1. Student Doctor Madelyn Pickle OMS I
Tubo Ovarian Abscess
Student Doctor Madelyn Pickle
OMS I

2. Clinical Presentation
CC: Right lower abdominal pain
Presenting Sx: pain has worsened in the past 24hrs, spotty vaginal bleeding
Patient Hx:
37 yo F
Single, sexually active (G2, P0, A2)
Trial lawyer
Remote cervical cone biopsy (24yo)
Mother died of breast cancer at 44yo
PE: pale, moderately obese woman. RLQ pain to deep palpation, no rebound tenderness.
Labs: mild, normocytic anemia. Elevated BUN and Creatinine
Presents to ER, periods have always been painful but advil doesn’t work this time
Unknown results of biopsy
Information deficits

3. Differentials1,2 Ectopic Pregnancy Pelvic Inflammatory Disease
Tubo Ovarian Abscess
Cancer
Ruptured Ovarian Cyst
Clinical key
Medscape
Many other possibilities

4. Labs + Tests 3,4,5 Pregnancy test! STI Pelvic Exam Ultrasound CBC
Herpes, Syphilis, HPV
Pelvic Exam
Ultrasound
CBC
Vitals
Vaginal sample
Urinalysis
Erythrocyte Sedimentation Rate
STI tests, Ask about IUD use = could increase chance of PID
Pelvic exam: look for abdominal pain, adnexal tenderness, cervical motion tenderness
TOA on US looks like complex adnexal masses w mult internal echoes. Transverse endovaginal US^, also looks like endometrioma or dermoid cyst
Leukocytes on wetmount of vaginal culture
ESR is nonspecific marker of inflammation that could be assoc w ectopic preg
Access medicine, DynaMed, NIH

5. What is a Tubo Ovarian Abscess? 3,5,6
Pocket of pus from infection of a fallopian tube and ovary
Complication of Pelvic Inflammatory Disease or STI
Neisseria gonorrhoeae, Chlamydia trachomatis
Original infection may be asymptomatic
PID= infection that ascends from the vagina and cervix (Access medicine), most common cause of death from PID is ruptured ovarian abscess.
Not all come with PID but 1/3 of women hospitalized for PID have a TOA
Sexually transmitted pathogens such as N gonorrhea facilitate the infection but are rarely isolated from the abscess
Starts w gonorrhea and chlamydia but can develop into a mixed organism infection as it progresses (harder to treat) anaerobic microbes predominate
Increased risk w multiple sexual partner, sperm transport pathogens to upper genital track ie fallopian tubes
Key in TOA is inflammation from fallopian extends into ovarian parenchyma and forms pus
Multicystic progression^
eMedicine, NIH

6. Pathophysiology 5,7 Pathogen enters
Inflammatory response = damaged endothelium, edema
Tubal blockage promotes abscess formation and bacterial proliferation
Polymicrobial
Escherichia coli, aerobic streptococci, Candida, Salmonella
Aerobic, anaerobic, and facultative species
Abscess is an infection containment mechanism of the body
Ruptured abscess can lead to sepsis
Pathogens sexually transmitted, spread from bowel or appendix infection, surgery, endogenous flora
Damaged endothelium loses secretory cells and cilia of fallopian tubes (can’t clear out pathogens and debris)
Edema could result in necrosis
Predisposal from prior infection
UpToDate, NIH

7. Ruptured Abscess 8
Actinomycosis infection – ruptured (sulfur granules characteristic of actinomycosis)
Deadly if causes sepsis, requires immediate surgical intervention
JPGO

8. Treatment 3,6,7,9 Antibiotics Drainage Surgical removal Clindamycin
Metronidazole w/ Doxycycline
Anaerobes & facultative
Drainage
Surgical removal
“small” (less than 9cm) abscesses usually resolve with only antibiotics (UpToDate)
Oral clindamycin 450mg PO 4 times a day (access med)
Clindamycin for most infections, M&D for anaerobes or facultative such as candida (drugs.com)
US guided drainage w needle
Surgical removal of infected tube and ovary
eMedicine

9. Patient Education 3,7,9 Predisposing risks Follow up 72 hrs
STIs, IUD, HIV
Follow up 72 hrs
Clindamycin
Finish antibiotics
“safe sex” techniques to avoid re-infection
Maintain abstinence for at least 1 week post treatment
Fertility
Notify sexual partners
HIV more susceptible to TOA
72 hrs and no improvement return for CT and maybe drainage, onset of abdominal distention could mean bleeding or ruptured abscess
Clindamycin can cause diarrhea, return if watery or bloody
Could affect fertility, especially with surgical removal
Notify any partners form the past 60 days bc risk of N gonhorrea or chlamydia trachomatis
UpToDate, drugs.com, Access med

10. Bibliography
Predictors of tuboovarian abscess in acute pelvic inflammatory disease.Halperin R, Svirsky R, Vaknin Z, Ben-Ami I, Schneider D, Pansky M - J Reprod Med - January 1, 2008; 53 (1); Accessed Feb. 1, 2016.
Imaging in PID and TOA. Medscape. Published Feb. 27, Accessed Feb. 1, 2016.
Shepherd SM, Weiss B, Shoff WH. Pelvic Inflammatory Disease. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill;   =  Accessed February 08, 2016.
Kruszka P, Kruszka S. Evaluation of acute pelvic pain in women. American Family Physician [serial online]. July 15, 2010;82(2): Available from: MEDLINE Complete, Ipswich, MA. Accessed February 8, 2016.
Osborne NG. Tubo-Ovarian Abscess: Pathogenesis and Management. Journal of the National Medical Association. 1986;78(10):
Marshall, Sarah. Pelvic Inflammatory Disease: Tubo Ovarian Abscess. eMedicine Health Website. ovarian_abscess-health/article_em.htm Published Oct. 30, Accessed Feb. 8,
Clinical key
Medscape
Access medicine
Dynamed
NIH
eMedicine

11. 7. Beigi, Richard H. Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. UpToDate. Jun 3, Accessed Feb 8, 2016.
Shah NH, Khambati B, Paranjpe SH, Shah VN. Actinomycosis of Ovary - Resurgence JPGO Volume 2 Number Available from:  Accessed Feb 8,2016.
Clindamycin. Cerner Multum, Inc. Version 9.02 Revised Aug 19, Accessed Feb 8, 2016.
Velcani A, Conklin P, Specht N. Sonographic features of tubo-ovarian abscess mimicking an endometrioma and review of cystic adnexal masses. Journal of Radiology Case Reports. 2010;4(2): doi: /jrcr.v4i2.133.
7. UpToDate
8. JPGO
9. drugs.com