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Tubo-ovarian Abscess: Pearls & Pitfalls

While TOA was once more commonly associated with being life-threatening, advancements in antibiotics and surgical techniques have resulted in a near absent mortality. However, failure to recognize it can result in irreversible tubal and ovarian damage, chronic pelvic pain, adhesion formation, ectopic pregnancy, and abscess rupture...

While the differential list is long and can span across the reproductive system, gastrointestinal tract, and urinary tract, key differentials to keep in mind in the ED are ectopic pregnancy, PID, ovarian torsion, appendicitis, and incarcerated hernia.

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Articles of Interest

TOA (Tubo-Ovarian Abscess): Three letters you don’t want to hear

Transvaginal US is the imaging modality of choice when a TOA is suspected (or transabdominal US with a full bladder). In one study, 89% of patients with suspected ovarian pathology had imaging studies performed, and of these, 97% were pelvic US. A TOA appears as a complex multilocular cystic mass with thick irregular walls, partitions, and internal echoes. , The sensitivity of transvaginal and transabdominal US for the diagnosis of TOA has been reported to be 75% and 83%, respectively.

EM@3AM: Pelvic Inflammatory Disease/Tubo-ovarian Abscess

The presence of a tubo-ovarian abscess is an indication for inpatient treatment of pelvic inflammatory disease with cefoxitin and doxycycline.

Episode 68: Tuba-Ovarian Abscess

Consider TOA in those who are acutely ill, have significant abdominal or pelvic tenderness, have an adnexal mass present on examination, or who present after failed therapy for PID.

Pelvic Inflammatory Disease & Tubo Ovarian Abscess

Diagnosis can be made via transvaginal US or CT A/P. Conventional teaching is that US is the preferred modality for imaging pelvic organs to assess for TOAs. However, recent studies have shown that CT has a higher sensitivity for diagnosing TOAs. Therefore, common practice is to start with US as it helps rule out other pathology, such as ovarian torsion, and is less expensive and less radiation for the patient. A positive US can help establish the diagnosis, however, a negative US does not exclude a TOA and a CT is often indicated. Ultimately, TOAs are a clinical diagnosis and are often diagnosed in the setting of pelvic mass in patients who meet the diagnostic criteria for PID. These patients should get an OBGYN consult and be started on IV abx.

Pelvic Inflammatory Disease and Tubo-ovarian Abscess

The most common physical exam findings are bilateral adnexal tenderness and purulent cervical discharge. Cervical motion, uterine, and lower abdominal tenderness may also be present. Unilateral adnexal tenderness or fullness may suggest the presence of a tuboovarian abscess, while right upper quadrant tenderness may suggest Fitz-Hugh-Curtis syndrome where the infection extends to cause a perihepatitis with inflammation of the liver capsule and ‘violin string’ scar tissue formation.

Pelvic Inflammatory Disease: Tricky Diagnosis

If signs of peritonitis are present, be concerned for rupture. This is now a surgical emergency! 25 Even if these signs aren’t present, surgery and drainage is often advised if the abscess is >7 cm.

Perforated appendix vs. Tubo ovarian abscess: A story of miscommunication

PID can be due to infections from an intrauterine device (IUD), chlamydia, or gonorrhea (none of which are a part of my sexual history). At times, it can be difficult for radiologists to differentiate between a tubo ovarian abscess and appendicitis given the close proximity of the appendix to a woman’s right ovary.

Tubo-Ovarian Abscess in Children

TOA is RARELY encountered in adolescents diagnosed with PID in the ED.

Resources

International Emergency Medicine Education Project

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).