Tubo-ovarian abscess

Last revised by Michael P Hartung on 26 Sep 2023

Tubo-ovarian abscesses are one of the late complications of pelvic inflammatory disease.

Risk factors for tubo-ovarian abscesses include 15:

Patients typically present with a combination of fever, elevated inflammatory markers, lower abdominopelvic pain, and vaginal discharge. Fever and leukocytosis may sometimes be absent.

Abscesses are often polymicrobial with a preponderance of anaerobic organisms 9.

Uncommon causes include actinomycosis, tuberculosis, and xanthogranulomatous inflammation 17.

The clinical context is extremely important in radiological interpretation. Patients will experience tenderness with endovaginal scanning. Some differentiate between:

  • tubo-ovarian "abscess": ovary and tube cannot be separately distinguished within the inflammatory mass

  • tubo-ovarian "complex": if the tube and ovary are separately discernible structures within the inflammatory mass

Features are non-specific and may include:

  • soft tissue density mass

  • loss of normal pelvic fat planes

  • an adynamic ileus may be present

Transabdominal and endovaginal ultrasound are the preferred initial imaging investigations. Findings may include:

  • multilocular complex retro uterine/adnexal mass

    • debris, septations, and irregular thick walls

  • commonly bilateral

  • echogenic debris within the pelvis

Can be a helpful adjunct to ultrasound, especially in determining the extent of disease 3,18:

  • high attenuation fluid pelvic masses which may contain fluid-fluid levels or gas

  • usually shows a thick enhancing abscess wall

  • a tubular multilocular configuration is more conclusive of a pyosalpinx

Can be useful especially when sonography is inconclusive or if the gas content is difficult to be differentiated from bowel gas 5.

Typically seen as thick-walled fluid-filled pelvic mass(es) 12

  • T1: abscess contents typically hypointense

  • T2: abscess contents typically heterogeneous signal or hyper-intense

Initial treatment can be with antibiotic therapy. Radiologically guided drainage or surgery may be required in patients resistant to antibiotic treatment. Drainage may be performed from an endovaginal, transgluteal, or transabdominal approach, dependent on patient and operator preference 4.

Recognized complications include:

Clinical features of infection is key to aid diagnosis as a number of other pathologies can give similar appearances 1:

Uncommon causes of tubo-ovarian abscesses such as actinomyces and tuberculosis have many overlapping features with ovarian malignancy, including:

  • relatively vague presentation

  • solid/cystic ovarian masses

  • peritoneal and/or serosal thickening and enhancement

There may be clues that favor uncommon causes of tubo-ovarian abscesses over malignancy:

  • long-standing intrauterine contraceptive device as a risk factor for actinomyces

  • smoother peritoneal enhancement more typical of peritonitis rather than carcinomatosis

In these cases, biopsy or fluid sampling is often most appropriate to guide therapy and avoid unnecessary surgical intervention 17.

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Cases and figures

  • Case 1
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  • Case 2: on MRI with incidental uterine didelphys
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  • Case 3: with IUCD
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  • Case 4: on MRI - complication of IUCD (removed)
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  • Case 5: on ultrasound
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  • Case 6
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  • Case 7
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  • Case 8: bilateral
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  • Case 9
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  • Case 10
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  • Case 11
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  • Case 12
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  • Case 13
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  • Case 14: tuberculosis
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  • Case 15
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  • Case 16
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  • Case 17: complicated by intestinal obstruction
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  • Case 18
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