Management of Bilateral Tubo-Ovarian Abscesses
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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 include infertility, ectopic pregnancy, and chronic pelvic pain.
The CDC recommends at least 24 hours of inpatient observation during parenteral antibiotic therapy for patients with TOAs. The approach should focus on preserving ovarian and tubal function in order to maintain fertility potential for those who desire future fertility and to avoid the complications associated with early menopause As such, the initial approach is typically non-surgical. Although antibiotic therapy is first line treatment in PID, the addition of aspiration may be appropriate in cases of TOA. In one study, patients with abscesses of less than 10 cm were randomized to antibiotics alone or in combination with transvaginal aspiration. Patients undergoing 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 2021 Center for Disease Control and Prevention Sexually Transmitted Diseases (CDC) Treatment Guidelines recommend inpatient intravenous antibiotics for at least 24 hours with cefotetan, cefoxitin or ceftriaxone, plus doxycycline administered orally when possible, with or without metronidazole. Gentamicin and clindamycin are recommended for patients with penicillin allergies. Upon discontinuation of parenteral therapy, the CDC recommends a total of 14 days of doxycycline and metronidazole. 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.
Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.Visit: Pelvic Inflammatory Disease (PID) - STI Treatment Guidelines (cdc.gov)
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, Revised and Renamed March 2022 - Previously titled "Management of Bilateral Tubo-Ovarian Abscesses in Young Nulligravida".
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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
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