A Clinical Experience of Ruptured Tuboovarian Abscesses

Written By: Sam Savage

Published Date: October 9, 2007 Last Edited: October 9, 2007

By Gupta, Nupur Arora, Manju; Singh, Neeta; Dadhwal, Vatsla; Et al

Abstract Introduction: Pelvic abscesses still remain a diagnostic and therapeutic challenge for the obstetrician and gynaecologist. Tubo ovarian abscesses (TOAS) are responsible for 1.6 2.2% of all gynaecological admissions in public urban hospitals.

Case Report: Out of six cases (mean age 28.1 years) who presented with this condition, two were following hysterosalpingography, one following oocyte retrieval for in vitro fertilization (IVF); one following cyst aspiration and the two of tubercular origin. The clinical presentation was pain abdomen (n=5), fever (n=4), diarrhoea (n=1), acute urinary retention (n=1) and backache (n=2). Pus revealed two PCR positive for mycobacterium tuberculosis and one patient was acid-fast bacillus (AFB) positive. Ultrasound and CECT pelvis (contrast enhanced computerized tomography) revealed multiloculated collection with echogenic fluid and thick septations in pelvis. All had laparotomy with pus drainage and peritoneal lavage under antibiotic cover; one patient required resuturing and one relaparotomy for drainage of abscess.

Conclusion: We conclude that physicians should consider the diagnosis of tubo-ovarian abscess in the differential diagnosis of abdominal pain, fever and leukocytosis after ovum retrieval for in vitro fertilisation, cyst aspiration, post HSG (hystersalpingogrphy) flare and pelvic tuberculosis.

Introduction: Antibiotic prophylaxis in practice of Obstetrics and Gynaecology has reduced the frequency of pelvic infections in the present era, but pelvic abscesses still remain a diagnostic and therapeutic challenge. The major types of pelvic abscesses are those secondary to ascending infection from the cervix, those that arise after puerperal infections, after any pelvic surgery or secondary to appendicitis or diverticulitis. Tuboovarian abscesses (TOAS) are responsible for 1.6 -2.2% of all gynaecological admissions in public urban hospitals (1).

Case Report: Out of six cases (mean age 28.1 years) who presented with this condition, two were following hysterosalpingography, one following oocyte retrieval for in vitro fertilization (IVF); one following cyst aspiration and the two of tubercular origin. The clinical presentation was pain abdomen (n=5), fever (n=4), diarrhoea (n=1), acute urinary retention (n=1) and backache (n=2). Pus revealed one PCR positive for mycobacterium tuberculosis and one patient was acid-fast bacillus (AFB) positive (Table 1). Ultrasound and CECT pelvis (contrast enhanced computerized tomography) revealed multiloculated collection with echogenic fluid and thick septations in pelvis (Table 2). All had laparotomy with pus drainage and peritoneal lavage under antibiotic cover; one patient required resuturing and one relaparotomy for drainage of abscess.

Case 1: Mrs. P, a 28-year-old nullipara presented to us with acute pain abdomen, high-grade fever (101 – 1020 F), tachycardia (pulse 120 per min), urinary retention following hysterosalpingography (HSG) at a private hospital. She underwent USG guided encysted pelvic fluid aspiration of nearly 700ml followed by laparoscopic drainage 2 months back in a private hospital, and was started empirically on antitubercular therapy. On laparoscopy, there was frozen pelvis with plastic peritonitis and extensive bowel and omental adhesions. Peritoneal biopsy did not reveal tubercular changes. AFB smear was negative. On admission, ultrasound revealed enlarged loculated thick walled fluid collection in pelvis of 12 x 16cm with internal debris. CECT abdomen pelvis at 72 hrs showed 8.5 x 13.5 x 20 cm fluid collection. Uterus was normal in appearance but bilateral adnexa were not clearly visualized. Ultrasound guided aspiration of 1160 ml pus from the pelvic abscess was done, which was AFB negative but grew E. coli sensitive tocefoperazone and sulbactum, metrogyl and amikacin. She received the same intravenously for 10 days. Her fever responded only partially and a repeat ultrasound still showed a residual collection of 12 x 7 x 6 cm in the pelvis. On laparotomy, there was 10 x 15 cm abscess that drained 1000ml pus. Deroofing of abscess with peritoneal lavage was done. She was discharged on the 7th post-operative day in a stable condition.

Case 2: Mrs. M, a 27-year-old lady presented to us with severe pain abdomen, fever (1020 F), tachycardia (pulse 110 per min), nausea and vomiting following HSG done in a private clinic during work-up for secondary infertility. She had a past history of pelvic inflammatory disease, and underwent diagnostic laparoscopy 2 years back for infertility. On admission, ultrasound showed a large loculated collection (7 X 8 cm) in the pelvis. Abscess was drained under ultrasound guidance and intravenous antibiotic cover (cefotaxime and metrogyl) followed by laparotomy a week later, which showed abscess involving left tube, ovary with bowel adhesions. Left salpingo-oophorectomy was performed. Inspite of good antibiotic cover, she continued to have fever and underwent re-laparotomy, abscess drainage and bowel injury repair. Pus was sent for aerobic, facultative and anaerobic culture which grew E coli sensitive to cefotaxime. She was discharged after 6 weeks in a good condition.

Case 3: Mrs. S, a 30-year-old nulliparous lady presented with fever (102 – 1030 F), tachycardia (pulse 126 per min), pain abdomen and vomiting following oocyte retrieval. She was diagnosed in the past to have an endometrioma; received danazol and then underwent laparoscopic bilateral endometrioma drainage, followed by six cycles of ovulation induction for infertility. USG guided endometrioma aspiration was done five times after this. On admission, ultrasound and CECT scan revealed large multi loculated inflammatory collection antero-superior to and on the lateral aspect of uterus with thick septations and internal echoes. Right ovary was displaced laterally and enlarged. Under broad-spectrum antibiotic cover and USG guidance, 120 ml pus was drained sensitive to piperacillin and tazobactum (Zosyn, Wyeth), amikacin and metrogyl. PCR from the collection was positive for tuberculosis and she was discharged on anti-tubercular treatment. After three weeks, was readmitted with peritonitis, for which she underwent emergency laparotomy with adhesiolysis and peritoneal lavage. Intraoperatively, left ovary was stuck to uterus encased in huge abscess. Re-laparotomy was undertaken for residual abscess one week later. She also developed pleural effusion after 2 weeks which was managed by USG guided pleural fluid tapping and insertion of chest tube. After six weeks, patient was discharged in a stable condition.

Case 4: Mrs. K, a 32- year- old nulliparous lady was referred from a private clinic with complaints of fever, pain abdomen and diarrhoea following aspiration of left ovarian endometrioma which turned out to be dermoid cyst. She continued to run temperature (102 -1040 F) (pulse 130 per min) and had diarrhoea. Under antibiotic cover (zosyn, amikacin and metrogyl), 150ml of pus was drained from ovarian abscess transvaginally. PCR for mycobacterium tuberculosis was positive. Examination under anaesthesia revealed ovarian abscess bulging in the anterior wall of rectum. There was 6 X 6cm cystic mass in the pouch of Douglas. On admission to our hospital, laparoscopy followed by laparotomy showed that pelvis was plastered with gut and omentum. Uterus and adnexae could not be visualized. On laparotomy, adhesiolysis and abscess drainage was done, followed by left ovaritomy. Pus was sterile. Patient was discharged in a stable condition on the eighth postoperative day.

Case 5: Mrs. R, a 26-year-old para one presented with difficulty in passing urine, abdominal pain, backache and lump abdomen. Four years back, she had an ovarian cyst aspiration, when 650 ml of clear fluid was aspirated. Presently, there was a cystic mass of 18 – 20 weeks size of uterus, mobile, which was arising from pelvis. Same mass could be felt through pouch of Douglas vaginally. Ultrasound showed in left hemipelvis, a large cystic lesion of 13.9 x 10.7 x 7.9 cm with internal septa, probably ovarian in origin. Uterus was normal in size and displaced to right by the cystic lesion. During laparotomy, left salpingo-ophorectomy with adhesiolysis and aspiration of straw colored fluid containing white cheesy flakes from cyst was undertaken. The ovarian cyst was 20 x 15 cm, adherent to left sidewall and bowel. Fallopian tube was stretched over the cyst on right side forming a terminal hydrosalpinx, and buried under adhesions with right ovary. Acid-fast bacilli were isolated from cyst wall scrap and histopathological examination of cyst wall showed features of granular inflammation compatible with tuberculosis. She was discharged in a stable condition on anti tubercular treatment.

Case 6: Mrs. T, a 26-year-old para three was admitted with pain abdomen and difficulty in passing urine. She had a cystic to firm mass of 20 weeks size uterus, with restricted mobility arising from pelvis. There was fullness in all fornices. Ultrasound showed fluid collection in pelvis with uterus and ovaries floating. Under intravenous antibiotic cover (Zosyn, metrogyl and gentamicin), laparotomy was done. Bowel loops were matted together into a cocoon like structure, which was suggestive of tuberculosis. Anterior to uterus, there was an abscess arising from pelvis measuring 15 X 20 X 10 cm. Another abscess of 5 x 6cm was seen posterior to uterus. Both ovaries were normal and fallopian tubes were inflamed. Anti- tubercular treatment was started. Pus culture grew E coli. Postoperatively, CECT scan revealed a large pelvic abscess with matted bowel loops and small mesenteric nodes. Abdominal drain was inserted under CT guidance. After four weeks of therapy, no pelvic collection was seen on a repeat CECT scan. Also developed wound infection and gaping which required resuturing later. Patient was discharged in a good condition. Discussion: Pelvic abscesses have been found to occur in 3 -16% of patients hospitalized for acute PID (2, 3). The major frequent presenting symptom is abdominal or pelvic pain in almost 90% of patients with tuboovarian abscesses (TOAS) (4). Fever and chills, vaginal discharge, nausea and abnormal vaginal bleeding accompany this. In a study by Landers and Sweet of 232 patients with TOAS; 50% had fever with chills, 28% vaginal discharge, 26% nausea and 21% had abnormal vaginal bleeding (5). Pelvic pain with fever was noted among all our patients; nausea in two, acute urinary retention in one, and diarrhoea in another patient. On pelvic examination, abdominal mass was present in three patients (50%) and deep tenderness in abdomen in rest three (50%). Commonly employed imaging techniques for diagnosis of abdominal or pelvic abscesses are ultrasound and computerized axial tomography. They are useful in both confirming the diagnosis and monitoring response to therapy. Transabdominal ultrasound has sensitivity of 90% for detecting a pelvic abscess (6). Its specificity has further increased since the advent of transvaginal ultrasonography. CT scan has been found to be superior to USG for the detection of abdominal abscess (78-100% sensitivity) as compared to ultrasound with a sensitivity of 75 – 82% (7). Ultrasound and CT scan was done in all our patients, but ideally CT scan should be reserved in those patients in whom USG fails to make a correct diagnosis. Formation of TOA starts with the destruction of epithelial cells in the endosalpinx. This leads to formation of purulent exudates. When the pus exudes from the fimbrial end, peritonitis occurs and infection may spread to the adjacent viscera. The abscess may be localized to the tube (pyosalpinx) or the ovary (primary ovarian abscess) or it may involve both (tuboovarian abscess). Adjacent bowel, bladder or the opposite adnexa may also be involved till finally it reaches the stage of rupture. Three of our patients had TO masses and another three patients had ruptured abscesses (Table 1, 2). Organisms isolated from pus culture were E coli in three patients; pus was sterile in rest three; two had PCR for mycobacterium tuberculosis positive; one had AFB positive. There have been many reports of conservative medical therapy as the initial approach to the management of tubo-ovarian abscess having variable responses (16 – 90%). The most effective antibiotic regimen available for treatment is the combination of metronidazole or clindamycin with aminoglycoside. Penicillin can also be added to this regimen (cefoxitin or cefotetan). Indications for surgery are failure to respond within 48 to 72 hours of medical management, uncertain diagnosis or there is suspicion of rupture. Intra- abdominal rupture of TOA is a surgical emergency with a very high mortality rate. Surgical intervention can be in the form of transvaginal colpotomy drainage, extraperitoneal drainage, transabdominal drainage, unilateral adenexectomy or total abdominal hysterectomy with bilateral adnexectomy. Newer approaches to management of TOA include laparoscopic drainage or percutaneous drainage with CT or USG guidance. Patients in whom future fertility is desired all measures should be undertaken to preserve the uterus and adnexa.

References:

1. Pedowitz P, Bloomfield RD. Ruptured adnexal abscess (tuboovarian) with generalized peritonitis. Am J Obstet Gynecol 1964; 88: 721-729.

2. McNeeley SG, Hendrix SL, Mazzoni MM et al. Medically sound, cost effective treatment for pelvic inflammatory disease and tubo- ovarian abscess. Am J Obstet Gynecol 1998; 178: 1272-1278.

3. Hager WD. Follow up of patients with tubo-ovarian abscess (es) in association with salpingitis. Obstet Gynecol 1983; 61: 680-84.

4. Nebel WA, Lucas WE. Management of tubo-ovarian abscess. Obstet Gynecol 1968; 32: 382-86.

5. Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis 1983; 5 (Suppl): 876.

6. Moir C, Robins RE. Role of ultrasound, gallium scanning and computed tomography in the diagnosis of intra-abdominal abscess. Am J Surg 1982:143; 582-85.

7. McClean KL, Sheehan GJ, Harding GKM. Intraabdominal infection: a review. Clin Infect Dis 1994; 19: 100-16.

1. Nupur Gupta MD, Pool Officer, AIIMS

2. Manju Arora DNB Pool Officer, AIIMS

3. Neeta Singh MD, Assistant Professor, AIIMS

4. Vatsla Dadhwal MD, Associate Professor, AIIMS

5. Deepika Deka MD, Additional Professor, AIIMS

6. Suneeta Mittal MD, FRCOG Professor and Head, AIIMS

Department of Obstetrics and Gynaecology

All India Institute of Medical Sciences, New Delhi, India

Address for correspondence: Dr Nupur Gupta

D-34, Pamposh Enclave, Greater Kailash -1

New Delhi – 110048

Tel: 09818077238

Fax: 091 – 11 – 26588449

Email: [email protected]

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