe, intermittent and unilateral with associated nausea and vomiting is more consistent with a TOA. Women with a ruptured TOA can present with signs and symptoms of an acute abdomen and sepsis.

B. History Part 2: Prevalence:

TOA is the most common intraabdominal abscess in women. It is frequently a complication of pelvic inflammatory disease. In the United States, 200,000 women are hospitalized annually for pelvic inflammatory disease. About one-third of these women with PID will have a TOA with an annual incidence of 67,000 to 100,000 cases per year. However, only 33 to 50% of cases of TOA are associated with PID.

The major risk factors for TOA are:

1) Multiple sexual partners

2) Prior history of PID

3) Age between 15 to 40 years old (reproductive age women)

C. History Part 3: Competing diagnoses that can mimic Tubo-Ovarian Abscess.

The differential diagnosis for TOA include conditions that can cause lower abdominal and pelvic pain. Gastrointestinal processes include appendicitis, cholecystitis, diverticulitis, gastroenteritis, and inflammatory bowel disease. Gynecological causes include PID, ovarian torsion, ectopic pregnancy, ruptured ovarian cyst and septic abortion. Urinary tract disorders like cystitis, pyelonephritis and urethritis should also be considered.

D. Physical Examination Findings.

A complete examination needs to be performed with particular focus on the pelvic exam. Vital signs should be obtained and monitored closely to assess for fever or signs of systemic inflammatory response syndrome (SIRS) or sepsis. Pelvic examination, including speculum and bimanual exam assessing the consistency, size and mobility of the uterus and both adnexa should be performed. Mucopurulent (green or yellow) discharge on speculum examination and acute cervical motion tenderness, uterine or adnexal tenderness are indicative for PID and TOA. Moreover, a detailed abdominal examination should also be performed to assess for an acute abdomen. Palpation of a tender adnexal mass requires further diagnostic evaluation.

E. What diagnostic tests should be performed?

The initial evaluation includes routine blood work, urine, vaginal and blood cultures and imaging study – either a transvaginal ultrasound (TVUS) or a computed tomography (CT) scan of the abdomen and pelvis.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

A urine pregnancy test should be performed in any woman of reproductive age with adnexal tenderness. If the pregnancy test is positive, then a beta subunit of human chorionic gonadotropin (β-hCG) level needs to be obtained. A complete blood count with differential may show an elevated WBC count with a left shift. If the patient is febrile or hemodynamically unstable, then blood and urine cultures need to be ordered. In addition, tests for sexually transmitted diseases including chlamydia and gonorrhea should also be obtained during the pelvic exam.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Radiographic studies are imperative in making the diagnosis of TOA, especially in the setting of PID. All women who appear acutely ill, fail to respond to antibiotic therapy or have an adnexal mass on examination or significant adnexal tenderness on a pelvic exam need further evaluation with imaging studies. Either a transvaginal ultrasound or an abdominal/pelvic CT can be utilized. An ultrasound is less expensive and avoids the need for radiation and contrast, and the TVUS provides a direct route from the vagina into the adnexal regions or cul-de-sac where TOAs arise. The classic finding of PID includes fallopian tube wall thickness greater than 5 mm, fluid in the cul-de-sac and incomplete septae within the tube. TOAs have complex multilocular masses that contain internal echoes consistent with inflammatory debris.

An abdominal/pelvic CT scan is preferred if a gastrointestinal tract process is strongly considered in the differential. The CT scan can better assess for appendicitis, inflammatory bowel disease and other GI tract processes. Typically, a CT scan will show a tubo-ovarian abscess as a thick-walled, rim-enhancing adnexal mass with multiple loculations.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

N/A

III. Default Management.

When a patient presents with classic signs and symptoms of a TOA and is hemodynamically stable, then a TVUS or pelvic CT should be ordered. However, if the study is non-diagnostic or if the patient is unstable (indicative of a potential ruptured TOA), then a diagnostic laparoscopy or laparatomy should be strongly considered, and the Gynecology service consulted to evaluate the patient. Moreover, if a postmenopausal women presents with evidence for a TOA, then surgical evaluation is indicated because of the higher incidence of associated malignancy.

A. Immediate management.

All patients with a high suspicion for a TOA need to be hospitalized and intravenous antibiotics immediately started. Prompt recognition and management of underlining SIRS/sepsis with volume resuscitation needs to commence, if present. Broad spectrum intravenous antibiotics including coverage for N. gonorrhea and C. trachomatis should be started empirically prior to confirming the diagnosis.

Empiric antibiotics regimens for the first 48 hrs to 72 hrs include:

Cefoxitin (2 grams IV every 6 hours) or cefotetan (2 grams IV every 12 hours) and doxycycline (100 mg orally or IV every 12 hours)

Ampicillin (2 grams IV every 6 hours) and gentamicin (2 mg/kg IV loading dose, then 1.5 mg/kg IV every 8 hours) and clindamycin (900 mg IV every 8 hours)

Ampicillin/sulbactam (3 grams IV every 6 hours) and doxycyline 100 mg IV or oral every 12 hours)

If the patient meets the following criteria, then medical management alone should be considered:

1) Hemodynamically stable

2) TOA is less than 9 cm

3) Premenopasual

4) Patent responding to ongoing antibiotic therapy

Antibiotic therapy alone is usually effective in about 70% of patients. However, if the patient does not meet these criteria or has any evidence of a ruptured TOA, then surgery is indicated – either a laparoscopy or laparotomy. Surgery involves the removal of the abscess cavity and irrigation of the peritoneal cavity with both aerobic and anerobic cultures sent.

In certain patients who remain hemodynamically stable but do not respond to antibiotics, CT or US guided drainage via an abdominal, vaginal, rectal or transgluteal approach should be considered. The procedure is minimally invasive, avoids general anesthesia and is less expensive. Current studies show that drainage is effective in stable patients as an alternative to surgery.

B. Physical Examination Tips to Guide Management.

It is important to perform daily abdominal examination and closely monitor the vital signs to ensure a patient is responding to antibiotic therapy, and is not developing an acute abdomen or early sepsis. Clinical signs of improvement include decreasing pelvic pain and size of mass, defervescence and stabilization of vital signs (blood pressure, heart rate).

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

A daily CBC should be obtained to ensure that the leukocytosis is resolving.

D. Long-term management.

Long-term management requires frequent reassessment of the TOA to ensure that it has resolved with empiric antibiotics. Intravenous antibiotics should be continued for at least 48 to 72 hours. The antibiotic regimen can be narrowed based on culture results and antibiotic susceptibility data. If cultures fail to grow any organisms, an oral regimen of Levofloxacin and Metronidazole is reasonable. If the patient has clear improvement with close follow-up, then she can be discharged with an oral antibiotic regimen for a total of 2 weeks or until the TOA has resolved on radiographic imaging.

If the patient does not improve clinically while hospitalized, then a repeat TVUS or CT scan should be performed to reassess the TOA. Infectious disease consultation should be considered to assist with further workup and/or management. If the repeat imaging study shows worsening of the TOA or there is no clinical response to antibiotics, then surgical treatment should be considered.

In cases where the TOA does not resolve after discharge from the hospital upon re-evaluation, antibiotics are continued and obtaining an infectious disease consult is recommended. Antibiotics need to be continued until there is resolution of the TOA upon repeat imaging studies.

If the cultures test positive for a sexually transmitted infection, a complete sexually-transmitted infection (STI) testing panel should be ordered, including HIV testing and the patient’s partner(s) referred for STI testing.

E. Common Pitfalls and Side-Effects of Management.

N/A

IV. Management with Co-Morbidities.

No change in standard management.

A. Renal Insufficiency.

N/A

B. Liver Insufficiency.

N/A

C. Systolic and Diastolic Heart Failure.

N/A

D. Coronary Artery Disease or Peripheral Vascular Disease.

N/A

E. Diabetes or other Endocrine issues.

N/A

F. Malignancy.

N/A

G. Immunosuppression (HIV, chronic steroids, etc).

N/A

H. Primary Lung Disease (COPD, Asthma, ILD).

N/A

I. Gastrointestinal or Nutrition Issues.

N/A

J. Hematologic or Coagulation Issues.

N/A

K. Dementia or Psychiatric Illness/Treatment.

N/A

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

Sign out considerations include any change in the patients current pain symptom rating or evidence of rupture of the TOA. If the patient has progression of symptoms, then repeat imaging studies are recommended with a low threshold for emergent surgical evaluation for laparotomy or laparoscopy.

B. Anticipated Length of Stay.

Typical length of stay for a TOA in a patient that responds to IV antibiotics is 3 – 4 days. If the patient has a ruptured TOA and/or requires surgery, then the patient may be hospitalized for 7 to 10 days.

C. When is the Patient Ready for Discharge.

The patient is ready for discharge when the TOA is responding to antibiotic therapy or the patient has recovered from surgery. Clinical signs of improvement include lessening of pelvic pain, decreasing WBC count, stabilization or decrease of the size of the mass and tolerating oral intake.

D. Arranging for Clinic Follow-up.

Typical follow-up is 3-5 days with consideration for a repeat imaging study using either a TVUS or CT Scan. If the cultures test positive for a sexually transmitted infection, the patient’s partner should be referred for STI testing.

1. When should clinic follow up be arranged and with whom.

N/A

2. What tests should be conducted prior to discharge to enable best clinic first visit.

N/A

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

N/A

E. Placement Considerations.

N/A

F. Prognosis and Patient Counseling.

N/A

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

N/A

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

N/A

VII. What’s the Evidence?

Lareau, SM, Beigi, RH. “Pelvic Inflammatory Disease and Tubo-ovarian Abscess”. Infect Dis Clin N Am. vol. 22. 2008. pp. 693-708.

Sweet, RL, Sweet, RL, Gibbs, RS. “Anaerobic-aerobic pelvic infection and pelvic abscess”. Infectious diseases of the female genital tract. 2001. pp. 189-206.

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