TUBO OVARIAN ABSCESS

TOG BASED

1. Diagnosis & Management of Tubo-Ovarian Abscesses Dr. Kavinda Hewawitharana

2. Introduction TOA are well known serious complication of PID Commonly affects reproductive age group females 60% of TOA pts are nulliparous (Rosen et al,2009) High morbidity & mortality When severe sepsis , mortality rises as high as 10% Carries important long term sequale like infertility, chronic pelvic pain, ectopic pregnancy risk

3. Cont. TOA-Inflammatory mass containing pus , involving tubes+/- ovaries Occasionally can involve bladder & bowel

4. Aetiology & Pathogenesis Mostly due to ascending upper genital tract infections causing purulent , organisms containing material spillage through tube into peritoneal cavity causing PID & progress to form TOA ( Chappel et al, 2012) 30-40% cases are polymicrobial in origin (Chan et al,1995) When other intra abdominal infections present , these can lead to local or hematogenous spread of organisms and cause PID/TOA

5. Organisms C.Trachomatis Mycoplasma N.Gonorrhoea H.Influenzae E.Coli Strep.Pyogenous Bacteriodes Peptococcus Peptostreptococcus Actinomycosis Tuberculosis (rare-HIV pts) G.vaginalis S.Agalactiae

6. Risk factors

7. Though younger female got more risk factors, those who are around 45 yrs age are likely to have much larger and highly inflamed TOAs.(Halperin et al,2003) Kubota et al,1997 showed that women with Endometriosis are likely to have higher incidence of severe PID/TOA (2.3%) compared with those who do not have.(0.2%) Women with endometrioma undergoing oocyte retrieval for ART are at risk for infection. But ESHRE consider this risk is less hence antibiotics not essential.

8. Why endometriosis pts are at risk of TOA? 1)Aetiology of endometriosis is associated with immune dysfunction 2) Wall of endometrioma is susceptible for organism entry rather healthy ovaries 3)Content of endometrioma is a good medium for organisms to grow.

9. Symptoms & Signs Fever Diarrhea Lower abdominal pain Vaginal discharge Adnexal tenderness Cervical excitation Other indicators of systemic infection as tachycardia, tachypnoea, hypotension Fever and diarrhea are much common with TOA rather PID alone. (90% vs 60%)

10. Blood investigations WBC increase High CRP (associated clinical signs are more sensitive predictor for TOA-Chan et al,1993) If ESR high, together with WBC, chance of TOA is higher than PID alone. TOA can happen in the absence of High WBC or Pyrexia.

11. Other investigations Pregnancy exclusion STI screening -Chlamydia -Gonorrhea -HIV

12. Ultrasound Scan 1 st line imaging Sensitivity 81% & specificity 78%

13. Cogwheel sign Thickened endo-salpingeal folds gives this appearance & sensitive marker of a TOA. Some believe that this is pathognomonic for acute salpingitis Overall, elongated, fluid filled, dilated tube with incomplete septae within tube is a sensitive sign for inflammation or abscess

14. Tubo-Ovarian Complex Edematous ovary appears polycystic &adheres to tube forming complex. In contrast to other ovarian tumors ,these locate in POD instead anterior & superior to uterus

15. Other features Enlarged uterus with ill defined margins & endometrium Echogenic FF in POD U/L or B/L complex solid-cystic ovarian masses

16. CT Scan 2 nd line When USS is not conclusive or when other DDs consider, use CT scan 1.Thick walled, fluid filled,septated adnexal masses 2.Anterior displacement of thickened mesosalphinx 3.Para rectal fat infiltration 4.Recto sigmoid involvement 5.Hydroureter or hydronephrosis

17. 6.Thick uterosacral ligament (not specific) 7.Haziness of pelvic fat 8.Presence of ovarian vein entering into adnexal mass- 94% sensitive 100% specific for TOA

18. MRI Scan Sensitivity 95% & sensitivity 89% Non irradiated mode of imaging T1-low signal intensity T2-high signal intensity

19. Management Careful monitoring & AntiDVT measures should be taken if no plan for imminent surgical management

20. Medical management Effective up to 70% but high chance of recurrence.(Gorharkhay et al,2007) BSAB that covers common pathogens started as IV AB Success rely on ability to penetrate abscess cavity , remain active within it & act against pathogens IV Clindamycin ,Metronidazole & Cefoxitin have higher penetration & shown reduce size of TOA

21. cont. Cefoxitin + doxycycline combination is effective as Clindamycin containing regimes Clinda+Genta+Ampicillin is effective as 87.5% than clinda+Genta alone (47%). ( McNeeley et al) Duration of treatment is still debatable as evidences are lacking But until clinically improve, AB to continue and once pt is stable convert to oral & continue for 14 days

22. Medical response poor if; >5cm TOA Age >40 Initial high WBC counts Smoking females Background chronic PID Dewitt et al, suggested that TOA > 8cm requires SX interventions & complication are high

23. Surgical management 1.If fails to respond to medical mx certainly by 48Hrs 2.Rapid clinical deterioration Urges for guided aspirations or more radical sx options. (25%) Technically challenging surgeries with high complication rates consider previous sx history, abscess size & fertility wishes before sx

24. Laparoscopy or Laparotomy

25. Furthermore If family completed- Salpingo -oophorectomy to reduce recurrence If fertility wishes present-drain abscess , irrigate abdomen & place a large drain Although pelvic clearance has good results, it has higher morbidity Laparoscopic approach with antibiotics were successful in about 90% Radical laparoscopic surgeries also carries high complication rates. TOA in postmenopausal life is rare (incidence 1.7% of all) but there may be underlying malignancy thus require low surgical threshold For elective surgeries, wait at least 6 weeks till tissue reactions settle.

26. CT/USS Guided Aspiration Transabdominal, Transvaginal ot Transgluteal routes Success rate is varying between 83%-100% Rapid improvement of pt Minimally invasive,well tolerated and avoid sx associated complications lowering lengthy hospital stays. For lager abscess , drains can be kept with success rate of 80% Smaller abscess do not require drains & 100% successful Residual dx or pain may require sx in about 6.8% pts.

27. TOA in Pregnancy Few reported cases MRI may help to differentiate from other infective masses Severity of infection & POG influence on mx modality Adverse fetal & maternal outcome can occur Expedition of delivery & mx TOA may need

28. TOA & Intrauterine Devices IUDs associate with TOA Better short-term outcome with removal.(Crespo et al,2014) If there was unprotected intercourse preceding 5 days, prior to removal may need precautions to avoid unwanted pregnancies

29. Long Term Complications 1.Chronic Pelvic Pain-33% cases present, severity & number of episodes influences this. 12% after 1 st TOA vs 30% after 2 nd . No difference between medical or Sx mx TOAs 2.Subfertility-32-63% women had pregnancies after laparoscopic Drainage Vs Medically mx females (4-15%).so consider Sx if fertility wishes exists. Tubal patency should be checked for SF pts those who had TOAs. Tubal occlusion or salpingectomy offer in case of persistent Hydrosalpinx + SF to optimize outcome with IVF

30. References TOG-2018/ JAN issue