Original Report
Tubo-Ovarian Abscess in Non−Sexually Active Adolescent Girls: A Case Series and Literature Review

This study was presented as a poster at the North American Society for Pediatric and Adolescent Gynecology (NASPAG) Annual Clinic and Research Meeting, New Orleans, Louisiana, April 11-13, 2019.
https://doi.org/10.1016/j.jpag.2020.12.002Get rights and content

Abstract

Study Objective

We investigated risk factors and common causes of tubo-ovarian abscess (TOA) in non−sexually active females in order to aid in earlier diagnosis, treatment, and improved outcomes.

Design

This is a retrospective observational case series of all non−sexually active females younger than age 25 years who were diagnosed with TOA. Review of the existing literature was also performed.

Setting

Academic tertiary care children's hospital.

Participants

Ten patients meeting study inclusion criteria were identified for the study, and 33 other patients were identified in the literature.

Results

Average age at time of diagnosis was 14 years. Average body mass index was 24 kg/m2. Most presented with abdominal pain, often associated with fevers, nausea, vomiting, and diarrhea. Seven of 10 patients were treated surgically with pelvic washout (4 primarily and 3 after failing empiric antibiotic therapy). Most frequently, anaerobic gut flora were isolated on culture. All patients received broad-spectrum intravenous antibiotics, and were then discharged on a course of doxycycline and metronidazole or clindamycin. Three patients required additional admissions and multiple rounds of antibiotics due to persistent symptoms. The average length of stay was 3 days for patients treated with antibiotics only and 6 days for patients requiring surgical intervention. Six patients had complete resolution of symptoms and improvement on ultrasound within 2-4 weeks. The remainder were lost to follow-up.

Conclusion

These cases, in conjunction with previous case reports, emphasize the importance of considering TOA in patients with concerning imaging or examination findings despite lack of sexual activity. Given the large proportion of cases attributable to anaerobic gut flora, treatment with antibiotics with adequate anaerobic coverage is recommended. Surgical drainage is not always necessary, but is often needed for diagnostic purposes or in patients not clinically improving with conservative measures.

Introduction

A tubo-ovarian abscess (TOA) is an infection involving the fallopian tubes and ovaries, resulting in the formation of a purulent fluid collection, which may also extend to nearby abdominal organs. This inflammatory process often occurs as a complication of pelvic inflammatory disease (PID). Up to one-third of cases of PID are associated with a TOA.1 The majority of TOA cases can be treated with broad-spectrum antibiotics, with approximately 70% success. Experts suggest that women who fail antibiotic therapy (with worsening clinical signs or symptoms), have large abscess >8 cm, are hemodynamically unstable, or have signs of ruptured TOA should be treated surgically.2,3 The mortality rate is extremely low for TOAs that have not ruptured, but can be 1.7%-3.7% in cases of TOA rupture.2

Although further research is needed to fully explain why TOAs form in certain cases and not others, most experts believe it is the result of an ascending genital tract infection, similar to the pathogenesis of PID. The bacteria cause direct injury to cells of the fallopian tubes, causing inflammation, edema, and necrosis, which may progress to form a complex mass. Less frequently, TOA can be the result of bacterial spread from bowel disease, appendicitis, or surgery. Etiology is usually polymicrobial. Microbes frequently isolated from TOAs include Escherichia coli, Streptococci, Bacteroides fragilis, Prevotella, and other gram-negative enteric organisms.4

Female individuals found to have PID and TOA are usually sexually active, between the ages of 15 and 40 years, have multiple sexual partners, and often have a prior history of PID. PID is the most common gynecologic disorder necessitating hospitalization in reproductive-aged females. PID is most common in sexually active women, as it is often attributable to sexually transmitted infections, such as gonorrhea and chlamydia, but it can also be found in other females who are not sexually active.4 Female individuals may be especially vulnerable for ascending infection during menses due to hormonal changes, alterations in the cervical mucus, and retrograde menstruation.5

Patients with PID or TOA often present with vague complaints, such as lower abdominal pain, fevers, chills, and vaginal discharge. TOAs in non−sexually active patients are often difficult to diagnose, given their rarity and vagueness of complaints. Proposed risk factors for TOA formation in non−sexually active adolescents include obesity, recurrent urinary tract infection, and poor hygiene, which can lead to ascending infection and bacterial seeding from the gastrointestinal tract.6 Few studies have been published on cases of TOA and PID in non−sexually active females; the existing literature involves mostly case studies.

Early diagnosis and treatment of PID, and especially TOA, are important for future quality of life. Untreated TOA can lead to injury to the fallopian tubes, increasing the risk of infertility and ectopic pregnancies. Inflammation and scar tissue in the abdomen can also lead to chronic pelvic pain.1 In this study, we aim to investigate risk factors and common causes of TOA in non−sexually active females, which may lead to earlier diagnoses and improved outcomes.

Section snippets

Materials and Methods

We conducted a retrospective observational case series of all cases of TOA diagnosed from 2012 to 2018 at a tertiary children's hospital in Columbus, Ohio. The electronic medical record was searched for all cases corresponding to International Classification of Diseases, 10th revision (ICD-10) codes for tubo-ovarian abscess, salpingitis, and oophoritis. Inclusion criteria included non−sexually active females, younger than 25 years of age, who had evidence of adnexal mass. A total of 57 cases

Results

As described in Table 1, 10 patients (patients 1-10) were found to meet all inclusion criteria. Average age at time of diagnosis was 14 years (SD 4.2 years). Average body mass index was 24 kg/m2 (SD 7.9 kg/m2). Nine of 10 of patients presented with abdominal pain, with symptoms lasting from 1 day to 3 months (Table 2). The other patient presented with dysmenorrhea and abnormal uterine bleeding for the prior 1.5 years. Other associated symptoms include nausea and vomiting (40%), diarrhea (20%),

Discussion

The diagnosis of TOA in a non−sexually active adolescent is a rare finding, and typically is a diagnosis of exclusion in a patient presenting with vague abdominopelvic symptoms and imaging findings of a complex pelvic mass. In fact, many of these cases are not diagnosed definitively until the time of surgery. Potential risk factors for TOA formation in non−sexually active adolescents include obesity, recurrent urinary tract infection, and poor hygiene.6 In our review of the literature, we

Conclusion

Both TOA and PID are common diagnoses made in the sexually active population, commonly presenting with abdomino-pelvic pain, vaginal discharge, abnormal vaginal bleeding, nausea, and vomiting. These are less frequently seen in the pediatric and adolescent population, but should be kept in mind, given the possibilities of long-term sequelae. When TOA is suspected, conservative management with empiric antibiotic therapy should remain first-line, especially in a stable patient. However, many

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    • Image-Guided Percutaneous Drainage Reduces the Need for Surgical Interventions in Patients with Tubo-Ovarian Abscess: A Cohort Study

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    The authors have no conflicts of interest to disclose.

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    © 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.