Tubo-ovarian abscess

Changed by Matt A. Morgan, 11 Oct 2016
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Tubo-ovarian abscesses (TOA) are one of the late complications of pelvic inflammatory disease (PID).

Clinical presentation

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.

Pathology

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

Radiographic features

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
  • tubo-ovarian "complex" (TOC): ovary and tube cannot be separately distinguished within the inflammatory mass
    •
Conventional radiographyPlain radiograph
  • findings on a plain film featuresradiograph 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

Treatment and prognosis

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 a endovaginal, transgluteal, or trans-abdominal approach, dependent on patient and operator preference 4.

Recognized complications include

Differential diagnosis

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

  • -<li>tubo-ovarian "abscess" (TOA): if the tube and ovary are separately discernible structures within the inflammatory mass</li>
  • -<li>tubo-ovarian "complex" (TOC): ovary and tube cannot be separately distinguished within the inflammatory mass</li>
  • -</ul><h5>Conventional radiography</h5><ul>
  • -<li>plain film features are non-specific</li>
  • +<li>tubo-ovarian "abscess" (TOA): ovary and tube cannot be separately distinguished within the inflammatory mass</li>
  • +<li>tubo-ovarian "complex" (TOC): if the tube and ovary are separately discernible structures within the inflammatory mass</li>
  • +</ul><h5>Plain radiograph</h5><ul>
  • +<li>findings on a plain radiograph are non-specific</li>

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