Nicole S. Fanning
History of present illness
A 21-year-old gravida 2, para 2 woman presented to the emergency department with a week of worsening right lower quadrant pain, subjective fevers, nausea, and emesis. One week prior she had been evaluated for similar symptoms and diag- nosed with pelvic inflammatory disease (PID). Intramuscular ceftriaxone was administered at this time, and oral doxycycline was prescribed for 14 days. She was unable to keep her initial follow-up appointment and her worsening symptoms prompted her to seek care in the emergency department. She is a three cigarettes-a-day smoker and previously had a dilatation and curettage for an elective abortion.
Physical examination
General appearance:Awake, alert woman who is in no acute distress
Vital signs:
Temperature: 38.7°C Pulse: 106 beats/min
Blood pressure: 111/58 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 99% on room air Cardiovascular: Tachycardic
Pulmonary: Clear to auscultation bilaterally
Abdomen:Soft, nondistended, tender to palpation diffusely, worse in right lower quadrant, but with no rebound or guarding
Genitourinary:
Normal appearing cervix with mucopurulent discharge, positive cervical motion tenderness, normal-appearing vaginal mucosa
Bimanual examination: Limited mobility of a pelvic mass with significant tenderness and uterine deviation Laboratory studies on admission:
Urine pregnancy test: Negative
WBCs: 26 700/μL (normal 3900–11 700/μL) Hb: 12.8 g/dL (normal 12.0–15.0 g/dL) Ht: 38.0% (normal 34.8–45.0%)
Platelets: 350 000/μL (normal 172 000–440 000/μL) Cervical gonorrhea, chlamydia, trichomonas: Pending Urinalysis: Specific gravity 1.08 and large blood Imaging:CT scan of pelvis showed a large pelvic mass (10 × 10 × 8 cm) having solid and cystic aspects. Cystic
components were defined as tubular; thus, interpretation was that of a tubo-ovarian abscess. A smallerfluid collection (7 × 3 cm) consistent with hemorrhage was also identified
How would you manage this patient?
This patient has a tubo-ovarian abscess (TOA), and thus was admitted to the inpatient Gynecology service where she was initiated on intravenous cefoxitin, doxycycline, and metronida- zole in addition to intravenous morphine for pain control.
After 48 hours of intravenous antibiotics she continued to be febrile with worsening pain. Thus, she was taken to the operat- ing room for exploratory laparotomy. Intraoperative findings were consistent with purulent drainage upon entering the peri- toneum and severely distorted pelvic anatomy. This included
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 24.1 Right tubo-ovarian abscess incised. This ovary contains loculations of purulent material.
an extremely enlarged right ovary with multiple loculations of purulent drainage as well as an edematous, thickened, and fibrous right fallopian tube adherent to the uterus and ovary.
Due to thesefindings, the right ovary and right fallopian tube were removed, and pathology was consistent with acute right- sided TOA and salpingitis (Figs 24.1&24.2, respectively). The patient was discharged to home on postoperative day 6 after an uncomplicated postoperative course. Discharge antibiotics included doxycycline and clindamycin orally to complete a total of 14-day course of antibiotics. She was seen one week following discharge, and was noted to be doing well. No anaer- obic cultures were sent, but blood and urine cultures were without growth. Polymerase chain reaction (PCR) testing for gonorrhea and chlamydia returned negative.
Tubo-ovarian abscess
A tubo-ovarian abscess (TOA) is an inflammatory mass that involves the fallopian tube and ovary, and can also involve other pelvic structures such as bowel and bladder. A TOA is usually found as a complication of PID, and is a polymicrobial- ascending infection that involves the upper genital tract. It can also be associated with other intra-abdominal processes such as diverticulitis or appendicitis. Risk factors for developing a TOA are the same as those for PID, including age between 15 and 25 years, multiple sexual partners, and a prior history of PID. The long-term sequela of a TOA can be significant including infer- tility, ectopic pregnancy, and chronic pelvic pain. For abscesses that go undiagnosed and rupture the consequences can be severe, leading to sepsis and potential death.
A patient with a TOA will typically present with one or more of the following: pelvic pain, fever, vaginal discharge, nausea, and abnormal vaginal bleeding. Physical examination findings will be similar to that of a patient with PID, including tenderness to palpation of the cervix, uterus, or adnexa and mucopurulent cervical discharge. It may be possible to palpate a tender adnexal mass, but this is often limited due to patient discomfort. One should have a low threshold for imaging when a TOA is suspected in order to aid in diagnosis and
management. The primary or preferable imaging modality is transvaginal ultrasonography, but transabdominal ultrasono- graphy can be used as well as CT scans and MRI. Typical ultrasound findings are cystic structures, either uni- or multilocular with thickened walls with or without septae.
Echogenicity of cystic contents are usually homogenous with ground-glass appearance [1]. A CT scan may be preferable in cases where the diagnosis is unclear and other etiologies need to be ruled out, such as appendicitis or diverticulitis.
Once TOA is diagnosed, parenteral antibiotics are the mainstay of treatment. Approximately 75% of all TOAs will resolve with parenteral antibiotics alone [2]. TOAs are poly- microbial infections with the most common pathogens being Escherichia coli, Bacteriodes fragilis, Baceteroides sp., Pepto- streptococcus, Peptococcus,and aerobicStreptococcus.Neisseria gonorrhoeae and Chlamydia trachomatisare thought to lead to an ascending infection; however, they are rarely recovered from an abscess. It is pertinent, however, to routinely screen forN. gonorrheaandC. trachomatisbefore initiating treatment given that they are commonly encountered sexually transmit- ted infections. With these isolates in mind, the Centers for Disease Control and Prevention (CDC) recommends inpatient intravenous antibiotics for at least 24 hours with cefotetan 2 g IV every 12 hours or cefoxitin 2 g IV every 6 hours, plus doxycycline 100 mg PO or IV every 12 hours. For patients with a significant penicillin allergy, clindamycin plus gentamy- cin is recommended. Following initial parenteral treatment, the CDC then recommends continuation of treatment with oral clindamycin or metronidazole along with doxycyline for a total of 14 days of treatment to improve anaerobic coverage [3]. Use of clindamycin, metronidazole, and cefoxitin should be highly considered in treating a TOA due to their increased ability to penetrate an abscess wall [4].
If there is no clinical improvement after 48–72 hours of parenteral antibiotics, more aggressive treatment with surgery or drainage should be considered. Historically, a patient’s response to parenteral antibiotics is dependent on the size of the abscess. Approximately 60% of abscesses greater than 10 cm will require surgical intervention, whereas 15% or less
Fig. 24.2 Right fallopian tube. Tube is friable, fibrous, edematous, and has clubbed ending.
of patients with abscesses less than 4 cm will require surgical intervention [5]. Surgical approach to a TOA is based on the experience of the surgeon. Many surgeons prefer laparotomy due to the complexity of adhesions formation that may poten- tially involve the bowel. In cases where there is no evidence of rupture, laparoscopy may be a reasonable approach for the experienced surgeon, resulting in quicker recovery times and lower surgical morbidity. For those patients who have completed childbearing, a complete hysterectomy and bilateral salpingo-opherectomy may be a reasonable option, but for those younger patients a more conservative resection with removal of the necrotic and infected tissue only is appropriate.
Approach to drainage can be accomplished via ultrasound or CT guidance through the abdomen, vagina, rectum, or transgluteal. Studies have found that treatment of a TOA with drainage combined with antibiotics allowed patients to avoid surgery in a majority of cases and was associated with signifi- cantly shorter hospital stays and decreased morbidity [1,6].
Based on the findings of these reports, minimally invasive
drainage may be an appropriate primary treatment along with antibiotic therapy, when available.
Key teaching points
A tubo-ovarian abscess (TOA) is a usually found as a complication of pelvic inflammatory disease (PID), but can also be associated with other intra-abdominal processes such as diverticulitis or appendicitis.
The long-term sequela of a TOA can be significant including infertility, ectopic pregnancy, and chronic pelvic pain.
The primary or preferable imaging modality is transvaginal ultrasonography, but transabdominal ultrasonography can be used as well as CT scans and MRI.
Approximately 75% of all TOAs will resolve with parenteral antibiotics alone.
Reassessment and possibly escalation of care should occur within 48–72 hours of initiating antibiotics if no improvement occurs.
References
1. Gjelland K, Ekerhovd E, Granberg S.
Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases.Am J Obstet Gynecol2005;193(4):1323–30.
2. Soper D. Pelvic inflammatory disease.
Obstet Gynecol2010;116:419–28.
3. Centers for Disease Control and Prevention.Sexually Transmitted
Diseases Treatment Guidelines, 2010.
Pelvic Inflammatory Disease. Available athttp://www.cdc.gov/std/treatment/
2010/pid.htm.
4. Joiner KA, Lowe BR, Dzink JL, et al.
Antibiotic levels in infected and sterile subcutaneous abscesses in mice.J Infect Dis1981;143:487–94.
5. Jaiyeoba O, Lazenby G, Soper DE.
Recommendations and rationale for
treatment of pelvic inflammatory disease. Expert review in anti-infective therapy.Expert Rev Anti Infect Ther 2011;9(1):61–70.
6. Perez-Medina T, Heuras MA, Bajo JM. Early ultrasound-guided transvaginal drainage of tubo-ovarian abcesses: a randomized study.
Ultrasound Obstet Gynecol1996;
7(6):435–8.
Case 24: A 21-year-old woman with persistent pain and fever after treatment for PID