Management of Chronic Tubo-Ovarian Abscess: Case Series and Review

Abstract

Background:

A tubo-ovarian abscess (TOA) occurs when there is an abscess involving the adnexa and is usually seen with pelvic inflammatory disease. Most patients with TOA are candidates for management with IV antibiotics alone. However, based on factors such as patient status and abscess size, percutaneous drainage or surgical removal may be needed. There are well-established guidelines for management of an acute TOA, including when surgery may be required, such as sepsis. However, after the initial hospitalization and management phase, there is a scarcity of information available about the management of chronic TOA, particularly for those who did not have surgery or drainage and those who require multiple hospitalizations.

Review:

In this case series and review, we discuss the management of three patients with chronic TOA as managed by the Minimally Invasive Gynecology Surgery division at an academic institution. We classify a TOA as chronic if repeat imaging at least 6 weeks after initial management with an appropriate course of antibiotics shows a persistent abscess. We describe our approach to management of a chronic TOA, including hospitalization for intravenous antibiotics for at least 24–48 hours per standard TOA treatment guidelines. We consult interventional radiology to assess for possible drainage of the TOA unless the patient warrants immediate surgical removal. Although drainage may sometimes be sufficient, we generally plan for surgical resection 4–6 weeks after the hospitalization. Once the patient is stable for discharge, in consultation with Infectious Diseases, we transition them to oral antibiotics—generally doxycycline and metronidazole—to continue until cultures are obtained at the time of surgery result. We intentionally schedule surgery 4–6 weeks after hospitalization or interventional radiology drainage to allow for a reduction in inflammation of the acute on chronic infection, given the difficulty and risk involved in abscess surgery. More research is needed on optimal timing of chronic TOA surgery and if continuation of antibiotics until surgery improves outcomes.