Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

The management of pelvic abscess

Seth Granberg, MD, PhD, Associate Professor a, *, Knut Gjelland, MD,
Consultant b, Erling Ekerhovd, MD, PhD, Associate Professor c, d
a
Department of Obstetrics and Gynaecology, Akershus University Hospital, 1478 Lørenskog, Norway
b
Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
c
Department of Obstetrics and Gynaecology, Førde Hospital, Førde, Norway
d
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

Keywords:
The optimum treatment for pelvic abscess would be an approach
management that is safe, efficacious, cost-effective, minimally invasive, and
tubo-ovarian abscess which affects the woman’s fertility potential as little as possible. In
transvaginal drainage women of reproductive age tubo-ovarian abscess is one of the
ultrasonography most common types of pelvic abscess. Tubo-ovarian abscesses are
classically treated with broad-spectrum antibiotics. Frequently this
approach fails and surgical intervention becomes necessary in
about 25% of all cases. Surgical procedures include laparotomy or
laparoscopy with drainage of abscess, unilateral or bilateral sal-
pingo-ophorectomy, and hysterectomy. However, surgery for tubo-
ovarian abscess is often technically difficult and associated with
complications. An alternative approach is the use of imaging-
guided drainage of abscess in combination with antibiotics.
Combined data from several studies indicate that ultrasound-
guided transvaginal drainage with concomitant antibiotics is
especially safe and efficacious. This chapter discusses the
management of pelvic abscess with a special focus on transvaginal
ultrasound-guided drainage of tubo-ovarian abscess.
Ó 2009 Elsevier Ltd. All rights reserved.

Pelvic inflammatory disease usually occurs because of an ascending infection affecting the uterus,
fallopian tubes, and surrounding structures. It has been estimated that one in ten women suffer from
pelvic inflammatory disease during their reproductive years.1 Because of the varying clinical appear-
ance and lack of specific laboratory tests medical therapy is often delayed and almost one in four

* Corresponding author. Tel.: þ47 41324517; Fax: þ47 64848485.

E-mail address: sethg@online.no (S. Granberg).

1521-6934/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bpobgyn.2009.01.010
668 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678

women with pelvic inflammatory disease experiences long-term sequelae, such as chronic abdominal
pain, ectopic pregnancy and infertility.2
If pelvic inflammatory disease is inadequately treated a pelvic abscess, typically a tubo-ovarian
abscess is the consequence. Tubo-ovarian abscesses are generally reported as complicating 10–15% of
hospitalized cases of pelvic inflammatory disease.3 Risk factors for tubo-ovarian abscess are similar to
those of pelvic inflammatory disease and include a history of pelvic inflammatory disease, multiple
sexual partners, intrauterine device, and immunosuppression.4 Many cases of tubo-ovarian abscess are
thought to be initiated by bacteria that constitute part of the patient’s normal vaginal flora. Nearly 70%
of tubo-ovarian abscesses are unilateral. Tubo-ovarian abscesses are most common in the third and
fourth decades of life.5,6 Pelvic abscesses can also result from other causes, such as diverticulitis,
appendicitis, inflammatory bowel disease, and gynaecologic or obstetric surgery.
In Scandinavia, the number of women hospitalized for tubo-ovarian abscess has remained
unchanged from 1990 to 2002, despite the fact that the number of hospitalizations due to pelvic
inflammatory disease has decreased substantially.7 It was therefore suggested that women with tubo-
ovarian abscess may represent a different aetiology than for pelvic inflammatory disease. According to
an Israeli study, an increasing number of older women appear to be diagnosed with tubo-ovarian
abscess.8
Previously, treatment for tubo-ovarian abscess consisted of antibiotics and laparotomy, usually
involving unilateral or bilateral salpingo-ophorectomy, hysterectomy, and in some cases, colpotomy.
Although removal of affected organs offered high cure rates, the procedure was associated with
significant morbidity, infertility and early menopause. In order to prevent such adverse effects a more
organ-preserving approach was desirable. Today, surgical intervention, either laparoscopy or lapa-
rotomy, with adhesiolysis, excision of infected tissue and drainage of the abscess in combination with
intravenous antibiotics is frequently performed.7,9
The use of broad-spectrum intravenous antibiotics alone is successful in 34% to 87.5% of women
with a pelvic abscess.3 In patients with large adnexal masses the success rate of antibiotics alone is
especially low.10 In addition, there is a high recurrence rate for tubo-ovarian abscess following treat-
ment with antibiotics alone. Surgical intervention was reported to be necessary in about 25% of all
patients with tubo-ovarian abscess.11
Over the last two decades, drainage of abscesses with concomitant use of antibiotics has become
more accepted. Several studies have reported success rates in the range of 80 to 100% following either
ultrasound-guided or computed tomography-guided drainage.12–21 Ultrasonography, as part of the
gynaecological examination, is normally performed on all women admitted to hospital with lower
abdominal pain since it provides information of high diagnostic accuracy. The ultrasonographic
markers of a tubo-ovarian abscess include breakdown of the normal ovarian and tubal architecture in
which neither the ovary nor the tube can be separately recognized.22 Generally, the ultrasonographic
diagnosis of tubo-ovarian abscess is based on the demonstration of a complex cystic mass with thick
irregular walls, partitions and internal echoes, and no peristalsis.20 The present article reviews causes,
diagnosis, therapies, and outcomes of pelvic abscesses, with a special focus on transvaginal ultrasound-
guided drainage of tubo-ovarian abscess.

Aetiology and pathogenesis

Two principles are essential for the understanding of the pathogenesis of female genital infections.
The first one is that except for a few microorganisms such as group A b-haemolytic streptococcus,
Chlamydia trachomatis, and Neisseria gonorrhoaea, the pathogens that cause genital tract infections
arise from the normal microflora of the vagina and cervix. The second principle is that pelvic infections
usually are of polymicrobic aetiology.23
The microbial content of tubo-ovarian abscesses is predominantly a mixture of anaerobic, aerobic,
and facultative microorganisms. Anaerobic bacteria are particularly prevalent in tubo-ovarian
abscesses and are isolated in more than half of the infections. Some microorganisms frequently
cultured, according to a study by Landers and Sweet, are Escherichia coli (37%), Bacteroides fragilis (22%),
various Bacteroides species (26%), peptostreptococci (18%), and peptococci (11%).24
 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678 669

In long-term intrauterine device users tubo-ovarian abscesses may be caused by Actinomyces

israelii, a gram-positive anaerobe.25 The percentage of intrauterine device users diagnosed with tubo-
ovarian abscess ranges from 20 to 54%.23 However, actinomycetes are difficult to culture. They are
therefore often identified by histology in pathology specimens or by cytology on Papanicolaou smears.
Whether Actinomyces israelii is a sole pathogen or just a marker for mixed anaerob-facultative infection
resulting in the development of tubo-ovarian abscess is unclear. Thus, the potential role of actino-
mycetes in abscess formation among intrauterine device users remains to be elucidated.
The mechanisms by which tubo-ovarian abscesses are formed have been difficult to establish due to
the various presentations and degrees of tubo-ovarian damage present when the infection is diag-
nosed. It seems clear that tubo-ovarian abscesses often are the consequence of pelvic inflammatory
disease. However, in many women with tubo-ovarian abscess no symptoms or signs of sexually
transmitted disease can be traced. Clearly, many tubo-ovarian abscesses are not associated with
sexually transmitted disease.
It has been suggested that the initial step in the formation of a tubo-ovarian abscess is damage and
necrosis of fallopian tube epithelium by a pathogen, thereby establishing a favourable environment for
anaerobic invasion and growth. The destruction of the fallopian tube results in production of a purulent
exudate.23 After a while the ovary becomes involved in the inflammation. The abscess may also engage
neighbouring structures, such as bowel, bladder and the contralateral fallopian tube and ovary. If the
inflammation is not stopped, tissue planes are lost and the identification of pelvic structures and
organs becomes difficult.23 At this stage rupture of the abscess may occur, causing life-threatening
peritonitis.

Diagnosis

Patients typically present with lower abdominal pain with or without fever and chills. A history of
pelvic inflammatory disease is unveiled in almost 50% of the cases.10 Physical examination commonly
shows lower abdominal pain with peritoneal signs of rebound tenderness and guarding. Vaginal
examination often demonstrates mucopurulent cervicovaginal discharge, while bimanual examination
may give a suspicion of a tender adnexal mass. An adnexal mass is sometimes difficult to identify by
physical examination, particularly when pain precludes an adequate examination. In a study by
Landers and Sweet comprising 232 patients with a tubo-ovarian abscess, a complaint of abdominal or
pelvic pain was elicited in 98%, fever and chills in 50%, vaginal discharge in 28%, nausea in 26%, and
abnormal vaginal bleeding in 21%.24 A clinically important finding is that many patients present with
temperatures and white blood cell counts in the normal range. C-reactive protein is usually only
moderately elevated.25
Since clinical findings and laboratory data are non-specific, imaging studies are essential for the
diagnosis of a tubo-ovarian abscess. At most departments of obstetrics and gynaecology, pelvic
ultrasonography is usually performed on admission as part of the initial clinical examination. Endo-
vaginal ultrasonography in particular provides clear images of pelvic structures, and vulnerable
structures such as blood vessels can be visualized by means of colour Doppler sonography. Typically,
a tubo-ovarian abscess is seen as a complex cystic adnexal or cul-de-sac mass with thick irregular
walls, septations, and internal echoes (Figs 1 and 2). Often hyperechoic septa that originate as
triangular protrusions from the walls of the abscess, but which do not reach the opposite wall, can be
visualised. In addition, thick walls of more than 5 mm and sonolucent cogwheel-shaped structures
(cogwheel sign) can frequently be seen in cross-sections of the tube. In one study the sensitivity of
ultrasonography in the diagnosis of tubo-ovarian abscess was found to be 93%, whilst specificity was
98.6%.26
Little is known about the role of 3-dimensional and 4-dimensional ultrasonography for the
assessment of adnexal masses. Only a few years ago the 3-dimensional inversion rendering technique
was introduced for evaluation of fluid-filled structures.27 The use of 3-dimensional ultrasound makes it
possible to evaluate the three planes (sagittal, axial and coronal) of the abscess. In 3-dimensional
sonography the primary multiplanar image shows all three mutually perpendicular sectional planes
(orthogonal image planes) immediately after volume acquisition. Furthermore, since the scan is stored
on the ultrasound machine it can be re-examined at a later time. When 3-dimensional ultrasound is
670 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678

Fig. 1. Images of tubo-ovarian abscesses. A): A cystic abscess adherent to the uterus. B): The same abscess as in A after ultrasound-
guided drainage. C): A sausage-shaped ‘‘unilocular’’ tubal abscess, with pseudo-septa. To the right a part of the contralateral tubal
abscess is seen. D): Tomographic ultrasound imaging (TUI) of a cystic tubal abscess in the coronal plane. E). A multilocular tubal
abscess with pseudo-septa.

performed, the three perpendicular planes displayed on the screen can be rotated and adjusted
simultaneously into a more suitable anatomic orientation than that obtained from any arbitrary planes.
The optimal display of stored volume data by rotation can also provide more detailed morphological
information. By using this technique it is possible to follow a cystic structure in all three planes at the
same time. Consequently, diagnostic accuracy is increased.
Computed tomography and magnetic resonance imaging are other imaging procedures of great
importance for the diagnosis of tubo-ovarian abscess. If the symptoms are more generalised or non-
specific, computed tomography or magnetic resonance imaging is often performed on admission to
hospital. Typical computed tomography and magnetic resonance imaging findings of tubo-ovarian
abscess are thick-walled cystic adnexal masses with internal septations and surrounding inflammatory
changes.28–33 Anterior displacement of a thickened mesosalpinx is a common finding and indicates
that the mass is of adnexal origin. Using magnetic resonance imaging a tubo-ovarian abscess usually
appears as a pelvic mass with low signal intensity on T1-weighted images and heterogeneous high
signal intensity on T2-weighted images.34 A hydroureter or hydronephrosis is often an associated
 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678 671

Fig. 2. Images of tubo-ovarian abscesses. A). 3-dimensional ultrasound image of a cystic tubal abscess. In the upper left corner in the
sagittal plane, in the right upper corner in the axial plane, in the lower left corner in the coronal plane and in the right lower corner
a rendering image of the abscess. B, C and D). A cystic structure, imaged by 3-dimensional ultrasound, in an asymptomatic woman
who earlier had a tubo-ovarian abscess treated only with antibiotics. These images show some steps in the 3-dimensional inversion
rendering process of a cystic adnexal mass. With activation of the ‘‘invert’’ button, the inverted tube appears as in B. The rendered
volume is shown in C. By use of volume contrast imaging (VCI) the tube can be visualized as in D. This woman had a hydrosalpinx.
Pseudoseptations and ‘‘beads on a string’’ are seen in B and D. E). A cystic abscess prior to puncture. Uterus is seen adherent to the
abscess. F). The same abscess following drainage. G). Bilateral tubo-ovarian abscess. The one on the left side is multilocular, while the
one on the right side is ‘‘sausage-shaped’’.

finding, presumably because of inflammatory involvement of the periureteral tissues impeding the
peristaltic activity of the ureters.
In our departments, transvaginal ultrasonography is normally performed initially when a woman is
admitted due to abdominal or pelvic pain. If the ultrasound examination is inconclusive, the patient
may undergo either computed tomography or magnetic resonance imaging. In this way, unnecessary
computed tomography and magnetic resonance imaging examinations can be avoided and the
investigation can be as effective in terms of cost and time as possible. In our opinion most tubo-ovarian
abscesses can be diagnosed on the basis of: a) medical history, b) gynaecological examination,
c) transvaginal ultrasonography and d) relevant laboratory tests. Computed tomography or magnetic
resonance imaging should be carried out if the investigation is inconclusive. The use such a strategy is
advantageous since in many cases exploratory surgery can be avoided on the basis of the information
obtained by computed tomography or magnetic resonance imaging.
672 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678

Therapies

Antibiotics only

Most pelvic abscesses respond to intravenous broad-spectrum antibiotics followed by oral antibi-
otics over a prolonged period of time. It is important that the antibiotic regimen chosen has appropriate
coverage against common organisms in tubo-ovarian abscesses, including Bacteroides fragilis, pep-
tostreptococci, gram-negative aerobes, Chlamydia trachomatis, and Neisseria gonorrhoeae. Triple anti-
biotic therapy seems to be the treatment of choice. A success rate of 87.5% following treatment with
clindamycin plus gentamycin and ampicillin in women with tubo-ovarian abscess was reported by
McNeeley and co-workers.3 Another common triple agent therapy is the combination of cephalosporin
with gentamycin and metronidazole.8 The combination of cephalosporin and metronidazole is also
frequently used initially for treatment of tubo-ovarian abscess.20

Surgery in combination with antibiotics

Historically, surgical management ranging from posterior colpotomy, transabdominal surgical

drainage, unilateral salpingo-ophorectomy to total abdominal hysterectomy and bilateral salpingo-
ophorectomy in combination with antibiotics was performed in women with tubo-ovarian abscess.
Although this approach offered high cure rates, it resulted in hormone deficiency and left women of
child-bearing age without reproductive potential. In addition, due to the presence of friable inflam-
matory tissues and adhesions, surgery in this group of patients is often technically difficult and
associated with complications. Thus, Kaplan and co-workers reported that bowel injury occurred in
8.4% of the patients who underwent laparotomy.35
Today, the aim of management is to be as minimally invasive and as conservative as possible. This
means that when surgery is undertaken lysis of adhesions, drainage of the abscess, excision of infected
and necrotic tissues, and irrigation of the peritoneal cavity are usually conducted.
In many clinics laparoscopy has been the gold standard for diagnosis and treatment of tubo-ovarian
abscess for many years. Henry-Suchet and co-workers carried out laparoscopic adhesiolysis and
drainage of abscess in combination with antibiotics in 50 women.36 In 45 patients (90%) the approach
was successful, whilst five patients (10%) required further surgery. Like the study by Henry-Suchet and
co-workers, Reich and co-workers reported no complications following laparoscopic and organ-
preserving management of tubo-ovarian abscess in 25 patients.37 Raiga and co-workers also demon-
strated that operative laparoscopy involving drainage of adnexal abscesses is a safe and effective
procedure.38 In their study, they also examined the importance of second-look laparoscopy involving
the use of the methylene blue dye test in women desiring future pregnancy. During second-look
laparoscopy, adhesiolysis was performed in all women. Twelve of 19 women (63%) obtained a naturally
conceived intrauterine pregnancy. Buchweitz and co-workers compared the intraoperative and post-
operative safety and prospects of fertility in women who had laparoscopic incision of the abscess cavity
and lavage only to women who had laparoscopic salpingectomy or salpingo-ophorectomy.39 They
found that a significantly higher incidence of complications occurred when ablative treatment was
performed compared with organ-preserving surgery. No complications occurred in the patients who
underwent laparoscopic organ-preserving treatment, except for one woman who was readmitted 2
weeks after discharge due to lower pelvic pain. Of the 35 women who had either laparoscopic sal-
pingectomy or salpingo-ophorectomy nine intraoperative and nine postoperative complications were
registered: one intestinal perforation requiring laparotomy, four serosal lesions, two lesions of the
greater omentum, two lacerated collaterals of the internal iliac artery, one postoperative fever higher
than 38  C for two days, two bowel obstructions, one thrombosis of the upper leg, and one thrombosis
of the lower leg. Four of the women who had laparoscopic salpingectomy or salpingo-ophorectomy
were readmitted due to pelvic pain.39 Of the 40 women questioned about their reproductive outcome,
16 had undergone organ-preserving surgery, while 24 had undergone either salpingectomy or sal-
pingo-ophorectomy. In the organ-preserving group, three intrauterine pregnancies, resulting in live
births were reported. In the ablative group, one woman conceived. No ectopic pregnancies in either
group were registered.
 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678 673

Imaging-guided drainage in combination with antibiotics

During the past two decades, several studies have described imaging-guided drainage of pelvic
abscesses with concomitant antibiotics to be an efficacious mode of treatment. Various approaches for
abscess drainage have been reported, including transabdominal, transgluteal, transrectal, and trans-
vaginal drainage with the use of either computed tomographic or ultrasonographic guidance. Percu-
taneous catheter drainage through the abdominal wall is the most common method for drainage of
abdominal and upper pelvic abscesses, while the transvaginal route is the optimal approach for
drainage of low-lying pelvic abscesses in most women.40
Several reports have assessed the efficacy and safety of transvaginal ultrasound-guided drainage of
abscesses in combination with antibiotic therapy (Table 1). Transvaginal drainage under ultrasound
guidance using an indwelling catheter was first described in 1987.41 Transvaginal ultrasound-guided
needle aspiration of pelvic abscess without the use of an indwelling catheter was then described in
1990.12,42 In the report by Teisala and co-workers 10–120 mL of pus was aspirated in 10 women with
tubo-ovarian abscess.12 In all women recovery was quick and uncomplicated. Subsequently, Picker and
co-workers reported 12 cases of pelvic abscesses with a successful outcome following transvaginal
aspiration of purulent material.13 The patients were followed up for two years with no clinical recur-
rence. In another series reported by van Sonnenberg and co-workers ultrasound-guided transvaginal
drainage was performed in 14 women for a variety of pelvic abscesses.14 Twelve of the 14 patients were
spared a major operation. Surgery was undertaken in two women who both had a persistent tubo-
ovarian phlegmon. Feld and co-workers reported an overall success rate of 78% in 27 patients following
transvaginal sonographically guided catheter drainage of pelvic abscesses.43 Aboulghar and co-workers
treated 15 women with pyosalpinges and tubo-ovarian abscesses with transvaginal aspiration of pus.16
In that study, antibiotics were installed locally in addition to systemic antibiotic therapy. All patients
improved and were afebrile within 72 hours of aspiration. A follow-up evaluation six months after
aspiration showed that all women were free of symptoms. Nelson and co-workers reported a success
rate of 84% in 31 women with pelvic abscess refractory to antibiotic therapy following transvaginal
needle aspiration under endovaginal ultrasonographic guidance.44 In a prospective randomized study
including 40 women with a tubo-ovarian abscess Perez-Medina and co-workers compared the
outcome of treatment with intravenous broad-spectrum antibiotic therapy alone or in association with
early ultrasound-guided transvaginal needle aspiration.17 A significant difference in success rates as
well as mean hospital stay was registered between the groups. Seventeen of the 20 patients (85%)
responded to antibiotics plus transvaginal aspiration of pus, whilst in only 10 of the 20 patients (50%)
who had intravenous antibiotic therapy was the treatment successful. The average time from aspiration
of abscess material to discharge from hospital was 3.9 days. The corresponding figure in women treated

Table 1
Overview of some reports describing success rate following transvaginal needle aspiration/catheter drainage of pelvic abscesses
in combination with antibiotic therapy.

Study group (N) Successfully treated (n) Percentage

Nosher and co-workers (1987) 2 2 100
Teisala and co-workers (1990) 10 10 100
Picker and co-workers (1991) 12 12 100
vanSonnenberg and co-workers (1991) 14 12 85.7
Feld and co-workers (1994) 27 21 77.8
Aboulghar and co-workers (1995) 15 15 100
Nelson and co-workers (1995) 31 26 83.9
Perez-Medina and co-workers (1996) 20 17 85
Caspi and co-workers (1996) 10 10 100
Corsi and co-workers (1999) 22 20 90.9
Lee and co-workers (2002) 22 19 86.4
Gjelland and co-workers (2005) 302 282 93.4
Goharkhay and co-workers (2007) 27 26 96.3

N ¼ Number of women who had transvaginal needle aspiration/catheter drainage of abscess in combination with antibiotics.
n ¼ Number of women where transvaginal needle aspiration/catheter drainage of abscess in combination with antibiotics
proved to be successful.
674 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678

with antibiotics only was 9.1 days. Caspi and co-workers treated 10 women who failed to respond to
systemic antibiotic therapy with transvaginal ultrasound-guided needle aspiration of tubo-ovarian
abscess in combination with intracavitary instillation of antibiotics. All women improved clinically and
none required surgery.18 Corsi and co-workers reported successful abscess drainage in 20 of 22 women
(90.9%) following transvaginal sonographically guided aspiration and catheter placement.19 Two
women underwent surgery. One patient in whom drainage of bilateral tubo-ovarian abscesses was
successful underwent total abdominal hysterectomy and bilateral salpingo-ophorectomy due to
persistent abdominal pain. Another patient was diagnosed with a thick-walled organized abscess. It
was not possible to drain the abscess transvaginally and laparotomy was therefore carried out.
Transvaginal needle aspiration or catheter drainage of pelvic abscesses refractory to antibiotic therapy
was successful in 19 (86%) of 22 patients in a study reported by Lee and co-workers.45 Drainage
catheters were placed in 15 of the 22 patients and were left in place for an average of 3.7 days. Needle
aspiration alone resulted in a 100% success rate, whereas drainage with catheter placement resulted in
a success rate of 80%. No complications were registered in any of the procedures.
In a Norwegian study involving 302 women with tubo-ovarian abscess we found that transvaginal
needle aspiration of abscess content together with antibiotics was successful in 282 (93.4%) of the
women.20 In 20 women (6.6%) laparotomy or laparoscopy was performed. The main indications for
surgery were diagnostic or therapeutic uncertainty, especially during the first years of the study when
little was known about the various clinical aspects and efficacy of the approach. Transvaginal needle
aspiration was repeated if a substantial amount of abscess material was seen by ultrasonography 2 to 4
days after the initial aspiration. In 197 women (65.2%) transvaginal needle aspiration was carried out
one time only. Eighty women (26.5%) had two aspirations, whereas three aspirations were performed
in 15 women (5.0%) and at least four aspirations in 10 women (3.2%). The success rate of the procedure
was neither affected by the size of the abscess, the presence of bilateral abscesses nor by the multi-
locularity of the abscess. Complete pain relief, defined as no use of analgesic medication, was found in
188 women (62.3%) within 48 hours of the first aspiration. No procedure-related complications, such as
bleeding or bowel perforation, were diagnosed.
In a recently published study Goharkhay and co-workers compared the outcome of treatment of
tubo-ovarian abscesses by imaging-guided drainage and concomitant antibiotics versus antibiotics
alone.21 Fifty patients were treated primarily with intravenous antibiotics alone, whilst in eight
patients transvaginal ultrasound-guided drainage in combination with antibiotics was performed.
When using ultrasound guidance for drainage, clindamycin was injected into the abscess at the end of
the procedure. Complete response was noted in 29 patients (58%) treated with antibiotics (gentamicin
and clindamycin as well as ampicillin, if not penicillin-allergic) alone. Failure to respond to antibiotic
therapy corresponded to the size of the abscess, while failure rates were similar for unilateral versus
bilateral lesions. All eight women who had primary drainage responded to treatment. Of the 21
treatment failures with primary antibiotics, two underwent surgery while 19 had salvage drainage
with either ultrasound (11 women) or computed tomography guidance (8 women). Eighteen of the 19
salvage drainages resulted in complete recovery. In addition, women in the primary drainage group
required a shorter hospital stay and showed more rapid resolution of fever than women who received
antibiotics only.

Comments

The optimum treatment regimen for women with a tubo-ovarian abscess is debatable since rela-
tively few studies have been undertaken to address this issue. Furthermore, in most studies a low
number of patients were included. However, based on the literature, transvaginal ultrasound-guided
needle aspiration with concomitant antibiotics seems to be an attractive approach.
At our clinics, intravenous antibiotics are instituted as soon as the diagnosis is reached. A combi-
nation of cefuroxim and metronidazole is usually administered initially.20 Since no diagnostic approach
is sufficiently accurate to identify those who need drainage and those who will be cured by antibiotic
therapy only, transvaginal aspiration of abscess material is normally performed within 24 hours. Thus,
this procedure is not reserved only for those who do not respond to antibiotics within 48 hours.
Aspiration of purulent material at an early time-point after admission to hospital is more efficient than
 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678 675

medical treatment alone with regard to treatment success and mean hospital stay.17 In addition, most
patients experience immediate pain relief following drainage of an abscess.20
In the 1990s, several studies showed that percutaneous drainage of pelvic abscess was efficient and
well tolerated by most patients.46,47 The access routes were either the transabdominal, transgluteal,
transrectal or transvaginal. Transabdominal drainage became especially popular at several clinics.
However, many pelvic abscesses are inaccessible by this route because of overlaying bowel, bladder,
reproductive organs, or vascular or osseous structures. When transabdominal drainage is performed
there is an increased risk of bowel injury compared with the transvaginal route. Worthen and Gunning
described one case of bowel injury out of nine cases following transabdominal drainage.48
Currently, endovaginal ultrasonography is normally performed since it provides improved visual-
ization of bowel loops and other structures adjacent to pelvic abscesses compared with
transabdominal scans. When transvaginal drainage is carried out it provides a direct route into the cul-
de-sac or adnexal regions where tubo-ovarian abscesses usually are located.20 As shown in the present
review procedure-related complications are very rare when this approach is chosen.
In some reports an indwelling catheter for drainage of tubo-ovarian abscess has been used.14,15,49
Various techniques, such as the Seldinger and the trocar techniques have been described for catheter
delivery.15,49 Suggested advantages of catheter placement are that it allows frequent irrigation to break
down loculi and reduces the viscosity of the abscess contents.48 However, transvaginal catheter
insertion is usually a difficult, lengthy, and painful procedure.15,43 In addition, catheter-related
complications such as malpositioning, dislodgement, and erosion into adjacent structures are some-
times a problem.
The advantages of transvaginal needle aspiration are that in most cases it can be completed in one
session and that it is typically well tolerated by the patients. Thus, the procedure can be performed
under conscious sedation or analgesia, or even without any extra medication.20 In our experience,
when the abscess content is particularly viscous or when transvaginal aspiration is performed on
multilocular abscesses, irrigation with sterile saline solution normally dilutes the abscess material and
breaks down loculations and needle repositioning can easily be performed. In many cases irrigation is
not necessary and often sequential collapse of multiple loculations during aspiration can be seen. On
the other hand, ultrasonographic findings of residual debris, despite complete resolution of symptoms,
can be visualised for months after transvaginal aspiration. According to our data, the risk of recurrence
of abscess following transvaginal aspiration of pus in combination with antibiotics is minimal.20
In our opinion, there are four main indications for surgical treatment in women with tubo-ovarian
abscess: 1) Suspicion of a surgical emergency, such as rupture of the abscess or bowel perforation; 2)
unsuccessful drainage of abscess material; 3) failure of response following treatment with antibiotics
and drainage; 4) uncertainty about the diagnosis. Generally, laparoscopy should be performed as the
initial approach when surgery is necessary, since it is a minimally invasive procedure. When surgery is
carried out, an organ-preserving approach should be undertaken regardless of the patient’s wish for
children since it offers a significantly lower risk of complications.39
Tubo-ovarian abscesses in postmenopausal women represent a rather unusual entity. In the study
by Gjelland and co-workers 16 of 302 women (5.3%) with tubo-ovarian abscess were post-
menopausal.20 In this group of patients a history of acute pelvic inflammatory disease is typically
absent and the majority present with only vague and non-specific symptoms.50,51 Tubo-ovarian
abscess in postmenopausal women seems to be associated with a high frequency of serious pathology,
including co-existing malignant tumours.52,53 In one study, Heaton and Ledger found pelvic malig-
nancy in three out of 12 postmenopausal women (33.3%).54 Hoffman and co-workers reported that
gynaecological malignancy was diagnosed in four out of nine postmenopausal women (44.4%) with
tubo-ovarian abscess.51 In another study, Protopapas and co-workers reported that concomitant
gynaecological malignancy was diagnosed in 8 out of 17 postmenopausal women (47.1%).52 In contrast,
in the Norwegian study only one of 16 postmenopausal women (6.3%) with a tubo-ovarian abscess was
diagnosed with pelvic malignancy.20 Taken together, it seems clear that a thorough investigation to
exclude concomitant intraabdominal malignancy should always be performed when tubo-ovarian
abscess is diagnosed in postmenopausal women.
More than ten years ago it was demonstrated that needle aspiration in combination with antibiotics
is efficacious for treatment of various types of abscesses.55,56 As listed in Table 1, several smaller and
676 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678

one large study, including one randomised study, have reported the success rate of transvaginal
drainage of pelvic abscesses. The combined data of these studies show that transvaginal drainage,
either catheter drainage or needle aspiration, was successful in 472 out of 514 women, giving a success
rate of 91.8%. The studies also show that this approach is well tolerated with minimal risks of proce-
dure-related complications. In addition, by using this treatment regimen the potential risks associated
with general anaesthesia and surgery are avoided. Transvaginal drainage is also associated with
substantial cost savings.17,21
During the last decade we have intensified the use of transvaginal ultrasound-guided needle
aspiration not only for treatment of tubo-ovarian abscess but also when a pyosalpinx is diagnosed. We
find that early intervention makes aspiration easier since the purulent fluid usually has not yet become
highly viscous, and pain relief and normalization of body temperature occur in most cases shortly after
drainage. It is an open question whether such an approach has a beneficial effect on fallopian tube
function, thereby preserving the chances of pregnancy without the use of in-vitro fertilization. Despite
the fact that transvaginal drainage in combination with antibiotics is safe and efficacious, it is our
impression that surgery is often performed as first line treatment when a pelvic abscess is diagnosed.
Whether laparoscopy or laparotomy is undertaken due to diagnostic insecurity or due to tradition is
not known. At present transvaginal drainage of a abscess seems to be an under-utilized procedure. The
data presented in this paper clearly indicate that transvaginal needle aspiration with concomitant
antibiotics should be a first-line treatment wherever available.

Summary

Tubo-ovarian abscess is a common cause of inflammatory pelvic masses in women of reproductive

age. Up to 50% of tubo-ovarian abscesses are associated with pelvic inflammatory disease. Many cases
of tubo-ovarian abscess are thought to be initiated by bacteria that are part of the patient’s normal
vaginal flora. Tubo-ovarian abscesses may also be the consequence of appendicitis, diverticulitis,
inflammatory bowel disease, or surgery. The microbiological content of tubo-ovarian abscesses is
usually a mixture of anaerobic, aerobic, and facultative bacteria. A medical history, clinical examination,
and laboratory data are usually nonspecific. Imaging studies, usually ultrasonography or computed
tomography, are crucial in the diagnosis of tubo-ovarian abscess. Classically, tubo-ovarian abscesses are
treated with intravenous followed by oral antibiotics. If this approach fails, laparoscopy or laparotomy
with drainage of the abscess, unilateral or bilateral adnexectomy, or hysterectomy is performed. An
alternative approach for the treatment of tubo-ovarian abscess is imaging-guided drainage, either
catheter drainage or needle aspiration of abscess content, in combination with antibiotics. Combined
data from several studies show a success rate of approximately 90% following this treatment regimen.
Transvaginal needle aspiration seems to be an especially attractive approach since it is safe, cost-
effective and well tolerated by the patients. Since no ovarian or tubal tissue is removed the procedure
affects the woman’s fertility potential as little as possible. However, further studies are needed to
evaluate if this approach has a beneficial effect on tubal function. Randomised trials are also warranted
to compare cost-effectiveness, natural pregnancy rate, and the safety of surgery versus transvaginal
drainage.

Practice points

 Transvaginal ultrasound-guided needle aspiration in combination with broad-spectrum

antibiotics is efficacious for the treatment of tubo-ovarian abscess
 When surgery is performed in women with tubo-ovarian abscess an organ-preserving
approach should be undertaken regardless of the patient’s wish for children since it reduces
the risk of intraoperative complications to a minimum
 When tubo-ovarian abscess is diagnosed in postmenopausal women a thorough investiga-
tion to exclude concomitant malignant disease should be performed
 S. Granberg et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 667–678 677

Research agenda

 The use of 3-dimensional and 4-dimensional ultrasonography for assessment of tubo-ovarian

abscess
 Natural pregnancy rate in women with tubo-ovarian abscess following transvaginal needle
aspiration versus fertility-preserving laparoscopy
 Cost-effectiveness of transvaginal needle aspiration versus laparoscopy for treatment of
tubo-ovarian abscess

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