Tubo-ovarian abscess: diagnosis, medical and surgical management

Similarities in Pathogenetic Mechanisms Underlying the Bidirectional Relationship between Endometriosis and Pelvic Inflammatory Disease

BACKGROUND

Endometriosis is a common inflammatory disease characterized by the presence of endometrial cells outside of the uterine cavity. Endometriosis affects 10% of women of reproductive age and significantly reduces their quality of life as a result of chronic pelvic pain and infertility. Biologic mechanisms, including persistent inflammation, immune dysfunction, and epigenetic modifications, have been proposed as the pathogenesis of endometriosis. In addition, endometriosis can potentially be associated with an increased risk of pelvic inflammatory disease (PID). Changes in the vaginal microbiota associated with bacterial vaginosis (BV) result in PID or a severe form of abscess formation, tubo-ovarian abscess (TOA). This review aims to summarize the pathophysiology of endometriosis and PID and to discuss whether endometriosis may predispose to PID and vice versa.

METHODS

Papers published between 2000 and 2022 in the PubMed and Google Scholar databases were included.

RESULTS

Available evidence supports that women with endometriosis are at increased risk of comorbid PID and vice versa, supporting that endometriosis and PID are likely to coexist. There is a bidirectional relationship between endometriosis and PID that shares a similar pathophysiology, which includes the distorted anatomy favorable to bacteria proliferation, hemorrhage from endometriotic lesions, alterations to the reproductive tract microbiome, and impaired immune response modulated by aberrant epigenetic processes. However, whether endometriosis predisposes to PID or vice versa has not been identified.

CONCLUSIONS

This review summarizes our current understanding of the pathogenesis of endometriosis and PID and discusses the similarities between them.

Endometriosis is a risk factor for recurrent pelvic inflammatory disease after tubo-ovarian abscess surgery

PURPOSE

To evaluate the clinical outcomes and prognosis of patients undergoing laparoscopic surgery for tubo-ovarian abscess (TOA) and identify risk factors for pelvic inflammatory disease (PID) recurrence.

METHODS

We conducted a retrospective cohort analysis including 98 women who underwent laparoscopic surgery for TOA at the Department of Obstetrics and Gynecology at the Bern University Hospital from January 2011 to May 2021. The primary outcome studied was the recurrence of PID after TOA surgery. Clinical, laboratory, imaging, and surgical outcomes were examined as possible risk factors for PID recurrence.

RESULTS

Out of the 98 patients included in the study, 21 (21.4%) presented at least one PID recurrence after surgery. In the univariate regression analysis, the presence of endometriosis, ovarian endometrioma, and the isolation of E. coli in the microbiology cultures correlated with PID recurrence. However, only endometriosis was identified as an independent risk factor in the multivariate analysis (OR (95% CI): 9.62 (1.931, 47.924), p < 0.01). With regard to the time of recurrence after surgery, two distinct recurrence clusters were observed. All patients with early recurrence (≤ 45 days after TOA surgery) were cured after 1 or 2 additional interventions, whereas 40% of the patients with late recurrence (> 45 days after TOA surgery) required 3 or more additional interventions until cured.

CONCLUSION

Endometriosis is a significant risk factor for PID recurrence after TOA surgery. Optimized therapeutic strategies such as closer postsurgical follow-up as well as longer antibiotic and hormonal therapy should be assessed in further studies in this specific patient population.

Antibiotic Resistance and Mechanisms of Pathogenic Bacteria in Tubo-Ovarian Abscess

A tubo-ovarian abscess (TOA) is a common type of inflammatory lump in clinical practice. TOA is an important, life-threatening disease, and it has become more common in recent years, posing a major health risk to women. Broad-spectrum antimicrobial agents are necessary to cover the most likely pathogens because the pathogens that cause TOA are polymicrobial. However, the response rate of antibiotic treatment is about 70%, whereas one-third of patients have poor clinical consequences and they require drainage or surgery. Rising antimicrobial resistance serves as a significant reason for the unsatisfactory medical outcomes. It is important to study the antibiotic resistance mechanism of TOA pathogens in solving the problems of multi-drug resistant strains. This paper focuses on the most common pathogenic bacteria isolated from TOA specimens and discusses the emerging trends and epidemiology of resistant Escherichia coli, Bacteroides fragilis, and gram-positive anaerobic cocci. Besides that, new methods that aim to solve the antibiotic resistance of related pathogens are discussed, such as CRISPR, nanoparticles, bacteriophages, antimicrobial peptides, and pathogen-specific monoclonal antibodies. Through this review, we hope to reveal the current situation of antibiotic resistance of common TOA pathogens, relevant mechanisms, and possible antibacterial strategies, providing references for the clinical treatment of drug-resistant pathogens.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Tubo-ovarian abscess: Exploring optimal treatment options based on current evidence

Purpose:

Tubo-ovarian abscess (TOA) and pelvic abscess are characterized by an inflammatory pelvic mass. In the majority of cases, this condition involves the ovaries, the fallopian tubes and/or any other adjacent tissue. TOA is considered a severe complication of PID and can cause severe sepsis. The main risk factors for women’s health are the size of the abscess, the initial amount of white blood cells (WBC), patients’ age as well as, any co-existing comorbidities.

Methods:

This study provides a review of the current literature regarding the management of TOA and the different criteria used in order to establish the optimal therapeutic approach or to predict outcome by individualizing cases. Four major search engines, MEDLINE, Google Scholar, PubMed and EMBASE, up to February 2020 were explored, focusing in epidemiology and risk factors, pathogenesis, diagnosis and treatment.

Results:

Our review suggests that there are no clear guidelines for best practice, in case of TOA, but it appears that intravenous antibiotics combined with interventional radiology have good results for TOA <5 cm. When TOA is >5 cm, laparoscopic approach is indicated. Further studies are needed in order to evaluate the best treatment for women with TOA.

Conclusions:

More prospective studies on large-series of patients are in need, in order to determine a clear pathway and to suggest specific criteria, which can guide clinicians to choose optimal approach in a timely manner.

Chronic tubo-ovarian abscess complicated by hepatic portal venous gas

44-year-old female with massive chronic tubo-ovarian abscess complicated by hepatic portal venous gas (HPVG). She presented to the emergency department of our hospital with a diffusely tender abdomen and 2 weeks history of frequent non-bloody loose stools. She had a relevant past medical history of poorly controlled type 1 diabetes mellitus and hypertension. Abdominal computerized tomography revealed massive right abdomino-pelvic mass measuring 17.6 × 12.1 × 20 cm and diffuse HPVG. Patient underwent exploratory laparotomy, salpingo-oophorectomy, peritoneal lavage with antibiotics and treatment for septic shock. No similar case known to us has been reported in the literature previously.

Emergency surgery for tubo-ovarian abscess identified extended-spectrum beta-lactamase-producing Escherichia coli: the first case presentation revealing causative bacteria

We report herein a 41-year-old female with a tubo-ovarian abscess (TOA), which microbial cultures showed to contain extended-spectrum beta-lactamase (ESBL)-producing E. coli, a causative agent of community-acquired infection. The patient initially presented with acute abdominal pain and back pain. Pelvic computed tomography and transvaginal ultrasonography revealed multiple cystic lesions in the bilateral ovaries that suggested TOA. An emergency laparotomy was therefore performed due to the potential for life-threatening septic shock from the TOA-associated pelvic inflammatory disease. Microbial cultures of postoperative fluid discharge from the placed intra-abdominal catheter, vaginal secretions, urine, blood, and feces detected ESBL-producing E.coli. In summary, we successfully performed emergency surgery for life-threatening septic TOA caused by ESBL-producing E. coli infection.

Predictive Markers of Tubo-Ovarian Abscess in Pelvic Inflammatory Disease

BACKGROUND/AIMS

The purpose of this study was to identify predictive markers for tubo-ovarian abscess (TOA) through a comparison of clinical and laboratory data in patients diagnosed with pelvic inflammatory disease (PID).

METHODS

We reviewed the medical charts of 499 females who were admitted to hospital with clinical, surgical, imaging-based diagnoses of PID between 2001 and 2011. The patients were divided into the following two groups: (1) PID with TOA and (2) PID without TOA.

RESULTS

The TOA and non-TOA groups were comprised of 69 and 430 females, respectively. Mean age, history of intrauterine device (IUD) insertion and inflammatory markers, including erythrocyte sedimentation rate, C-reactive protein (CRP) and CA-125 levels, were higher in the TOA group than the non-TOA group. Independent factors that predicted TOA were older age, IUD insertion, increased CRP and CA-125, and chlamydia infection. CA-125 was found to have the highest predictive value for TOA. TOA size was associated with increased surgical therapy compared to patients with smaller abscesses.

CONCLUSIONS

Increased age, IUD insertion, chlamydia infection, and increased CRP and CA-125 level were the independent factors predictive of TOA in acute PID. These predictive values will be expected to help decrease gynecological morbidity by early diagnosis and appropriate treatment of TOA. © 2015 S. Karger AG, Basel.

Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children

BACKGROUND

For decades, urgent operation has been considered the only appropriate management of acute appendicitis in children. The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children.

STUDY DESIGN

A prospective nonrandomized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy was performed. The primary result was 30-day success rate of nonoperative management. Secondary outcomes included comparisons of disability days, missed school days, hospital length of stay, and measures of quality of life and health care satisfaction.

RESULTS

Seventy-seven patients were enrolled during October 2012 to October 2013; 30 chose nonoperative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of nonoperative management were 93% (28 of 30) and 90% (27 of 30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed. Compared with the surgery group, the nonoperative group had fewer disability days (3 vs 17 days; p < 0.0001), returned to school more quickly (3 vs 5 days; p = 0.008), and exhibited higher quality of life scores in both the child (93 vs 88; p = 0.01) and the parent (96 vs 90; p = 0.03), but incurred a longer length of stay (38 vs 20 hours; p < 0.0001).

CONCLUSIONS

Nonoperative management of uncomplicated acute appendicitis in children is feasible, with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of longer-term success rate, safety, and cost effectiveness.