by Matthew Lisankie, Charlotte Derr, Tomislav Jelic
A 19-year-old female presents to the emergency department (ED) complaining of 48 hours of worsening, stabbing left lower quadrant abdominal pain. The patient notes an intermittent, foul-smelling vaginal discharge for the past week. She also endorses fever, nausea, vomiting, dyspareunia, dysuria, and generalized fatigue. The patient is sexually active with one male partner and uses combination OCPs in conjunction with inconsistent utilization of condoms. She denies vaginal bleeding, fevers, jaundice, vomiting, constipation, or diarrhea. Her last menstrual period (LMP) ended 16 days ago and was typical of her usual menses. The patient has a history of menarche at 14 and coitarche at 17. She denies any use of tobacco but admits intermittent alcohol and marijuana use. She has no past medical or relevant family history. There are no known drug allergies.
Physical exam reveals a well-developed female in mild discomfort but no acute distress. Her vitals are unremarkable except for a temperature of 38.5 and a heart rate of 102. Her abdominal exam reveals moderate tenderness to palpation, worse in the left lower quadrant, with no rebound tenderness. There is no costovertebral angle tenderness, Rovsing sign or McBurney point tenderness. External genitalia is unremarkable. A pelvic exam demonstrates foul purulent discharge in the vaginal vault emanating from the cervical os with no visible blood products. Cervical motion tenderness and pain on palpation of bilateral adnexa are present. Left adnexa is more tender and has a palpable mass on it.
Tubo-ovarian abscess (TOA) is a walled-off infection of adnexal structures, typically the fallopian tubes or ovary and occasionally adjacent intra-abdominal structures. It is a potentially life-threatening progression of the pelvic inflammatory disease (PID). Thus, TOA and PID share a great deal of pathophysiology and clinical manifestations. TOA is common in women of childbearing age, who have multiple sexual partners and a history of PID . Transvaginal ultrasound is the first choice to diagnose TOA. But, CT remains an important tool in determining further management.  Up to 70-80% of appropriately selected TOA cases resolve with appropriate antibiotics alone. However, many patients require either image-guided drainage or surgical exploration for resolution.
Critical Bedside Actions and General Approach
Assessment of the undifferentiated patient with a high suspicion for tubo-ovarian abscess begins with the measurement of vital signs and establishment of vascular access. Continuous cardiac and pulse oximetry monitoring is often prudent, especially if the patient appears distressed or toxic, or has vital signs that fulfill Systemic Inflammatory Response Syndrome (SIRS) criteria.
Rapid determination of the patient’s pregnancy status is critical. A positive result warrants immediate rule out of ectopic pregnancy and septic abortion. Additionally, it determines the appropriate interventions and diagnostic modalities. A thorough history and physical including pelvic exam are crucial to timely diagnosis and intervention. If available, bedside transabdominal and endocavitary ultrasound can be a powerful adjunct to the initial assessment of the patient with undifferentiated low abdominal or pelvic pain.
Consider the following critical actions to make a diagnosis and initiate effective treatment:
- Obtain a urine specimen to rule out cystitis and pyelonephritis. It may provide evidence for or against nephrolithiasis. It may determine pregnancy status and therefore, change the choice of radiologic modalities.
- Obtain basic lab work, namely complete blood count (CBC), blood urea nitrogen (BUN) and creatinine. CBC may provide information on the infection and anemia. BUN and creatinine determine if the patient can safely undergo contrasted imaging studies if required.
- Check serum lactate and venous blood gas if there is a concern for sepsis.
- Obtain blood and other indicated cultures if the patient is exhibiting signs of SIRS
- Check electrolytes as hemorrhage, intra-pelvic, and intra-abdominal catastrophes can often lead to severe metabolic derangements.
- Consider checking hepatic and pancreatic function assays. Abnormal values may suggest other etiologies including biliary obstruction, pancreatitis, Fitz-Hugh-Curtis syndrome, or hepatitis.
Next, prepare for the pelvic examination by obtaining:
- A lighted speculum to inspect the vagina and cervix
- Chlamydia/Gonorrhea PCR swabs
- Wet prep swab
A chaperone/assistant is recommended for both male and female examiners. Always be sure to discuss the major points of and rationale/risks/benefits/alternatives for the exam with the patient.
The initial pelvic exam is critical as it leads the investigation and provides valuable information to consulting physicians. At the minimum, the emergency physician should note the general appearance of external genitalia, any bleeding, discharge, or odors, the appearance of the cervix and caliber of the os, presence or absence of any cervical motion tenderness, and characteristics of the bilateral adnexa, making note specifically of mass, unilateral tenderness, and description of ovaries if palpable.
A chief complaint of acute lower abdominal pain in the female of reproductive age necessitates a rapid rule out of multiple surgical and gynecologic emergencies. The emergency physician should consider ruptured ectopic pregnancy, appendicitis, and TOA in the undifferentiated patient. Likewise, diagnoses including bowel obstruction, ovarian torsion, urinary obstruction should be excluded early as failure to diagnose these may lead to increases in morbidity and mortality. More common but less immediately-threatening diagnoses include constipation, gastroenteritis, colitis, diverticulitis, ruptured ovarian cyst, uncomplicated pelvic inflammatory disease, nephrolithiasis, urinary tract infection. Finally, consideration of pelvic malignancy, particularly in the post-menopausal patient with suspicion for TOA is recommended.
History and Physical Exam Hints
Presentation of the patient with TOA can vary from the post-menopausal
woman with only vague GI complaints to the teenage patient
with septic shock and peritonitis from a ruptured abscess.
The typical presentation of TOA consists of abdominal pain, pelvic mass on examination, fever, and leukocytosis. However, a significant portion of patients with TOA may lack one or more of these features. Therefore, emergency physician should bear a high index of suspicion in females of reproductive age.
The emergency physician should inquire about the sexual history of the patient. Multiple sexual factors and non-safe sex practices are among the risk factors.
Symptoms related to TOA are abdominal pain, fever, vaginal discharge, nausea, and abnormal vaginal bleeding. Physical examination features related to TOA are mucopurulent discharge, cervical motion tenderness, and uterine or adnexal tenderness.
Emergency Diagnostic Tests and Interpretation
Ultrasound is the first imaging modality to evaluate the female reproductory system due to low-cost and lack of ionizing radiation. Developing a facility with bedside ultrasound can have a profound impact on the patient’s course in the ER. A skilled operator with access to an endocavitary probe can incorporate diagnostic imaging into the initial pelvic exam within the first minutes of evaluation, and potentially shorten the time to effective antibiotics, definitive imaging, consultant evaluation, and disposition.
The computerized tomography (CT) with oral and IV contrast has improved sensitivity. The other advantages of CT are to show more detailed anatomy and rule in or rule out other differential diagnoses.
Emergency Treatment Options
Initial management of patients with TOA includes stabilization and timely diagnosis. Access and frequently reassess airway, breathing, and circulation (ABC). Establish IV access to draw blood, enable intravenous contrast CT and administer medications. Sound medical management is the primary concern of the emergency physician. Medical management primarily includes supportive care (e.g., fluid resuscitation, antiemetics, analgesics.) and broad-spectrum antibiotics.
Pregnancy testing is perhaps the most guiding first step in both diagnosis and treatment. A positive result limits the use of CT, raises the possibility of ruptured ectopic pregnancy, and limits the clinician’s armamentarium of antibiotics.
The mainstay of the medical therapy is antibiotics. TOA is typically a polymicrobial infectious process and necessitates initial broad coverage for anaerobes, aerobes, gram-positive, and gram-negative bacteria.
A summary of common empiric antibiotic regimens and respective pregnancy categories is as follows:
- Cefotetan (cat B) 2 g IV q12h + Doxycycline (cat D) 100 mg IV/PO q12h
- Cefoxitin (cat B) 2 g IV q6h + Doxycycline (cat D) 100 mg IV/PO q12h
- Clindamycin (cat B) 900 IV q8h + Gentamicin (cat D) 2mg/kg IV (load) then 1.5 mg/kg q8h
- Unasyn (cat B) 3g IV q6h + Doxycycline (cat D) 100 mg IV/PO q12h
- Imipenem-Cilastatin (cat C) 500 mg 16h
Evacuation of the abscess will typically be performed by either an interventional radiologist or gynecologist, depending on abscess characteristics and specific institutional policies.
Signs of peritonitis, sepsis, or toxic appearance suggest ruptured abscesses. These unstable patients need immediate surgical intervention. Stable patients with a high suspicion or radiographic evidence of TOA warrants ward admission for IV antibiotics and serial evaluation by a surgeon or gynecologist. Discharge from the emergency department and outpatient follow up are not recommended because of the risk of sepsis, peritonitis, and loss of fertility.
References and Further Reading
- Dewitt et al. Tuboovarian Abscesses: Is Size Associated with Duration of Hospitalization & Complications? Obstetrics and Gynecology International Volume 2010 (2010), Article ID 847041 http://dx.doi.org/10.1155/2010/847041
- Dupuis et al. Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women. Ultrasonography 2015; 34(4): 258-267.
- Gradison et al. Pelvic inflammatory disease. Am Fam Physician. 2012 Apr 15;85(8):791-6.
- Granberg, Seth. The management of pelvic abscess. Best Practice & Research Clinical Obstetrics & Gynaecology. October 2009Volume 23, Issue 5, Pages 667–678
- Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002;186(5):929–937.
- Reed, SD Antibiotic treatment of tuboovarian abscess: comparison of broad-spectrum beta-lactam agents versus clindamycin-containing regimens. Am J Obstet Gynecol. 1991 Jun;164(6 Pt 1):1556-61; discussion 1561-2.
- Kairys N, Roepke C. Abscess, Tubo-Ovarian. [Updated 2017 Oct 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448125/
- Workowski and Bolan. 2015 Sexually Transmitted Diseases Treatment Guidelines. Morbidity and Mortality Weekly Report. CDC. Recommendations and Reports Vol. 64 No. 3 June 5, 2015
- Flipping EM: Obstetrics and Gynecology – Bold City …. http://boldcityem.com/2016/10/flipping-em-obstetrics-and-gynecology/