Tubo-ovarian

abscesses

Definition
an encapsulated or confined pocket ofpus with defined
boundaries that forms during an infection of a fallopian
tube and ovary.
one of the latecomplicationsofpelvic inflammatory
disease(PID)
life-threatening ruptures sepsis

Epidemiology
The epidemiology of TOA is closely related to that of pelvic
inflammatory disease which is estimated to one million people yearly.
The mortality rate associated with tuboovarian abscess was
approximately 50 percent or higher prior to the advent of broadspectrum antibiotics and modern surgical practice .
In current practice, the mortality rate approaches zero for abscesses
that have not ruptured. Current mortality rates for patients with
ruptured abscesses are not reported in the literature; data from the
1960s suggested a mortality rate ranging from 1.7 to 3.7 percent .

Pathophysiology
Are presumed to occur in 2 stages
The first stage is acquisition of a vaginal or cervical
infection. This infection is often sexually transmitted and
may be asymptomatic.
The second stage is direct ascent of microorganisms from
the vagina or cervix to the upper genital tract, with
infection and inflammation of these structures.

Pathophysiology
The vaginal flora of most normal, healthy women includes
a variety of potentially pathogenic bacteria . Among these
are species of streptococci, staphylococci,
Enterobacteriaceae (most
commonlyKlebsiellaspp,Escherichia coli,
andProteusspp), and a variety of anaerobes. Compared
with the dominant, non-pathogenic, hydrogen peroxideproducingLactobacillusspecies, these other organisms
are present in low numbers, and ebb and flow under the
influence of hormonal changes (eg, pregnancy, menstrual
cycle), contraceptive method, sexual activity, and other as

Pathophysiology
The endocervical canal functions as a barrier protecting the normally
sterile upper genital tract from the organisms of the dynamic vaginal
ecosystem. Endocervical infection with sexually transmitted pathogens can
disrupt this barrier. Disturbance of this barrier provides vaginal bacteria
access to the upper genital organs, infecting the endometrium, then
endosalpinx, ovarian cortex, pelvic peritoneum, and their underlying
stroma. The resulting infection may be subclinical or manifest as the
clinical entity of pelvic inflammatory disease (PID). The reasons why lower
genital tract bacteria cause PID in some women but not others is not fully
understood but may relate to genetic variations in immune response,
estrogen levels affecting the viscosity of cervical mucus, and bacterial load

Diagnosis
Laparoscopyand other imaging tools can visualize the abscess.
Physicians are able to make thediagnosisif 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
forperitonitis.Sepsis, 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.

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 affectedovaryandfallopian tubeis 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.