Tubo-Ovarian Abscess Management Options for Women Who Desire Fertility

Complicated appendicitis in the pediatric patient: interventional perspectives

This pictorial review provides a comprehensive visual and textual overview of interventional radiology approaches in treating complicated appendicitis and other abdominal abscesses in children. This review discusses the incidence and complications associated with appendicitis in pediatric patients, highlighting the role of percutaneous drainage in managing appendicitis with abscesses. We present common mimics of intra-abdominal abscesses from other diseases such as tubo-ovarian abscesses, inflammatory bowel disease, and lymphomatous bowel involvement, emphasizing imaging pitfalls that can mimic appendiceal abscesses. The review also covers interventional radiology considerations, including antibiotic indications, local anesthesia considerations for children, the comparison between percutaneous and endocavitary approaches, and the roles of fibrinolytics are discussed here. Detailed discussions on catheter selection and insertion techniques, such as Seldinger and trocar, are provided along with post-procedure management strategies. These include drain maintenance, navigating drain associated complications, and determining when to remove the drain. Through high-quality images and concise descriptions, we illustrate procedural intricacies and clinical scenarios encountered in practice, offering a valuable educational resource for clinicians managing pediatric abscesses.

Tubo-ovarian abscess caused by Clostridioides difficile after eight months of surgery: Case report and review of extraintestinal abdominal abscess cases

We present a case of tubo-ovarian abscess (TOA) caused by Clostridioides difficile (CD) in a 43-year-old female. Despite lacking a history of sexually transmitted diseases, the patient had undergone paraovarian cystectomy nine months before admission. Transvaginal ultrasonography performed eight months post-surgery revealed left ovarian enlargement, accompanied by subsequent lower abdominal pain and fever exceeding 38 °C. As oral antibiotic treatment was ineffective, the patient was admitted to our hospital. Computed tomography upon admission revealed a massive TOA. Surgical drainage of the abscess was performed, and CD was identified in the culture from the pus. The TOA was treated with a three-month course of metronidazole and oral amoxicillin/clavulanic acid. While CD is commonly associated with colitis, extraintestinal manifestations are exceptionally rare. This case represents the inaugural report of TOA resulting from CD. A literature review on abdominal and pelvic CD abscesses found that patients undergoing surgical drainage had a favorable prognosis. Therefore, surgical intervention plays an important role in the management of CD abscesses.

Large Douglas Abscess with Distinctive Bilateral Salpingitis in a Young Virginal Woman 6 Months Following Small Bowel Perforation at the Level of the Jejunojejunostomy After Roux-en-Y Gastric Bypass: A Case Report

Douglas abscesses (DA) involving the ovaries and/or fallopian tubes and tubo-ovarian abscesses (TOA) constitute a very rare finding in virginal females. Underlying conditions are suspected to play a role in their development; often however, the exact pathomechanism remains hypothetical or unknown. We report the case of a 19-year-old virginal female who was referred to our outpatient clinic for further clarification of a 6-month ongoing secondary amenorrhea. In the course of the investigations, a large Douglas abscess with distinctive bilateral salpingitis was diagnosed as an incidental finding in a basically oligosymptomatic patient. Laparoscopic abscess drainage was performed and appropriate antibiotic therapy administered. Intraoperatively collected specimens revealed Escherichia coli to be the responsible pathogen and detected foreign body giant cell reaction to intestinal contents on histopathological workup. Retrospectively, a small bowel perforation at the level of the jejunojejunostomy after Roux-en-Y gastric bypass with spillage of intestinal contents and positive cultures for Escherichia coli, 6 months prior to her referral, was identified as the triggering event. This case, however unique its pathomechanism may be, demonstrates that a history of intestinal leakage in the context of bowel surgery should be considered a relevant risk factor for the development of DA and TOA in virginal females, even if the primary cause lies several months in the past. It is under these circumstances that the clinical presentation can be atypical and misleading, making it all the more difficult to diagnose. Nonetheless, considering the possibility of this rare condition in light of medical history is crucial.

Perioperative care of a patient with immune thrombocytopenia purpura undergoing tubo-ovarian abscess incision and drainage: Case report

Key Clinical Massage

Tubo-ovarian abscess (TOA) is a serious health hazard for women, causing severe sepsis. Antimicrobial treatment is effective, but one-third of patients experience unfavorable outcomes. ITP, an autoimmune condition, can lead to bruising and bleeding. Diagnosing TOA in women of childbearing age is crucial, and combining emergency surgery with ITP patients can increase treatment costs and reduce quality of life. ITP can lead to severe complications, including postoperative hemorrhage, and may require platelet transfusions, glucocorticosteroids, and immunoglobulin. These treatments increase costs, decrease quality of life, and impact prognosis. Preventing ITP is crucial. Patients should be administered blood products based on platelet count and anemia or spontaneous bleeding tendencies. Perioperative blood management should aim for a target platelet level of 30 × 109/L and a hemoglobin concentration of 80 g/L before surgery. Post-surgery, perioperative care is crucial and vigilant for secondary bleeding.

Abstract

A tubo-ovarian abscess (TOA) is a frequently encountered inflammatory mass in therapeutic settings. TOA is a serious consequence of pelvic inflammatory disease (PID) that can lead to severe sepsis. In recent years, the incidence of TOA has increased, presenting a significant health hazard for women. To effectively target the diverse range of bacteria responsible for TOA, it is essential to use antimicrobial medicines that have a wide spectrum of activity. Nevertheless, the efficacy of antibiotic treatment stands at approximately 70%, while a significant proportion of patients, around one-third, experience unfavorable clinical outcomes necessitating drainage or surgical intervention. Immune thrombocytopenia (ITP) is an autoimmune condition characterized by a marked decrease in the quantity of platelets present in the bloodstream. ITP is characterized by thrombocytopenia, which leads to a heightened susceptibility to bruising and bleeding. The diagnosis of ITP and the prediction of treatment response continue to pose important and persistent issues in the field of hematology. The platelet count is commonly employed as a surrogate indicator of disease severity in patients with ITP and thus plays a crucial role in determining the necessity of treatment. A 25-year-old woman with a history of sexual activity underwent open abdominal exploration due to the sudden onset of lower abdominal pain. During the operation, a left TOA was discovered, and an incision and drainage were performed. Symptomatic treatments, such as anti-infectives and abdominal drainage, were administered. The culture of pus in the abdominal cavity suggested the presence of Escherichia coli. However, the patient presented with ITP and had a platelet count of less than 50 × 109/L before the operation. After the operation, the patient developed incisional and pelvic hematomas with signs of infection. As a result, the patient was discharged from the hospital after undergoing another laparotomy and receiving platelet transfusions and immunotherapy. Clinicians should be vigilant when diagnosing TOA in women of childbearing age, even in the absence of high-risk factors. A timely antibiotic or surgical intervention is necessary to preserve fertility and ensure quality of life. Combining emergency surgery with ITP patients poses a significant challenge for clinicians in terms of treatment. ITP can lead to serious complications, such as postoperative bleeding, which may require platelet transfusions, glucocorticoids, and immunoglobulin. This can increase the cost of treatment, reduce the quality of life, and seriously affect the prognosis. Therefore, preventing ITP is crucial. It is important to pay attention to the perioperative care of patients after surgery and be alert to the possibility of secondary hemorrhage.

Dispelling the Myths of Percutaneous Catheter Drainage of Infected Abdominal Collections

When consulted for percutaneous catheter drainage (PCD) of abdominopelvic collections, interventional radiologists (IRs) should consider the appropriateness of this technique in the context of other options such as conservative, endoscopic, or surgical management. Whenever possible, published data should be considered prior to performing percutaneous drainage, especially as regards controversial scenarios such as the use of fibrinolytic therapy, the primary placement of large-bore drainage catheters, the drainage of cystic tumors, the drainage of splenic abscesses, and the treatment of collections lacking an in-line drainage window. This article examines past and present published data on PCD to dispel some common myths and guide IRs toward the best applications of PCD.

Resolution of two cases of ovarian abscesses in mares subjected to ovum pick up

BACKGROUND

Currently, for in vitro embryo production in live mares, immature oocytes are retrieved by transvaginal follicular aspiration or ovum pick up (OPU). Occasionally, ovarian abscesses have been described after OPU, but no current consensus exists on how to treat this condition.

OBJECTIVES

To describe diagnosis and successful treatment of ovarian abscesses in two mares subjected to OPU.

STUDY DESIGN

Case report.

METHODS

Case records were reviewed and summarised.

RESULTS

In the first case, a pony mare showed tachypnoea, tachycardia, high temperature, leukocytosis, left hindlimb lameness and slight increase in concentration of serum amyloid A. Ultrasonography revealed an increase in the size of the left ovary and two well defined structures suggestive of ovarian abscess. A left ovariectomy by standing laparoscopy was the treatment of choice: the diagnosis was confirmed, and bacterial culture produced heavy growth of Streptococcus equi Zooepidemicus. In the second mare, an abnormal structure was observed in the left ovary in a routine transrectal ultrasonographic exam in the absence of any clinical signs or abnormal blood parameters. A medical approach was chosen and a sample of the purulent material was aspirated with a transvaginal ultrasound-guided approach. The sample yielded a heavy growth of Streptococcus equi Zooepidemicus after culture. Treatment was initiated with rifampicin and trimethoprim-sulfadiazine based on the antibiogram results and the abscess completely resolved after 40 days.

MAIN LIMITATIONS

Limited to two cases.

CONCLUSIONS

Ovarian abscesses in mares can be successfully treated both surgically and medically.

Ethanol endometrioma sclerotherapy: safety through 8 years of experience

STUDY QUESTION

What are the complications of transvaginal ethanol sclerotherapy for the treatment of endometriomas?

SUMMARY ANSWER

Sclerotherapy is a reliable, minimally invasive method applicable in outpatient procedures but with specific and potential life-threatening complications that need to be identified and prevented.

WHAT IS KNOWN ALREADY

There are currently few data on the use of transvaginal ethanol sclerotherapy, and we mainly note septic complications.

STUDY DESIGN, SIZE, DURATION

A retrospective observational cohort study was carried out. The study was conducted at an academic hospital and included 126 women aged 31.9 ± 5.5 years (mean ± SD), between November 2013 and June 2021. We analyzed a total of 157 ethanol sclerotherapy treatment (EST), treated by 131 EST procedures, in 126 women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included women with an indication for transvaginal ethanol sclerotherapy. Indications were women with at least one endometrioma over 10 mm, isolated or associated with other endometriosis locations, requiring treatment for pain or infertility before assisted reproductive treatment. We followed a standardized transvaginal ethanol sclerotherapy procedure consisting of an ultrasound-guided transvaginal puncture of one or more endometriomas under general anesthesia. The cyst content was completely removed and flushed with saline solution. Ethanol (96%) was injected at 60% of the initial volume of the endometrioma, remained in the cyst for 10 min and was then completely removed. Ethanol loss was defined as a loss of 5 ml or more than 10% of the initial volume of the injected ethanol. Failure was defined by the contraindication of endometrioma puncture because of interposition of the digestive tract, ethanol loss in the previous endometrioma treated (in case of multiple ESTs), failure to aspirate the endometriotic fluid, contraindication to start ethanol injection owing to saline solution leakage, or contraindication to continue ethanol injection owing to suspicions of ethanol leakage at sonography. Intraoperative complications were defined by ethanol loss, positive blood alcohol level, and ethanol intoxication. Postoperative complications were defined by fever, biological inflammatory syndrome, and ovarian abscess. Complications were classified according to the Clavien and Dindo surgical classification, which is a system for classifying postoperative complications in five grades of increasing severity.

MAIN RESULTS AND THE ROLE OF CHANCE

We reported a total of 17/157 (10.8%) transvaginal ethanol sclerotherapy failures during 14/131 (10.7%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. In the same sets of data, complication was reported for 15/157 (9.5%) transvaginal ethanol sclerotherapy in 13/131 (9.9%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. Nine of 126 women (7.1%) had a grade I complication, one (0.8%) had a grade II complication (medical treatment for suspicion of pelvic infection), two (1.6%) had a grade III complication (ovarian abscess) and one (0.8%) had a grade IV complication (ethanol intoxication). We did not observe any grade V complications.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study and pain assessment not considered. The benefit-risk balance of endometrioma transvaginal ethanol sclerotherapy was not evaluated.

WIDER IMPLICATIONS OF THE FINDINGS

Our study is the first to evaluate the complications of transvaginal ethanol sclerotherapy with such a large cohort of women in a standardized protocol. Transvaginal ethanol sclerotherapy seems to be an effective alternative to laparoscopic surgery in the management of endometriomas and limits the alteration of ovarian reserve. Transvaginal ethanol sclerotherapy is a reliable, minimally invasive method applicable on an outpatient basis. The majority of complications are Clavien-Dindo ≤IV, for which preventative measures, or at least early diagnosis and treatment, can be easily performed. The risk of ethanol intoxication is rare, but it is a life-threatening risk that must be avoided by appropriate implementation and promotion of the sclerotherapy procedures.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

Aix Marseille University's ethics committee registration number 2021-06-03-01.

Bilateral or unilateral tubo-ovarian abscess: exploring its clinical significance

OBJECTIVES

To assess the characteristics of patients with unilateral and bilateral tubo-ovarian abscess (TOA).

METHODS

Women diagnosed with TOA during 2003-2017 were included in this retrospective cohort study. TOA was diagnosed using sonography or computerized tomography and clinical criteria, or by surgical diagnosis. Demographics, sonographic data, clinical treatment, surgical treatment, and post-operative information were retrieved.

RESULTS

The study cohort included 144 women who met the inclusion criteria, of whom 78 (54.2%) had unilateral TOA and 66 (45.8%) had bilateral TOA. Baseline characteristics were not different between the groups. There was a statistical trend that women with fewer events of previous PID were less likely to have with bilateral TOA (75.3% vs. 64.1%, respectively; p = 0.074). Women diagnosed with bilateral TOA were more likely to undergo surgical treratment for bilateral salpingo-oophorectomy compared to unilateral TOA (61.5% vs. 42.3%, respectively; p = 0.04). There was no difference in maximum TOA size between groups.

CONCLUSIONS

This study detected a trend toward increased need for surgical treatment in women diagnosed with bilateral TOA. These findings may contribute to determining the optimal medical or surgical treatment, potentially leading to a decrease in the duration of hospitalization, antibiotic exposure, and resistance. However, it is important to acknowledge that the results of the current study are limited, and further research is warranted to validate these potential outcomes.

Image-guided drainage management of tubo-ovarian abscess and the role of C-reactive protein measurements in monitoring treatment response: a single-center experience

PURPOSE

We aimed to compare the results of image-guided drainage in addition to antibiotic therapy (antibiotherapy) with antibiotherapy alone in the treatment of tubo-ovarian abscesses (TOAs) and evaluate C-reactive protein (CRP) levels in predicting the success of antibiotherapy.

METHODS

This was a retrospective study of 194 patients hospitalized with TOA. Patients were divided into the following two groups: those who underwent image-guided drainage in addition to parenteral antibiotherapy and those who did not undergo image-guided drainage and received antibiotherapy alone. CRP levels on the day of admission (day 0), day 4 of hospitalization (day 4), and day of discharge (last day) were recorded. The percentage of decrease in CRP levels during day 4 and the last day compared with that on day 0 was calculated.

RESULTS

A total of 106 patients (54.6%) underwent image-guided drainage with antibiotherapy, whereas 88 patients (45.4%) did not undergo drainage and received antibiotherapy alone. At admission, the mean CRP level was 203.4 (± 96.7) mg/L and was similar in both groups. The mean decrease in the CRP level on day 4 compared with that on day 0 was 48.5% and was statistically higher in the group that underwent image-guided drainage. Antibiotherapy failed in 18 patients, and a statistically significant difference was observed between treatment failure and the rate of decrease in the CRP level on day 4 compared with that on day 0. According to the receiver operating characteristic (ROC) analysis, if the CRP level measured on day 4 decreased by < 37.1% compared with that on day 0, the probability of treatment failure would increase (area under the curve = 0.755; 95% confidence interval, 0.668-0.841; sensitivity, 73.6%; specificity, 60%).

CONCLUSIONS

Image-guided drainage combined with antibiotherapy in the treatment of TOA has high success rates, lower recurrence rates, and lower surgical requirement, and the mean decrease in the CRP level on day 4 can be monitored at treatment follow-up. In patients receiving antibiotherapy alone, if the CRP level on day 4 decreases by < 37.1%, the treatment protocol should be changed.

Tubo-ovarian abscess after vaginal delivery: A case report and review of current literature

Tubo-ovarian abscesses in pregnancy and the post-partum period are extremely rare. We report a case of a 31-year-old woman who presented with an acute abdomen and sepsis in the post-partum period with a background of a large endometrioma diagnosed prior to conception. Exploratory laparoscopy revealed a ruptured tubo-ovarian abscess which was surgically drained and then treated with intravenous antibiotics. This report is seemingly unique in presenting the development of antenatal endometrioma into a tubo-ovarian abscess and an unusual differential for abdominal pain to consider in the immediate postpartum period.

Tubal Pathologies and Fertility Outcomes: A Review

Anomalies of the fallopian tubes represent one of the most significant elements that might contribute to reproductive issues. They can be inherited or acquired; they are among the most important problems of the profession. Although there is much discussion regarding which therapies for each tubal disease are the most effective and result in the best long-term reproductive outcomes. During the evaluation of an infertile couple, certain anomalies of the fallopian tubes are frequently discovered. These abnormalities were thought, for a long time, to not have an influence on fertility; however, in recent years, researchers have discovered that they seem to play a crucial role in fertility problems. Couples in industrialized countries are postponing childbearing, which raises the risk of women developing tubal diseases before they are ready to become pregnant. These disorders may have a negative impact on a woman's ability to get pregnant. The goals of this study are to conduct research to gain a deeper understanding of the recent advancements that have been made in the field of tubal diseases and to carry out an evaluation of the medical conducts that have the best fertility outcomes. We searched both Medline and PubMed, paying special attention to the most relevant articles that have been added to either database over the course of the last six years.

Identification and Treatment of Acute Pelvic Inflammatory Disease and Associated Sequelae

Pelvic inflammatory disease (PID) is an ascending polymicrobial infection of the upper female genital tract. The presentation of PID varies from asymptomatic cases to severe sepsis. The diagnosis of PID is often one of exclusion. Primary treatment for PID includes broad-spectrum antibiotics with coverage against gonorrhea, chlamydia, and common anaerobic and aerobic bacteria. If not clinically improved by antibiotics, percutaneous drain placement can promote efficient source control, as is often the case with large tubo-ovarian abscesses. Ultimately, even with treatment, PID can result in long-term morbidity, including chronic pelvic pain, infertility, and ectopic pregnancy.

Tubo-ovarian abscess: A proposed new scoring system to guide clinical management

OBJECTIVE

To create a risk scoring system comprised of clinical and radiological characteristics that can predict the likelihood of antibiotic treatment failure of tubo-ovarian abscesses. The score should guide clinicians in identifying patients to whom early intervention should be offered instead of a prolonged trial of antibiotics.

METHODS

A multicenter, retrospective cohort study carried out between January 1, 2013 and September 30, 2019, identified consecutive patients with tubo-ovarian abscess. Using a chronological split, patients were allocated to two groups for the development and subsequent validation of the postulated scoring system. Univariate and bivariate analyses were performed to identify statistically significant variables for the failure of intravenous antibiotic treatment.

RESULTS

In total, 214 consecutive patients with tubo-ovarian abscesses were identified. Data from the first 150 patients were used for the development of the postulated scoring system; data from the subsequent 64 patients were used for validation. Statistically significant clinical features between those having successful and unsuccessful management were: temperature (median = 37.1℃ vs 38.2℃, P = 0.0001), C-reactive protein (151 mg/L vs 243 mg/L, P = 0.0001), and tubo-ovarian abscess diameter (6.0 cm vs 8.0 cm, P = 0.0001). These parameters were used to create a risk prediction score. A score of four or more was predictive of requiring surgical/radiological intervention of tubo-ovarian abscess (P < 0.001). The score had a sensitivity of 69% and a specificity of 88%, with area under the curve (AUC) = 0.859.

CONCLUSION

Currently, there is no guidance for clinicians on when to operate on a tubo-ovarian abscess. Our prediction score is simple, using only three easily obtained clinical characteristics.

The Combination of Clindamycin and Gentamicin Is Adequate for Pelvic Inflammatory Disease: A Retrospective Cohort Study

Pelvic inflammatory disease (PID) affects 4.4% of women aged 18-44 in the United States, and may cause infertility if it is ineffectively treated. A combination of clindamycin and gentamicin is generally used for the treatment of PID. The benefit of adding metronidazole into the treatment combination still remains unclear, and this study was designed to evaluate its effectiveness. We retrospectively included 107 women who were diagnosed with PID from May 2013 to September 2020 in a single hospital. Based on their used antibiotic regimens, the patients were divided into three groups-those who were treated with clindamycin + gentamicin (group 1, n = 46), those who took regular antibiotics plus metronidazole (group 2, n = 27), and others (group 3, n = 34). Primary outcomes included the rates of taking surgery after failed antibiotics, occurrence/rupture of tubo-ovarian abscesses, and readmission within the following 6 months of first treatment. Secondary outcomes to assess were the length of stay (LOS) and expenditure for PID. There were no significant differences in the surgical rates, readmission rates, LOS and expenditure noted between the three groups. Subgroup analysis showed that visual analogue pain scores being 5 or more would increase the LOS by 3.83 days (p < 0.001), and body temperature > 38.3 °C or more would increase the treatment total expenditure (p < 0.001). Our study results suggest that the combination of clindamycin + gentamicin is a convincible treatment protocol for PID.

Tubo-Ovarian Abscess in Non-Sexually Active Adolescent Girls: A Case Series and Literature Review

STUDY OBJECTIVE

We investigated risk factors and common causes of tubo-ovarian abscess (TOA) in non-sexually active females in order to aid in earlier diagnosis, treatment, and improved outcomes.

DESIGN

This is a retrospective observational case series of all non-sexually active females younger than age 25 years who were diagnosed with TOA. Review of the existing literature was also performed.

SETTING

Academic tertiary care children's hospital.

PARTICIPANTS

Ten patients meeting study inclusion criteria were identified for the study, and 33 other patients were identified in the literature.

RESULTS

Average age at time of diagnosis was 14 years. Average body mass index was 24 kg/m². Most presented with abdominal pain, often associated with fevers, nausea, vomiting, and diarrhea. Seven of 10 patients were treated surgically with pelvic washout (4 primarily and 3 after failing empiric antibiotic therapy). Most frequently, anaerobic gut flora were isolated on culture. All patients received broad-spectrum intravenous antibiotics, and were then discharged on a course of doxycycline and metronidazole or clindamycin. Three patients required additional admissions and multiple rounds of antibiotics due to persistent symptoms. The average length of stay was 3 days for patients treated with antibiotics only and 6 days for patients requiring surgical intervention. Six patients had complete resolution of symptoms and improvement on ultrasound within 2-4 weeks. The remainder were lost to follow-up.

CONCLUSION

These cases, in conjunction with previous case reports, emphasize the importance of considering TOA in patients with concerning imaging or examination findings despite lack of sexual activity. Given the large proportion of cases attributable to anaerobic gut flora, treatment with antibiotics with adequate anaerobic coverage is recommended. Surgical drainage is not always necessary, but is often needed for diagnostic purposes or in patients not clinically improving with conservative measures.

Outcomes of Minimally Invasive Management of Tubo-ovarian Abscess: A Systematic Review

OBJECTIVE

To compare the success rate, complications, and hospital length-of-stay of 3 modalities of minimally invasive management of tubo-ovarian abscesses (TOAs): laparoscopy, ultrasound-guided drainage, and computed tomography-guided drainage.

DATA SOURCES

Electronic-based search in PubMed, EMBASE, Ovid MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, using the following Medical Subject Heading terms: "minimally invasive surgical procedures," "drainage," "abscess," "tubo-ovarian," "ovarian diseases," and "fallopian tube diseases."

METHODS OF STUDY SELECTION

Of the 831 articles in the initial results, 10 studies were eligible for inclusion in our systematic review.

TABULATION, INTEGRATION, AND RESULTS

A total of 975 patients were included in our study; 107 (11%) had laparoscopic drainage procedures, and 406 (42%) had image-guided (ultrasound or computed tomography) drainage of TOAs. Image-guided TOA drainage had higher success rates (90%-100%) than laparoscopic drainage (89%-96%) and the use of antibiotic treatment alone (65%-83%). Patients treated with image-guided drainage had no complications (for up to 6 months of follow-up) and shorter lengths of hospital stay (0-3 days on average) compared with laparoscopic drainage (5-12 days) or conservative management with antibiotics alone (7-9 days).

CONCLUSION

Although conservative management of TOAs with antibiotics alone remains first-line, our review indicates that better outcomes in the management of TOA were achieved by minimally invasive approach compared with conservative treatment with antibiotics only. Of the minimally invasive techniques, image-guided drainage of TOAs provided the highest success rates, the fewest complications, and the shortest hospital stays compared with laparoscopy. The low magnitude of evidence in the included studies calls for further randomized trials. This systematic review was registered in the International Prospective Register of Systematic Review (register, http://www.crd.york.ac.uk/PROSPERO;CRD 42020170345).

Teaching the Evaluation of Female Pelvic Pain: A Hands-On Simulation to Reinforce Exam Skills and Introduce Transvaginal Ultrasound

INTRODUCTION

Reproductive-age female patients commonly seek evaluation for pelvic pain in a variety of health care settings. Thus, teaching medical students how to effectively evaluate female pelvic pain is a necessary part of medical education. There are limited opportunities, however, to reinforce the needed skills for this common but sensitive presentation that can be anxiety-producing for preclinical students.

METHODS

The case involved a 23-year-old female presenting with lower abdominal/pelvic pain. Students performed the necessary history, physical examination, cervical sampling, and transvaginal ultrasound evaluation to make the diagnosis of pelvic inflammatory disease (PID) complicated by a tubo-ovarian abscess. The 30-minute simulated patient encounter was followed by a 30-40 minute faculty-led debrief.

RESULTS

This simulation case has been sustained in the curriculum since 2011 for 65 students per year. Through use of a faculty critical action checklist, debrief discussion, examination performance, and student evaluation feedback, this simulation has demonstrated effectiveness. Of students, 93 of 193 students (48%) who participated in the simulation case from 2018-2020 completed a survey in which they rated the degree of agreement with statements about the simulation based on a 5-point Likert Scale (1 = strongly disagree, 5 = strongly agree). All questions had a mean response of 4.5-4.8 in 2018-2020, demonstrating the consistent agreement by students of the clarity, fidelity, and knowledge-enhancing value of the simulation.

DISCUSSION

This simulation provided a useful opportunity and a safe environment for preclinical medical students to acquire knowledge and skills necessary to evaluate a female patient with pelvic pain and PID.

Can antibiotic treatment failure in tubo-ovarian abscess be predictable?

INTRODUCTION

We aimed to identify factors that would predict the success of antibiotic treatment and the need for surgical treatment in tubo-ovarian abscess (TOA) patients.

MATERIALS AND METHODS

The data of 146 patients with a diagnosis of TOA were analyzed retrospectively. Patients were separated into two groups; successfully treated with antibiotics and going under surgery after antibiotic treatment failure. Demographic, clinical and laboratory data of patients were examined between both groups that could determine the success of treatment.

RESULTS

In the surgical treatment group, age, body mass index (BMI), and C-reactive protein (CRP) values ​​were higher than the antibiotic treatment group (p = 0.017, p = 0.026, and p < 0.001 respectively). Patients who underwent surgery had a significantly larger abscess than those who received antibiotic therapy (79.4 ± 21.1 mm vs. 50.9 ± 13.2 mm, p < 0.001). Cut-off values of the findings, which were identified as risk factors in predicting the failure of antibiotic treatment, were found with ROC analyses. This cut-off was 41.5 years for age (sensitivity 71.3 %, specificity 60 %), 26.72 kg/m² for BMI (sensitivity 51.5 %, specificity 71.1 %), and 143.5 mg/L for CRP value on admission (sensitivity 68.3 %, specificity 71.1 %). The cut-off for abscess diameter was 62.5 mm (sensitivity 88.1 %, specificity 82.2 %).

CONCLUSION

Especially in large tubo-ovarian abscesses, early surgical intervention should be preferred considering the age, BMI, and CRP values.

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.

Perioperative Complications of Laparoscopic versus Open Surgery for Pelvic Inflammatory Disease

STUDY OBJECTIVE

To compare complications in patients undergoing laparoscopic vs open surgery for acute pelvic inflammatory disease (PID).

DESIGN

We performed a retrospective cohort study of patients who underwent surgery for PID, using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2015. Propensity score matching was used to balance baseline characteristics and compare complications in patients who underwent laparoscopic vs open surgery.

SETTING

Surgical management of acute PID.

PATIENTS

Patients with a preoperative diagnosis of PID were identified using International Classification of Diseases, Ninth Revision, codes. We excluded patients with chronic PID, gynecologic malignancy, and those for whom the surgical route was unknown.

INTERVENTIONS

Surgery for acute PID.

MEASUREMENTS AND MAIN RESULTS

The study included 367 patients. The mean age was 43.0 ± 11.1 years, body mass index was 30.9 ± 11.2 kg/m², and American Society of Anesthesiology class was 2 (interquartile range 2-3). Preoperative signs of sepsis were noted in 33.8% of the patients, and septic shock was present in 1.4%. Hysterectomy was performed in 67.6%, oophorectomy in 12.0%, and salpingectomy in 4.6%. Complications were experienced by 114 patients (31.1%), 11 (3.0%) of which were potentially life-threatening. Multivariate logistic regression identified the following to be independently associated with complications: laparoscopy (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI], 0.3-0.8; p <.01), operative time (aOR 1.01; 95% CI, 1.00-1.01; p <.01), appendectomy (aOR 2.36; 95% CI, 1.0-5.4; p = .04), elevated international normalized ratio (aOR 2.30; 95% CI, 1.3-4.2; p <.01), and low hematocrit level (aOR 2.53; 95% CI, 1.4-4.5; p <.01). Propensity scores were calculated and used to generate a matched cohort of patients who underwent laparoscopic vs open surgery; the groups were similar, with p <.05 for all covariates. After balancing confounding variables, a laparoscopic approach to surgery remained significantly associated with a lower risk of complications (coefficient -0.07; 95% CI, -0.11 to -0.02; p = .008).

CONCLUSION

Laparoscopy was associated with lower complication rates than open surgery in this well-matched cohort of patients who underwent surgery for acute PID.

ACR Appropriateness Criteria® Radiologic Management of Infected Fluid Collections

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pneumoperitoneum secondary to tubo-ovarian abscess: A case report

Pneumoperitoneum seen on an X-ray or computed tomography (CT) image points to a diagnosis of ruptured viscus and immediate surgery is warranted. A case of tubo-ovarian abscess (TOA) presenting with pneumoperitoneum is unusual. Very few cases have been reported where the pneumoperitoneum is caused by an abscess involving the adnexa. We present the case of a 17-year-old patient who presented with acute abdomen and raised inflammatory markers and had laparoscopy for suspected bowel perforation based on the finding of pneumoperitoneum on CT scan. Bowel perforation was ruled out and the findings were consistent with TOA. She had drainage of the abscess, subsequently received intravenous antibiotics and postoperatively recovered well. The pneumoperitoneum could have been due to coinfection with E. coli, as the patient had had a urinary tract infection due to E. coli three weeks before presentation, or slow leakage of the TOA. In conclusion, gas under the diaphragm can be related to non-bowel-related gynaecological pathology, but it vital to rule out sinister causes.

Ovarian abscess caused by Helicobacter cinaedi in a patient with endometriosis

Helicobacter cinaedi is a rarely encountered pathogen that easily induces bacteremia. Various foci of H. cinaedi infection have been reported; however, no case of adnexal abscess caused by H. cinaedi has been reported in the English literature. We herein report a case of ovarian abscess caused by H. cinaedi.

A 38-year-old nulligravid Japanese woman was admitted to our hospital with an adnexal abscess. Clinical findings included fever, leukocytosis, and elevated C-reactive protein. Laparoscopic right partial oophorectomy with abdominal lavage was performed. H. cinaedi was isolated from cultures of blood and ovarian abscess fluid after surgery. Intravenous ampicillin/sulbactam was administered for 2 weeks, followed by oral amoxicillin for an additional 2 weeks. The postoperative course was uneventful and clinical findings improved. There was no evidence of relapse. H. cinaedi can cause ovarian abscess and is likely an under-recognized pathogen.

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.

Predictive factors for emergent surgical intervention in patients with ovarian endometrioma hospitalized for pelvic inflammatory disease: A retrospective observational study

AIM

The aim of this study was to identify predictive factors for emergent surgical interventions in patients with ovarian endometriomas hospitalized for pelvic inflammatory disease (PID).

METHODS

We retrospectively identified 22 patients with ovarian endometriomas who were hospitalized to manage PID. Patients were divided into two groups: those who required emergent surgery after failed antibiotic therapy (emergent surgery group, n = 6) and those who were discharged with successful antibiotic therapy (conservative group, n = 16). Logistic regression analysis was performed to analyze the factors associated with emergent surgery.

RESULTS

Patients in the emergent surgery group were significantly more likely to have intrauterine or intrapelvic procedures before the onset of PID compared to those in the conservative group (83% vs 38%, odds ratio 8.33, 95% confidence interval 1.02-181.3; P = 0.048). The mean interval between the onset of PID symptoms and the commencement of parenteral antibiotic therapy was significantly longer in the emergent surgery compared to the conservative group (6.5 vs 1 day, odds ratio 1.28, 95% confidence interval 1.01-1.75; P = 0.041).

CONCLUSION

A history of an intrauterine or intrapelvic procedure before the onset of PID was more likely to result in emergent surgery. A longer interval between the onset of PID symptoms and the commencement of parenteral antibiotics was also associated with emergent surgery. These findings could help to identify patients with ovarian endometriomas hospitalized with PID at higher risk of emergent surgical intervention.

Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses

Adnexal masses (ie, masses of the ovary, fallopian tube, or surrounding tissues) commonly are encountered by obstetrician-gynecologists and often present diagnostic and management dilemmas. Most adnexal masses are detected incidentally on physical examination or at the time of pelvic imaging. Less commonly, a mass may present with symptoms of acute or intermittent pain. Management decisions often are influenced by the age and family history of the patient. Although most adnexal masses are benign, the main goal of the diagnostic evaluation is to exclude malignancy. The purpose of this document is to provide guidelines for the evaluation and management of adnexal masses in adolescents, pregnant women, and nonpregnant women and to outline criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist.

Middlemore Hospital experience with tubo-ovarian abscesses: an observational retrospective study

AIM

The aim of this paper was to study the characteristics of patients presenting to Middlemore Hospital with tubo-ovarian abscess (TOA) and to compare the outcomes of conservative medical management versus medical management with surgical drainage and medical management with radiological drainage.

METHODS

All patients admitted with a radiologically or surgically proven TOA between January 01, 2008 and December 31, 2010, were included and followed up until June 30, 2011. The total number of patient/index admission was 174.

RESULTS

The mean age of patients was 37.8 years. One hundred thirty patients had medical treatment only with hospitalization and antibiotics, and 44 patients were managed with antibiotics and surgical drainage. Complete resolution of TOA was 77.3% (99/128) for patients managed medically and 93.2% (41/44) for patients managed surgically. When the two groups were compared, patients who were managed surgically were more likely to have complete resolution of TOA within 6 months of index admission with an odds ratio (OR) of 4 and a P-value of 0.029. There was no statistically significant difference in the secondary outcomes namely of readmission with TOA (OR: 0.47) and the need for repeat surgical or radiological drainage (OR: 1.48). Nonetheless, the relative duration of hospitalization was longer for the surgical group with a P-value of <0.0001. The C-reactive protein and the size of TOA were the significant factors involved in the resolution of TOA.

CONCLUSION

The results of this study confirmed our initial hypothesis that we should consider surgical drainage more often, probably earlier, especially for the younger patients still desiring fertility preservation and for larger abscesses. Laparoscopic surgical drainage is safe and could be used as the procedure of choice. Conservative medical management is still acceptable with good cure rates of 77%. C-reactive protein and the size of the abscess were the important factors to consider when managing patients with TOA.

Risks of tubo-ovarian abscess in cases of endometrioma and assisted reproductive technologies are both under- and overreported

OBJECTIVE

To study possible associations among endometriosis, pelvic infectious disease, and ART.

DESIGN

Retrospective cohort analysis over 4 consecutive years, based on medical records and insurance coding in a tertiary endometriosis reference center.

SETTING

Tertiary university-based reference center for endometriosis.

PATIENT(S)

We retrieved all charts carrying the diagnoses infectious process and endometriosis in 2009-2012. Each chart was individually analyzed for categorization of the infectious episode and determining whether ART had been performed.

MAIN OUTCOME MEASURE(S)

Hospitalization for acute infection in women with known endometriosis and possible past ART.

INTERVENTION

Retrospective insurance codes-triggered chart analysis.

RESULT(S)

Ten patients were admitted for an acute infection with fever, acute abdomen syndrome, elevated white blood cell count, and adnexal mass. Three women had oocyte retrieval, and an endometrioma was present 16, 57, and 102 days earlier. In one patient, the complication occurred 37 days after a cesarean section without prior ART. In the remaining six cases tubo-ovarian abscesses (TOAs) occurred spontaneously in endometriosis women who never had ART. Medical treatment succeeded in only two patients, and the remaining eight needed laparoscopic drainage. In 6 out of those 8 cases, laparoscopic drainage was a second-stage measure justified by failure to respond to antibiotic therapy.

CONCLUSION(S)

Our data indicate that some putative complications of ART and endometrioma may actually not be linked to ART, but rather constitute sporadic occurrences in endometriosis. Furthermore, TOAs occurring in women with endometriosis are best treated by early surgical drainage together with intravenous antibiotics.

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.

Tubo-Ovarian Abscess Caused by Candida Albicans in an Obese Patient

BACKGROUND

Tubo-ovarian abscess (TOA) arises in most cases from pelvic infection. Appropriate treatment includes use of antimicrobials and, especially in patients with increased BMI, drainage of the contents.

CASE

A 44-year-old morbidly obese woman (BMI 72) had a persistent TOA despite receiving antibiotic treatment for four months. She had no history of diabetes, and denied being sexually active. Imaging demonstrated a pelvic abscess of 14.9 × 8.9 × 11.1 cm. Successful percutaneous drainage was performed yielding purulent material which grew Candida albicans. The patient recovered after drainage of the abscess and the addition of fluconazole to her antimicrobials. She had no apparent risk factor for acquiring such an opportunistic infection, other than her morbid obesity.

CONCLUSION

Because morbid obesity may confer a relative immunodeficiency, morbidly obese patients may develop unusual infections such as opportunistic fungal abscesses.

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.

Pelvic surgical site infections in gynecologic surgery

The development of surgical site infection (SSI) remains the most common complication of gynecologic surgical procedures and results in significant patient morbidity. Gynecologic procedures pose a unique challenge in that potential pathogenic microorganisms from the skin or vagina and endocervix may migrate to operative sites and can result in vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscesses. Multiple host and surgical risk factors have been identified as risks that increase infectious sequelae after pelvic surgery. This paper will review these risk factors as many are modifiable and care should be taken to address such factors in order to decrease the chance of infection. We will also review the definitions, microbiology, pathogenesis, diagnosis, and management of pelvic SSIs after gynecologic surgery.

Comparison of severe pelvic inflammatory disease, pyosalpinx and tubo-ovarian abscess

AIM

Inflammation of the upper genital tract causes pelvic inflammatory disease (PID), which may be complicated by pelvic abscesses, such as pyosalpinx and tubo-ovarian abscess (TOA). This study aimed to determine the clinical differences between pyosalpinx and TOA in patients with PID.

MATERIAL AND METHODS

We retrospectively evaluated 458 female patients who were admitted to Hallym University Kang Dong Sacred Heart Hospital for a clinical diagnosis of PID from 1 January 2007 to 30 April 2012. Sociodemographic, clinical and laboratory data were compared among the non-abscess, pyosalpinx, and TOA groups.

RESULTS

We identified 110 patients (24%) diagnosed with pelvic abscess associated with PID, including 34 with pyosalpinx and 76 with TOA. The pyosalpinx group had shorter hospital stays (P = 0.007), lower C-reactive protein levels (P = 0.015), smaller mass sizes (P < 0.001), and fewer surgical interventions (P < 0.001) than the TOA group.

CONCLUSIONS

Pyosalpinx is a less severe form of PID that leads to shorter hospital stays and more favorable outcomes than TOA.

Image-guided drainage versus antibiotic-only treatment of pelvic abscesses: short-term and long-term outcomes

OBJECTIVE

To determine the efficacy of image-guided drainage versus antibiotic-only treatment of pelvic abscesses.

DESIGN

Retrospective cohort analysis.

SETTING

An academic, inner-city medical center.

PATIENT(S)

Women ages 11-49, admitted between 1998 and 2008 with ICD9 code 614.x (inflammatory diseases of ovary, fallopian tube, pelvic cellular tissue, and peritoneum).

INTERVENTION(S)

Medical records search, chart review, and phone survey.

MAIN OUTCOME MEASURE(S)

Surgical intervention.

RESULT(S)

We identified 6,151 initial patients, of whom 240 patients met inclusion criteria. Of the included patients, 199 women received antibiotic-only treatment, and 41 received additional image-guided drainage. There was no statistically significant difference between the two groups in terms of age, body mass index, parity, incidence of diabetes, obesity, endometriosis, or history of sexually transmitted infection excluding human immunodeficiency virus (HIV). Abscesses in the drainage cohort were noted to be larger in dimension (5.9 cm vs. 8.5 cm); 16.1% of patients who received antibiotics alone required surgical intervention versus only 2.4% of the drainage cohort. Patients who received drainage had longer hospital stays, but the time from treatment to discharge was similar in both groups (7.4 days vs. 6.7 days). We successfully contacted 150 patients, and the differences in long-term pregnancy outcomes, pain, or infertility were not statistically significant.

CONCLUSION(S)

Patients who received antibiotics alone were more likely to require further surgical intervention when compared with patients who additionally received image-guided drainage. There were no observable long-term differences.

Term delivery following tuboovarian abscess after in vitro fertilization and embryo transfer

A tuboovarian abscess (TOA) during pregnancy following oocyte retrieval is extremely rare. We report a rare case of pregnancy complicated by the development of a TOA following in vitro fertilization-embryo transfer that was treated successfully with laparoscopy. We also review all similar cases reported in the English-language literature.