Tubo-ovarian Abscess Research Articles

1259 Invasive Procedure in Patients with Tubo-Ovarian Abscess: A Retrospective Study

Study Objective Tubo-ovarian abscess (TOA) is a well-established sequel of acute pelvic inflammatory disease (PID). While as up to 25% of women will experience conservative treatment failure, the factors associated with treatment failure are not clearly-established, and the role of Cancer antigen 125 (CA-125) is under-studied. We aim to evaluate the role of CA-125 in the conservative management of TOA. Design A retrospective cohort study. Setting A tertiary university-affiliated hospital during 2007-2018 Patients or Participants Ninety one patients were diagnosed with a TOA and underwent a trial of conservative management with intravenous antibiotics. Interventions Patients who eventually underwent surgical intervention were compared with patients managed conservatively. Measurements and Main Results Overall, 39/91 (42.8%) underwent an invasive intervention subsequent to failed antibiotic treatment. Patients who experienced conservative treatment failure had higher medians of inflammatory markers as CRP (15.7 vs. 10.8 mg/L, p=0.02), WBC count (14.2 vs. 12.4 1,000/mm3, p=0.04) and platelet count (374 vs. 295 109/L, p=0.04) at admission. Higher levels of CA-125 at admission were found in those who required an invasive intervention (57 vs. 30 U\ml, p=0.02) as well. The largest diameter of TOA at admission was higher in those who required an invasive intervention as compared to those who were successfully treated conservatively ((75 mm. vs. 57 mm, p=0.01). CA-125 level was found to be the only independent factor associated with conservative treatment failure (OR; 95% confidence interval [CI], 1.27, 1.08-1.48, p=0.03). Conclusion Elevated CA-125 serum levels were found to be associated with failure of conservative parenteral antibiotic therapy for TOA. This finding should be better evaluated in a prospective manner.

1885 Robotic-Assisted Hysterectomy and Bilateral Salpingo-Oophorectomy with Uterine Artery Ligation in a Case of Tubo-Ovarian Abscess with Severe Pelvic Adhesion

Video Objective Surgeries for tubo-ovarian abscess (TOA) may be very challenging due to severe adhesions from the abscess to the surrounding inflamed tissue. Treatment was often limited to drainage of the abscess due to the difficulty of more extensive surgery. This video demonstrates successful robotic-assisted total hysterectomy with bilateral salpingo-oophorectomy and uterine artery ligation with adhesiolysis for treatment of a case with tubo-ovarian abscess. Techniques of visualizing surgical anatomy and localizing the uterine artery will also be demonstrated. Setting A 41 year-old G3P2SA1 female patient presented to our out-patient clinic with lower abdominal pain with fever for 1 month. She had undergone cesarean delivery twice 17 and 18 years ago with no other significant gynecologic history. On pelvic examination, lifting tenderness with moderate odorous discharge was noted. Transvaginal ultrasound showed bialteral adnexal mass, measuring 5 × 2 cm and 5 × 3 cm. She was then admitted to our department under the tentative diagnosis of tubo-ovarian abscess. Interventions Robotic-assisted total hysterectomy with bilateral salpingo-oophorectomy, uterine artery ligation and adhesiolysis was performed on the second day of hospitalization. Conclusion Total hysterectomy with bilateral salpingo-oophorectomy may be feasible in the treatment of tubo-ovarian abscess by using robotic-assisted instruments. Due to the greater precision, better visualization, and higher dexterity of robotic-assisted surgeries.

1787 A Case of Female Genital Tuberculosis with Superimposed Tubo-Ovarian Abscess in a Developed Nation

Video Objective To describe the surgical techniques in a case of female genital tuberculosis (TB) with superimposed tubo-ovarian abscess (TOA) in a developed country. Setting A 22-year-old G0 who was born in Vietnam presented to the emergency room with pelvic pain and known bilateral hydrosalpinx. She was treated for pelvic inflammatory disease, and a TB test was sent and later returned as positive. Her initial chest x-ray was read as normal. When she returned for follow up, a CT scan was planned to evaluate the extent of pulmonary and possible pelvic disease. However, before this could be done, she became febrile, requiring hospitalization with concern for TB or TOA. Interventions Once pulmonary and peritoneal TB were suspected based on imaging, diagnosis of TB was attempted via sputum culture and endometrial biopsy. However, there was significant concern that the patient had a tubo-ovarian abscess given the high fevers, dilated tubes, and delay in urogenital TB diagnosis confirmation. This led to the patient being taken to the operating room for diagnostic laparoscopy and drainage of the tube. This video shows the techniques used to evaluate pelvic organs when acute infection is suspected. Ultimately, the endometrial biopsy returned positive for culture of Mycobacterium tuberculosis, confirming the diagnosis of female genital tuberculosis. Conclusion This patient was diagnosed genital TB with superimposed bacterial infection, leading to the pyosalpinx. Female genital TB can cause a diagnostic challenge, and surgery may be required to achieve a diagnosis. Pre-operative planning and careful surgical technique is essential when faced with dense adhesions.

2199 Endoscopic Ultrasound-Guided Transrectal Drainage of a Tubo-Ovarian Abscess via a Lumen-Apposing Metal Stent

INTRODUCTION: Tubo-ovarian abscess (TOA) is a potentially lethal condition requiring a combination of medical and surgical intervention. Endoscopic ultrasound (EUS)-guided drainage is a known modality for safe and effective management of pelvic collections, but its role in TOA drainage is not well documented. We present a case of a TOA treated successfully with EUS-guided transrectal drainage using a lumen apposing metal stent (LAMS). CASE DESCRIPTION/METHODS: A 45-year-old woman presented to the hospital with a 4-day history of left lower quadrant abdominal pain. Her medical history included a right-sided TOA treated with antibiotics one year ago, type II diabetes mellitus, and obesity. She was tachycardic and tachypneic on arrival with a leukocytosis and elevated inflammatory markers. Computed tomography (CT) revealed a 11.3 × 10.3 × 9.4 cm complex cystic structure within the left adnexa consistent with a TOA (Image 1). Due to worsening leukocytosis and abdominal pain, interventional radiology was consulted but could not find a safe window for percutaneous drainage. A rectal EUS subsequently revealed a 50 × 45 mm abscess 20 cm from the anal verge (Image 2). A 19-gauge EZ-Shot 3 FNA needle was advanced with return of purulent fluid. After injection of 15 cc ionic contrast to delineate the abscess and confirm positioning, EUS-guided transrectal drainage of the TOA with placement of a 15 × 10 mm AXIOS stent (Boston Scientific, Marlborough, MA, USA) was successfully performed. The distal flange was deployed within the abscess cavity and the proximal flange was deployed within the rectal lumen with copious amounts of purulent drainage through the AXIOS stent (Image 3). Repeat CT performed one week later revealed significant interval decrease in the size of the TOA. DISCUSSION: EUS-guided drainage of pelvic collections has been established as a lower-risk alternative to surgical interventions, especially for collections greater than 4 cm and within a 1-2 cm reach of the EUS transducer. Furthermore, use of LAMS can facilitate drainage through a wider conduit, promoting rapid evacuation and source control. To our knowledge, this is the first reported case of successful EUS-guided transrectal drainage of a TOA using a LAMS.

Surgical Intervention in Patients With Tubo-Ovarian Abscess: Clinical Predictors and a Simple Risk Score

(Abstracted from J Minim Invasive Gynecol 2019;26:535–543) Tubo-ovarian abscess (TOA) presents as an infectious mass of the adnexa and is a late complication of pelvic inflammatory disease (PID) in up to 30% of cases. TOA is associated with significant patient morbidities, including pain, sepsis, and recurrent hospitalizations and may lead to long-term complications such as chronic pelvic pain, pelvic adhesions, infertility, and ectopic pregnancies.

1498 A Rare Case of an Atypical Mass Involving the Sigmoid Colon

INTRODUCTION: The etiology of colonic masses is broad including benign polyps, primary adenocarcinoma, metastases, and diverticular mass. Presentation may be similar; therefore, the differentiation generally involves biopsy for histological evaluation and appropriate diagnosis. CASE DESCRIPTION/METHODS: A 34-year-old female presented with hematochezia and constipation. Her past medical history was significant for tubo-ovarian ovarian abscesses (TOAs), endometriosis fibroids and schwannoma of the paraspinal area. She reported new onset red blood per rectum, worsening constipation, and pelvic discomfort. Family history was notable for esophageal and colorectal cancer. She subsequently underwent colonoscopy which demonstrated a 3-4 cm nodular, polypoid fungating mass in the distal sigmoid colon located at 20-25 cm from the anal verge (Figure 1). Biopsies were obtained and the site was tattooed. A subsequent MRI of the abdomen and pelvis showed a heterogeneous inflammatory soft tissue encasing the ovaries and tethering the rectosigmoid colon (Figure 2). Additionally, there was a enhancing soft tissue mass invading the inferior wall of the distal sigmoid colon with an intraluminal component. The MRI findings were felt to be consistent with invasive endometriosis. Histological examination of the sigmoid mass showed colonic mucosa with polypoid endometriosis without evidence of malignancy (Figure 3). Cells showed positive immunohistochemical staining consistent with endometriosis. Surgical resection was recommended. DISCUSSION: This case demonstrates the importance of having a high suspicion of endometriosis involving the bowel in reproductive age women presenting with abdominal pain, dysmenorrhea, dyspareunia, and dyschezia. Endometriosis is a condition involving the implantation of endometrial stroma and glands at extra-uterine sites. Endometriosis tends to involve bowel serosa. It rarely encompasses full thickness of the bowel wall. The latter represents invasive endometriosis. Many patients are incorrectly diagnosed given their presentation. This disease increases risk of gastrointestinal tumors, primarily adenocarcinoma. Therefore, prompt recognition and treatment with hormonal therapy or surgical excision is important for symptom relief, increase in fertility, and later complications such as bowel stenosis, hydronephrosis, and malignant transformation.

Evaluation of risk factors predicting surgical treatment in tuboovarian abscess cases

Objective: The main outcome measure of the present study was to find out the predictive factors affecting the need for surgery in patients diagnosed with tuboovarian abscess (TOA). We also examined the success of different medical treatment regimens in those patients.
 Material and Methods: This was a retrospective clinical study performed on 96 TOA patients who were treated in the current hospital between August 2015 and August 2019. All patients underwent physical examination and ultrasonographic imaging with some laboratory tests to investigate the presence of TOA. Two different medical treatment regimens were administered as recommended by the international guidelines after the initial diagnoses. Patients with worsening clinical and/or laboratory findings and/or who did not respond to medical treatment were taken to surgery. Predictive factors for surgical intervention and success rates of medical treatment regimens were evaluated.
 Results: White blood cell (WBC) levels≥ 16000 and abscess size≥ 7 cm was strongly correlated with the requirement for surgery. The 94 patients received the Regimen 1. Six patients underwent surgery urgently when they were under medical treatment. Regimen 1 failed in 21 (22.34 %) patients out of 94, Regimen 2 was shifted to. Six patients (28.5%) out of 21 underwent surgery because of treatment failure with Regimen 2. Recovery was achieved in the remaining 15 (71.4%) patients.
 Conclusion: The success of medical TOA treatment was found to be high. Therefore, medical treatment can be applied first, except in case of acute abdomen. It was found that WBC and abscess diameter in patients with TOA in admission were the most important factors affecting the need for surgery. The factors affecting the duration of medical treatment were found to be age, WBC count, CRP (C-Reactive Protein), ESR (Erythrocyte Sedimentation Rate) and NLR (Neutrophil/Lymphocyte Ratio) levels.

EP33.17: Prolapsed submucous myoma with incidental finding of endocervical adenocarcinoma

A 31 y.o. nulligravid, with vaginal bleeding and hypogastric pain for 17 days. Treated as abnormal uterine bleeding due to prolapsed submucous myoma and pelvic inflammatory disease. Pap smear negative for premalignant lesions and HPV DNA test negative, with 6 x 5 cm firm mass at the internal cervical os, uterus 14 week size with bilateral adnexal tenderness. TVS showed enlarged uterus, 9.30 x 7.47 x 9.59 cm, dilated endometrial cavity with fluid of low level echoes, three intramural myomas as with subserous 3.58 x 3.28 x 3.68 cm; 4.74 x 2.71 x 4.10 cm and 1.70 x 1.18 x 1.41 cm. Enlarged cervix 5.61 x 4.05 x 5.95 cm heterogeneous mass 4.03 x 0.99 x 2.60 cm, colour score = 3, moderate flow. Endometrial thickness is 8 mm, with sub mucous myoma 2.67 x 2.63 x 1.44 cm. Right adnexa has irregular mass 8.00 x 3.37 x 7.88 cm or tubo-ovarian abscess. Treated by a gynecologic-oncologist, given 2 doses of Leupron injection 3.75 mg/IM and treated for PID, readmitted with the same TVS findings. Patient underwent hysteroscopic resection of the endocervical myoma and endometrial curettage. Histopathology result was cervical and endometrial adenocarcinoma. Immunochemical stains were negative for P16, ER, PR and positive for CK20, CDX2, CEA and CK 7 (focal). Immunomorphologic findings compatible with colon primary. In the USA, cervical cone biopsy done, colonoscopy and endoscopy, CT with contrast and PET scan are negative for primary colon. Diagnosed as endocervical cancer stage 2B and is for chemotherapy, radiation and brachytherapy. Incidence cervical adenocarcinoma is more common than squamous cell carcinoma. Human papillomavirus (HPV) is a primary cause. The average age is 45-55 years old, but can be seen in younger women. The symptom is abnormal vaginal bleeding. Diagnosis is based on cervical biopsy. According to FIGO clinical staging is based on pelvic exam, cystoscopy, and rectoscopy. Pelvic ultrasound with Doppler studies, MRI and PET scan can be used for evaluation of cervical cancer for optimal treatment. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Can the Need for Invasive Intervention in Tubo-ovarian Abscess Be Predicted? The Implication of C-reactive Protein Measurements

To evaluate the clinical parameters of hospitalized patients with pelvic inflammatory disease (PID) for the presence of tubo-ovarian abscess (TOA) and predict the need for intervention. A prospective cohort study. A tertiary care university medical center. Ninety-four patients were diagnosed with complicated PID and hospitalized between 2015 and 2017. Patients with PID were treated with parenteral antibiotics according to Centers for Disease Control guidelines. Demographic, clinical, sonographic, and laboratory data for patients with PID were analyzed. Inflammatory markers including C-reactive protein (CRP), white blood cells (WBCs), erythrocyte sedimentation rate (ESR), and clinical parameters were collected at admission and during hospitalization. Forty-eight of 94 patients (51.1%) hospitalized with complicated PID were diagnosed with TOA sonographically. CRP levels were the strongest predictor of TOA, followed by WBC count, ESR, and fever on admission. The areas under the receiver operating characteristic (ROC) curve for CRP, WBC, ESR, and fever were .92, .75, .73 and .62, respectively. CRP specificity was 93.4% and sensitivity was 85.4% for predicting TOA, with cutoff value of 49.3 mg/L. Twelve patients (25%) failed conservative management and underwent surgical intervention including laparoscopy (n = 7), computed tomography (CT)-guided drainage (n = 4), and laparotomy (n = 1). In this group, CRP levels significantly increased from admission to day 1 and day 2 during hospitalization (128.26, 173.75, and 214.66 mg/L, respectively; p < .05 for both). In the conservative management group, CRP levels showed a plateau from admission to day 1 and then a decrease until day 3 (110, 120.49, 97.52, and 78.45 mg/L, respectively). CRP is a sensitive, specific inflammatory marker for predicting TOA in patients with complicated PID, and levels >49.3 mg/L suggest the presence of TOA. In the TOA group, CRP level trends correlated well with success or failure of conservative management. Increasing CRP levels during treatment may be used as an indicator of the need for invasive intervention, and daily CRP measurements can help predict the need for invasive intervention.

Xanthogranulomatous Salpingitis.

There are approximately a dozen cases of xanthogranulomatous salpingitis reported in the literature, mostly as case reports. Thirteen such cases were identified from 2003 to 2018 at our institution. Patient's ages ranged from 21 to 75 yr old (median and mean, 49 yr). Clinical presentations and surgical indications included pelvic inflammatory disease (5 cases), endometrial carcinoma (4 cases), suspicion of ovarian malignancy (1 case), symptomatic fibroids (1 case), endometriosis (1 case), and infertility (1 case). Surgical-pathologic correlation resulted in diagnoses of tubo-ovarian abscess (4 cases), ovarian abscess (2 cases), pyosalpinx (2 cases), and chronic endometritis (2 cases). Of the remaining 3 cases, 2 presented clinically as pelvic inflammatory disease and the other was seen in the context of an endometrial carcinoma. In summary, this case series from a single institution shows that xanthogranulomatous salpingitis is an uncommon form of chronic inflammation that may be diagnosed from reproductive to menopausal age. With one exception, the cases in this series represent pelvic inflammatory disease despite variable clinical presentations. Pseudoxanthomatous salpingitis should be in the differential diagnosis.

A tubo-ovarian abscess mimicking an appendiceal abscess: a rare presentation of Streptococcus agalactiae.

A tubo-ovarian abscess (TOA) is a relatively rare medical complication that results from an untreated/unrecognized ascending pelvic infection of the female genital tract. In a right-sided TOA, this clinical entity may mimic appendicitis on computed tomography (CT). In addition, both disease processes can present with pelvic pain, leukocytosis and fever. We present the case of a 47-year-old female with mid right-sided abdominal pain that was diagnosed on CT scan with an appendiceal abscess. She underwent CT-guided percutaneous drainage with interventional radiology. On Day 8, a CT limited study involving a contrast injection was performed to evaluate for abscess resolution. The contrast within the drain filled the fallopian tube, endometrial cavity and contralateral fallopian tube. These findings demonstrated that the initial diagnosis actually represented a TOA. To the authors’ knowledge, this is the only reported case involving a TOA secondary to Streptococcus agalactiae (GBS) mimicking an appendicitis with abscess formation.

No. 385-Indications for Pelvic Examination.

No. 385-Indications for Pelvic Examination.

Fertility outcomes in patients with tubo-ovarian abscesses after an oocyte retrieval: a longitudinal cohort analysis.

To determine the impact of pelvic inflammation caused by tubo-ovarian abscess (TOA) on ovarian response to stimulation. This retrospective longitudinal cohort analysis that was carried out in a tertiary university-affiliated medical center included 15 women with TOA during in vitro fertilization (IVF) cycles. The ovarian response to stimulation and the pregnancy rate were compared in two subsequent cycles, the initial IVF cycle that was complicated by TOA after oocyte retrieval (first treatment cycle) and the following IVF treatment (second treatment cycle) that occurred within a period of a year from the first cycle. The mean number of retrieved oocytes was significantly higher in the first IVF cycle compared to the second cycle (8.1 ± 3.2 vs. 5.4 ± 2.5, P = .003], corresponding to a 30% reduction in ovarian response to gonadotropin stimulation. Fertilization rates were significantly lower in the second cycle (4.1 ± 2.9 vs. 2.9 ± 1.7, P = .015). Twelve women (80%) reached embryo transfer in the first cycle compared to 14 women (93.3%) in the second cycle. The mean number of transferred embryos was similar between the two cycles. There were no clinical pregnancies following the first cycle, and only one patient (6.6%) had a clinical pregnancy in the second treatment cycle. TOA following fertility treatment has a detrimental effect on ovarian function. The pregnancy rate in the immediate period following TOA is poor. Current data for recommending the deferral of fertility treatment following a TOA episode are insufficient, calling for more studies to address these issues.

Conservative management for postmenopausal women with tubo-ovarian abscess.

The aim of the study was to describe the experience of one institution in management and outcome of tubo-ovarian abscess (TOA) in pre- and postmenopausal women and to reassess the optimal approach for TOA in postmenopausal women. A retrospective cohort study included women diagnosed with TOA between 2003 and 2017 in a tertiary referral center. TOA was diagnosed by sonography or computerized tomography and at least one of the following criteria: temperature more than 38°C, leukocytosis more than 15,000 mm, or surgically proven disease. Women were followed up for a mean of 7.6 years (range 6 mo to 14 y). The rates of conservative management and pelvic malignancy were evaluated. The study cohort included 144 (69.23%) women who met the inclusion criteria, of which 105 (72.92%) were premenopausal and 39 (27.08%) were postmenopausal. Univariate analysis found no differences in risk factors and disease characteristics between the two groups. Among the study sample, 22 (56.4%) postmenopausal women and 48 (45.7%) premenopausal women were treated surgically (P = 0.5). None of the premenopausal women and 1 (2.6%) postmenopausal woman were diagnosed with pelvic malignancy. In postmenopausal women with TOA, the prevalence of concurrent pelvic malignancy was 2.6%, which is higher than in the general population, but lower than that reported in the literature; 44% were conservatively managed without any apparent cases of misdiagnoses of cancer.

Acute pelvic inflammatory disease: a narrative review

Background and objective: Pelvic inflammatory disease (PID) is an upper genital tract infection in females that is typically acquired via sexual activity. It usually is initiated by the presence of Chlamydia trachomatis and/or Neisseria gonorrhoeae and escalates into a polymicrobial infection from local genital tract flora. Research identifies various known risk factors including young age, immunopathology and others. This article reviews the epidemiology, differential diagnosis, management, and concepts of prevention for PID. Methods: An electronic search was performed on MEDLINE to identify relevant articles from 2010 to 2018. Key Content and Findings: PID continues to be a major sexually transmitted disease among adolescent and young adult females. Among the 1 million cases that are found in the United States (U.S.) each year, about one-third are in adolescent females. It is typically a polymicrobial infection that can lead to acute salpingitis, perihepatitis, endometritis, oophoritis, pelvic peritonitis and/or tubo-ovarian abscess. Diagnostic criteria and recommended treatment have been developed by the U.S. Centers for Disease Control and Prevention (CDC). Complication of PID include chronic pelvic pain, ectopic pregnancy and infertility. Conclusions: PID is a common sexually transmitted disease that is found in many adolescents and young women. The possibility of PID should be seriously considered by clinicians when evaluating a sexually active teenage or young adult female with lower abdominal pain, vaginal discharge, vaginal bleeding, urinary symptoms, post-coital bleeding and/or dyspareunia. It may be a silent infection as well. Various risk factors for PID are noted including the adolescent age group, ectropion of young adolescent females, immature immune system, multiple coital partners and others. Clinicians should follow treatment protocols established by the CDC and the World Health Organization (WHO). The problem of PID should stimulate clinicians and society to provide comprehensive sexuality education to our youth.

Clinical value of early laparoscopic therapy in the management of tubo‑ovarian or pelvic abscess

Broad-spectrum antibiotics are the conservative treatment for tubo-ovarian abscess (TOA) or pelvic abscess, but the failure rate of antibiotic therapy remains higher in patients with a larger abscess. The present study aimed to evaluate the clinical value of early laparoscopic therapy in the management of TOA or pelvic abscess. A total of 100 patients were enrolled and their medical records were retrospectively analyzed after excluding 6 patients with malignant diseases. Based on the treatment they had received, the patients were divided into a conservative treatment group (n=41) and an early laparoscopic treatment group (n=53). In the conservative treatment group, 21 patients (51.2%) finally received laparoscopic exploration (late laparoscopic treatment group), and 20 patients (48.8%) achieved a success of antibiotic therapy (successful antibiotic therapy group). The cut-off value of abscess size for predicting antibiotic treatment failure was determined using receiver operating characteristic curve analysis. Multivariate logistic regression analyses were used to explore the association between the clinical variables and antibiotic therapy failure in conservative treatment group. The durations of elevated temperature >38.0°C and hospitalization were significantly longer in the conservative treatment group than those in the early laparoscopic treatment group (all P<0.001). The patients in the late laparoscopic treatment group had a larger abscess size than those in the successful antibiotic therapy group (6.2±1.8 cm vs. 4.8±1.4 cm, P=0.008). An abscess diameter of 5.5 cm was obtained as the cut-off of antibiotic failure, and the sensitivity and specificity were 81.0 and 85.0%, respectively. An abscess diameter of ≥5.5 cm was independently associated with antibiotic failure (odds ratio=5.724; 95%CI: 2.025–16.182; P=0.001). In conclusion, early laparoscopic treatment was associated with a better clinical prognosis than conservative treatment and late laparoscopic therapy for TOA or pelvic abscess patients.

Tubo-ovarian abscess with sepsis in a nonagenarian woman: a case report and literature review

BackgroundA complete infectious focus survey relies on a thorough physical examination as well as a pelvic examination. Tubo-ovarian abscess, though less likely to occur in senior women, may become a life-threatening disease requiring emergent surgery. Hence, clinical awareness and aggressive management are warranted to avoid delayed diagnosis and subsequent complications.Case presentationWe report a post-menopausal woman presented with sepsis of unknown origin, which turned out to be a huge tubo-ovarian abscess. Although tubo-ovarian abscess mostly occurs in women of fertile age, it is likely that the immune status of our post-menopausal patient was compromised because of old age and uremia. Moreover, due to underlying dementia, she could not express her discomfort in the early stage. Her sepsis resolved after a unilateral salpingo-oophorectomy surgery and antibiotic treatment. It is crucial to exclude pelvic inflammatory disease (PID) if no specific source of infection can be identified.ConclusionsRupture of the tubo-ovarian abscess is a condition of high mortality rate. Although tubo-ovarian abscess is more likely to develop in patients aged 15–25 years old, the tubo-ovarian abscess should be listed as a differential diagnosis in all post-menopausal women, especially those who are immunocompromised or with a palpable pelvic mass, to enable timely management and better prognosis.

Tubo-Ovarian Abscesses in Nonsexually Active Adolescent Females: A Large Case Series

PurposeThe aim of the study was to review the incidence, presentation, and management of tubo-ovarian abscesses (TOA) in nonsexually active (NSA) adolescents. MethodsA retrospective chart review was performed at a single children's hospital. We evaluated self-reported NSA females aged < 21 years diagnosed with TOA. Demographics, presenting symptoms, medical history, laboratory studies, imaging, and treatment were reviewed. ResultsSixteen NSA females met inclusion criteria, with one patient presenting with two separate TOAs. Mean age at diagnosis was 14.6 ± 1.8 years; all were menarchal. Presenting symptoms included abdominal pain (88%), fever (76%), and vomiting (53%). Eleven patients (65%) received transabdominal pelvic ultrasound, 2 (12%) had magnetic resonance imaging of pelvis, and 11 (65%) had computed tomography of abdomen/pelvis. All patients had negative gonorrhea and chlamydia testing. Thirteen (76%) had comorbid disease including obstructed hemivagina ipsilateral renal agenesis, active or recent appendicitis, or genitourinary tract anomalies. Sixteen cases underwent drainage via interventional radiology or surgery. Twelve cases (71%) had TOA fluid cultured; five (29%) grew Escherichia coli species. All cases received intravenous antibiotics, and 88% of cases continued outpatient oral antibiotics. ConclusionsAlthough uncommon in NSA females, patients with underlying comorbidities may be at increased risk for TOA formation. Providers should consider the diagnosis of TOA even in NSA females.

Surgical Management of Severe Pelvic Inflammatory Disease: Laparoscopy or Laparotomy?

Treatment of women with severe pelvic inflammatory disease (PID) and tubo-ovarian abscesses is complex, typically including broad-spectrum antibiotics

Tubo-Ovarian Abscesses: Epidemiology and Predictors for Failed Response to Medical Management in an Asian Population.

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.