Tubo-ovarian abscess: Difference between revisions
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*Age 15-25 years old | *Age 15-25 years old | ||
*Prior history of [[PID]] | *Prior history of [[PID]] | ||
*IUD | *[[IUD]] (within 21 days of insertion<ref>https://www.cdc.gov/std/tg2015/pid.htm</ref>) | ||
*[[HIV]] infection | *[[HIV]] infection | ||
==Clinical Features== | ==Clinical Features== | ||
*+/-[[Fever]] | *+/-[[Fever]] | ||
*Vaginal discharge | *[[Vaginal discharge]] | ||
*Dyspareunia | *Dyspareunia | ||
*Disproportionate unilateral adnexal tenderness or adnexal mass or fullness | *Disproportionate unilateral adnexal tenderness or adnexal mass or fullness | ||
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===Outpatient=== | ===Outpatient=== | ||
*[[Ceftriaxone]] 250mg IM once '''PLUS''' [[doxycycline]] 100mg PO BID x14 days | *[[Ceftriaxone]] 250mg IM once '''PLUS''' [[doxycycline]] 100mg PO BID x14 days | ||
* | *[[Metronidazole]] 500mg PO BID x14 days now recommended empirically by European guidelines <ref>Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.</ref>. Supported by CDC. Definitely give if suspicion of bacterial [[vaginitis]] or gynecological instrumentation in preceding 2-3 wks | ||
===Inpatient=== | ===Inpatient=== | ||
Revision as of 19:15, 13 February 2020
Background
- Typically a complication of PID, although inflammatory bowel, appendicitis, and hematologic nidius have been reported
- Mortality if not ruptured: <1% if treated; 2-4% if untreated
- Infections are often polymicrobial
- Common organisms: Escherichia coli, aerobic streptococci, Bacteroides fragilis, Prevotella, Peptostreptococcus
- N. gonorrhoeae and C. trachomatis are rarely culprit organisms
Risk factors
- Multiple sex partners
- Age 15-25 years old
- Prior history of PID
- IUD (within 21 days of insertion[1])
- HIV infection
Clinical Features
- +/-Fever
- Vaginal discharge
- Dyspareunia
- Disproportionate unilateral adnexal tenderness or adnexal mass or fullness
- Suspect in patient who does not respond after 72hr of treatment for PID
Differential Diagnosis
Acute Pelvic Pain
Gynecologic/Obstetric
- Pregnancy-related
- Ectopic Pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
Evaluation
- CBC
- ESR/CRP
- Transvaginal pelvic ultrasound (Sn 75-82%)
- CT pelvis (Sn 78-100%) - preferred in patients in whom associated GI pathology must be excluded
Management
- OB/GYN consult for possible operative drainage.
- Majority (60-80%) resolve with antibiotics alone
- Predictors of antibiotic treatment failure and possible indications for IR drainage upon admission to Ob[3]
- WBC > 16,000
- TOA size > 5.2 cm
Outpatient
- Ceftriaxone 250mg IM once PLUS doxycycline 100mg PO BID x14 days
- Metronidazole 500mg PO BID x14 days now recommended empirically by European guidelines [4]. Supported by CDC. Definitely give if suspicion of bacterial vaginitis or gynecological instrumentation in preceding 2-3 wks
Inpatient
- Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100mg q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg QD OR
- Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
Disposition
- Decision should be made in conjunction with gynecological colleague
- Patient with fevers, elevated WBC, abscess greater than 5 cm, or systemic toxicity demand admission
- Hemodynamically stable, afebrile patients with a relatively small abscess can be safely discharged with close gynecological follow up on antibiotics
See Also
References
- ↑ https://www.cdc.gov/std/tg2015/pid.htm
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Huma F et al. Inpatient Management of Tubo-Ovarian Abscesses: What Is the Threshold of Parenteral Antibiotic Treatment Failure? Obstetrics & Gynecology: May 2015
- ↑ Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.