Tubo-ovarian abscess

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Tubo-ovarian abscess
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A tubo-ovarian abscess (TOA) is one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis. It consists of an encapsulated or confined pocket of pus with defined boundaries that forms during an infection of a fallopian tube and ovary. These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. [1] [2] It is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs. A TOA can also develop as a complication of a hysterectomy. [3] : 103 

Contents

Symptoms typically include fever, an elevated white blood cell count, lower abdominal-pelvic pain, and/or vaginal discharge. Fever and leukocytosis may be absent. TOAs are often polymicrobial with a high percentage of anaerobic bacteria. The cost of treatment in the United States is approximately $2,000 per patient, which equals about $1.5 billion annually. [1] Though rare, TOA can occur without a preceding episode of PID or sexual activity. [4] [5]

Signs and symptoms

Bacteroides fragilis BacteroidesFragilis Gram.jpg
Bacteroides fragilis

The signs and symptoms of tubo-ovarian abscess (TOA) are the same as with pelvic inflammatory disease (PID) with the exception that the abscess can be found with magnetic resonance imaging (MRI), sonography and x-ray. [1] It also differs from PID in that it can create symptoms of acute-onset pelvic pain. [6] Typically this disease is found in sexually active women. [4] [7] Tubo-ovarian abscess can mimic abdominal tumours. [8]

Complications

Complications of TOA are related to the possible removal of one or both ovaries and fallopian tubes. Without these reproductive structures, fertility can be affected. Surgical complications can develop and include:[ citation needed ]

Cause

The development of TOA is thought to begin with the pathogens spreading from the cervix to the endometrium, through the salpinx, into the peritoneal cavity and forming the tubo-ovarian abscess with (in some cases) pelvic peritonitis. TOA can develop from the lymphatic system with infection of the parametrium from an intrauterine device (IUD). [1] Bacteria recovered from TOAs are Escherichia coli , Bacteroides fragilis , other Bacteroides species, Peptostreptococcus , Peptococcus , and aerobic streptococci . [9] Long term IUD use is associated with TOA. [10] Actinomyces is also recovered from TOA. [10]

GenusspeciesGram stainformgenome sequencedreference
Neisseria gonorrhoeae spp.-cocci [1] [11]
Chlamydia trachomatis spp.-intracellular [1] [11]
Mycoplasma genitalium spp.+bacillus [11]
Mycoplasma hominis [11]
Ureaplasma urealyticum +bacillus [11]
Escherichia coli -bacillusX [4] [9] [11]
Corynebacterium jeikeium +bacillusX [11]
Bacteroides fragilis +bacillusX [9] [11]
Lactobacillus jensenii +bacillus [11]
Cutibacterium acnes +bacillus [11]
Haemophilus influenzae +bacillus [11]
Streptococcus pneumoniae +cocci [11]
Streptococcus constellatus +cocci [9] [11]
Prevotella bivia -bacillus [11]
Fusobacterium nucleatum +bacillus [11]
Enterococcus faecium +cocci [11]
Actinomyces neuii +bacillusX [11]
Lactobacillus delbrueckii +bacillus [11]
Streptococcus intermedius +cocci [9] [11]
Eikenella corrodens +bacillusX [11]
Abiotrophia +bacillusX [4]
Granulicatella +bacillusX [4]


Diagnosis

Laparoscopy and other imaging tools can visualize the abscess. Physicians are able to make the diagnosis if the abscess ruptures when the woman begins to have lower abdominal pain that then begins to spread. The symptoms then become the same as the symptoms for peritonitis. Sepsis occurs, if left untreated. [3] : 103  Ultrasonography is a sensitive enough imaging tool that it can accurately differentiate between pregnancy, hemorrhagic ovarian cysts, endometriosis, ovarian torsion, and tubo-ovarian abscess. Its availability, the relative advancement in the training of its use, its low cost, and because it does not expose the woman (or fetus) to ionizing radiation, ultrasonography an ideal imaging procedure for women of reproductive age. [6]

Prevention

Risk factors have been identified which indicate what women will be more likely to develop TOA. These are: increased age, IUD insertion, chlamydia infection, and increased levels of certain proteins (CRP and CA-125) and will alert clinicians to follow up on unresolved symptoms of PID. [12]

Treatment

Treatment for TOA differs from PID in that some clinicians recommend patients with tubo-ovarian abscesses have at least 24 hours of inpatient parenteral treatment with antibiotics, and that they may require surgery. [1] [13] If surgery becomes necessary, pre-operative administration of broad-spectrum antibiotics is started and removal of the abscess, the affected ovary and fallopian tube is done. After discharge from the hospital, oral antibiotics are continued for the length of time prescribed by the physician. [3] : 103 

Treatment is different if the TOA is discovered before it ruptures and can be treated with IV antibiotics. During this treatment, IV antibiotics are usually replaced with oral antibiotics on an outpatient basis. Patients are usually seen three days after hospital discharge and then again one to two weeks later to confirm that the infection has cleared. [3] : 103  Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess. Parenteral Regimens described by the Centers for Disease Control and prevention are Ampicillin/Sulbactam 3 g IV every 6 hours and Doxycycline 200 mg orally or IV every 24 hours, though other regiments that are used for pelvic inflammatory disease have been effective. [14]

Epidemiology

The epidemiology of TOA is closely related to that of pelvic inflammatory disease which is estimated to one million people yearly. [15]

Related Research Articles

<span class="mw-page-title-main">Pelvic inflammatory disease</span> Infection of uterus, fallopian tubes, ovaries or the inner surface of pelvis

Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no symptoms. Signs and symptoms, when present, may include lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, bleeding after sex, or irregular menstruation. Untreated PID can result in long-term complications including infertility, ectopic pregnancy, chronic pelvic pain, and cancer.

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Ovarian cyst</span> Fluid-filled sac in the ovary

An ovarian cyst is a fluid-filled sac within the ovary. Often they cause no symptoms. Occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either breaks open or causes twisting of the ovary, it may cause severe pain. This may result in vomiting or feeling faint, and even cause head aches.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both cancer and serious medical issues.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Gynecologic ultrasonography</span>

Gynecologic ultrasonography or gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs as well as the bladder, the adnexa, and the recto-uterine pouch. The procedure may lead to other medically relevant findings in the pelvis.This technique is useful to detect myomas or mullerian malformations.

<span class="mw-page-title-main">Endometritis</span> Medical condition

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. It is also part of spectrum of diseases that make up pelvic inflammatory disease.

<span class="mw-page-title-main">Salpingitis</span> Medical condition

Salpingitis is an infection causing inflammation in the Fallopian tubes. It is often included in the umbrella term of pelvic inflammatory disease (PID), along with endometritis, oophoritis, myometritis, parametritis, and peritonitis.

<span class="mw-page-title-main">Hydrosalpinx</span> Medical condition

A hydrosalpinx is a condition that occurs when a Fallopian tube is blocked and fills with serous or clear fluid near the ovary. The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape. The condition is often bilateral and the affected tubes may reach several centimeters in diameter. The blocked tubes cause infertility. A Fallopian tube filled with blood is a hematosalpinx, and with pus a pyosalpinx.

An adnexal mass is a lump in tissue of the adnexa of uterus. Adnexal masses can be benign or cancerous, and they can be categorized as simple or complex. One of the most important factors used to determine the clinical suspicion of malignancy of an adnexal mass is the sonographic appearance of the mass. Indications that the mass is at a higher risk of being malignant include the presence of loculations, nodules, papillary structures, or septations or a size greater than 10 cm.

Primary fallopian tube cancer (PFTC), often just tubal cancer, is a malignant neoplasm that originates from the fallopian tube.

<span class="mw-page-title-main">Heterotopic pregnancy</span> Medical condition

A heterotopic pregnancy is a complication of pregnancy in which both extrauterine (ectopic) pregnancy and intrauterine pregnancy occur simultaneously. It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or coincident pregnancy.

<span class="mw-page-title-main">Ovarian torsion</span> Medical condition

Ovarian torsion (OT) or adnexal torsion is an abnormal condition where an ovary twists on its attachment to other structures, such that blood flow is decreased. Symptoms typically include pelvic pain on one side. While classically the pain is sudden in onset, this is not always the case. Other symptoms may include nausea. Complications may include infection, bleeding, or infertility.

Septic abortion describes any type of abortion, due to an upper genital tract bacterial infection including the inflammation of the endometrium during or after 20 weeks of gestation. The genital tract during this period is particularly vulnerable to infection, and sepsis in most cases is caused by a combination of factors both due to facility conditions and/or individual predispositions. The infection often starts in the placenta and fetus, with a potential complication of also affecting the uterus, that can result in sepsis spreading to surrounding organs, or pelvic infections.

Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proceed past the first four weeks of pregnancy. An untreated ovarian pregnancy causes potentially fatal intra-abdominal bleeding and thus may become a medical emergency.

Theca lutein cyst is a type of bilateral functional ovarian cyst filled with clear, straw-colored fluid. These cysts result from exaggerated physiological stimulation due to elevated levels of beta-human chorionic gonadotropin (beta-hCG) or hypersensitivity to beta-hCG. On ultrasound and MRI, theca lutein cysts appear in multiples on ovaries that are enlarged.

Septic pelvic thrombophlebitis (SPT), also known as suppurative pelvic thrombophlebitis, is a rare postpartum complication which consists of a persistent postpartum fever that is not responsive to broad-spectrum antibiotics, in which pelvic infection leads to infection of the vein wall and intimal damage leading to thrombogenesis in the ovarian veins. The thrombus is then invaded by microorganisms. Ascending infections cause 99% of postpartum SPT.

<span class="mw-page-title-main">Tubal factor infertility</span> Medical condition

Tubal factor infertility (TFI) is female infertility caused by diseases, obstructions, damage, scarring, congenital malformations or other factors which impede the descent of a fertilized or unfertilized ovum into the uterus through the Fallopian tubes and prevents a normal pregnancy and full term birth. Tubal factors cause 25-30% of infertility cases. Tubal factor is one complication of Chlamydia trachomatis infection in women.

Pelvic abscess is a collection of pus in the pelvis, typically occurring following lower abdominal surgical procedures, or as a complication of pelvic inflammatory disease (PID), appendicitis, or lower genital tract infections. Signs and symptoms include a high fever, pelvic mass, vaginal bleeding or discharge, and lower abdominal pain. It can lead to sepsis and death.

References

  1. 1 2 3 4 5 6 7 Pelvic inflammatory disease. American Family Physician, Vol. 85, No. 8. (15 April 2012), pp. 791-796 by Margaret Gradison
  2. ↑ "CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines" . Retrieved 2015-05-16.
  3. 1 2 3 4 Hoffman, Barbara (2012). Williams gynecology. New York: McGraw-Hill Medical. ISBN   9780071716727.
  4. 1 2 3 4 5 Goodwin, K.; Fleming, N.; Dumont, T. (2013). "Tubo-ovarian Abscess in Virginal Adolescent Females: A Case Report and Review of the Literature". Journal of Pediatric and Adolescent Gynecology. 26 (4): e99–e102. doi:10.1016/j.jpag.2013.02.004. ISSN   1083-3188. PMID   23566794.
  5. ↑ Ho, Jeh Wen; Angstetra, D.; Loong, R.; Fleming, T. (2014). "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.
  6. 1 2 Dupuis, Carolyn S.; Kim, Young H. (2015). "Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women". Ultrasonography. 34 (4): 258–267. doi:10.14366/usg.15013. ISSN   2288-5919. PMC   4603210 . PMID   26062637.
  7. ↑ Cho, Hyun-Woong; Koo, Yu-Jin; Min, Kyung-Jin; Hong, Jin-Hwa; Lee, Jae-Kwan (2015). "Pelvic Inflammatory Disease in Virgin Women with Tubo-ovarian Abscess: A Single-center Experience and Literature Review". Journal of Pediatric and Adolescent Gynecology. 30 (2): 203–208. doi:10.1016/j.jpag.2015.08.001. ISSN   1083-3188. PMID   26260586.
  8. ↑ Lim, Andy; Pourya, Pouryahya; Lim, Alvin (2020). "Tubo-ovarian Abscess Masquerading as Dual Tumours". OSP Journal of Case Reports. 2 (2). doi:10.26180/5ed852773f47e . Retrieved 4 June 2020.
  9. 1 2 3 4 5 Landers, D. V.; Sweet, R. L. (1983). "Tubo-ovarian Abscess: Contemporary Approach to Management". Clinical Infectious Diseases. 5 (5): 876–884. doi:10.1093/clinids/5.5.876. ISSN   1058-4838. PMID   6635426.
  10. 1 2 Lentz, Gretchen (2013). Comprehensive gynecology. Philadelphia: Mosby Elsevier. p. 558. ISBN   9780323069861.
  11. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Dessein, Rodrigue; Giraudet, Géraldine; Marceau, Laure; Kipnis, Eric; Galichet, Sébastien; Lucot, Jean-Philippe; Faure, Karine; Munson, E. (2015). "Identification of Sexually Transmitted Bacteria in Tubo-Ovarian Abscesses through Nucleic Acid Amplification: TABLE 1". Journal of Clinical Microbiology. 53 (1): 357–359. doi:10.1128/JCM.02575-14. ISSN   0095-1137. PMC   4290956 . PMID   25355760.
  12. ↑ Lee, Suk Woo; Rhim, Chae Chun; Kim, Jang Heub; Lee, Sung Jong; Yoo, Sie Hyeon; Kim, Shin Young; Hwang, Young Bin; Shin, So Young; Yoon, Joo Hee (2015). "Predictive Markers of Tubo-Ovarian Abscess in Pelvic Inflammatory Disease". Gynecologic and Obstetric Investigation. 81 (2): 97–104. doi:10.1159/000381772. ISSN   0378-7346. PMID   25926103. S2CID   27186672.
  13. ↑ Lentz, Gretchen (2013). Comprehensive gynecology. Philadelphia: Mosby Elsevier. p. 584. ISBN   9780323069861.
  14. ↑ "CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines". www.cdc.gov. Archived from the original on 2011-02-09.
  15. ↑ "PID Epidemiology". Center for Disease Control. Archived from the original on 2015-02-22. Retrieved 2015-05-21.
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