1. Low-Invasive Imaging Guided Treatment of Tubo-Ovarian Abscess
Malkhaz Mizandari, MD, PhD
Ultrasound Education Centre “GEOJEFF”
State Medical University
Tbilisi, Georgia

2. Etiology-Pathogenesis
TOA
TOA is a complication of PID
(15.0 to 30.0% of cases)
Pathogenesis
Ascending lower genital tract infection
Tube epithelium inflammation and necrosis
a) Altered pH
b) Devitalized or necrotic tissue from infection
c) Impaired blood supply from edema
d) Pathogenic organism growth

3. Diagnosis - Clinical Findings
TOA
Diagnosis - Clinical Findings
Pain in Small Pelvis
High Temperature
Vaginal Discharge (Purulent)
Painful Mass in Adnexal Region
Tenderness or Pain of Cervix on Physical Examination

4. TOA
Diagnosis - Imaging
Ultrasound CT
MR imaging

5. Ultrasound Diagnosis TOA Irregularly Shaped Mass in Adnexa Thick Walls
Complex Mass (Predominantly Cystic)
Internal Septi
Fluid-Fluid Level
Fluid-Debris level
Gas (Gas-Forming Microorganizms)
Often Adnexal Region Occupied Bilaterally

6. Microbiology TOA Supplemented Infection
The Most Common Primary Causes:
a) Chlamydia trachomatis
b) Neisseria gonorrhea
Less Common
Gardneralla vaginalis, Peptostreptococcus sp, Streptococcus agalectiae, Ureaplasma sp, Mycobacterium tuberculosis, Haemophilus influenzae, Actinomyces
Supplemented Infection
Escherichia Coli

7. Treatment TOA Medical (Broad Spectrum Antibiotics for PID)
TOA - Content Evacuation:
Surgery
Surgical options include laparoscopy or laparotomy with unilateral adnexectomy or total abdominal hysterectomy with bilateral oophorectomy
Low-Invasive
Intervention
Imaging guided percutaneal or endocavity aspiration/drainage:
a) CT b) Ultrasound c)Combined (Ultrasound-Fluoroscopy)

8. Invasive Ultrasound - Advantages
TOA
No Ionizing Radiation
Real-Time Technique
Doppler Capability
Puncture Aiming and Needle Movement Guidance Capability
Abdominal and Endocavity Approach
Cost-Saving

9. Material and Methods TOA TOA – 28 patients
Percutaneal approach (Drainage) – 4 patients
Perrectal approach (Aspiration, Rinsing) – 4 patients
Pervaginal approach (Aspiration, Rinsing) – 22 patient
(Note – all patients received antibiotics according the findings of bacteriology of aspirated material)

10. Procedures
TOA
Rinsing (Saline and Antiseptics) was performed to all patients
Proteolythic Enzyme Injection was performed to
6 patients because of inadequate rinsing due to TOA Septi and viscous content
Single Procedure - 7 patients total (2 percutaneal drainages and 5 aspirations)
2 procedures – 10 patients (among them – 1 after percutaneal drainage)
3 and more procedures – 11 patients (among them – 1 after percutaneal drainage)

11. Abdominal vs. endocavity approach - Indications
TOA
Abdominal Approach – Relatively Big Mass, Fixed to Anterior Abdominal Wall (advantage – Drainage Easily Performed)
Rectal Approach – Big Amount of Purulent Vaginal Discharge, Painful Vaginal Examination, Virgo Patient
Vaginal Approach – Small Masses Easily Achievable for Puncture

12. TOA
Needle Inserted in TOA

13. TOA
Saline Injection

14. TOA
Rinsing (Bubbles in TOA cavity)

15. TOA
Betadine Injected

16. TOA
Aspiration (Cavity is Collapsing)

17. TOA
Aspiration (Cavity is Collapsing)

18. TOA
Aspiration (Cavity Collapsed)

19. Results TOA Positive Result was Achieved in 27 (96.6%) cases
Open Surgery Required (Total Abdominal Hysterectomy with Bilateral Oophorectomy) – 1 (3.4 %) case

20. Summary
TOA
Low-Invasive Treatment (LIT) under Imaging Guidance Control Is Safe, Effective and Cost-Saving Technique
LIT is Easily Tolerated by Patients (Multiple Procedures)
Combination of Percutaneal Drainage and Endocavity Aspiration Might Be Helpful
LIT Should Be Used as a First Choice Treatment Procedure in TOA Patients Management

21. TOA
Thank you for your
attention