Tubo-ovarian Abscess

Archie R McGowan, MD
Carol B Benson, MD

October 10, 1996

Presentation

A 33-year-old woman presented with pelvic pain one day after removal of an intrauterine contraceptive device (IUD).

Imaging Findings

Sagittal transvaginal sonogram at presentation

Sonogram, 10 days after IUD removal

Sonogram--12 days after IUD removal

A sagittal transvaginal sonogram obtained on the day of presentation demonstrates a 2.8 cm cystic mass (arrows) inseparable from the right ovary.

A sagittal transvaginal sonogram obtained 9 days later demonstrates an enlarged complex cystic mass (arrows) with heterogeneous echo texture. The maximal dimension of the cystic component is 3.3 cm.

A sagittal transvaginal sonogram obtained 12 days after IUD removal demonstrates the right adnexal mass (arrows). Complex cystic components measure 4.4 cm.

Differential Diagnosis

Tubo-ovarian abscess
Hemorrhagic cyst
Endometrioma
Ectopic pregnancy - if pregnancy test positive
Cystadenoma
Cystadenocarcinoma
Dermoid cyst
Acute appendicitis
Diverticulitis

Diagnosis

Tubo-ovarian abscess (operatively proven)

Discussion

Tubo-ovarian abscess is an advanced form of pelvic inflammatory disease most often caused by spread of bacteria from the lower genital tract. (The most common bacterial pathogens are anaerobic.) Risk factors for pelvic inflammatory disease include those associated with increased risk of contracting a sexually transmitted disease: early age of first sexual encounter, multiple sexual partners, history of sexually transmitted disease, and douching. In addition, women using IUDs are at increased risk for pelvic inflammatory disease and tubo-ovarian abscess. Diverticulitis and appendicitis are also potential causes.

Complications of pelvic inflammatory disease and tubo-ovarian abscesses include infertility due to tubal occlusion, increased risk of ectopic pregnancy, and chronic pelvic pain as the result of adhesions.

The typical ultrasonographic appearance of a tubo-ovarian abscess is a multilocular, cystic, complex adnexal mass often with debris and thick septations.

This patient was unresponsive to a triple antibiotic regimen of ampicillin, clindamycin, and flagyl. Her condition required surgical intervention.

References

1. Cacciatore B. Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. Obstetrics and Gynecology 1992; 80: 912-916.

2. Jossens MO, Schachter J, Sweet RL. Risk factors associated with pelvic inflammatory disease of differing microbial etiologies. Obstetrics and Gynecology 1994; 83: 989-97.

3. Bulas D. Pelvic inflammatory disease in the adolescent: comparison of transabdominal and transvaginal sonographic evaluation. Radiology 1992; 183: 435-439.

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