Abstract
Pelvic inflammatory disease (PID) complicated by tubo-ovarian abscesses (TOA) has long-term sequelae in women of reproductive age. Consensus on the optimal treatment of TOA remains lacking. Most clinicians utilize antibiotics as a first-line conservative approach, failing which invasive intervention is adopted. Our aim is to identify risk factors predicting failed response to conservative medical management for TOA in an Asian population. A retrospective cohort study of 136 patients admitted to a tertiary hospital in Singapore for TOA between July 2013 and December 2017 was performed. Patients were classified into 2 groups: successful medical treatment with intravenous antibiotics and failed medical treatment requiring invasive intervention. 111 (81.6%) of patients were successfully treated with conservative medical approach using intravenous antibiotics; 25 (18.4%) required invasive intervention having failed medical therapy. Multivariate logistic regression model adjusted for age, ethnicity, C-reactive Protein (CRP), TOA size, and body mass index (BMI) showed the odds ratio (OR) of each centimetre increase in TOA size to be 1.28 (95% confidence interval (CI) 1.03-1.61; P=0.030) and every kg/m2 increase in BMI to be 1.10 (95% CI 1.00-1.21; P=0.040). Failed medical management was predicted by a cutoff of TOA size ≥ 7.4 cm and ≥ BMI 24.9 kg/m2. Patients who failed medical treatment received a mean of 4.0±2.1 days of antibiotics before a decision for invasive intervention was made, with a significantly longer intravenous antibiotic duration (9.4±4.3 versus 3.6±2.2 days; P <0.001) and prolonged hospitalization (10.8± 3.6 versus 4.5 ± 2.0 days; P <0.001) compared to the medical group. Patients with higher BMI and larger TOA size were associated with failed response to conservative medical management in our study population. Early identification of these patients for failed medical therapy is imperative for timely invasive intervention to avoid prolonged hospitalization, antibiotic usage, and patient morbidity.
Highlights
Pelvic inflammatory disease (PID) is an ascending upper genital tract infection resulting in endometritis ans salpingitis and, in severe cases, tubo-ovarian abscesses (TOA)
A retrospective cohort study was performed on a total of 136 patients admitted to a tertiary hospital in Singapore for PID complicated by TOA between July 2013 and December 2017
There were no patients who were immunocompromised or had underlying gynaecological malignancy in our cohort. 227 patients’ charts were reviewed to confirm eligibility. 77 patients were excluded as they were admitted for PID without any tubo- ovarian abscess on imaging. 14 patients were excluded due to incorrect diagnosis on admission or TOA attributable to secondary causes. 136 patients were eventually included in our study for analysis (Figure 1)
Summary
Pelvic inflammatory disease (PID) is an ascending upper genital tract infection resulting in endometritis ans salpingitis and, in severe cases, tubo-ovarian abscesses (TOA). TOA is an inflammatory mass involving the ovary, fallopian tube, and surrounding pelvic organs. It is a serious complication of PID, affecting 10-15% of patients [1]. Typical presenting complaints include fever, abdominal pain, and foul-smelling vaginal discharge. Lower abdominal tenderness, cervical excitation, and adnexal tenderness may be present, with raised inflammatory markers [5]. Delayed treatment could result in long-term sequelae in affected women, such as chronic pelvic pain, recurrent PID, distorted pelvic anatomy, infertility, and ectopic pregnancies [6, 7]
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