Tubo Ovarian Abscess

Outline

Tubo Ovarian Abscess

1. Introduction

2. Epidemiology and Risk Factors

3. Pathogenesis

• Bacterial culprits

4. Evaluation and Diagnosis

• Imaging

5. Treatment

• Antibiotics
• Surgery
• IR

Unilateral Adnexectomy

1/3 patients with TOA have microscopic abscesses in contralateral ovary

Sweet R et al.

Laparoscopy + Antibiotics

Fertility

Antibiotics only

Rosen et al.

**contraception and women not attempting pregnancy not excluded

Rosen et al

Laparotomy

Rosen et al.

Laparoscopic Drainage

Surgery

• Direct visualization
• Challenging due to anatomic distortion and friable tissue planes
• Decreased morbidity
• Dependent on operator skill

Rosen et al.

Yang CC et al.

pathologyoutlines.com

Case Series for TOA treated with Antibiotics + Laparoscopy

Rosen et al.

History

Rosa Liu

MSIV, GWU

Post 1950's

Prior to 1950's

• Surgical Intervention rare
• Mortality rate 48-100%

• 1909: Prognosis worsens with delayed surgery

TAH/BSO within 24-72 hours of antibiotic treatment

• Mortality rates decreased
• Unruptured: 1.7-3.7%
• Ruptured: 3-4%
• IV PCN or 1st generation cephalosporin

+ aminoglycoside

1950

1970

1960

Medical Conservative Treatment

Advent of Antibiotics

• women with TOA no longer needed to become sterile, have surgical morbidity or premature menopause

1. Indications

• Ruptured
• Sepsis
• Enlarging pelvic mass
• New onset, elevation or persistent fever or WBC
• Persistent or worsening abdominopelvic tenderness

2. ________________women - may be associated with malignancy

3. Copious irrigation

4. Delayed primary closure or secondary intention

Antibiotics

Size of TOA:

Correlated with failed antibiotic and need for surgery

% failure

Size of TOA

• Recommended regardless of surgical or IR intervention
• Antibiotics alone (70% response)
• No signs of rupture
• Hemodynamically stable
• Premenopausal
• Abscess <9cm diameter
• Inpatient IV Abx at least 24 hours

Sweet R et al.

Recommended Regimens

Cefotetan/Cefoxitin + doxycycline + clindamycin/metronidazole

• 14 days
• Increased resistance to:
• Cefotetan --> Cefoxitin
• Clindamycin --> metronidazole

First choice

• Cefoxitin + Doxycycline

• Cefotetan + Doxycycline

• Clindamycin + Gentamicin

• Ampicilin + Clindamycin + Gentamicin

• Ampicillin-sulbactam + Doxycycline

Outpatient oral regimens

• Levofloxacin or Ofloxacin

+ Metronidazole

Treatment

Evaluation and Diagnosis

Considerations:

1. Ruptured

2. Patient hemodynamic status

3. Fertility Preservation

4. Abscess characteristics

Epidemiology

First things first:

Differential

• Assess the severity
• Is the TOA "ruptured"?
• 15% of cases
• Sepsis - 10-20%
• hypotension, tachycardia, tachypnea, acidosis
• Acute abdomen

Treatment

• Start Antibiotics
• Immediate surgery

GI

Reproductive Tract

Diagnosis

• Appendiceal Abscess
• Diverticular Abscess
• IBS
• IBD

• PID
• Ruptured Ovarian Cyst
• Ovarian torsion
• Degenerating fibroid
• Adenomyoma
• Ectopic pregnancy
• Septic abortion
• Pelvic neoplasm
• Endometrioma
• Hemorrhagic cyst

• 66,000 women annually in the US
• MC in women <40yo
• 25-50% nulliparous

• Based on finding of inflammatory adnexal mass on imaging and meeting diagnostic criteria for PID
• Gold standard: _______________

Signs & Symptoms

PID minimum criteria

Labs

• Pelvic or lower abdominal pain + 1 or more of the following:
• CMT
• Uterine tenderness
• Adnexal tenderness

Introduction

• CBC
• GC/CT
• B-HCG
• ESR
• CRP

IR Drainage

Imaging. Who?

In patients with PID, pts who appear:

• Acutely ill
• Abdominopelvic tenderness
• Adnexal mass
• Poor response to antibiotic therapy

Inflammatory Markers:

• ESR: good to assess severity of infection and resolution
• CRP: may be more sensitive than ESR or leukocytosis

Bowel changes/Ileus

Risk Factors

• 75% success rate
• Appropriate for patients who do not worsen or seem to improve
• Considerations:
• Unilocular>Multilocular
• Bleeding profile
• Accessibility
• Risks: hemorrhage, nerve injury, damage to adjacent organs
• Radiologic assistance:
• Ultrasound
• CT
• Fluoroscopy
• JP Drain: 1-2 weeks on average
• Repeat scan 48 hours to assess response

• Inflammatory mass involving fallopian tubes, ovaries, or other pelvic organs (bowel, bladder)
• Agglutination of pelvic organs
• Collection of pus
• Usually a major complication or sequelae of acute PID
• Can be life-threatening

Image-guided Success rates

Similar to RFs of PID:

• Multiple sex partners
• Age between 15-25yo
• Prior history of PID
• distorted anatomy
• Oocyte retrieval
• IUD
• HIV+

Pathogenesis

Sweet R et al.

IUD

• Risk for PID mostly confined to the first 3 weeks after insertion
• Association with _____________________ and long-term users
• Early retrospective studies suggest 20-54% of IUD use among TOA patients
• Recent studies do not show this association.

Levenson RB et al

Fische, A.

Sweet R et al.

Viberga et al.

Grimes, DA.

Imaging

Relationship with PID

• 15-30% of hospitalized patients with acute PID have TOA
• TOA must be assessed in women with PID
• predictors: women >42yo with palpable adnexal mass, ESR >50
• Distinguish the two by detecting an inflammatory adnexal mass

Halperin R et al.

• Ultrasound
• CT
• MRI
• Radionucleotide scanning

Algorithm

CT

uptodate.com

Ultrasound

Intra-abdominal Processes

• Helpful in excluding GI etiology
• Sensitivity: 78-100%
• Specificity: 100%

• Bowel perforation adjacent to adnexa
• Local spread of infection
• uncontrolled IBD
• appendicitis
• adnexal surgery

• First line
• Transvaginal>Transabdominal
• Sensitivity: 75-82%
• Specificity: 91%
• Better availability, tolerability, speed, and lower cost.

Bacterial Culprits

Resources

CT

US

• Complex
• Cystic
• Thick walled
• Internal echoes
• Usually hypoechoic
• Can be multiloculated
• Septations or solid components leading to varied echotexture
• Air fluid levels
• Free fluid

• uniform, thick-walls
• rim-enhancing
• internal septations
• fluid-filled tubular lesions (pyosalpinx)
• free abdominopelvic fluid if ruptured

radiopaedia.org

• Polymicrobial: anaerobic, aerobic, facultative
• E. Coli (37%)
• B. Fragilis (22%)
• Bacteroides/Prevotella (26%)
• Peptococcus/peptostreptococcus (11%/18%)
• P. bivia
• Unusuals: Pasteurella, Salmonellae, S. pneumonia, actinomyces israelii, mycobacterium TB

Thank you so so much for a great month at Kaiser SF and for helping to shape my career as a budding OBGYN!

Special thanks to:

Bao, Tina, Barrie, Morgan, Steph, Jana

• Beigi, R. Management and Complications of tuboovarian abscess. Uptodate.com. 2013.
• El-Shawarby, Salem (06/2004). A review of complications following transvaginal oocyte retrieval for in-vitro fertilization. Human fertility (Cambridge, England). , 7 (2), p. 127 - 33. (ISSN: 1464-7273)
• Evans, DTP. Actinomyces in the female genital tract. Gen Med 1993; 69:54-9.
• Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000;356(9234):1013–19.
• Fische, A. Personal communication. 21 Oct. 2013.
• Gjelland K, Granberg S, Kiserud T, Wentezel-Larsen T, Ekerhovd E. Pregnancies following ultrasound-guided draingage of tubo-ovarian abscess. Fertil Steril. 2012 Jul;98(1):136-40. doi: 10.1016/j.fertnstert.2012.03.054. Epub 2012 May 11.
• Halperin R, Svirsky R, Vaknin Z, et al. Predictors of tuboovarian abscess in acute pelvic inflammatory disease. J Reprod Med 2008; 53:40.
• Levenson RB, Pearson KM, Saokar A, et al. Image-guided drainage of tuboovarian abscesses of gastrointestinal or genitourinary origin: a retrospective analysis. J Vasc Interv Radiol 2011; 22:678.
• Rosen M, Breitkopf D, Waud K. Tubo-ovarian abscess management options for women who desire fertility. Obstet Gynecol Surv 2009; 64:681.
• Sweet RL. Soft tissue infection and pelvic abscess. In: Infectious diseases of the female genital tract, 5th ed, Sweet RL, Gibbs RS (Eds), Lippincott Williams and Wilkins, Philadelphia 2009.
• Viberga I, Odlind V, Lazdane G, et al. Microbiology profile in women with pelvic inflammatory disease in relation to IUD use. Infect Dis Obstet Gynecol 2005;13:183–90.
• Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59:1.
• Yang CC, Chen P, Tseng JY, Wang PH. Advantages of open laparoscopic surgery over exploratory laparotomy in patients with tubo-ovarian abscess. J Am Assoc Gynecol Laparosc 2002; 9:327.

B. Fragilis

Gonorrhea + Chlamydia?

• Virulent!
• Resistance to opsonophagocystosis
• Promotes abscess formation by:
• collegenases and hyaluronidase to prevent walling off of infection
• heparinase promotes clotting small vessels to decrease blood supply to infected tissue

Unlike PID, TOA aspirates do NOT contain GC/CT.

• ______% of TOA aspirates had gonorrhea
• 31% of patients with TOA tested positive for gonorrhea in endocervix specimens

Chlamydia

Gonorrhea

• Hypersensitivity-like reaction
• host cell-mediated immune response to chlamydial heat shock protein

• attaches, penetrates and destroys ciliated and secretory cells of tube
• purulent exudates
• tissue edema
• adheres and coalesces with adjacent ovarian tissue
• complex mass

Sweet R et al.