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Tubo-ovarian abscess
From WikEM
Contents
Background
- Typically a complication of PID, although inflammatory bowel, appendicitis, and hematologic nidius have been reported
- Mortality if not ruptured: <1% if treated; 2-4% if untreated
- Infections are often polymicrobial
- Common organisms: Escherichia coli, aerobic streptococci, Bacteroides fragilis, Prevotella, Peptostreptococcus
- N. gonorrhoeae and C. trachomatis are rarely culprit organisms
Risk factors
Clinical Features
- +/-Fever
- Vaginal discharge
- Dyspareunia
- Disproportionate unilateral adnexal tenderness or adnexal mass or fullness
- Suspect in patient who does not respond after 72hr of treatment for PID
Differential Diagnosis
Pelvic Pain
Pelvic origin
- Urinary Tract Infection
- Ectopic
- Ovarian torsion
- Endometriosis
- PID
- Cervicitis
- Ectopic Pregnancy
- Ovarian Torsion
- Spontaneous abortion
- Septic abortion
- Myoma (degenerating)
- Ovarian cyst (rupture)
- Tubo-ovarian abscess
- Mittelschmerz
- Sexual assault/trauma
- Ovarian hyperstimulation syndrome
Abdominal origin
- Appendicitis
- Kidney stone
- Psoas abscess
- Mesenteric adenitis
- Incarcerated hernia
- Diverticulitis
- Pyelonephritis
Evaluation
- CBC
- ESR/CRP
- TVUS (Sn 75-82%)
- or
- CT pelvis (Sn 78-100%)
- Preferred with patients in whom associated GI pathology must be excluded
Management
- OB/GYN consult
- Majority (60-80%) resolve with antibiotics alone
Outpatient
- Ceftriaxone 250mg IM once PLUS doxycycline 100mg PO BID x14 days
- Add metronidazole 500mg PO BID x14 days if suspicion of bacterial vaginitis or gyn instrumentation in preceding 2-3 wks
Inpatient
- Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100mg q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg QD OR
- Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
Disposition
- Decision should be made in conjunction with gynecological colleague
- Patient with fevers, elevated WBC, abscess greater than 5 cm, or systemic toxicity demand admission
- Hemodynamically stable, afebrile patients with a relatively small abscess can be safely discharged with close gynecological follow up on antibiotics
