Ultrasonographically guided transvaginal aspiration of tuboovarian abscesses and pyosalpinges: an optional treatment for acute pelvic inflammatory disease

Outcomes of Minimally Invasive Management of Tubo-ovarian Abscess: A Systematic Review

OBJECTIVE

To compare the success rate, complications, and hospital length-of-stay of 3 modalities of minimally invasive management of tubo-ovarian abscesses (TOAs): laparoscopy, ultrasound-guided drainage, and computed tomography-guided drainage.

DATA SOURCES

Electronic-based search in PubMed, EMBASE, Ovid MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, using the following Medical Subject Heading terms: "minimally invasive surgical procedures," "drainage," "abscess," "tubo-ovarian," "ovarian diseases," and "fallopian tube diseases."

METHODS OF STUDY SELECTION

Of the 831 articles in the initial results, 10 studies were eligible for inclusion in our systematic review.

TABULATION, INTEGRATION, AND RESULTS

A total of 975 patients were included in our study; 107 (11%) had laparoscopic drainage procedures, and 406 (42%) had image-guided (ultrasound or computed tomography) drainage of TOAs. Image-guided TOA drainage had higher success rates (90%-100%) than laparoscopic drainage (89%-96%) and the use of antibiotic treatment alone (65%-83%). Patients treated with image-guided drainage had no complications (for up to 6 months of follow-up) and shorter lengths of hospital stay (0-3 days on average) compared with laparoscopic drainage (5-12 days) or conservative management with antibiotics alone (7-9 days).

CONCLUSION

Although conservative management of TOAs with antibiotics alone remains first-line, our review indicates that better outcomes in the management of TOA were achieved by minimally invasive approach compared with conservative treatment with antibiotics only. Of the minimally invasive techniques, image-guided drainage of TOAs provided the highest success rates, the fewest complications, and the shortest hospital stays compared with laparoscopy. The low magnitude of evidence in the included studies calls for further randomized trials. This systematic review was registered in the International Prospective Register of Systematic Review (register, http://www.crd.york.ac.uk/PROSPERO;CRD 42020170345).

Tubo-ovarian abscess: Exploring optimal treatment options based on current evidence

Purpose:

Tubo-ovarian abscess (TOA) and pelvic abscess are characterized by an inflammatory pelvic mass. In the majority of cases, this condition involves the ovaries, the fallopian tubes and/or any other adjacent tissue. TOA is considered a severe complication of PID and can cause severe sepsis. The main risk factors for women’s health are the size of the abscess, the initial amount of white blood cells (WBC), patients’ age as well as, any co-existing comorbidities.

Methods:

This study provides a review of the current literature regarding the management of TOA and the different criteria used in order to establish the optimal therapeutic approach or to predict outcome by individualizing cases. Four major search engines, MEDLINE, Google Scholar, PubMed and EMBASE, up to February 2020 were explored, focusing in epidemiology and risk factors, pathogenesis, diagnosis and treatment.

Results:

Our review suggests that there are no clear guidelines for best practice, in case of TOA, but it appears that intravenous antibiotics combined with interventional radiology have good results for TOA <5 cm. When TOA is >5 cm, laparoscopic approach is indicated. Further studies are needed in order to evaluate the best treatment for women with TOA.

Conclusions:

More prospective studies on large-series of patients are in need, in order to determine a clear pathway and to suggest specific criteria, which can guide clinicians to choose optimal approach in a timely manner.

Tubo-Ovarian Abscesses: Epidemiology and Predictors for Failed Response to Medical Management in an Asian Population

Pelvic inflammatory disease (PID) complicated by tubo-ovarian abscesses (TOA) has long-term sequelae in women of reproductive age. Consensus on the optimal treatment of TOA remains lacking. Most clinicians utilize antibiotics as a first-line conservative approach, failing which invasive intervention is adopted. Our aim is to identify risk factors predicting failed response to conservative medical management for TOA in an Asian population. A retrospective cohort study of 136 patients admitted to a tertiary hospital in Singapore for TOA between July 2013 and December 2017 was performed. Patients were classified into 2 groups: successful medical treatment with intravenous antibiotics and failed medical treatment requiring invasive intervention. 111 (81.6%) of patients were successfully treated with conservative medical approach using intravenous antibiotics; 25 (18.4%) required invasive intervention having failed medical therapy. Multivariate logistic regression model adjusted for age, ethnicity, C-reactive Protein (CRP), TOA size, and body mass index (BMI) showed the odds ratio (OR) of each centimetre increase in TOA size to be 1.28 (95% confidence interval (CI) 1.03-1.61; P=0.030) and every kg/m2 increase in BMI to be 1.10 (95% CI 1.00-1.21; P=0.040). Failed medical management was predicted by a cutoff of TOA size ≥ 7.4 cm and ≥ BMI 24.9 kg/m2. Patients who failed medical treatment received a mean of 4.0±2.1 days of antibiotics before a decision for invasive intervention was made, with a significantly longer intravenous antibiotic duration (9.4±4.3 versus 3.6±2.2 days; P <0.001) and prolonged hospitalization (10.8± 3.6 versus 4.5 ± 2.0 days; P <0.001) compared to the medical group. Patients with higher BMI and larger TOA size were associated with failed response to conservative medical management in our study population. Early identification of these patients for failed medical therapy is imperative for timely invasive intervention to avoid prolonged hospitalization, antibiotic usage, and patient morbidity.

Transvaginal Ultrasound-Guided Biopsy of Deep Pelvic Masses: How We Do It

The purpose of this review is to discuss the rationale and indications for transvaginal ultrasound-guided biopsy. Transvaginal ultrasound-guided biopsy can be a helpful tool for diagnosis and treatment planning in the evaluation of pelvic masses, particularly when the anatomy precludes a transabdominal or posterior transgluteal percutaneous biopsy approach. A step-by-step summary of the technique with preprocedure and postprocedure considerations is included.

Ultrasonography of ovarian masses using a pattern recognition approach

As a primary imaging modality, ultrasonography (US) can provide diagnostic information for evaluating ovarian masses. Using a pattern recognition approach through gray-scale transvaginal US, ovarian masses can be diagnosed with high specificity and sensitivity. Doppler US may allow ovarian masses to be diagnosed as benign or malignant with even greater confidence. In order to differentiate benign and malignant ovarian masses, it is necessary to categorize ovarian masses into unilocular cyst, unilocular solid cyst, multilocular cyst, multilocular solid cyst, and solid tumor, and then to detect typical US features that demonstrate malignancy based on pattern recognition approach.

Severe pelvic abscess formation following caesarean section

We report a case of a 24-year-old woman with severe pelvic abscess formation 2 weeks after secondary caesarean section. The isolated pathogens were a mixture of Gardnerella vaginalis, Mycoplasma hominis and Ureaplasma urealyticum. After initial resistance to systemic antibiotic treatment, she underwent radiologically-guided drainage of the abscesses, whereon she had a continuous recovery.

Pelvic surgical site infections in gynecologic surgery

The development of surgical site infection (SSI) remains the most common complication of gynecologic surgical procedures and results in significant patient morbidity. Gynecologic procedures pose a unique challenge in that potential pathogenic microorganisms from the skin or vagina and endocervix may migrate to operative sites and can result in vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscesses. Multiple host and surgical risk factors have been identified as risks that increase infectious sequelae after pelvic surgery. This paper will review these risk factors as many are modifiable and care should be taken to address such factors in order to decrease the chance of infection. We will also review the definitions, microbiology, pathogenesis, diagnosis, and management of pelvic SSIs after gynecologic surgery.

Endoscopic ultrasound-guided pelvic abscess drainage (with video)

Pelvic abscesses present a serious and challenging management problem. Endoscopic ultrasound (EUS)-guided drainage provides a safe and effective minimally invasive treatment option. The likelihood of a successful outcome is dependent on appropriate patient selection, drainage technique and postoperative management. This review outlines the evidence behind and procedural steps required for EUS-guided pelvic abscess drainage.

Postoperative infections in obstetrics and gynecology

Postoperative infection is the most commonly seen complication of surgery in obstetrics and gynecology. The use of antibiotic prophylaxis has greatly decreased though not completely eliminated this adverse outcome. Postoperative infections include wound cellulitis, wound abscess, endomyometritis, pelvic cellulitis, and pelvic abscess. Infections usually manifest as fever and greater than normal postoperative pain. Refractory fevers maybe because of septic pelvic vein thrombophlebitis or maybe noninfectious in origin. Broad-spectrum antibiotics should be initiated as soon as possible when diagnosis of postoperative infection is made; most patients will respond to treatment within 24 to 48 hours when appropriate antibiotics are selected.

[Treatment of the tubo-ovarian abscesses]

The antibiotic treatment is indispensable for the treatment of the tubo-ovarian abscesses (TOA). It has to have a wide spectre and would be secondarily adapted in case of a sexually transmitted infection. The surgery remains indicated in first intention in case of vital threat (generalized peritonitis, toxic shock). In the not complicated TOA, the evacuation of abscesses (by draining under imaging or laparoscopy) with the antibiotic treatment gives better rates of cure than the antibiotic treatment alone. For the surgery, several entrys are possible. The laparoscopy allows a shorter hospitalization with fewer complications and a faster resolution of the fever than the laparotomy. The conservative surgery, realized by laparoscopy, has hight rates of successes with few complications. The radical surgery, by coelioscopy or by laparotomy, has high rates of complications. Transvaginal ultrasound guided aspiration is an alternative in the drainage by laparscopy with identical succes. It has been well evaluated. It has low morbidity and can be proposed in first intention in not complicated TOA.

The management of pelvic abscess

The optimum treatment for pelvic abscess would be an approach that is safe, efficacious, cost-effective, minimally invasive, and which affects the woman's fertility potential as little as possible. In women of reproductive age tubo-ovarian abscess is one of the most common types of pelvic abscess. Tubo-ovarian abscesses are classically treated with broad-spectrum antibiotics. Frequently this approach fails and surgical intervention becomes necessary in about 25% of all cases. Surgical procedures include laparotomy or laparoscopy with drainage of abscess, unilateral or bilateral salpingo-ophorectomy, and hysterectomy. However, surgery for tubo-ovarian abscess is often technically difficult and associated with complications. An alternative approach is the use of imaging-guided drainage of abscess in combination with antibiotics. Combined data from several studies indicate that ultrasound-guided transvaginal drainage with concomitant antibiotics is especially safe and efficacious. This chapter discusses the management of pelvic abscess with a special focus on transvaginal ultrasound-guided drainage of tubo-ovarian abscess.

Gynecologic emergencies

Gynecologic emergencies are relatively common and include ectopic pregnancies, adnexal torsion, tubo-ovarian abscess, hemorrhagic ovarian cysts, gynecologic hemorrhage, and vulvovaginal trauma. The purpose of this article is to provide a concise review of these emergencies, focusing on the evaluation and treatment options for the patient. In many cases, other causes of an acute abdomen are in the differential diagnosis. Understanding the tenets of diagnosis helps the surgeon narrow the etiology and guide appropriate treatment.

Comparison of CT- or ultrasound-guided drainage with concomitant intravenous antibiotics vs. intravenous antibiotics alone in the management of tubo-ovarian abscesses

OBJECTIVE

The purpose of this study was to compare the outcome of treatment of tubo-ovarian abscesses by imaging-guided drainage and antibiotics vs. intravenous antibiotics alone.

METHODS

A retrospective chart review of all patients hospitalized with a diagnosis of tubo-ovarian abscess was performed. Patients were categorized into two groups. The first group consisted of subjects treated with intravenous antibiotics alone. Patients in the second group had primary image-guided drainage with concomitant intravenous antibiotics. Treatment failures in the primary antibiotics group underwent salvage drainage when feasible. The primary outcome of interest was complete response. Secondary outcomes included need for additional treatment, duration of resolution of fever, total length of hospital stay, and complication rates. We also evaluated the effectiveness of secondary drainage in patients who failed primary antibiotic therapy alone.

RESULTS

A total of 58 patients were included in the study. Fifty patients were treated primarily with intravenous antibiotics; eight patients had primary drainage, which was guided by ultrasound in all cases. Complete response was noted in 29 (58%) patients treated with antibiotics alone. All eight (100%) patients in the primary drainage group responded to treatment. Of the 21 treatment failures with primary antibiotics, two underwent surgery and 19 (90.5%) had salvage drainage with either ultrasound or computed tomographic guidance; 18 of 19 salvage drainages led to complete recovery. Subjects in the primary drainage group required shorter hospital stays and showed more rapid resolution of fever. No significant morbidity was noted as a consequence of drainage procedures. A higher failure rate for secondary drainage was noted in older patients, those with larger tubo-ovarian abscesses, and those with a history of pelvic inflammatory disease.

CONCLUSION

Drainage of tubo-ovarian abscesses with concomitant intravenous antibiotics is an effective and safe treatment for the primary or secondary treatment of tubo-ovarian abscesses.

Emergency gynaecology

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.

Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases

OBJECTIVE

Our purpose was to evaluate the effectiveness and safety of transvaginal ultrasound-guided aspiration together with antibiotic therapy for treatment of tubo-ovarian abscess.

STUDY DESIGN

A review of women treated with transvaginal ultrasound-guided aspiration for tubo-ovarian abscess at Haukeland University Hospital, Bergen, Norway, between June 1986 and July 2003 was performed. Immediate clinical response and longer-term follow-up results were assessed.

RESULTS

A total of 449 transvaginal aspirations were performed on 302 women. A total of 282 women (93.4%) were successfully treated for transvaginal aspiration of purulent fluid, together with antibiotic therapy. In the other 20 women (6.6%), surgery was performed. The main indications for surgery were diagnostic or therapeutic uncertainty, such as suspected residual tubo-ovarian abscess or pain. No procedure-related complications were diagnosed.

CONCLUSION

Transvaginal ultrasound-guided aspiration combined with antibiotics is an effective and safe treatment regimen for tubo-ovarian abscess. The high success rate indicates that it should be a first-line procedure.

Emergent ultrasound interventions

The interventionist can perform many emergent procedures with ultrasound guidance, because of its real-time, multiplanar imaging capability and portability. With the use of color Doppler, additional important information, such as aberrant vessels, can be ascertained to help plan needle trajectory. Ultrasound is also useful for nonemergent procedures, such as biopsies. All interventionists are encouraged to be facile with the use of ultrasound.

Advantages of open laparoscopic surgery over exploratory laparotomy in patients with tubo-ovarian abscess

STUDY OBJECTIVE

To compare laparoscopic surgery and conventional laparotomy in managing patients with tubo-ovarian abscess (TOA).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

Regional hospital.

PATIENTS

Sixty-nine women with clinically suspicious TOA.

INTERVENTION

Operative laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Laparoscopic surgery in 19 women had significant advantages over laparotomy in 37 women. It decreased hospital stay (5.37 +/-1.38 days vs 8.92 +/- 2.59 days, p = 0.0001), had a lower percentage of wound infections, and had a shorter time for fever to subside (25.79 +/- 11.45 vs 39.46 +/- 17.47 hrs, p = 0.003).

CONCLUSION

Although management of TOA consists of conservative medical treatment with antibiotics, it is now widely accepted that surgical intervention should be pursued early after the diagnosis. Open laparoscopy seems to be a good alternative to traditional laparotomy in managing these patients.

Transrectal ultrasonographically guided drainage of gynecologic pelvic abscesses

OBJECTIVE

This study assessed the feasibility of ultrasonographically guided transrectal aspiration of gynecologic pelvic abscesses to treat patients for whom intravenous antibiotic therapies failed and whose abscesses were not optimally amenable to colpotomy drainage or transabdominal or transvaginal ultrasonographically guided aspiration.

STUDY DESIGN

This was a retrospective review of the first 15 women with pelvic abscesses that resulted from salpingitis or complications of gynecologic surgery who underwent transrectal pelvic abscess drainage after failure of antibiotic therapy.

RESULTS

Purulent material was aspirated from the abscesses in 14 of the 15 women. All 14 women with aspirated material were successfully treated with real-time ultrasonographically guided transrectal drainage; only 4 of the 14 had indwelling catheter placement.

CONCLUSION

Ultrasonographically guided transrectal drainage of gynecologic pelvic abscesses is a safe and effective treatment of pelvic abscesses for women who do not have an adequate response to antibiotic therapy.

Transvaginal ultrasound-guided aspiration of pelvic abscesses

OBJECTIVE

To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration.

METHODS

A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data.

RESULTS

The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported.

CONCLUSION

In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.

Ultrasound-guided transvaginal aspiration in the management of actinomyces pelvic abscess

BACKGROUND

Increasing reports of intrauterine device (IUD)-related abdominopelvic actinomycosis have been described recently. Surgical therapy has been the usual treatment when tubo-ovarian abscess is identified.

CASE

A 38-year-old woman suffering from Actinomyces pelvic abscess unresponsive to medical treatment underwent transvaginal ultrasound-guided needle aspiration. It resulted in marked improvement and avoided surgical treatment.

CONCLUSION

Transvaginal needle aspiration of Actinomyces pelvic abscess may be an alternative to surgical therapy, thereby allowing the preservation of pelvic organs.