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Management of Bilateral Tubo-Ovarian Abscesses in Young Nulligravida

3/1/2013 - Anita K. Blanchard, MD

Editor:  Eduardo Lara-Torre, MD

Tuboovarian abscess (TOA) is a complication of Pelvic Inflammatory Disease (PID) in 15% of cases, and 33% of patients with PID requiring admission have a TOA. PID and TOAs are polymicrobial infections of anaerobic and aerobic bacteria. While Neisseria gonorrhoeae and Chlamydia trachomatis are thought to facilitate the infection, they are rarely recovered from an abscess. The most commonly isolated organisms from TOAs are Escherichia coli and Bacteroides species. Mortality associated with TOA has decreased dramatically over the last 50 years. However, the morbidity associated with TOA remains significant with complications including infertility, ectopic pregnancy, chronic pelvic pain, pelvic thrombophlebitis, and ovarian vein thrombosis.

Management in previous decades included the use of antibiotics and in many cases open or laparoscopic drainage of the abscess, leading to removal of some or all pelvic organs in the process. The significance of the loss of both ovaries in a young nulligravida must be considered, particularly as castration would cause infertility and lead to menopausal-associated health risks.

Currently, broad spectrum antibiotics are generally considered the appropriate initial management for unruptured TOAs. The 2015 Center for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines recommend inpatient intravenous antibiotics for at least 24 hours with cefotetan or cefoxitin IV , plus doxycycline orally or IV. Gentamicin and clindamycin are recommended for patients with penicillin allergies. Upon discontinuation of parenteral therapy, the CDC recommends that clindamycin or metronidazole be given with doxycycline for a total of 14 days. Oral therapy and hospital discharge are acceptable when the patient has had a favorable clinical response to therapy. If an IUD is present, it may be kept in place unless failure is demonstrated after 48-72 hours of initiation of treatment.

If the patient fails to respond to parenteral antibiotics in 48 to 72 hours, drainage or surgery should be considered. Treatment failure occurs in approximately 25% of cases. There is some evidence that the need for intervention is associated with TOA size. Several studies have shown that early drainage of all TOAs is safe, improves outcomes, and may be appropriate as primary therapy. Drainage may be accomplished by CT or ultrasound through the abdomen, vagina, rectum, or gluteus muscle. Transvaginal drainage of TOA combined with antibiotics has a success rate of 90-93%, avoiding surgery and major procedure-related complications. Early transvaginal drainage is associated with significantly shorter hospital stays and decreased morbidity.

Further Reading:

Center for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR 2015; 64(RR-3);1-137.Accessed August 2015, http://www.cdc.gov/std/tg2015/default.htm

Gjelland K, Ekerhovd E, Granberg S. Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases. Am J Obstet Gynecol 2005;193:1323-30

Initial Approval:  March 2013; Revised September 2015, Reaffirmed March 2017

 

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