A tubo-ovarian abscess (TOA) is one of the late complications of

pelvic inflammatory disease Pelvic inflammatory disease (PID), also known as pelvic inflammatory disorder, is an infection of the upper part of the female reproductive system, mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...

(PID) and can be life-threatening if the

abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...

ruptures and results in

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

. It consists of an encapsulated or confined pocket of

pus Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during infections, regardless of cause. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collect ...

with defined boundaries that forms during an infection of a

fallopian tube The fallopian tubes, also known as uterine tubes, oviducts or salpinges (: salpinx), are paired tubular sex organs in the human female body that stretch from the Ovary, ovaries to the uterus. The fallopian tubes are part of the female reproduct ...

and

ovary The ovary () is a gonad in the female reproductive system that produces ova; when released, an ovum travels through the fallopian tube/ oviduct into the uterus. There is an ovary on the left and the right side of the body. The ovaries are end ...

. These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection.Pelvic inflammatory disease. American Family Physician, Vol. 85, No. 8. (15 April 2012), pp. 791-796 by Margaret Gradison It is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs. A TOA can also develop as a complication of a hysterectomy. Symptoms typically include fever, an elevated

white blood cell White blood cells (scientific name leukocytes), also called immune cells or immunocytes, are cells of the immune system that are involved in protecting the body against both infectious disease and foreign entities. White blood cells are genera ...

count, lower abdominal-pelvic pain, and/or vaginal discharge. Fever and leukocytosis may be absent. TOAs are often polymicrobial with a high percentage of anaerobic bacteria. The cost of treatment in the United States is approximately $2,000 per patient, which equals about $1.5 billion annually. Though rare, TOA can occur without a preceding episode of PID or sexual activity.

Signs and symptoms

The signs and symptoms of tubo-ovarian abscess (TOA) are the same as with

(PID) with the exception that the abscess can be found with

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

(MRI),

sonography Medical ultrasound includes diagnostic techniques (mainly imaging) using ultrasound, as well as therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal body structures such as tendons, muscles, joints ...

and

x-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

. It also differs from PID in that it can create symptoms of acute-onset pelvic pain. Typically this disease is found in sexually active women. Tubo-ovarian abscess can mimic abdominal tumours.

Complications

Complications of TOA are related to the possible removal of one or both ovaries and fallopian tubes. Without these reproductive structures, fertility can be affected. Surgical complications can develop and include: * Allergic

shock Shock may refer to: Common uses Healthcare * Acute stress reaction, also known as psychological or mental shock ** Shell shock, soldiers' reaction to battle trauma * Circulatory shock, a medical emergency ** Cardiogenic shock, resulting from ...

due to

anesthetic An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia ⁠— ⁠in other words, to result in a temporary loss of sensation or awareness. They may be divided into t ...

s * A

paradoxical reaction A paradoxical reaction (or paradoxical effect) is an effect of a chemical substance, such as a medical drug, that is opposite to what would usually be expected. An example of a paradoxical reaction is pain caused by a pain relief medication. Sub ...

to a drug * Infection

Cause

The development of TOA is thought to begin with the

pathogen In biology, a pathogen (, "suffering", "passion" and , "producer of"), in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a Germ theory of d ...

s spreading from the

cervix The cervix (: cervices) or cervix uteri is a dynamic fibromuscular sexual organ of the female reproductive system that connects the vagina with the uterine cavity. The human female cervix has been documented anatomically since at least the time ...

to the

endometrium The endometrium is the inner epithelium, epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The funct ...

, through the

salpinx A salpinx (; plural salpinges ; Greek σάλπιγξ) was a trumpet-like instrument of the ancient Greeks. Construction The salpinx consisted of a straight, narrow bronze tube with a mouthpiece of bone and a bell (also constructed of bronze) o ...

, into the

peritoneal cavity The peritoneal cavity is a potential space located between the two layers of the peritoneum—the parietal peritoneum, the serous membrane that lines the abdominal wall, and visceral peritoneum, which surrounds the internal organs. While situated ...

and forming the tubo-ovarian abscess with (in some cases) pelvic peritonitis. TOA can develop from the

lymphatic system The lymphatic system, or lymphoid system, is an organ system in vertebrates that is part of the immune system and complementary to the circulatory system. It consists of a large network of lymphatic vessels, lymph nodes, lymphoid organs, lympha ...

with infection of the

parametrium The parametrium is the fibrous and fatty connective tissue that surrounds the uterus. This tissue separates the supravaginal portion of the cervix from the bladder. The parametrium lies in front of the cervix and extends laterally between the lay ...

from an

intrauterine device An intrauterine device (IUD), also known as an intrauterine contraceptive device (IUCD or ICD) or coil, is a small, often T-shaped birth control device that is inserted into the uterus to prevent pregnancy. IUDs are a form of long-acting rever ...

(IUD). Bacteria recovered from TOAs are ''

Escherichia coli ''Escherichia coli'' ( )Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. is a gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus '' Escherichia'' that is commonly fo ...

'', ''

Bacteroides fragilis ''Bacteroides fragilis'' is an anaerobic, Gram-negative, pleomorphic to rod-shaped bacterium. It is part of the normal microbiota of the human colon and is generally commensal, but can cause infection if displaced into the bloodstream or surrou ...

'', other ''

Bacteroides ''Bacteroides'' is a genus of Gram-negative, obligate anaerobic bacteria. ''Bacteroides'' species are non endospore–forming bacilli, and may be either motile or nonmotile, depending on the species. The DNA base composition is 40–48% GC. Un ...

'' species, ''

Peptostreptococcus ''Peptostreptococcus'' is a genus of anaerobic, Gram-positive, non-spore forming bacteria. The cells are small, spherical, and can occur in short chains, in pairs or individually. They typically move using cilia. ''Peptostreptococcus'' are slow- ...

'', ''

Peptococcus ''Peptococcus'' is a Gram-positive bacterium genus in the family Peptococcaceae. Species in the genus are part of the human microbiome, especially in the bacteria that form the gut flora. They are part of the flora of the mouth, upper respirato ...

'', and

aerobic Aerobic means "requiring air," in which "air" usually means oxygen. Aerobic may also refer to * Aerobic exercise, prolonged exercise of moderate intensity * Aerobics, a form of aerobic exercise * Aerobic respiration, the aerobic process of cellu ...

streptococci ''Streptococcus'' is a genus of gram-positive spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales (lactic acid bacteria), in the phylum Bacillota. Cell division in streptococci occurs along a sing ...

''. Long term IUD use is associated with TOA. Actinomyces is also recovered from TOA.

Diagnosis

Laparoscopy Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medli ...

and other imaging tools can visualize the abscess. Physicians are able to make the

diagnosis Diagnosis (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...

if the abscess ruptures when the woman begins to have lower abdominal pain that then begins to spread. The symptoms then become the same as the symptoms for

peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...

Sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

occurs, if left untreated. Ultrasonography is a sensitive enough imaging tool that it can accurately differentiate between pregnancy, hemorrhagic ovarian cysts, endometriosis, ovarian torsion, and tubo-ovarian abscess. Its availability, the relative advancement in the training of its use, its low cost, and because it does not expose the woman (or fetus) to ionizing radiation, ultrasonography an ideal imaging procedure for women of reproductive age.

Prevention

Risk factors have been identified which indicate what women will be more likely to develop TOA. These are: increased age, IUD insertion, chlamydia infection, and increased levels of certain proteins (CRP and CA-125) and will alert clinicians to follow up on unresolved symptoms of PID.

Treatment

Treatment for TOA differs from PID in that some clinicians recommend patients with tubo-ovarian abscesses have at least 24 hours of inpatient parenteral treatment with antibiotics, and that they may require surgery. If surgery becomes necessary, pre-operative administration of broad-spectrum antibiotics is started and removal of the abscess, the affected

and

is done. After discharge from the hospital, oral antibiotics are continued for the length of time prescribed by the physician. Treatment is different if the TOA is discovered before it ruptures and can be treated with IV antibiotics. During this treatment, IV antibiotics are usually replaced with oral antibiotics on an outpatient basis. Patients are usually seen three days after hospital discharge and then again one to two weeks later to confirm that the infection has cleared. Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess. Parenteral Regimens described by the Centers for Disease Control and prevention are Ampicillin/Sulbactam 3 g IV every 6 hours and Doxycycline 200 mg orally or IV every 24 hours, though other regiments that are used for pelvic inflammatory disease have been effective.

Epidemiology

The epidemiology of TOA is closely related to that of pelvic inflammatory disease which is estimated to one million people yearly.

References

External links

{{STD/STI Abdominal pain Sexually transmitted diseases and infections Bacterial diseases Chlamydia infections Infections with a predominantly sexual mode of transmission Inflammatory diseases of female pelvic organs Reproductive system Gynaecology Sexual health Mycoplasma