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3/1/2013

Management of Bilateral Tubo-Ovarian Abscesses

The prevalence of TOA is 2.3%.  When TOA is diagnosed, then 46% can be bilateral.  Bilateral TOAs are associated with past PID events, higher risk for surgical treatment, and risk for confusing it with a malignancy.   

PID and TOAs are polymicrobial infections of anaerobic and aerobic bacteria. While Neisseria Gonorrhoeae and Chlamydia are thought to facilitate the infection, they are rarely recovered from an abscess. The most commonly isolated organisms from TOAs are Ecoli and Bacteroides species. Organisms that make up the vaginal flora (e.g., anaerobes, Gardnerella, H influenzae, enteric Gram-negative rods, and S. agalactiae) may be associated with PID and TOA. In addition, CMV, M. hominis, U. urealyticum, and Mycoplasma genitalium may also play a role in the pathogenesis. Mortality associated with TOA has decreased dramatically over the last 50 years. However, the morbidity associated with TOA remains significant, with complications that include infertility, torsion, ectopic pregnancy, and chronic pelvic pain.

The CDC recommends at least 24 hours of inpatient observation during parenteral antibiotic therapy.  The approach should focus on preserving ovarian and tubal function and to avoid the complications associated with iatrogenic menopause. As such, the initial approach is typically non-surgical. However, the addition of aspiration may be appropriate in cases of TOA.  In one study, patients with abscesses of less than 10 cm were randomized to antibiotics alone or in combination with transvaginal aspiration.  Patients undergoing drainage had shorter average hospital stay and were less likely to require surgical intervention.

Broad spectrum antibiotics are the appropriate initial management for unruptured TOAs. The 2021 Center for Disease Control and Prevention Sexually Transmitted Diseases (CDC) Treatment Guidelines recommend intravenous antibiotics for at least 24 hours with cefotetan,  cefoxitin or ceftriaxone, plus doxycycline administered orally when possible, with or without metronidazole or ampicillin-sulbactam plus doxycycline. Gentamicin and clindamycin are recommended for patients with penicillin allergies. Upon discontinuation of parenteral therapy, the CDC recommends a total of 14 days of doxycycline and metronidazole or clindamycin. Oral therapy and hospital discharge are acceptable when the patient has had a favorable clinical response to therapy including resolution of fever for more than 24 hours and improvement of pain. If an IUD is present, it may be kept in place unless the patient has failed to improve after 48-72 hours of antibiotics.

If the patient fails to respond to parenteral antibiotics in 48 to 72 hours, drainage or surgery should be considered. Treatment with antibiotics results in failure in approximately 25% of cases. The need for invasive intervention may be associated with TOA size. Drainage may be accomplished by CT or ultrasound guidance. Transvaginal drainage of TOA combined with antibiotics has a success rate of 90-93%. Persons who have had sexual contact with a partner with PID during the 60 days preceding symptoms should be evaluated, tested, and presumptively treated for chlamydia and gonorrhea, regardless of the PID etiology or pathogens isolated. If the last sexual intercourse was >60 days before symptom onset or diagnosis, the most recent sex partner should be treated.  EPT (Expedited Partner Therapy) is an alternative approach to treating sex partners. All women who have received a diagnosis of PID should be retested 3 months after treatment.  

Further Reading:

Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187. doi: 10.15585/mmwr.rr7004a1. PMID: 34292926; PMCID: PMC8344968.

Soper DE. Pelvic inflammatory disease. Obstet Gynecol. 2010 Aug;116(2 Pt 1):419-428. doi: 10.1097/AOG.0b013e3181e92c54. PMID: 20664404.

Chappell CA, Wiesenfeld HC. Pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and tuboovarian abscess. Clin Obstet Gynecol. 2012 Dec;55(4):893-903. doi: 10.1097/GRF.0b013e3182714681.

 

Initial Approval:  March 2013

Revised September 2015

Reaffirmed March 2017

Revised January 2019

Revised September 2020

Revised and Renamed March 2022 - Previously titled "Management of Bilateral Tubo-Ovarian Abscesses in Young Nulligravida".

Revised January 2024

 

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