Diagnosis and management of tubo-ovarian abscess, A Blog about FCPS-II OBG Theory and Viva Preparation By MedHome
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Tubo-ovarian abscess (TOA) Background | Tubo-ovarian abscess (TOA) is a recognized and serious complication of untreated pelvic inflammatory disease (PID).It most commonly affects women of reproductive age and nearly 60% of women with TOA are nulliparous. |
Definition | TOA is defined as an inflammatory mass involving the tube and/or ovary characterised by the presence of pus. The most common cause is ascending/upper genital tract infection when purulent material can discharge through the tube directly into the peritoneal cavity causing initial PID and progression to form a TOA. The infection can occasionally involve other adjacent organs such as the bowel and bladder. |
Aetiology- | Studies demonstrate that in 30–40% of cases, PID is poly microbial.PID and TOAs can also occur secondary to other intra-abdominal pathology such as appendicitis, diverticulitis or pyelonephritis and may be caused by direct or haematogenous spread of infection. However anerobes are usually found with acute tubo ovarian abscess.SBA |
Risk factors- | non-use of barrier contraception, intrauterine contraceptive devices, previous episode(s) of PID, earlier age at first intercourse, multiple sexual partners, diabetes and an immunocompromised state. Around 15–35% of women being treated for proven PID will be diagnosed with a TOA. |
Causative organisms of pelvic inflammatory disease and tubo-ovarian abscesses
| Anaerobe, Peptococcus Anaerobe, Peptostreptococcus Anaerobe,Chlamydia trachomatis Sexually transmitted, Neisseria gonorrhoeae Sexually transmitted, Escherichia coli Enterobacteriaceae, Bacteroides Actinomyces Usually associated with the presence of an intrauterine device, Pelvic tuberculosis Rare – reported with co-existing HIV, Gardnerella vaginalis, Streptococccus agalactiae, Mycoplasma genitalium, Haemophilus influenza, Streptococcus pyogenes The incidence of a TOA was 2.3% in women with co-existing PID and endometriomas compared with 0.2% in women without endometriomas. |
Diagnosis
| l Adnexal tenderness (bilateral or unilateral) l Cervical excitation l Pyrexia l Abnormal cervical or vaginal discharge l Elevated white cell count l Elevated erythrocyte sedimentation rate l Elevated C-reactive protein l An adnexal mass on abdominal palpation/bimanual examination or seen by imaging (TOA only). Other indicators of systemic sepsis may be present in severe cases. Fever and diarrhoea are more common in women with TOA than in women with PID (90% versus 60%, respectively). |
| Differential diagnoses include an appendicular mass, an endometrioma (or other ovarian cyst), an extrauterine pregnancy, diverticulitis or underlying malignancy. |
Investigation | l A screen for sexually transmitted disease such as N. gonorrhea and C. trachomatis l Immunodeficiency, for example, HIV, should also be considered. l A pregnancy test should be performed in women of reproductive age. l A serum lactate and blood cultures are essential if the woman is systemically unwell (pyrexia, tachycardia, increased respiratory rate). A TOA can be diagnosed by ultrasound, appearing as a complex solid/cystic mass. This can be unilateral or bilateral. A pyosalpinx may be seen as an elongated, dilated, fluid-filled mass with partial septae and thick walls. Incomplete septae within the tubes is a sensitive sign of tubal inflammation or an abscess.There may be a ‘cogwheel’ sign resulting from thickened endosalpingeal folds .This cogwheel sign is a sensitive marker of a TOA, pathognomonic of acute tubal inflammation. The inflamed ovary can acquire a reactive polycystic appearance (because of oedema), and eventually become adherent to the tube. There may be complex free fluid in the pouch of Douglas, often with an echogenic appearance. The uterus can appear enlarged with ill-defined margins and endometrium. l Computed tomography (CT) imaging is useful when there is a suspicion of gastrointestinal pathology such as an appendix mass. When a TOA is present, a common finding on CT is a thick-walled, fluid-dense mass in the adnexa(e), often with internal septations. There may be anterior displacement of the thickened mesosalpinx. Internal gas bubbles are usually specific for bowel-associated abscesses on CT and this sign is unusual with a TOA. There may also be rectosigmoid involvement. This is a result of the posterior spread of inflammation (and consequent fibrosis) from the nearby TOA. Pararectal fat may be infiltrated. The ureter is the other most commonly involved structure and there may be associated hydroureter/hydronephrosis. These findings highlight why surgery for TOAs can be complex and carry increased surgical risks. l Magnetic resonance imaging (MRI) . MRI has been found to have a higher sensitivity and specificity than ultrasound for the diagnosis of TOA: |
Management
| In the presence of systemic sepsis, appropriate resuscitation and prompt surgery, with concurrent commencement of broadspectrum intravenous antibiotics, may be considered. The ‘sepsis six’ protocol should be followed: administer oxygen, take blood cultures prior to commencing antibiotics, commence intravenous antibiotics, measure serum lactate, commence intravenous fluids and accurately measure urine output. |
Medical treatment | If the woman is systemically well and/or clinically stable then consideration can be given to initial treatment with antibiotic therapy with delayed or possible avoidance of any surgical intervention. Medical treatment of a TOA with antibiotics can be effective in up to 70% of patients Initially, intravenous broad-spectrum antibiotics that cover the commonest causative pathogens are required. Once clinical improvement is noted and pyrexia has resolved, antibiotics should be changed to an oral preparation and continued for 14 days. Possible antibiotic regimens for a tubo-ovarian abscess
|
Surgical treatment
| after 24 hours (and certainly after 48 hours) of intravenous antibiotics if no improvement in clinical condition is demonstrated. factors that influence the decision including previous surgical history, fertility wishes and size of the abscess. In the event of an acute abdomen where rupture of an abscess is suspected, surgery may be necessary. If conservative surgery is felt to be appropriate in women wishing fertility. Drainage of the pelvic abscess with copious irrigation of the abdominal cavity can be considered if fertility is to be preserved. A large drain should be considered to allow any remaining pus or wash to be expelled. Ultrasound/CT-guided drainage The success rate is reported between 83% and 100%. Image-guided drainage is minimally invasive, appears to be well tolerated, offers a reduced length of stay in hospital and avoids the risks associated with surgery and anaesthesia. TOAs can be drained by ultrasound guided aspiration or drainage with catheter placement. The transvaginal approach provides a direct route from the vagina into the pouch of Douglas or adnexal regions where TOAs are usually found. If the woman has completed her family, consideration should be given to salpingo-oophorectomy. Although outcomes from pelvic clearance results are good, there is significant morbidity in terms of surgical risks, infertility and premature menopause. Henry-Suchet carried out laparoscopic adhesiolysis and drainage of abscess with antibiotic cover. In 90% of women, the approach was successful, with only 10% needing further surgery. They found a significantly high incidence of intraoperative and postoperative complications with the radical approach, such as bowel perforation, internal iliac artery lacerations, higher postoperative fever, bowel obstruction and postoperative pelvic pain. There should be a lower threshold for consideration of surgical intervention in postmenopausal women because of the risk of underlying malignancy. Postoperatively, intravenous antibiotics should be continued. A swab of the pus should be taken. Microbiology results must be assessed as contact tracing will be indicated if sexually transmitted infections have been diagnosed in the woman. -not show continued improvement following surgery or if there is sustained fluctuating pyrexia, further imaging may be required to exclude rare complications such as a subphrenic abscess or, more rarely, an intrathoracic abscess. - elective surgery later. This could be because of symptoms such as chronic pain, a persistent adnexal mass or repeated admissions/antibiotic courses for a TOA. The first 6 weeks after an acute episode of a TOA should be avoided as inflammation and tissue quality will be particularly poor at this time. |
Poor prognostic factors- | Poor prognostic factors- associated with a lack of response to medical treatment include the size of abscess (larger than 5 cm), age (older women above the age of 40 years), higher initial white cell count and smoking. Careful monitoring of observations with a standardized early warning system chart is mandatory: pulse, blood pressure, temperature, and respiratory rate and oxygen saturations. Fluid balance and urine output must be carefully monitored and consideration must be given to a urinary catheter to carefully assess fluid balance. Blood parameters should be checked daily, particularly the white cell count and the C-reactive protein levels. Prophylaxis against venous thromboembolism should be initiated with compression stockings. Low molecular- weight heparin should be considered if surgery is unlikely to be imminent. The woman should be reviewed at least twice every 24 hours by a senior clinician. A multidisciplinary approach is likely to result in the best outcomes for the woman, liaising with colleagues in anesthetics, microbiology and radiology. A higher level of care in a high-dependency unit or intensive care unit may be needed if the woman becomes systemically unwell. Removal of an intrauterine device or intrauterine system should be considered as it may be associated with better short-term clinical outcomes. There is a relationship with intrauterine devices and Actinomyces. Actinomyces tends to respond well to penicillin. |
Ultrasound features of tubo ovarioan abcess: (Viva Question)
Transabdominal and endovaginal ultrasound are the preferred initial imaging investigations. Findings may include:
- multilocular complex retro uterine/adnexal mass
- debris, septations, and irregular thick walls
- commonly bilateral
- echogenic debris within the pelvis
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