Management of Bilateral Tubo-Ovarian Abscesses in Young Nulligravida
Tubo-ovarian abscess (TOA) occurs in 15% of cases of pelvic inflammatory disease (PID), and in 33% of patients with PID requiring admission. 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. Organisms that make up the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) may be associated with PID and TOA. In addition, cytomegalovirus, Mycoplasma hominis, Ureaplasm urealyticum, and Mycoplasma genitalium may also play a role in the pathogenesis. Mortality associated with TOA has decreased dramatically over the last 50 years. However, the morbidity associated with TOA remains significant, with complications that including infertility, ectopic pregnancy, and chronic pelvic pain.
The CDC recommends at least 24 hours of inpatient observation during parenteral antibiotic therapy in women with TOAs. In young nulligravidas, the approach should focus on preserving ovarian and tubal function to maintain fertility potential, and the non-surgical approach should be considered as part of the initial intervention. Although antibiotic therapy is first line treatment in PID, the addition of aspiration may be appropriate in cases of tubo-ovarian abscess. In one study, women with abscesses of less than 10 cm were randomized to antibiotics alone or in combination with transvaginal aspiration. Women treated with drainage had shorter average hospital stay and were less likely to require surgical intervention.
Broad spectrum antibiotics are the appropriate initial management for unruptured TOAs. The 2015 Center for Disease Control and Prevention Sexually Transmitted Diseases (CDC) Treatment Guidelines recommend inpatient intravenous antibiotics for at least 24 hours with cefotetan or cefoxitin, plus doxycycline administered orally when possible. Gentamicin and clindamycin are recommended for patients with penicillin allergies. Upon discontinuation of parenteral therapy, the CDC recommends a total of 14 days of clindamycin or metronidazole given with doxycycline. Oral therapy and hospital discharge are acceptable when the patient has had a favorable clinical response to therapy including resolution of fever for more than 24 hours and improvement of pain. If an IUD is present, it may be kept in place unless the patient has failed to improve after 48-72 hours of antibiotics.
If the patient fails to respond to parenteral antibiotics in 48 to 72 hours, drainage or surgery should be considered. Treatment with antibiotics results in failure in approximately 25% of cases. Need for invasive intervention may be associated with TOA size. Drainage may be accomplished by CT or ultrasound guidance through the abdomen, vagina, rectum, or gluteus muscle. Transvaginal drainage of TOA combined with antibiotics has a success rate of 90-93%, and avoids surgery and major procedure-related complications that could lead to removal of reproductive organs.
Center for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR 2015; 64(RR-3);1-137. Visit: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.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 Oct;193(4):1323-30.
Chappell CA, Wiesenfeld HC. Pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and tuboovarian abscess. Clin Obstet Gynecol. 2012 Dec;55(4):893-903. doi: 10.1097/GRF.0b013e3182714681.
Initial Approval: March 2013; Revised September 2015, Reaffirmed March 2017, Revised January 2019, Revised September 2020
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