Risk factors for the development of tubo-ovarian abscesses in women with ovarian endometriosis: a retrospective matched case-control study

Extraperitoneal Spillage in Ruptured Tubo-Ovarian Abscess: A Case Report and Review of Literature

We report herein a case of a 43-year-old female with a ruptured tubo-ovarian abscess complicated by sepsis and extraperitoneal spillage into the anterior abdominal wall. The patient initially presented with acute abdominal pain and septic shock. Pelvic computed tomography revealed a collection in the abdomen that suggested a ruptured tubo-ovarian abscess, which dissects into the right rectus plane. There was a complete resolution of sepsis following surgical drainage. The patient underwent a hysterectomy with a bilateral salpingo-oophrectomy.

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.

Evaluation of endometrioma size effect on ovarian reserve, embryo quality and pregnancy outcome after in vitro fertilization cycle; a cross-sectional study

INTRODUCTION

Investigation of endometrioma size and its laterality on the quality of the embryo in patients with endometrioma compared to healthy subjects.

MATERIALS AND METHODS

In this retrospective and cross-sectional study, 70 patients with unilateral and bilateral endometrioma were recruited and compared with 70 age-matched infertile patients as the control group in terms of AMH before ovum pick-up, embryo quality as well as pregnancy outcome. Additionally, in the case group, we divided both unilateral (n = 32) and bilateral endometrioma patients (n = 38) into three groups based on the size of endometrioma. (1-3 cm, 3-6 cm, 6-10 cm) RESULTS: There was no difference in terms of age, BMI, parity, and age of menarche between the case and control groups. Moreover, no significant difference was observed in the baseline level of AMH between the case 2.96 ± 2.72 ng/dl (0.21-11.3) and control 2.73 ± 2.39 (0.21-12.8) groups. (P = 0.59) There was also no significant difference concerning AMH level between unilateral 3.58 ± 3.20 ng/dl (0.21-12.8) and bilateral endometrioma 2.45 ± 2.14 (0.21 - 0.20) groups. In terms of the quality and number of embryos, there was no significant difference between the case and control groups. (P = 0.30) Although the AMH level decreased with the increase in endometrioma size, this difference was not statistically significant. (P = 0.07) There was no significant difference in terms of the embryo quality between the groups based on the size of endometrioma. (P = 0.77) In addition, no significant difference was observed between the case and control groups in the terms of birth weight and pregnancy complications, such as premature delivery, cesarean section rate, neonatal respiratory distress, jaundice, as well as hospitalization rate. Head circumference of the newborns was higher in the endometrioma group while their Apgar score was lower in the case compared to the control group.

CONCLUSION

The presence of endometrioma by itself does not affect the main result of IVF procedures, including the number and quality of embryos and pregnancy outcome. Thus, IVF and embryo preservation and even pregnancy before surgery seem to be reasonable for endometriotic patients.

Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endometrioma increases the risk of antibiotic treatment failure and surgical intervention in patients with pelvic inflammatory disease

OBJECTIVE

To evaluate the outcome of pelvic inflammatory disease (PID) in patients with endometriosis with and without ovarian endometrioma.

DESIGN

A retrospective cohort study.

SETTING

A single university-affiliated tertiary center.

PATIENT(S)

A total of 116 patients with endometriosis hospitalized because of PID between the years 2011-2021. Fifty-nine patients with an ovarian endometrioma component were compared with 57 patients with endometriosis without endometrioma.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was severe PID defined as the need for surgical intervention or drainage. Secondary outcomes included tubo-ovarian abscess, number of hospitalization days, a positive cervical bacterial culture or urine sexually trasmitted disease polymerase chain reaction (STD PCR) test, and readmission because of partially treated or relapsing PID.

RESULT(S)

PID in patients with endometrioma was found less likely to respond to antibiotic treatment with increased risk for surgical intervention or drainage compared with endometriosis patients without endometrioma (adjusted odds ratio, 3.5; confidence interval, 1.25-9.87). On admission, patients with endometrioma were older (26.5 vs. 31.0) and less likely to have an intrauterine device (19.3% vs. 5.1%) compared with patients without endometrioma. The rate of the tubo-ovarian abscess (52.5% vs. 19.3%) was significantly higher in patients with endometrioma. Readmission rate, positive bacterial culture, and hospitalization duration were higher in the endometrioma group; however, they did not reach statistical significance. Recent oocyte retrieval and patient's age were not associated with an increased risk of severe PID.

CONCLUSION(S)

Endometrioma patients with PID are less likely to respond to antibiotic treatment and present a higher risk for surgical intervention.

Fertility preservation for women with ovarian endometriosis: results from a retrospective cohort study

RESEARCH QUESTION

What is the outcome of fertility-preservation treatments in women with endometrioma, especially those with endometrioma larger than 4 cm?

DESIGN

Retrospective cohort study. Women with definitive diagnosis of ovarian endometriosis (by histology or ultrasound), who underwent fertility-preservation treatment in two IVF units between 2016 and 2021, were included. As some women cryopreserved oocytes and other embryos, the primary outcome was the number of metaphase II (MII) oocytes retrieved.

RESULTS

Seventy-one women with ovarian endometriosis (OMA) underwent 138 fertility-preservation cycles. The median age of patients was 31 years. Forty out of 71 (56%) women underwent at least one surgery for OMA before fertility-preservation treatment. Multivariate analysis of each patient's first cycle was used. Women who underwent OMA surgery before fertility-preservation treatment had a 51.7% reduction (95% CI 26.1 to 68.5, P = 0.001) in the number of MII oocytes compared with women with OMA who did not undergo surgery. Among a subgroup who did not undergo surgery, those with an endometrioma larger than 4 cm had similar anti-Müllerian hormone concentration (2.6 ng/ml versus 2.1 ng/ml), number of oocytes retrieved (9 versus 9) and number of MII oocytes (7.6 versus seven 7) compared with women with an endometrioma of 4 cm or less.

CONCLUSIONS

Discussing fertility-preservation treatment options with patients with OMA is recommended, especially if surgery is planned.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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 in a patient with cri du chat syndrome: A case report

A tubo-ovarian abscess is an infection that occurs as a sequela of pelvic inflammatory disease. There is no reported association between a tubo-ovarian abscess and cri du chat syndrome in the medical literature. Herein, we report the case of a 44-year-old woman with cri du chat syndrome who was subsequently diagnosed with a tubo-ovarian abscess. After emergent laparotomy, simple total hysterectomy, and bilateral adnexectomy, the patient was discharged 13 days postoperatively without complications.

Acute Diffuse Peritonitis Due to Spontaneous Rupture of an Infected Endometrioma: A Case Report

Background.

Endometriosis is defined as a chronic, inflammatory, estrogen-dependent gynaecologic disease. It affects approximately 5–10% of reproductive-age women worldwide. Ovarian endometriosis is the most frequent form of this condition. Endometriotic cysts are found in about 17–44% of women diagnosed with endometriosis. It is well known, that ovarian endometriomas can cause infertility and chronic pelvic pain. Enlarging cysts can also cause ovarian torsion. In addition, ovarian endometriosis slightly increases the risk for ovarian cancer. The rupture of endometriotic ovarian cysts is an exceptional complication. According to the literature, the prevalence is less than 3% among women with endometriosis. The rupture of an ovarian endometrioma can cause acute peritonitis, which can lead to sepsis, septic shock and can be lethal. The occurrence of abscesses within an ovarian endometrioma is an extremely rare complication. Generally, the origin of infected endometriotic ovarian cysts is related to the previous invasive procedures involving pelvic organs or the use of intrauterine devices. Also, ovarian abscesses can be caused by the hematogenous or lymphatic spread of bacteria. Although, the literature points out that infection of endometriotic ovarian cysts can develop spontaneously. In these rare cases, reservoir and route of infection remains an enigma.

Case report.

A 49-year-old female was brought to the emergency room with severe generalized lower abdominal pain (6/10) and three days lasting fever. Abdominal examination revealed diffuse abdominal pain with anterior abdominal wall muscle tension. Painful solid masses were felt on both sides of the uterus during the pelvic examination. Cystic masses were detected in both ovaries during transvaginal sonography. Computer tomography (CT) of the abdomen and pelvis revealed abnormal changes in both ovaries. A small amount of free fluid was found in the pelvic cavity along with thickened pelvic peritoneum. Suspecting acute peritonitis and bilateral tubo-ovarian abscesses, surgical treatment was performed. Lower midline laparotomy with bilateral adnexectomy and abdominal lavage with 4000 ml normal saline were done. The outcome of peritonitis was evaluated using the Mannheim peritonitis index (MPI=17 – low risk of morbidity and mortality). The histopathological examination revealed the diagnosis of bilateral endometriotic cysts complicated with acute inflammation, with associated acute inflammation of both fallopian tubes. Microbiological cultures from the purulent fluid were negative.

Conclusions.

Although the occurrence of abscesses within an ovarian endometrioma is an extremely rare finding in clinical practice, it has to be considered by gynaecologists because it might result in a surgical emergency that can be life-threatening. Being aware of the risk factors of abscesses within an endometrioma can lead to an early diagnosis of this rare condition and help to avoid serious complications.

Minimally invasive approach to the management of tubo-ovarian abscesses

PURPOSE OF REVIEW

The purpose of this publication is to review the most up-to-date literature regarding the pathogenesis, diagnosis and management of tubo-ovarian abscesses.

RECENT FINDINGS

Prior to the advent of broad-spectrum antibiotics, tubo-ovarian abscesses necessitated total abdominal hysterectomy and bilateral salpingo-oophorectomy. Although it carries a risk of treatment failure, antibiotic therapy enabled fertility-sparing treatment for many women. Recent studies have identified key predictors for antibiotic treatment failure, including age, BMI and abscess diameter. C-reactive protein was also found to be a strong predictor of antibiotic treatment response. Given the growing evidence of treatment failure with antibiotic therapy alone, along with increased availability and access to interventional radiology, image-guided drainage with or without catheter placement, combined with broad-spectrum antibiotics, is now considered first-line therapy.

SUMMARY

Tubo-ovarian abscess is a diagnostic challenge, as presentation can vary. Inadequate treatment is associated with severe morbidity and mortality. Despite adequate conservative treatment, recurrence risk is high and clinical sequelae can have devastating effects on reproductive health. Recent evidence-based developments, including a risk score system to predict antibiotic failure, serve to provide appropriately directed risk-based care. However, large-scale randomized controlled trials are needed to clarify the most appropriate treatment modalities.