Tubo-ovarian abscess

Tubo-ovarian abscesses (TOA) are one of the late complications of pelvic inflammatory disease (PID).

Patients typically present with fever, elevated white blood cell count, lower abdominal-pelvic pain, and/or vaginal discharge. Fever and leukocytosis may sometimes be absent.

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

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

  • tubo-ovarian "abscess" (TOA): ovary and tube cannot be separately distinguished within the inflammatory mass
  • tubo-ovarian "complex" (TOC): if the tube and ovary are separately discernible structures within the inflammatory mass
Plain radiograph
  • findings on a plain radiograph are non-specific
  • may show evidence of a soft tissue density mass
  • loss of the normal fat planes in the true pelvis
  • there may be an added adynamic ileus
Ultrasound

Transabdominal and endovaginal ultrasound is the initial imaging modality of choice

  • often shows multilocular complex retro-uterine/adnexal mass(es) with debris, septations, and irregular thick walls
  • commonly bilateral
  • may be echogenic debris in the pelvis
CT

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

  • fluid attenuation pelvic masses which may contain fluid-fluid levels or gas
  • usually shows a thick enhancing wall 
  • a tubular configuration is more conclusive of a pyosalpinx
MRI

Can be useful especially when sonography is inconclusive or if 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. Radiological guided drainage or surgery may be required in patients resistant to antibiotic treatment. Drainage may be performed from an endovaginal, transgluteal, or trans-abdominal approach, dependent on patient and operator preference 4.

Recognized complications include:

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

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Article Information

rID: 9818
System: Gynaecology
Section: Pathology
Synonyms or Alternate Spellings:
  • Tuboovarian abscess
  • Tuboovarian abscess (TOA)
  • Tubo-ovarian abscesses
  • Tuboovarian abscesses
  • Tubo-ovarian complex
  • Tuboovarian complex

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Cases and Figures

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    Case 1
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    Axial T2
    Case 2: on MRI with incidental uterine didelphys
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    Pyosalpinx
    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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