Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Tuboovarian Abscess
Emily C. Wasco, Tufts Medical School 4th year Gillian Lieberman MD Advanced Radiology Clerkship Beth Israel Deaconess Medical Center October 17, 2003

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Patient
61 year-old female with vague lower abdominal pain, constipation, intermittent nausea and vomiting for 10 days. PMH: significant only for tubal ligation at age 35

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Patient
PE significant for palpable 5 cm right adnexal mass, soft, non-tender. No guarding or rebound. Labs significant only for WBC 16.7 Diagnostic tests performed showed a right tuboovarian abscess
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Next, a differential diagnosis to keep in mind when choosing imaging.

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Differential Diagnosis
Ectopic pregnancy Pelvic neoplasm Endometrioma Ovarian torsion Hemorrhagic cyst Ovarian hematoma Appendiceal and diverticular abscesses Tuboovarian abscess
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Definition and Epidemiology

Tuboovarian abscess (TOA): Abscess involving the ovary or fallopian tube Tuboovarian complex (TOC): Edematous, dilated infected pelvic structures without abscess formation, vague margins Pyosalpinx: infected fallopian tube Incidence 100,000/year Women 20-40, peak 20-24
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Anatomy that may be involved in TOA

Mesosalpinx

Ampulla

Broad ligament

Ovarian ligament

http://www.infertilitypa.com/images/pelvic.jpg

Uterosacral ligament 7

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Causes of TOA
Pelvic inflammatory disease (PID) IUD (older devices, Dalkon Shield) Pelvic surgery Intra-abdominal processes/infections Infertility treatments
Ovarian hyperstimulation Oocyte retrieval

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

PID and TOA

Virtually all cases of primary TOA TOA is most severe/late form of PID 1/3 hospitalized with PID, 15% of PID Reproductive tract flora migrates into pelvic peritoneal cavity, endometritis salpingitis Tissue damage, surfaces adhere and form a closed space Bowel, ovary, fallopian tube, peritoneum, uterus and omentum can be involved Perfusion is compromised, anaerobes flourish
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Intra-abdominal process
Any cause of bowel perforation adjacent to adnexa can lead to TOA
Appendicitis Diverticulitis

Intraperitoneal spread of infection with abscess formation as described with PID

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Pathogens
Polymicrobial
Strep species E. Coli Other gram negatives enterics Gonococci and Chlamydia common in PID but rare in TOA

Anaerobes
Bacteroides Prevotella Peptostreptococcus

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Signs and Symptoms

90% abdominal/pelvic pain 60-80% fever/leukocytosis 80-90% Palpable mass Findings of ileus are common, TOA can lead to bowel obstruction (distension, decreased bowel sounds)

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Moving on to imaging: Case images and description of when to use ultrasound, CT, and MRI for TOA

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Ultrasound
Test of choice for suspected TOA Transvaginal is best for visualizing adnexa Differentiates between TOA and TOC Sensitivity 82%, specificity 91% Increased availability, tolerability, speed and decreased cost (compared with CT, MRI) Ultrasound guided drainage
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Ultrasound TOA
Complex cystic, thick walled, well-defined mass/contiguous masses in adnexa or retrouterine Usually hypoechoic Can be multiloculated with septations or solid components leading to varied echotexture Air fluid levels Free fluid Indistinct uterine margins

Kaakaji et al, Sonography of Obstetric and Gynecological Emergencies, AJR 2000, 174:651

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Ultrasound TOA

Right Adnexa

Uterus

Left Adnexa

Kaakaji et al, Sonography of Obstetric and Gynecological Emergencies, AJR 2000, 174:651

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Ultrasound TOC
Dilated fallopian tubes Echogenic Fluid (pyosalpinx) Enlarged, hyperemic ovary (oophoritis) can be seen with ultrasound but not shown here
Kaakaji et al, Sonography of Obstetric and Gynecological Emergencies, AJR 2000, 174:651

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Ultrasound of Patient
Complex, hypoechoic cystic mass predominately containing fluid and debris 5.0 x 5.4 x 6.7 cm Slight peripheral Doppler color flow only

BIDMC PACS

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Computed Tomography
Adjunct to ultrasound if atypical, unresponsive to therapy or differential is large CT recommended to evaluate for full range of collections if free fluid/peritonitis Look for abscess in adnexa
Thick walled, fluid density (low attenuation mass) Internal septations common Internal gas bubbles Loss of definition of uterine wall Thickened uterosacral ligaments/increased density of presacral and perirectal fat Hydronephrosis if ureters involved Para-aortic LAD
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

CT of Patient
Contrast enhanced CT Abd/Pelvis 5.0 x 5.2 cm right adnexal fluid collection, closely associated with uterus and broad ligament Heterogeneously enhancing rim Indistinct uterine margins
Fluid Collection (TOA) Surrounding inflammation, Indistinct uterine borders

BIDMC PACS

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

CT of Patient
Non-dependent gas Compressed loop of small bowel Appendix visualized with no evidence of inflammation No diverticulitis Consistent with TOA

BIDMC PACS

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

CT of Patient: Reconstructions

BIDMC PACS

TOA 22
BIDMC PACS

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Magnetic Resonance Imaging

MRI also accurate at diagnosing PID, however not well studied Good soft tissue contrast between pelvic organs Visualize fluid filled tubes, abscesses, and smaller amounts of free fluid than ultrasound Abscess with low intensity on T1 and high on T2 and thick, irregular walls Not first line for evaluation of pelvic masses Cost, time
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Magnetic Resonance Imaging

T1

T2
Tukeva et al, MR Imaging in Pelvic Inflammatory Disease: Comparison with laparoscopy and ultrasound, Radiology 1999, 210:209

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Now that we have seen how to diagnose TOA, what are the treatment options?

Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Treatment
No standard of care Medical: Inpatient 10 day trial of IV broad spectrum antibiotics with anaerobic coverage, especially if young, stable.
Watch for sepsis If condition does not improve in 2-3 days, further intervention warranted Mass may take up to 6 months to resolve
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Radiologic Drainage
Ultrasound guided drainage: 80-85% effective
Transcutaneous is standard Transvaginal with endovaginal sonographic can be more direct if abscess better visualized, but can be painful if PID or prepubescent Transgluteal, transrectal can be chosen depending on location of abscess Drainage catheter placement or needle aspiration Avoids risks associated with general anesthesia and surgery Minimally invasive
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Radiologic Drainage
Drainage catheter placed in adnexal mass in woman with PID

Lee et al, Single-step transvaginal aspiration and drainage for suspected pelvic abscesses refractory to antibiotic therapy, J Ultrasound Med 2002, 21:731

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Surgical Drainage
Laparoscopic drainage: 90-95% effective Laparotomy:
Often used if diagnosis of TOA versus perforated viscus unclear increased in women over childbearing age unstable/septic rupture of TOA Resection of all infected organs (hysterectomy, salpingo-oophorectomy), assess for metastatic abscesses Drawbacks include loss of future fertility and endogenous estrogen if premenopausal
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

TOA Risks
If left untreated, TOA associated with:
increased morbidity from rupture and peritonitis chronic pelvic pain adhesion formation ectopic pregnancy impaired future fertility

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Patient
Patient did not improve on antibiotics so exploratory laparotomy with abscess drainage was performed. Tip of appendix adherent to superior aspect of mass, question of small appendiceal tear but no frank appendicitis Diagnosis: TOA from prior episode of undiagnosed appendicitis
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Conclusions
TOA is an abscess of the adnexa, caused most often by PID, but also from instrumentation and GI tract infections Diagnostic imaging first line is transvaginal sonography, with CT and MRI offering additional detail in complicated or unclear cases Serious condition which must be treated due to avoid known sequelae Treatment includes medical, radiologic and surgical options
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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

References
Ginsburg et al, Tuboovarian abscess: A retrospective review, Am J Obstet Gynecol 1980, 138: 1055. Sweet et al, Pelvic infection and abscess, in Infectious Diseases of the Female Genital Tract, Williams and Wilkins, Baltimore, 1990: 90. Wiesenfeld et al, Progress in the management of tuboovarian abscesses, Clin Obstet Gynecol 1993, 36: 433. Burkman et al, Intrauterine devices and pelvic inflammatory disease: evolving perspectives on the data, Obstet Gynecol Survey 1996, 51: s35 Moir et al, Role of ultrasound, gallium scannin and CT in the diagnosis of intraabdominal abscess, Am J Surg 1982, 143:582. Reed et al, Antibiotic treatment of tuboovarian abscess, Am J Obstet Gynecol, 1991, 164:1556. Nelson et al, Endovaginal ultrasonographically guided transvaginal drainage of pelvic abscess, Am J Obstet 1995, 172:1926. Casola et al, Percutaneous drainage of tuboovarian abscesses, Radiology 1992, 182: 399. Caspi et al, Sonographically guided aspiration: an alternative therapy for tuboovarian abscess, Ultrasound Obstet Gynecol 1996, 7:439. Van Sonnenberg et al, US-guided transvaginal aspiration of pelvic abscesses and fluid collections, Radiology 1991, 181:53.

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

References
Shulman et al, Percutaneous catheter drainage of tuboovarian abscess, Obstet Gynecol, 1992, 80:55. Teisala et al, Transvaginal ultrasound in the diagnosis and treatment of tuboovarian abscess. Br J Obstet Gynaecol 1990, 97:178. Reich et al, Laparoscopic treatment of tuboovarian and pelvic abscess, J Reprod Med 1987, 32_747. Kaakaji et al, Sonography of Obstetric and Gynecological Emergencies, AJR 2000, 174:651. Varghese et al, Transvaginal Catheter drainage of tuboovarian abscess using the trocar method, AJR 2001, 177:139. Lee et al, Single-step transvaginal aspiration and drainage for suspected pelvic abscesses refractory to antibiotic therapy, J Ultrasound Med 2002, 21:731. Wilbur et al, CT findings in Tuboovarian Abscess, AJR 1992, 158:575. www.eMedicine.com, Pelvic Inflammatory Disease/Tubo-ovarian Abscess, November 2002. Tukeva et al, MR Imaging in Pelvic Inflammatory Disease: Comparison with laparoscopy and ultrasound, Radiology 1999, 210:209. Bennet et al, Gynecologic Causes of Acute Pelvic Pain: Spectrum of CT Findings, Radiographics 2002, 22:785. http://www.infertilitypa.com/images/pelvic.jpg

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Emily Wasco, Tufts Medical Student 4th year Gillian Lieberman MD

Acknowledgements
Staff, Residents and Fellows, BIDMC Gillian Lieberman, MD Larry Barbaras, webmaster Pamela Lepkowski

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