Tubo Ovarian and Pelvic Abscess

TOA is generally a consequence of salpingitis or PID of acute or chronic nature. Other conditions associated with pelvic abscess formation include endometritis, pyelonephritis, uterine fibroids, and malignancy in the pelvic area. Most pelvic abscesses are polymicrobial with preponderance of anaerobic bacteria, with Bacteroides spp. predominating, followed by peptostreptococci and rarely, clostridia. P. bivia and P. disiens are major pathogens in these infections (51); these pathogens possess virulence characteristics similar to the B. fragilis group (35).

Swenson and colleagues (19) recovered anaerobes from 8 of 10 pelvic abscesses, and these organisms were the exclusive pathogens in five patients. Similarly, Thadepalli (52) isolated anaerobes from all 13 patients with pelvic abscess; these organisms were the only isolates in nine patients. The specimens for culture were obtained in both studies either at operation or by culdocentesis, thereby avoiding contamination by the normal vaginal flora.

We studied 53 TOA, 13 of which were in adolescent females (34). The predominant aerobic bacteria were N. gonorrhoeae (18 isolates), Enterobacteriaceae (7), and S. aureus (4). The predominant anaerobes were AGNB (45 isolates, including 15 of the B. fragilis group, 12 pigmented Prevotella and Porphyromonas spp. and six P. bivia) and anaerobic cocci (34). BLPB were isolated in 31 (58%) patients. These included all 15 B. fragilis group, five of 12 pigmented Prevotella and Porphyromonas spp. and seven of 18 N. gonorrhoeae.

The bacteriology of TOA is somewhat different from that of other pelvic abscesses. Whereas pelvic abscesses are caused by mixed aerobic and anaerobic bacteria, exclusively anaerobic bacteria were found in nearly one-half of the cases of TOA. Patients with TOA most commonly present with lower abdominal pain or an adnexal mass(es). Fever and leukocytosis may be absent. Ultrasound, computed tomography scans and magnetic resonance imaging, laparoscopy, or laparotomy may be necessary to confirm the diagnosis (53-55). TOA may be unilateral or bilateral, regardless of IUD usage.

Slap et al. (56) attempted to determine whether the clinical features of PID differ in adolescents with and without TOA. Some clinical characteristics were found to help identify adolescents with acute PID who have TOA. These patients may have fewer signs of acute illness than those without TOA and may develop symptoms later in the menstrual cycle. A six variable model was developed that performed best in differentiating the TOA and non-TOA group: last menstrual period more than 18 days prior to admission, previous PID, palpable adnexal mass, white blood cell count greater than or equal to 10,500/mL, erythrocyte sedimentation rate greater than 15 mm/h, and heart rate greater than 90/min.

Rupture of a TOA causes severe pain referred to the site of involvement. Chills, fever, and signs of progressing peritonitis follow the onset of pain. Diarrhea may occur early but ceases as the peritonitis worsens. If large volumes of pus are released into the peritoneal cavity, infection may spread upward along the colonic gutters; subphrenic abscesses may form, causing pain in the shoulders.

Intravenous clindamycin, cefoxitin, or metronidazole in combination with an aminoglycoside or single-agent therapy with a carbapenem, or a beta-lactamase inhibitor plus a penicillin (i.e. piperacillin plus tazobactam), are suitable choices for therapy. If no clinical response occurs after 48 to 72 hours or if the abscess enlarges, sonographiclly guided aspiration or surgery is necessary, while antibiotic therapy is continued (57,58).

Surgery is also necessary with a TOA rupture. This is vital since the patient fatality rate approaches 90% with medical therapy alone. Rapid diagnosis of such an abscess is the key to a successful outcome (53).

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