TOG BASED

1. Diagnosis & Management of
Tubo-Ovarian Abscesses
Dr. Kavinda Hewawitharana

2. Introduction
• TOA are well known serious complication of PID
• Commonly affects reproductive age group females
• 60% of TOA pts are nulliparous (Rosen et al,2009)
• High morbidity & mortality
• When severe sepsis , mortality rises as high as 10%
• Carries important long term sequale like infertility, chronic pelvic pain,
ectopic pregnancy risk

3. Cont.
• TOA-Inflammatory mass containing pus , involving tubes+/- ovaries
• Occasionally can involve bladder & bowel

4. Aetiology & Pathogenesis
• Mostly due to ascending upper genital tract infections causing
purulent , organisms containing material spillage through tube into
peritoneal cavity causing PID & progress to form TOA (Chappel et al,
2012)
• 30-40% cases are polymicrobial in origin (Chan et al,1995)
• When other intra abdominal infections present , these can lead to
local or hematogenous spread of organisms and cause PID/TOA

5. Organisms
C.Trachomatis Mycoplasma
N.Gonorrhoea H.Influenzae
E.Coli Strep.Pyogenous
Bacteriodes
Peptococcus
Peptostreptococcus
Actinomycosis
Tuberculosis (rare-HIV pts)
G.vaginalis
S.Agalactiae

6. Risk factors
Avoidance of barrier methods
IUD systems
Previous PID (15-30% proven PID pts will be diagnosed for
TOA)
Early sexual exposure
Multiple sexual partners (with unprotected intercourse)
DM & Immunocompromised patients
TOAs were reported even in women with no sexual activity.

7. • Though younger female got more risk factors, those who are around
45 yrs age are likely to have much larger and highly inflamed
TOAs.(Halperin et al,2003)
• Kubota et al,1997 showed that women with Endometriosis are likely
to have higher incidence of severe PID/TOA (2.3%) compared with
those who do not have.(0.2%)
• Women with endometrioma undergoing oocyte retrieval for ART are
at risk for infection. But ESHRE consider this risk is less hence
antibiotics not essential.

8. Why endometriosis pts are at risk of TOA?
1)Aetiology of endometriosis is associated with immune dysfunction
2) Wall of endometrioma is susceptible for organism entry rather
healthy ovaries
3)Content of endometrioma is a good medium for organisms to grow.

9. Symptoms & Signs
• Fever
• Diarrhea
• Lower abdominal pain
• Vaginal discharge
• Adnexal tenderness
• Cervical excitation
• Other indicators of systemic infection as tachycardia, tachypnoea,
hypotension
Fever and diarrhea are much common with TOA rather PID alone.
(90% vs 60%)

10. Blood investigations
• WBC increase
• High CRP (associated clinical signs are more sensitive predictor for
TOA-Chan et al,1993)
• If ESR high, together with WBC, chance of TOA is higher than PID
alone.
• TOA can happen in the absence of High WBC or Pyrexia.

11. Other
investigations
• Pregnancy exclusion
• STI screening
-Chlamydia
-Gonorrhea
-HIV

12. Ultrasound Scan
• 1st line imaging
• Sensitivity 81% &
specificity 78%

13. Cogwheel sign
Thickened endo-salpingeal folds gives this
appearance & sensitive marker of a TOA.
Some believe that this is pathognomonic for acute
salpingitis
Overall, elongated, fluid filled, dilated tube with
incomplete septae within tube is a sensitive sign for
inflammation or abscess

14. Tubo-Ovarian
Complex
• Edematous ovary appears
polycystic &adheres to tube
forming complex.
• In contrast to other ovarian
tumors ,these locate in POD
instead anterior & superior to
uterus

15. Other features
• Enlarged uterus with ill defined margins & endometrium
• Echogenic FF in POD
• U/L or B/L complex solid-cystic ovarian masses

16. CT Scan
• 2nd line
• When USS is not conclusive or when other DDs consider, use CT scan
1.Thick walled, fluid filled,septated adnexal masses
2.Anterior displacement of thickened mesosalphinx
3.Para rectal fat infiltration
4.Recto sigmoid involvement
5.Hydroureter or hydronephrosis

17. 6.Thick uterosacral ligament (not specific)
7.Haziness of pelvic fat
8.Presence of ovarian vein entering into adnexal mass-
94% sensitive
100% specific for TOA

18. MRI Scan
• Sensitivity 95% & sensitivity 89%
• Non irradiated mode of imaging
T1-low signal intensity
T2-high signal intensity

19. Management
Careful monitoring & AntiDVT measures should be taken if no plan for
imminent surgical management

20. Medical management
• Effective up to 70% but high chance of recurrence.(Gorharkhay et al,2007)
• BSAB that covers common pathogens started as IV AB
• Success rely on ability to penetrate abscess cavity , remain active within it & act
against pathogens
• IV Clindamycin ,Metronidazole & Cefoxitin have higher penetration & shown
reduce size of TOA

21. cont.
• Cefoxitin + doxycycline combination is effective as Clindamycin
containing regimes
• Clinda+Genta+Ampicillin is effective as 87.5% than clinda+Genta
alone (47%). (McNeeley et al)
• Duration of treatment is still debatable as evidences are lacking
• But until clinically improve, AB to continue and once pt is stable
convert to oral & continue for 14 days

22. Medical response poor if;
• >5cm TOA
• Age >40
• Initial high WBC counts
• Smoking females
• Background chronic PID
Dewitt et al, suggested that TOA > 8cm requires SX interventions &
complication are high

23. Surgical management
• 1.If fails to respond to medical mx certainly by 48Hrs
• 2.Rapid clinical deterioration
Urges for guided aspirations or more radical sx options. (25%)
Technically challenging surgeries with high complication rates
consider previous sx history, abscess size & fertility wishes before sx

24. Laparoscopy or Laparotomy

25. Furthermore
• If family completed-Salpingo-oophorectomy to reduce recurrence
• If fertility wishes present-drain abscess , irrigate abdomen & place a
large drain
• Although pelvic clearance has good results, it has higher morbidity
• Laparoscopic approach with antibiotics were successful in about 90%
• Radical laparoscopic surgeries also carries high complication rates.
• TOA in postmenopausal life is rare(incidence 1.7% of all) but there
may be underlying malignancy thus require low surgical threshold
• For elective surgeries, wait at least 6 weeks till tissue reactions settle.

26. CT/USS Guided Aspiration
• Transabdominal,Transvaginal ot Transgluteal routes
• Success rate is varying between 83%-100%
• Rapid improvement of pt
• Minimally invasive,well tolerated and avoid sx associated
complications lowering lengthy hospital stays.
• For lager abscess , drains can be kept with success rate of 80%
• Smaller abscess do not require drains & 100% successful
• Residual dx or pain may require sx in about 6.8% pts.

27. TOA in Pregnancy
• Few reported cases
• MRI may help to differentiate from other infective masses
• Severity of infection & POG influence on mx modality
• Adverse fetal & maternal outcome can occur
• Expedition of delivery & mx TOA may need

28. TOA & Intrauterine Devices
• IUDs associate with TOA
• Better short-term outcome with removal.(Crespo et al,2014)
• If there was unprotected intercourse preceding 5 days, prior to
removal may need precautions to avoid unwanted pregnancies

29. Long Term Complications
1.Chronic Pelvic Pain-33% cases present, severity & number of episodes
influences this.
12% after 1st TOA vs 30% after 2nd .
No difference between medical or Sx mx TOAs
2.Subfertility-32-63% women had pregnancies after laparoscopic
Drainage Vs Medically mx females (4-15%).so consider Sx if
fertility wishes exists.
Tubal patency should be checked for SF pts those who
had TOAs.
Tubal occlusion or salpingectomy offer in case of persistent
Hydrosalpinx + SF to optimize outcome with IVF

30. References
• TOG-2018/JAN issue