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MANANGEMENT OF
TUBO-OVARIAN
ABSCESS
Tarafdari MD,
OB & GYN
Assistant
Professor ,
TUMS
TOA
 A tubo-ovarian abscess is an inflammatory mass involving the
fallopian tube, ovary, and, occasionally, other adjacent pelvic
organs (eg, bowel, bladder) .
 These abscesses are found most commonly in reproductive
age women and typically result from upper genital tract
infection. Tubo-ovarian abscess is usually a complication of
pelvic inflammatory disease.
EPIDEMIOLOGY AND RISK FACTORS
 Women with a TOA are most likely to be between the ages of
15 and 40 years, but age should not exclude the diagnosis.
 The risk factors for TOA are the same as for PID: multiple
sexual partners, age between 15 to 25 years ,OPU, and a
prior history of PID.
CLINICAL PRESENTATION
 (TOA) is typically considered a complication of pelvic
inflammatory disease (PID), and the classic presentation is
the same as for PID alone, including acute lower abdominal
pain, fever, chills, and vaginal discharge .
 However, the presentation of some women with TOA dif fers
from the classic scenario.
ESTABLISHING A DIAGNOSIS OF TOA
 TOA is a potentially life -threatening condition. Once a woman has been
diagnosed with PID, it is a clinical priority to decide whether she requires
fur ther evaluation for TOA .
 Imaging studies are recomended for women with a diagnosis of PID who
have one or more of the following characteristics:
●Acutely ill
●Significant abdominopelvi c tenderness precluding a complete
pelvic examination
●Adnexal mass noted on examination, par ticularly a tender mass
●Lack of, or poor response to, antibiotic therapy
MANAGEMENT OF TOA
 Intensive antibiotic therapy
 Minimally -invasive drainage procedures
 Invasive surgery
 A combination of these interventions
CANDIDATES FOR ANTIBIOTIC THERAPY
ALONE
● Hemodynamically stable with no signs of a ruptured TOA
(acute abdomen, sepsis)
● Abscess <9 cm in diameter
● Adequate response to antibiotic therapy
● Premenopausal
AB THERAPY
 Women who are immunosuppressed ( eg , HIV patients) should
be treated as the same.
 In some patients with large abscesses ( ≥9 cm):
 A history of pelvic surgery that suggests the presence of
pelvic adhesions
 Desire to preserve fertility
 Otherwise appear clinically stable.
WOMEN WHO FAIL ANTIBIOTIC THERAPY
 After 48 to 72 hours of treatment with antibiotics alone, patients
with TOA who:
● New onset or persistent fever
● Persistent or worsening abdominopelvic tenderness
● Enlarging pelvic mass
● New onset, persistent, or further elevation of the white blood
cell count
● Signs of sepsis
ANTIBIOTIC THERAPY
 Experts agree that women with a TOA should be treated as an
inpatient with intravenous antibiotics, at least initially. This is
consistent with the recommendation by the United States
Centers for Disease Control (CDC) .
 Antibiotic therapy is effective alone in approximately 70 percent
of women, as noted above .
 Antibiotic therapy for TOA is similar to treatment for pelvic
inflammatory disease (PID).
 Patients require close observation for at least 48 to 72 hours
due to the serious nature of the infection, the potential for
abscess rupture and ensuing sepsis, and occasional diagnostic
uncertainty .
DURATION OF THERAPY
 The duration of antibiotic therapy required for treatment of a TOA is
not well-established. When antibiotics alone are the chosen therapy, a
minimum of two weeks is most commonly used.
 In cases in which the patient is improving on antibiotics alone, but the
abscess has not completely resolved, longer cour ses of outpatient
antibiotics may be given.
 Af ter imaging -guided drainage procedures and/ surger y , 10 to 14 days
of total antibiotic therapy is usually ef fective.
 Finishing the cour se of therapy with oral antibiotics as an outpatient is
reasonable in select patients. Ideal candidates for outpatient therapy
should meet the following criteria: demonstrate clear clinical
improvement, tolerate oral medications, and be able to comply with
follow -up communication and appointments.
MINIMALLY-INVASIVE DRAINAGE
PROCEDURES
 Minimally -invasive imaging-guided drainage procedures
appear to be appropriate for patients who do not worsen, but
fail to clearly improve on antibiotics alone.
 No studies have directly compared surgical intervention with
minimally invasive drainage procedures in this clinical
scenario.
MINIMALLY-INVASIVE …
 It is recommended to move promptly to surgery when the
patient is clearly clinically worsening using the clinical
parameters listed above.
 In addition, surgical intervention is required in patients who
are not improving on antimicrobial therapy and in whom
minimally invasive drainage is not feasible ( eg, mass is
multiloculated or dif ficult to access or a physician
experienced in these procedures is not available)
MINIMALLY-INVASIVE …
 guided by either computed tomography or ultrasonography
 anatomic approaches, including percutaneous, transvaginal,
transrectal, and transgluteal.
 In general, studies have reported higher success rates
(defined as clinical improvement without the need for surgery)
for smaller, unilocular fluid collections.
INDICATIONS FOR IMMEDIATE SURGERY
 Suspected intraabdominal rupture of a tubo-ovarian abscess (TOA) is
a life-threatening emergency and requires prompt surgical
inter vention .
 Clinical findings suggestive of intraabdominal rupture include, but are
not limited to:
hypotension,
tachycardia,
tachypnea,
acute peritoneal signs, or acidosis.

Even in the absence of evidence of abscess rupture, surgical
exploration and treatment are advisable in any woman with over t
signs of sepsis and a large abscess. In our experience, most women
who are acutely ill will not improve without surgical removal of the
nidus of infection.
 In women who are treated surgically, antibiotics should also be
star ted as soon as possible, either before or during the urgent
operative inter vention. Impor tantly, in an unstable patient with the
presumptive diagnosis of abscess rupture, surger y should not be
delayed for the administration of antibiotics.
RUPTURED TOA
 Preoperative phase :
 Heamodynamic Stabilization
 Broad spectrum AB:
- piperacillin-tazobactam 3.75 mg QID +
- entrapenem 1 g daily
 Foley catheter
 Oxygen administration &ABG
RUPTURED TOA
 Operative phase
 Low midline inscision
 Smear & culture of pus
 Usually definitive surger y is indicated
 Exploration of upper abdomen
 Irrigation with warm saline
 Closed suction drains (Jackson - Pratt)
 Vagina vault should be lef t open for drainage
RUPTURED TOA
Postoperative phase
 Monitor the patients for symptoms of DIC & ARDS
 Respiratory & hemodynamic support
 Semi-Fowler position
 Close attention to fluid balance & blood chemistry
THANKS FOR YOUR
ATTENSION