Author
D. Brady Pregerson, MD
Dept. of Emergency Medicine
Cedars-Sinai Medical Center, Los Angeles, CA
Dept. of Emergency Medicine
Tri-City Medical Center, Oceanside, CA
Disclosure: D. Brady Pregerson, MD, has disclosed a relevant financial relationship with ERPocketbooks.com.
Editors
Catherine A. Lynch, MD
Assistant Professor
Department of Surgery, Division of Emergency Medicine
Duke University Medical Center
Faculty, Duke Global Health Institute
Durham, North Carolina
Disclosure: Catherine A. Lynch, MD, has disclosed no relevant financial relationships.
Editors (continued)
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Michel E. Rivlin, MD
Professor, Coordinator of Quality Assurance/Quality Improvement
Department of Obstetrics and Gynecology
University of Mississippi School of Medicine
Jackson, Mississippi
Disclosure: Michel E. Rivlin, MD, has disclosed no relevant financial relationships.
A healthy 30-year-old woman presents to the emergency department with a 5-day history of intermittent and increasing nonradiating pain in the lower left part of her abdomen. She describes having fevers but denies dysuria, increased urinary frequency, hematuria, vaginal discharge, or change in her bowel habits. She is married and monogamous, and her last instance of sexual intercourse was 2 weeks ago. She has regular menses; her last menstrual period occurred approximately 3 weeks ago. She has no history of any sexually transmitted diseases. She does not smoke and does not use any illicit substances. An abdominal radiograph is ordered by the triage nurses.
On physical examination, the patient is clearly uncomfortable but does not appear to be toxic. Except for tachycardia, the cardiac and respiratory examinations are unremarkable. The abdominal examination reveals tenderness in the lower abdomen (specifically, in the left lower quadrant), but no rebound or guarding is noted. A pelvic examination is performed that reveals scant blood in the vagina and cervical motion tenderness. An 8-cm mass is palpated in the left adnexa, with marked tenderness. The uterus is tender and normal in size. The right adnexa is tender, but no palpable masses are detected.
Answer: C. Transvaginal and transabdominal ultrasonography.
Transabdominal ultrasonography is performed. A normal-appearing urinary bladder (red arrow) filled with fluid is identified. A multiloculated, complex mass is seen in the left adnexa (blue arrow). This corresponds with the area of tenderness appreciated on the physical examination.
Answer: C. Tubo-ovarian abscess.
A tubo-ovarian abscess (TOA) usually occurs after recurrent, chronic, or refractory pelvic inflammatory disease (PID). PID is an infection of the female upper genital tract that includes a broad category of diseases, including endometritis, salpingitis, salpingo-oophoritis, TOA, and pelvic peritonitis. A TOA may develop in as many as one third of patients diagnosed with PID. In the above transvaginal image, the right ovary and TOA (red outline) and the uterus (blue outline) are indicated.
TOA usually occurs in sexually active women who are between the ages of 20 and 40 years, with risk factors including a history of sexually transmitted disease and new or multiple sexual partners. It usually results from recurrent infections superimposed on damaged tissue; fibrinous attachments to nearby organs from previous episodes of PID may serve as the entry point for the extension of infection. Rarely, a secondary TOA may occur from the intraperitoneal spread of an infection resulting from a bowel perforation, or in association with a pelvic malignancy.[1,2] The red arrows point to the dilated, sausage-shaped fallopian tube. Image courtesy of World Laparoscopy Hospital.
In the majority of women with a TOA, abdominal or pelvic pain is the primary presenting complaint. The clinical picture of TOA is one of pelvic pain, a tender adnexal mass, fever, and tachycardia. On pelvic examination, excessive mucopurulent cervicitis may be found, and abscesses may be bilateral. Other PID findings, including uterine and bilateral adnexal tenderness, are usually present.[1]
In this ultrasound image, what is the abnormal finding that may occur with peritonitis?
A. Endometrial hyperplasia
B. Ovarian cyst
C. Free intraperitoneal fluid
D. Necrotic fibroid
Answer: C. Free intraperitoneal fluid (as shown in the previous image) can be present with peritonitis.
The typical TOA is polymicrobial, with a preponderance of gram-negative and anaerobic organisms. The inciting organism will be either Chlamydia trachomatis, as the predominant sexually transmitted disease-related organism that causes PID or TOA, or Neisseria gonorrhea, which has decreased in the United States. The polymicrobial mix seen in a TOA is generally composed of organisms usually found as normal flora in the gastrointestinal and genitourinary tracts.[2]
The differential diagnosis for lower abdominal pain in young women is broad, and caution is recommended when ruling out other infectious and inflammatory conditions specifically related to the gastrointestinal/genitourinary tracts and the reproductive system.[2]
What is the imaging modality of choice for TOA?
A. Clinical examination
B. Radiography
C. CT
D. Ultrasonography
E. MRI
Answer: C. Ultrasonography.
Ultrasonography is the imaging modality of choice because of its lack of ionizing radiation, noninvasive nature, and accuracy. On an ultrasound image, a TOA will appear as a complex adnexal mass with thickened walls and central fluid. A transvaginal approach allows for better resolution. The transvaginal ultrasound shown here demonstrates "dirty shadowing" from air in the endometrial cavity (blue arrows) and bilateral TOA (red arrows). Some studies have also suggested a high specificity for the diagnosis of TOA when ultrasound is performed at the bedside by a clinician.[3]
CT should also be considered when the diagnosis is not definitively established with ultrasonography. Ultrasound is operator-dependent, and overlying bowel or a very large body habitus may limit evaluation of the adnexa. CT has the notable advantage of improving the accuracy of diagnosing appendiceal or other gastrointestinal pathologies (which can mimic PID or TOA). The CT scan shown here demonstrates thickened fallopian tubes (arrows) consistent with TOA. Image courtesy of World Laparoscopy Hospital.
In suspected cases of TOA with equivocal ultrasonographic findings, MRI is an excellent, radiation-free modality. A TOA on MRI will classically appear as a thick-walled mass, with low T1 and high T2 signal intensity. Recent findings have suggested that MRI is as effective or, possibly, more accurate than other studies for diagnosing TOA and PID.[2,4,5] This MR image shows a 5 x 4 cm, thick-walled, cystic lesion (yellow arrow) in the right adnexa. Also noted is an elongated, sausage-shaped cystic lesion (red arrows) in the left-sided cul-de-sac, with a fluid-fluid level (green arrows) consistent with TOA. Image courtesy of World Laparoscopy Hospital.
The initial treatment for TOA is broad-spectrum antibiotic therapy (as shown). Sixty percent to 80% of cases of TOA resolve with antibiotics alone. Most clinicians will add clindamycin in addition to doxycycline for added anaerobic coverage.
In cases that do not respond to IV antibiotics or in those with a ruptured TOA, laparoscopy, US/CT-guided drainage, or emergency surgery may be indicated to drain any purulence. A transvaginal US- or CT-guided aspiration, in combination with intravenous antibiotic therapy or the placement of intracavitary antibiotic therapy, has also been described as effective for draining TOAs.[4,5] Imaging-guided drainage may be an effective salvage technique for patients nonresponsive to primary antibiotics, and patients undergoing primary drainage may have shorter hospital stays and faster resolutions.[6,7]
Patients treated for TOA should be offered screening for other sexually transmitted diseases because coinfection is common. Despite treatment, PID and TOA complications include adhesions in the pelvis and near the liver called Fitz-Hugh-Curtis syndrome (shown), permanent tubal damage, and a substantial reduction in long-term fertility (even after a TOA has been sterilized). Patients who do become pregnant are at an increased risk for ectopic pregnancy and must be counseled regarding this risk.
The patient in this case had a large TOA in her left adnexa. She was admitted to the gynecology service and started on cefotetan and doxycycline for 6 days, to which she responded favorably. She was discharged home with a plan to complete a 14-day course of oral broad-spectrum antibiotics, which included oral clindamycin and doxycycline.
Author
D. Brady Pregerson, MD
Dept. of Emergency Medicine
Cedars-Sinai Medical Center, Los Angeles, CA
Dept. of Emergency Medicine
Tri-City Medical Center, Oceanside, CA
Disclosure: D. Brady Pregerson, MD, has disclosed a relevant financial relationship with ERPocketbooks.com.
Editors
Catherine A. Lynch, MD
Assistant Professor
Department of Surgery, Division of Emergency Medicine
Duke University Medical Center
Faculty, Duke Global Health Institute
Durham, North Carolina
Disclosure: Catherine A. Lynch, MD, has disclosed no relevant financial relationships.
Editors (continued)
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Michel E. Rivlin, MD
Professor, Coordinator of Quality Assurance/Quality Improvement
Department of Obstetrics and Gynecology
University of Mississippi School of Medicine
Jackson, Mississippi
Disclosure: Michel E. Rivlin, MD, has disclosed no relevant financial relationships.
Abdominal Vascular Occlusion
Bedside Ultrasonography, Gallbladder Evaluation
Can't Miss Diagnoses in the Pregnant Patient With Abdominal Pain
Can't Miss Intestinal Complications on Abdominal Radiographs
Common Intestinal Parasites
Critical Findings on Plain Abdominal Radiographs
