Imagerie de l’infection pelvienne

Middlemore Hospital experience with tubo-ovarian abscesses: an observational retrospective study

AIM

The aim of this paper was to study the characteristics of patients presenting to Middlemore Hospital with tubo-ovarian abscess (TOA) and to compare the outcomes of conservative medical management versus medical management with surgical drainage and medical management with radiological drainage.

METHODS

All patients admitted with a radiologically or surgically proven TOA between January 01, 2008 and December 31, 2010, were included and followed up until June 30, 2011. The total number of patient/index admission was 174.

RESULTS

The mean age of patients was 37.8 years. One hundred thirty patients had medical treatment only with hospitalization and antibiotics, and 44 patients were managed with antibiotics and surgical drainage. Complete resolution of TOA was 77.3% (99/128) for patients managed medically and 93.2% (41/44) for patients managed surgically. When the two groups were compared, patients who were managed surgically were more likely to have complete resolution of TOA within 6 months of index admission with an odds ratio (OR) of 4 and a P-value of 0.029. There was no statistically significant difference in the secondary outcomes namely of readmission with TOA (OR: 0.47) and the need for repeat surgical or radiological drainage (OR: 1.48). Nonetheless, the relative duration of hospitalization was longer for the surgical group with a P-value of <0.0001. The C-reactive protein and the size of TOA were the significant factors involved in the resolution of TOA.

CONCLUSION

The results of this study confirmed our initial hypothesis that we should consider surgical drainage more often, probably earlier, especially for the younger patients still desiring fertility preservation and for larger abscesses. Laparoscopic surgical drainage is safe and could be used as the procedure of choice. Conservative medical management is still acceptable with good cure rates of 77%. C-reactive protein and the size of the abscess were the important factors to consider when managing patients with TOA.

[Pelvic actinomycosis: Diagnostic and therapeutic aspects]

OBJECTIVES

Actinomycosis is a rare little known granulomatous suppurative disease, more common in women, aided by the use of contraceptive purposes intrauterine device (IUD). Pelvic location is the rarest with an extension to adjacent organs making preoperative diagnosis difficult and misleading clinical presentation. Early diagnosis of this affection determines the therapeutic strategy and avoids mutilating interventions especially in young women.

METHODS

We reviewed the record of women who consulted the department of obstetrics and gynecology at Ben Arous hospital (Tunisia) between January 2003 and December 2013 for a pelvic pain syndrome and in whom diagnosis of actinomycosis was suspected by clinical and imaging and confirmed by pathology.

RESULTS

Eight cases of gynecologic abdominopelvic actinomycosis were diagnosed during the study period. Seven patients were carriers of an intrauterine device, with an average duration of 5 years wearing. Functional signs were essentially pelvic pain and fever. Physical examination of patients mainly showed two clinical presentations: a pelvic tumor syndrome or abdominopelvic and an array of pelvic abscess or pelvic inflammatory disease. Radiological investigations were allowed to suspect the diagnosis of actinomycosis only in one patient, in whom percutaneous biopsy confirmed the histological diagnosis without resorting to a surgical procedure. Operative procedures performed were varied as appropriate. The diagnosis of actinomycosis was made by pathology without any cases of bacterial isolation. All patients received antibiotic treatment with penicillin. The subsequent evolution was favorable.

CONCLUSION

The diagnosis of actinomycosis should be considered in any invasive abdominal mass of neoplastic appearance and in case of table of genital infection especially in patients bearing IUD for 5 years or more.

Gynecological pelvic infection: what is the role of imaging?

The diagnosis of pelvic infection is most often made clinically, based on a combination of pelvic pain and fever, and possibly a foul discharge. The patient is referred to radiology in two very different circumstances: either in the acute phase where the challenge is to differentiate a pelvic infection from appendicitis, urinary tract infection, and complications of a hemorrhagic luteal cyst; or some time after the infectious episode, which may have gone unnoticed, and the patient presents with an undetermined pelvic mass that needs to be characterized, where the challenge in that situation is not to confuse it with ovarian cancer. The signs and symptoms on the pelvic ultrasound, CT scan, and MRI suggest the correct diagnosis.

Benign and Suspicious Ovarian Masses-MR Imaging Criteria for Characterization: Pictorial Review

Ovarian masses present a special diagnostic challenge when imaging findings cannot be categorized into benign or malignant pathology. Ultrasonography (US), Computed Tomography (CT), and Magnetic Resonance Imaging (MRI) are currently used to evaluate ovarian tumors. US is the first-line imaging investigation for suspected adnexal masses. Color Doppler US helps the diagnosis identifying vascularized components within the mass. CT is commonly performed in preoperative evaluation of a suspected ovarian malignancy, but it exposes patients to radiation. When US findings are nondiagnostic or equivocal, MRI can be a valuable problem solving tool, useful to give also surgical planning information. MRI is well known to provide accurate information about hemorrhage, fat, and collagen. It is able to identify different types of tissue contained in pelvic masses, distinguishing benign from malignant ovarian tumors. The knowledge of clinical syndromes and MRI features of these conditions is crucial in establishing an accurate diagnosis and determining appropriate treatment. The purpose of this paper is to illustrate MRI findings in neoplastic and non-neoplastic ovarian masses, which were assessed into three groups: cystic, solid, and solid/cystic lesions. MRI criteria for the correct diagnosis and characteristics for differentiating benign from malignant conditions are shown in this paper.

[Hygiene in endovaginal gynecologic and obstetrical ultrasound in 2008]

Hygiene of ultrasound probes is a hot topic in obstetric and gynecologic ultrasound. The issue concerns mainly the risk of contamination and the need for specific procedures to ensure a high degree of protection against infectious diseases, even if a disposable barrier cover is used. As there are no referenced quality criteria for these disposable probe covers, it is crucial to verify that they are CE marked. The use of condoms as probe covers is not recommended even though they present a lower rate of disruption compared to commercial probe covers. The global rate of probe cover perforation is of 1 to 9%. To date, there are no case reports of contamination by ultrasound examination, be it vaginal or abdominal. Nevertheless, every patient must be regarded as a potential source of infection. The French recommendations consider endovaginal ultrasound probes as semi-critical instruments and thus require intermediate-level disinfection. Because of the risk of disruption, American as well as Canadian and Australian recommendations insist on high-level disinfection of the probe. Every operator should follow reasonable hygiene rules and appropriate precautions should be taken in order to reassure the patients about the risks of contamination during any ultrasound examination.