US-guided transvaginal drainage of pelvic abscesses and fluid collections

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.

Non-surgical treatment for hematocele in the bladder associated with ascites puncture in a patient with ovarian hyperstimulation syndrome: a case report

Ovarian hyperstimulation syndrome (OHSS) is a well-known complication induced by the application of LH or GnRH analogs in the process of assisted reproduction controlled ovarian stimulation (COS). Ascites puncture is one of the treatments for severe OHSS. In the vast majority of circumstances, transvaginal (TV) ascites puncture under B ultrasound guidance is safe; however, bladder injury is a rare complication that may occur during the puncture process. We presented the case of a 28-year-old woman who presented with hematuria and dysuria following TV puncture for ascites aspiration for OHSS. Ultrasonographic examination revealed a 8.33 × 4.88 cm hematocele in the bladder; it was thought to have been caused by blood clot formation and concurrent urinary retention resulting from the puncture needle-induced bladder injury during TV puncture for ascites aspiration. The patient recovered with conservative treatment. Therefore, it is important to emphasize that avoidance of OHSS is necessary to avoid complications such as bladder damage from treatment of ascites.

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.

Image-Guided Transvesicular Drainage of Pelvic Fluid Collections: A Safe and Effective Alternative Approach

To evaluate the safety and efficacy of percutaneous transvesicular drainage of pathologic pelvic fluid collections, a series of 15 patients who underwent 16 transvesicular drainage catheter placements was retrospectively reviewed. All patients had collections suspicious for infection that were posterior to the bladder or superior to the bladder behind loops of bowel, and were otherwise inaccessible. All 15 collections were percutaneously accessed via the bladder with standard drainage catheters. All collections resolved completely with no complications. Percutaneous transvesicular drainage was a safe and effective technique in this series, and can be considered when no direct percutaneous access routes are available.

Transvaginal Drainage of Pelvic Abscesses and Collections Using Transabdominal Ultrasound Guidance

Objectives. To evaluate clinical outcomes following transvaginal catheter placement using transabdominal ultrasound guidance for management of pelvic fluid collections. Methods. A retrospective review was performed for all patients who underwent transvaginal catheter drainage of pelvic fluid collections utilizing transabdominal ultrasound guidance between July 2008 and July 2013. 24 consecutive patients were identified and 24 catheters were placed. Results. The mean age of patients was 48.1 years (range = 27–76 y). 88% of collections were postoperative (n = 21), 8% were from pelvic inflammatory disease (n = 2), and 4% were idiopathic (n = 1). Of the 24 patients, 83% of patients (n = 20) had previously undergone a hysterectomy and 1 patient (4%) was pregnant at the time of drainage. The mean volume of initial drainage was 108 mL (range = 5 to 570). Catheters were left in place for an average of 4.3 days (range = 1–17 d). Microbial sampling was performed in all patients with 71% (n = 17) returning a positive culture. All collections were successfully managed percutaneously. There were no technical complications. Conclusions. Transvaginal catheter drainage of pelvic fluid collections using transabdominal ultrasound guidance is a safe and clinically effective procedure. Appropriate percutaneous management can avoid the need for surgery.

Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature

AIM

Percutaneous drainage of abdominal and pelvic abscesses is a first-line alternative to surgery. Anterior and lateral approaches are limited by the presence of obstacles, such as the pelvic bones, bowel, bladder, and iliac vessels. The objective of this study was to assess the feasibility, safety, tolerability, and efficacy of a percutaneous, transgluteal approach by reviewing our clinical experience and the literature.

MATERIALS AND METHODS

We reviewed demographic, clinical and morphological data in the medical records of 30 patients having undergone percutaneous, computed tomography (CT)-guided, transgluteal drainage. In particular, we studied the duration of catheter drainage, the types of microorganisms in biological fluid cultures, complications related to procedures and the patient's short-term treatment outcome.

RESULTS

From January 2005 to October 2011, 345 patients underwent CT-guided percutaneous drainage of pelvis abscesses in our institution. A transgluteal approach was adopted in 30 cases (10 women and 20 men; mean age: 52.6 [range 14-88]). The fluid collections were related to post-operative complications in 26 patients (86.7 %) and inflammatory or infectious intra-abdominal disease in the remaining 4 patients (acute diverticulitis: n = 2; appendicitis: n = 1; Crohn's disease: n = 1) (13.3 %). The mean duration of drainage was 8.7 days (range 3-33). Laboratory cultures were positive in 27 patients (90 %) and Escherichia coli was the most frequently present microorganism (in 77.8 % of the positive samples). A transpiriformis approach (n = 5) was more frequently associated with immediate procedural pain (n = 3). No major complications were observed, either during or after the transgluteal procedure. Drainage was successful in 29 patients (96.7 %). One patient died from massive, acute cerebral stroke 14 days after drainage.

CONCLUSION

When an anterior approach is unfeasible, transgluteal, percutaneous, CT-guided drainage is a safe, well tolerated and effective procedure. Major complications are rare. This type of drainage is an alternative to surgery for the treatment of deep pelvic abscesses (especially for post-surgical collections).

Complications of percutaneous fluid drainage

Percutaneous abscess drainage is one of the most common and rewarding procedures performed by interventional radiologists. Technical success is immediately apparent by aspiration of purulent contents and is nearly always achieved, with rates exceeding 90% in most literature studies. Clinical success is typical even for many abscesses colonized with multidrug-resistant organisms. In patients presenting with sepsis, this procedure offers an immediate and minimally invasive solution to a life-threatening condition, often resulting in defervescence and restoration of hemodynamic stability within 1 to 2 days. Although complications of abscess drainage are uncommon, radiologists should be able to recognize and treat all adverse sequelae discussed in this article.

Ultrasound-guided drainage of deep pelvic abscesses: experience with 33 cases

The aim of this study was to demonstrate and evaluate the ultrasound-guided drainage of deep pelvic abscesses in which transabdominal percutaneous access could not be performed because of overlying structures. A retrospective analysis of 32 consecutive patients with 33 deep pelvic abscesses was performed. The underlying causes of the abscesses included postsurgical fluid collection or surgical complications in 18 of the 32 patients, and 11 of these patients underwent recent rectal cancer surgery. The locations of the abscesses, which had a median diameter of 6 cm (range 2-10 cm), were as follows: perirectal (n=13), presacral (n=9), pouch of Douglas (n=7), internal genitals (n=2) and between the bowel loops (n=2). The abscesses were all drained using ultrasound (US) guidance with a transrectal (n=18), transvaginal (n=11), transperineal ( n=2) or transgluteal (n=2) approach. Of the larger abscesses (median diameter 7 cm), 19 were treated with catheter drainage and 18 of these cases resulted in favorable clinical outcomes. Of the smaller abscesses (median diameter 4 cm), 14 were treated with needle drainage. In two of these cases, follow-up US showed that a repeat puncture and drainage was necessary. All needle drainages resulted in favorable clinical outcomes. Sixteen of the 29 transrectal or transvaginal drainage procedures were performed without any anesthesia (10 were performed with a needle and six were performed with a catheter). Apart from minor discomfort during the drainage procedure and the subsequent in-dwelling catheter period, there were no serious complications related to the drainage procedures. We conclude that ultrasound-guided transrectal, transvaginal, transperineal and transgluteal drainage of deep pelvic abscesses are safe and effective treatment approaches. Based on our findings, needle drainage will be our most common first-line treatment approach because of the simplicity of the procedure, improved patient comfort and reduced costs. Catheter drainage will be reserved for large multiloculated abscesses.

Image-guided drainage of tuboovarian abscesses of gastrointestinal or genitourinary origin: a retrospective analysis

PURPOSE

To analyze the authors' success with image-guided drainage of tuboovarian abscesses (TOAs).

MATERIALS AND METHODS

Retrospective analysis of patients with image-guided TOA drainage from 1999 to 2008 was performed. Patient recovery without salpingo-oophorectomy was considered clinical success. A total of 57 TOAs were drained in 49 female patients (mean age, 43; range, 12 to > 89).

RESULTS

Thirty-three (58%) TOAs were drained percutaneously using computed tomography guidance and 24 were ultrasound guided (21 transvaginally, three transabdominally). Fifty-three TOAs were drained with catheter placement, and four were drained with aspiration alone. Abscess etiologies include pelvic inflammatory disease (n = 21, 37%), gastrointestinal conditions related (n = 21, 37%), gynecologic surgery (n = 8, 14%), and other (12%). Image-guided drainage resolved TOAs without salpingo-oophorectomy in 74% of cases overall (42 of 57) and 88% (29 of 33) of gynecologic-related cases, including 95% (20 of 21) of pelvic inflammatory disease cases. Salpingo-oophorectomy was performed more often in gastrointestinal-related cases (10 of 21, 48%) than for all other causes (five of 36, 14%; P < .001), with concurrent bowel surgery performed in the majority of the gastrointestinal-related cases. Mean follow-up after image-guided drainage was 48 months (range, 1-113) in patients who did not have related surgery. In patients who underwent salpingo-oophorectomy, it was performed on average 2.2 months (range, 0.5-5) after initial drainage. Two minor complications occurred; both involved catheter transgression of the urinary bladder in patients with transvaginal ultrasound-guided drainages. The patients were successfully treated conservatively with Foley catheter bladder decompression, without prolonged hospitalization.

CONCLUSIONS

TOAs, especially of gynecologic origin, can often be managed successfully with image-guided drainage. After image-guided drainage, patients with gynecologic-related TOA were less likely to undergo salpingo-oophorectomy than patients with gastrointestinal-related TOAs.

The management of pelvic abscess

The optimum treatment for pelvic abscess would be an approach that is safe, efficacious, cost-effective, minimally invasive, and which affects the woman's fertility potential as little as possible. In women of reproductive age tubo-ovarian abscess is one of the most common types of pelvic abscess. Tubo-ovarian abscesses are classically treated with broad-spectrum antibiotics. Frequently this approach fails and surgical intervention becomes necessary in about 25% of all cases. Surgical procedures include laparotomy or laparoscopy with drainage of abscess, unilateral or bilateral salpingo-ophorectomy, and hysterectomy. However, surgery for tubo-ovarian abscess is often technically difficult and associated with complications. An alternative approach is the use of imaging-guided drainage of abscess in combination with antibiotics. Combined data from several studies indicate that ultrasound-guided transvaginal drainage with concomitant antibiotics is especially safe and efficacious. This chapter discusses the management of pelvic abscess with a special focus on transvaginal ultrasound-guided drainage of tubo-ovarian abscess.

Endoscopic transcolonic catheter-free pelvic abscess drainage

Natural orifice transluminal endoscopic surgery is a novel therapeutic method in development that uses different routes of surgical approach. The use of various methods, instruments and accessories during this procedure are currently being investigated. A case of appendicitis-related intra-abdominal abscess that was resolved by a transcolonic endoscopic approach using a wide-channel colonoscope with the help of precut and standard sphincterotome without radiological percutaneous drainage is presented.

Transvaginal drainage of pelvic fluid collections: results, expectations, and experience

OBJECTIVE

The purpose of this study was to review our 13-year experience with sonographically guided transvaginal drainage procedures in terms of type of transvaginal procedure, that is, aspiration or catheter drainage, complication rate, and long-term success.

MATERIALS AND METHODS

A search of an interventional radiology database identified 85 transvaginal drainage procedures on 67 patients. Pertinent medical records and images were reviewed. Clinical success was defined as no need for surgery.

RESULTS

The mean follow-up period was 36.6 months (range, 7 days-132 months). Forty-five aspiration and 40 catheter drainage procedures were performed on 67 patients. Indications for the procedures included postoperative fluid collection (n = 25), tuboovarian abscess unresponsive to medical therapy (n = 17), symptomatic ovarian cyst (n = 17), and miscellaneous causes (n = 8). Clinical success was achieved in 50 of 67 cases (75%), including all cases of 25 postoperative fluid collection, 12 of 17 tuboovarian abscesses (71%), and seven of 17 ovarian cysts (41%). No complications were found in patients who underwent aspiration alone. The following minor complications occurred in patients who underwent catheter drainage: two cases of bladder transgression, one case of infection, and one case of catheter-related pain. Premature dislodgment of the catheter was an issue for four of 40 patients (10%).

CONCLUSION

Postoperative fluid collections can be managed with a high rate of success by means of transvaginal aspiration or catheter drainage. Transvaginal catheter drainage is an alternative to surgery in the management of tuboovarian abscesses unresponsive to medical management. Aspiration alone is sufficient to drain ovarian cysts and provide symptomatic relief. Most cysts recur, however, ultimately necessitating surgery. Aspiration is safe, but catheter drainage is associated with a 10% rate of minor complications.

Computed tomography-guided percutaneous abscess drainage in coloproctology: review of the literature

BACKGROUND

Percutaneous abscess drainage (PAD) of the lower abdomen and pelvis has been reported to reduce morbidity and mortality, shorten hospital stay and cut costs compared to a surgical approach. However, the wide differences in outcome reported by different authors indicate the need for an overview and further evaluations. This review evaluates each point of the procedure to explain the possible causes for such discrepancies in results.

METHODS

We performed a PubMed search of outcomes for percutaneous abscesses drainage, focusing on deep pelvic collections, which represent the most difficult task, searching among papers published from 1981 to 2006.

RESULTS

Ninety-nine papers were selected. Most authors emphasized that the most important steps of the care process are: (a) patient selection; (b) indications and contraindications; (c) choice of the best access route; (d) procedure performance; and (e) outcome (success and complication rates).

CONCLUSIONS

PAD is a safe and effective alternative to surgery for draining deep infected fluid collections, with a higher success rate, lower complication rate and shorter hospital stay compared to surgical drainage. Meticulous technique and careful access planning seem to be the two most important factors affecting the outcome.

Comparison of CT- or ultrasound-guided drainage with concomitant intravenous antibiotics vs. intravenous antibiotics alone in the management of tubo-ovarian abscesses

OBJECTIVE

The purpose of this study was to compare the outcome of treatment of tubo-ovarian abscesses by imaging-guided drainage and antibiotics vs. intravenous antibiotics alone.

METHODS

A retrospective chart review of all patients hospitalized with a diagnosis of tubo-ovarian abscess was performed. Patients were categorized into two groups. The first group consisted of subjects treated with intravenous antibiotics alone. Patients in the second group had primary image-guided drainage with concomitant intravenous antibiotics. Treatment failures in the primary antibiotics group underwent salvage drainage when feasible. The primary outcome of interest was complete response. Secondary outcomes included need for additional treatment, duration of resolution of fever, total length of hospital stay, and complication rates. We also evaluated the effectiveness of secondary drainage in patients who failed primary antibiotic therapy alone.

RESULTS

A total of 58 patients were included in the study. Fifty patients were treated primarily with intravenous antibiotics; eight patients had primary drainage, which was guided by ultrasound in all cases. Complete response was noted in 29 (58%) patients treated with antibiotics alone. All eight (100%) patients in the primary drainage group responded to treatment. Of the 21 treatment failures with primary antibiotics, two underwent surgery and 19 (90.5%) had salvage drainage with either ultrasound or computed tomographic guidance; 18 of 19 salvage drainages led to complete recovery. Subjects in the primary drainage group required shorter hospital stays and showed more rapid resolution of fever. No significant morbidity was noted as a consequence of drainage procedures. A higher failure rate for secondary drainage was noted in older patients, those with larger tubo-ovarian abscesses, and those with a history of pelvic inflammatory disease.

CONCLUSION

Drainage of tubo-ovarian abscesses with concomitant intravenous antibiotics is an effective and safe treatment for the primary or secondary treatment of tubo-ovarian abscesses.

Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases

OBJECTIVE

Our purpose was to evaluate the effectiveness and safety of transvaginal ultrasound-guided aspiration together with antibiotic therapy for treatment of tubo-ovarian abscess.

STUDY DESIGN

A review of women treated with transvaginal ultrasound-guided aspiration for tubo-ovarian abscess at Haukeland University Hospital, Bergen, Norway, between June 1986 and July 2003 was performed. Immediate clinical response and longer-term follow-up results were assessed.

RESULTS

A total of 449 transvaginal aspirations were performed on 302 women. A total of 282 women (93.4%) were successfully treated for transvaginal aspiration of purulent fluid, together with antibiotic therapy. In the other 20 women (6.6%), surgery was performed. The main indications for surgery were diagnostic or therapeutic uncertainty, such as suspected residual tubo-ovarian abscess or pain. No procedure-related complications were diagnosed.

CONCLUSION

Transvaginal ultrasound-guided aspiration combined with antibiotics is an effective and safe treatment regimen for tubo-ovarian abscess. The high success rate indicates that it should be a first-line procedure.

Endocavitary Three-dimensional Ultrasonographic Assistance for Transvaginal or Transrectal Drainage of Pelvic Fluid Collections

PURPOSE

Determine the feasibility of using three-dimensional ultrasonography (3D US) to assist in planning and performing endocavitary drainage of deep pelvic fluid collections.

MATERIALS AND METHODS

Retrospective review of images and medical records of 16 patients in whom endocavitary 3D US was used during transvaginal or transrectal drainage of 17 deep fluid collections. 3D US was assessed regarding its ability to display the relevant structures, whether new information was provided compared with pelvic computed tomography (CT) and conventional two-dimensional US (2D US) displays, and whether this information altered drainage techniques.

RESULTS

Targeted fluid collections were visualized in all patients. 3D US added information in 11 of 16 patients (69%) that, in turn, resulted in adjustment of interventional technique in eight of 16 patients (50%). Specific features of 3D US that provided new information included the simultaneous display of three orthogonal US images, display of reconstructed US image plane orientations not possible with 2D US, and the ability to interactively scroll images through complex structures to assess for communication between the loculations. An attached needle guide was used in 15 of 16 patients to improve the precision of needle placement.

CONCLUSION

Endocavitary 3D US is feasible for assistance in transvaginal and transrectal drainage procedures, usually adds new information, frequently alters interventional technique, and permits precise access needle placement.

Pelvic Inflammatory Disease in Adolescents

Pelvic inflammatory disease (PID) is a polymicrobial infection typically occurring in sexually active females. It occurs when microorganisms ascend from the lower genital tract into the upper genital tract. The clinical presentation varies in severity, with most patients presenting with mild disease. Complications include tubo-ovarian abscess, ectopic pregnancy, infertility, and chronic pain. The newly revised criteria issued by the Centers for Disease Control and Prevention now include either cervical motion tenderness or adnexal tenderness with unchanged additional criteria.

Drenaje de colecciones abscesificadas abdominales. Ventajas del uso de fibrinolíticos

Image-guided percutaneous abscess drainage has become the standard method of treatment for most abdominal abscesses. In many cases, it should be considered the treatment of choice, but there are certain circumstances that require specific approaches and methods. Typical abscesses within solid parenchymal organs or those in the peritoneal spaces can be reliably detected by imaging techniques and efficiently drained. Abscesses that are multiple or long and circuitous require careful placement of one or more catheters. Management of the drainage catheters includes irrigation with saline solution to prevent obstruction. Despite the use of saline irrigations and large caliber catheters, catheter drainage sometimes fails and conventional surgery is required. In selected cases, fibrinolytic agents have been proved to be effective in shortening drainage times and length of hospital stay. The use of fibrinolytic agents in the drainage of some anatomical sites, such as the spleen and pancreas, is controversial and the technique should be meticulously selected. Successful treatment is most likely when an interdisciplinary approach is used. The present article reviews the state of the art of the use of fibrinolytic agents to improve percutaneous abdominal abscess drainage.

[Image guided drainage of pelvic fluid collections: results in 42 patients]

PURPOSE

To review the etiology, location, and morphology of pelvic collection as well as the technique and results of image guided drainage.

MATERIALS AND METHODS

From June 1996 to August 2002, we performed image guided drainage of pelvic fluid collections in 21 males and 21 females. In patients where a direct contact between the collection and the endocavitary probe was present, the drainage was performed either by transrectal or transvaginal approach using 10F, 12F, 14F or 16F catheters according to the viscosity of the fluid. When the patients were no longer septic, when drainage had stopped, the drains were removed at day 5. When a fistula was present, the drain was left in place until the fistula healed.

RESULTS

The most common location of pelvic collections was the cul-desac (43%). A total of 81% of pelvic abscesses were digestive in origin, either from the colon or appendix. Transrectal or transvaginal drainage was possible in 83% of cases. Mean follow-up was 41 months. No drainage related complication was recorded. In two patients with collections of clear fluid, a simple aspiration was performed without insertion of a drain. In the 40 other patients, a drainage catheter was inserted. Twenty-nine patients were cured after 15 days of drainage. Two patients had recurrent collections. Image guided drainage failed in five patients, and all underwent successful surgical management.

CONCLUSION

Image guided drainage of pelvic collections is a safe and effective procedure. Failures were due to initially undiagnosed pathology requiring surgical treatment.

Emergent ultrasound interventions

The interventionist can perform many emergent procedures with ultrasound guidance, because of its real-time, multiplanar imaging capability and portability. With the use of color Doppler, additional important information, such as aberrant vessels, can be ascertained to help plan needle trajectory. Ultrasound is also useful for nonemergent procedures, such as biopsies. All interventionists are encouraged to be facile with the use of ultrasound.

Intérêt de la voie d’abord transglutéale sous contrôle tomodensitométrique dans les procédures radiologiques interventionnelles percutanées

PURPOSE

To assess the CT-guided transgluteal approach for percutaneous interventional image guided procedures.

MATERIALS AND METHODS

CT guided transgluteal approach through the greater sciatic foramen was used for diagnostic procedure (CT guided needle biopsy of presacral masses n=5) or percutaneous treatment (aspiration n=4, and drainage n=10) in 19 patients, mean age 58 years (age range 20-86).

RESULTS

No technical failure occurred. A histological diagnostic was obtained in all diagnostic procedures. The success rate for therapeutic procedures was 87% and allowed to postpone surgery in 2 cases. In 2 patients a small pelvic hematoma occurred after catheter placement, but remained without consequence. Recurrences of collection occurred in 2 cases, one treated medically and the other surgically. Two patients suffered from transient deep pelvic pain, which resolved after catheter removal.

CONCLUSION

CT-guided percutaneous transgluteal procedures may be successfully performed in patients who cannot undergo trans-perineal, trans-rectal or trans-vaginal approach and is a safe and effective diagnostic and therapeutic option.

Transgluteal approach for percutaneous drainage of deep pelvic abscesses: 154 cases

PURPOSE

To assess the effectiveness of a computed tomographic (CT) image-guided transgluteal approach for percutaneous drainage of deep pelvic abscesses as an alternative to surgical drainage.

MATERIALS AND METHODS

The medical records of 140 patients who underwent percutaneous CT-guided transgluteal drainage of 154 deep pelvic abscesses were reviewed to determine the origins, location, and size of the abscesses; volume of initial aspirate; organisms identified in fluid culture; duration of catheter drainage; incidence of catheter-related pain and procedure-related complications; and short- and long-term outcomes. The resultant data were analyzed with a Fisher exact test for difference in the incidence of postprocedural catheter-site pain between transpiriformis and infrapiriformis approaches.

RESULTS

The origins of the pelvic abscesses included postoperative fluid collection (n = 115), perforating appendicitis (n = 6), diverticulitis (n = 16), tubo-ovarian inflammation (n = 5), Crohn disease (n = 10), and internal bowel fistula due to irradiation (n = 2). The abscesses were 4-12 cm in diameter. The volume of the aspirate was 5-310 mL. Laboratory cultures of the aspirate grew mixed flora, but the organism most frequently isolated was Escherichia coli. Catheters were removed after a mean of 8 days. In 134 (96%) of 140 patients, there was complete resolution of the abscess following transgluteal drainage, without subsequent surgery. In six of 140 (4%) patients, incomplete resolution necessitated subsequent surgery for postoperative fluid collection (n = 3), diverticulitis (n = 2), or perforating appendicitis (n = 1). Complications of transgluteal drainage were rare and included hemorrhage in three (2%) of the 140 patients. There was no procedure-related mortality. A transpiriformis approach was significantly more likely to be associated with postprocedural pain (P <.001) than was an infrapiriformis approach.

CONCLUSION

Percutaneous CT-guided transgluteal drainage is a safe and effective alternative to surgery for deep pelvic abscesses. Major complications are rare.

Ultrasound of the acute female pelvis

Ultrasound is the most valuable imaging modality in evaluating the premenopausal female presenting with acute pelvic pain. The appropriate interpretation of the ultrasound study requires correlation with the patient's clinical history and laboratory values. This is especially true of the serum beta-hCG, where ultrasound relies on this test to make the diagnosis of ectopic pregnancy. When the serum test for pregnancy is negative and the patient has an adnexal mass this could be secondary to a complicated ovarian cyst (hemorrhage, rupture), ovarian torsion or pelvic inflammatory disease. The ultrasound image can usually make the diagnosis in conjunction with the clinical papameters, however, this is most difficult in patients with ovarian torsion.

Ultrasound-guided endocavitary drainage of pelvic abscesses: technique, results and complications

AIM

To evaluate the experience in our institution with ultrasound-guided transrectal and transvaginal (endocavitary) drainage of pelvic abscesses.

MATERIALS AND METHODS

Eighteen patients (four male, 14 female; mean age 55 years, range 30-78 years) presenting with pelvic abscesses were referred to our institution for therapeutic drainage over a 4 year period. Patients received broad-spectrum antibiotics prior to drainage, which was performed by either the transvaginal or transrectal route under ultrasound guidance. Patients were given sedo-analgesia in the form of midazolam and fentanyl and local anaesthesia was also employed. Eight French catheters were inserted into the abscess cavities, and patients were subsequently monitored on a daily basis by a member of the interventional radiology team until such time as it was deemed appropriate to remove the catheter.

RESULTS

Eighteen catheters were placed in 17 patients, and transvaginal aspiration alone was performed in one patient. Drainage was successful in 16 of 17 patients, but a transgluteal approach was ultimately required in the remaining patient to enable passage of a larger catheter into an infected haematoma. The mean duration of drainage was 5 days, mean time to defervesce 2 days. Spontaneous catheter dislodgement occurred in four patients associated with straining, but this did not have any adverse effect in three of the four patients.

CONCLUSION

Endocavitary drainage is an effective method of treatment for pelvic abscesses. Spontaneous catheter dislodgement does not affect patient outcome.

Percutaneous drainage of abdominal abcess

The mortality in undrained abdominal abscesses is high with a mortality rate ranging between 45 and 100%. The outcome in abdominal abscesses, however, has improved due to advances in image guided percutaneous interventional techniques. The main indications for the catheter drainage include treatment or palliation of sepsis associated with an infected fluid collection, and alleviation of the symptoms that may be caused by fluid collections by virtue of their size, like pancreatic pseudocele or lymphocele. The single liver abscesses may be drained with ultrasound guidance only, whereas the multiple abscesses usually require computed tomography (CT) guidance and placement of multiple catheters. The pancreatic abscesses are generally drained routinely and urgently. Non-infected pancreatic pseudocysts may be simply observed unless they are symptomatic or cause problems such as pain or obstruction of the biliary or the gastrointestinal tract. Percutaneous routes that have been described to drain pelvic abscesses include transrectal or transvaginal approach with sonographic guidance, a transgluteal, paracoccygeal-infragluteal, or perineal approach through the greater sciatic foramen with CT guidance. Both the renal and the perirenal abscesses are amenable to percutaneous drainage. Percutaneous drainage provides an effective and safe alternative to more invasive surgical drainage in most patients with psoas abscesses as well.

Single-step transvaginal aspiration and drainage for suspected pelvic abscesses refractory to antibiotic therapy

OBJECTIVE

For treatment of suspected pelvic abscesses, the use of the trocar technique avoids many of the technical challenges of the Seldinger method. The purpose of this study was to evaluate the effectiveness and safety of sonographically guided transvaginal aspiration or drainage with the trocar technique in suspected pelvic abscesses that were refractory to antibiotic treatment.

METHODS

We retrospectively reviewed 22 patients with suspected pelvic abscesses refractory to antibiotic therapy who underwent single-step transvaginal pelvic aspiration or drainage between 1995 and 2000.

RESULTS

Transvaginal aspiration or drainage was successful in 19 (86%) of the 22 patients. Of the 3 patients in whom aspiration or drainage failed, all ultimately went on to have surgery despite undergoing repeated drainage procedures. Drainage catheters were placed in 15 (68%) of the 22 patients and left in place an average of 3.7 days. Aspiration alone resulted in a 100% success rate, whereas drainage with catheter placement resulted in an 80% success rate. No complications, including bleeding, bowel perforation, and death, were reported in any of the procedures.

CONCLUSIONS

Transvaginal ultrasonographically guided aspiration or catheter placement with the trocar technique is a safe and effective treatment for suspected pelvic abscesses refractory to antibiotic therapy.

Transvaginal Interventional Procedures: Aspiration, Biopsy, and Catheter Drainage

Transvaginal ultrasonographically (US) guided procedures are simple and safe and often represent the only means of access to pelvic disease. Aspiration of cystic pelvic masses and core biopsy of solid pelvic masses can be easily performed by using the transvaginal route, an endoluminal US transducer, and a needle guide. Because of concerns about false-negative diagnosis and potential tumor seeding with biopsy of primary ovarian cystic lesions, the indications for transvaginal aspiration and biopsy of ovarian and adnexal lesions are predominantly therapeutic. Similarly, using an endoluminal probe with modification of the guide, one can also perform safe and effective trocar catheter drainage of pelvic abscesses via the transvaginal route. The transvaginal route is ideally suited to pelvic abscess drainage because of the proximity of the vaginal fornices to most pelvic fluid collections. The transvaginal route has the disadvantage of being semisterile; because of the risk of superinfecting previously noninfected pelvic pathologic conditions, the transvaginal approach should be used only for solid lesions or cystic lesions that can be completely aspirated. Familiarity with the transvaginal route of access is crucial for adequate treatment of many gynecologic and nongynecologic pelvic pathologic conditions.

Invasive procedures in the female pelvis: value of transabdominal, endovaginal, and endorectal US guidance

Transabdominal, endovaginal, and endorectal ultrasonographic (US) guidance is indispensable for a multitude of invasive procedures in the female pelvis. Transabdominal uterine US performed with a fluid-filled bladder is appropriate and convenient for guidance of difficult dilation and curettage procedures. Transabdominal intraoperative US can be employed to guide several procedures for which the more expensive intraoperative hysteroscopic procedure is now used. Aspiration of symptomatic ovarian cysts that appear benign at US with an endovaginally guided small-gauge needle is simple and effective. Simple noninfected pelvic fluid collections may be aspirated transvaginally for both diagnosis and therapy by using endovaginal guidance. Endovaginal US demonstrates the anatomic relationships of a pelvic abscess to adjacent structures, allowing safe access for transvaginal drainage. By using an endovaginal transducer with a needle guide, cervical and vaginal cuff masses may be easily sampled. An obstructed uterus may be accessed by puncturing obstructive tissue with a trocar-containing needle guided by an endorectal probe. US guidance for placement of a central brachytherapy tandem is performed via the abdominal approach after the bladder has been distended with sterile water. Endorectal US transducers may be effectively used to guide placement of interstitial brachytherapy needles in pelvic soft-tissue masses.

Transrectal ultrasonographically guided drainage of gynecologic pelvic abscesses

OBJECTIVE

This study assessed the feasibility of ultrasonographically guided transrectal aspiration of gynecologic pelvic abscesses to treat patients for whom intravenous antibiotic therapies failed and whose abscesses were not optimally amenable to colpotomy drainage or transabdominal or transvaginal ultrasonographically guided aspiration.

STUDY DESIGN

This was a retrospective review of the first 15 women with pelvic abscesses that resulted from salpingitis or complications of gynecologic surgery who underwent transrectal pelvic abscess drainage after failure of antibiotic therapy.

RESULTS

Purulent material was aspirated from the abscesses in 14 of the 15 women. All 14 women with aspirated material were successfully treated with real-time ultrasonographically guided transrectal drainage; only 4 of the 14 had indwelling catheter placement.

CONCLUSION

Ultrasonographically guided transrectal drainage of gynecologic pelvic abscesses is a safe and effective treatment of pelvic abscesses for women who do not have an adequate response to antibiotic therapy.

Bedside diagnostic ultrasound and therapeutic ultrasound-guided procedures in the intensive care setting

The availability, portability, safety, and other features of ultrasound have ushered this relatively new imaging modality into the everyday clinical practice of multiple disciplines. Features unique to ultrasound lend this imaging modality the opportunity for extensive use in the ICU. A review of its uses in this capacity includes bedside diagnosis of common disorders seen in the ICU setting, such as DVT, cholecystitis, and abscess. Bedside sonography also can aid in the treatment of such disorders, including DGC of pseudoaneurysms, fluid aspirations, and abscess drainages. This article is a review and could not possibly cover all bedside uses of ultrasound or provide in-depth information of specific uses described in this article. Hopefully, this article will spark an interest and prove as a starting point on a rewarding learning adventure.

Management of pelvic abscess during pregnancy: a case and review of the literature

Cases of pelvic or abdominal abscess complicating pregnancy are rare. Noninvasive diagnostic techniques including ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) have enabled early diagnosis of this unusual complication of pregnancy. We describe a patient in whom the diagnosis of a pelvic mass was made by sonography and MRI at 25 weeks' gestation. At laparotomy, a pelvic abscess was partially resected and drained. Two weeks later when the patient again became symptomatic, a recurrent pelvic abscess was detected by CT and treated with intravenous antibiotics and CT-guided transcatheter drainage. The patient's recovery was thereafter uncomplicated and she delivered a healthy male infant by elective repeat cesarean at 38 weeks' gestation. The literature concerning pelvic and abdominal abscesses during pregnancy is reviewed. The potential advantages of imaging-guided, percutaneous transcatheter drainage for the treatment of such patients are emphasized.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to understand the nonsurgical alternatives for the drainage of intraabdominal abscesses, the possible etiologies of intraabdominal abscess formation in the pregnant population, and the various approaches to percutaneous catheter drainage of intraabdominal abscesses.

Nongynecologic applications of transvaginal US

Transvaginal ultrasonography (US) is a noninvasive, readily available imaging technique that has greatly enhanced diagnostic sensitivity and accuracy for both gynecologic and nongynecologic disease. High-frequency US probes placed in the vagina allow high-resolution assessment of all the pelvic viscera, including portions of the gut and urinary tract. In addition, they allow visualization of the peritoneum of the pelvic pouch and the pelvic side walls without interference from bowel gas or adipose tissue. Evaluation of these areas requires a modified US technique that includes the use of the highest-frequency probes with angulation of the transducer to allow assessment of the region of interest. In women of childbearing age, the similarity of symptoms in gynecologic and gastrointestinal tract disease in particular underscores the potential utility of transvaginal US, which may, for example, help differentiate appendicitis in a pelvic appendix from pelvic inflammatory disease. Transvaginal US may also help determine the correct course of therapy, thereby improving patient management. Other indications for transvaginal US include assessment for pelvic appendicitis and diverticulitis, rectal and perianal complications of Crohn disease, and ureteric and bladder calculi and tumors as well as evaluation of the anal sphincters in women with fecal incontinence. Transvaginal US is also superior to routine US in the detection and characterization of ascites and peritoneal disease. Transvaginal US examination should include the entire pelvic cavity and contents, especially in women at risk for pelvic sepsis or peritoneal disease.

Transrectal versus transvaginal abscess drainage: survey of patient tolerance and effect on activities of daily living

PURPOSE

To evaluate patient perception of pain related to transrectal and transvaginal drainage and the catheter's effect on activities of daily living.

MATERIALS AND METHODS

From July 1993 to August 1997, 22 male and 40 female patients (mean age, 41 years; age range, 4-80 years) underwent transrectal or transvaginal aspiration or drainage. Fifty-seven drainages were performed. In a follow-up survey, patients were asked to score pain experienced during the procedure and afterward on a scale of 1-10 and to rate the effect of the catheter on their activities of daily living.

RESULTS

Twenty-two patients participated in the telephone survey. For those able to recall the insertion procedure, the mean pain score was 3.2 for transrectal and 5.9 for transvaginal drainage. Mean indwelling catheter pain was 1.6 for transrectal and 4.8 for transvaginal drainage. Pain after removal was 1.4 for transrectal and 2.3 for transvaginal drainage. Only one patient with a transrectal catheter reported severe limitation (bowel movement), with no reports of any serious effect on urinating, bathing, sitting, or walking. Transvaginally placed catheters caused marked limitation in all categories and were more painful than transrectal catheters (P < .05).

CONCLUSION

Of the transrectal and transvaginal approaches, transrectal is better tolerated.

Transvaginal ultrasound-guided aspiration of pelvic abscesses

OBJECTIVE

To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration.

METHODS

A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data.

RESULTS

The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported.

CONCLUSION

In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.

Transrectal and transvaginal abscess drainage

The TR and TV approaches to deep pelvic abscesses have been made safe and easy by improvements in endoluminal US technology. Most procedures take well under an hour, and standard intravenous sedation is usually sufficient for patient comfort. The simplest and safest technique employs a combination of endoluminal US, with biopsy guides for precision needle advancement, and fluoroscopy for dilating the tract and placing a drainage catheter. Patient acceptance of TR and TV catheters is high, and resolution can typically be expected within 3-5 days. In the majority of cases, catheter treatment, combined with antibiotic therapy, is curative.