cervical infections Flashcards
1
Q
most common causes of intectious cervicitis
A
Neisseria gonorrheoeae Chlamydia trachomatis herpes simples virus human papilloma virus trichomoniasis mycoplasma genitalium cytomegalovirus bacterial vaginosis
2
Q
If untreated, cervicitis can lead to
A
Pelvic inflammatory disease
higher risk of infertility
ectopic pregnancy
chronic pelvic pain
3
Q
methods for testing gonorrhea
A
urethral gram stain
culture on Thayer-Martin media
DNA probes
DNA amplification techniques on cervical or urine specimens
4
Q
Testing for chlamydia
A
nucleic acid amplification techniques on cervical or urine specimens
5
Q
HPV infection testing
A
cervical cytology (Pap test) and HPV testing are used with colposcopy and biopsy
6
Q
The signs of cervicitis
A
edema and increased vascularity, making the cervix appear swollen and reddened.
7
Q
Cervicitis can be diagnosed histologically when
A
polymorphonuclear leukocytes, lymphocytes, or histiocytes are noted
8
Q
The cervix is in direct contact with the vagina and is exposed to
A
viral, bacterial, fungal, and parasitic agents
9
Q
Cervical infections occur in the absence of
A
vaginal disease
10
Q
Through sexual contact, the cervix may be infected with
A
N gonorrhoeae, C trachomatis, HSV, HPV, and Mycoplasma spp.
11
Q
Why is screening high-risk populations important?
A
Because many women are asymptomatic
12
Q
Patients diagnosed with gonorrhea or chlamydia are at risk for infection with other sexually transmitted diseases (STDs). Counseling and testing should be offered for
A
syphilis, hepatitis B, and HIV, as well as testing for HPV
13
Q
Pathogenesis of C trachomatis
A
C trachomatis is often “silent,” an undiagnosed, ongoing infection may ascend into the endometrial cavity to the fallopian tubes, causing salpingitis as well as pelvic peritonitis.
14
Q
Complications of chlamydia
A
With the cervix as a reservoir, the organism may infect the fetus during its passage through the birth canal. C trachomatis transmitted to the eyes causes trachoma and inclusion conjunctivitis or pneumonia of the newborn.
15
Q
Pathogenesis of N. gonorrhoeae
A
Cervical infection which ascends to infect the endometrium and fallopian tubes.
16
Q
At what time in a woman’s cycle is she most at risk for cervicitis ascending into the upper reproductive tract?
A
at the end of menses when there is no protective mucus plug.
17
Q
Fitz-Hugh-Curtis syndrome or perihepatitis
A
rare complication usually caused by C trachomatis and N gonorrhoeae and is characterized by adhesions between the liver and the parietal peritoneum.
18
Q
2 types of HSV
A
herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2)
19
Q
Which HSV infection causes most of the genital herpes infections
A
HSV-2
20
Q
When can HSV-1 cause genital herpes
A
oral-genital or genital-genital contact
21
Q
HSV infection presentation
A
cervical lesions similar to those found on the vulva. First the lesion is vesicular and then becomes an ulcer. Primary infections may be extensive and severe, producing constitutional symptoms of low-grade fever, myalgia, and malaise lasting approximately 2 weeks. The ulcers heal without scarring. Once infection has occurred, even after healing, the virus continues to reside in the nerve cells of the affected area for life.
22
Q
HSV recurrence
A
less severe in symptoms and duration
23
Q
HSV is found in the lesions caused by HSV infection, but viral shedding can also occur
A
in asymptomatic patients without obvious lesions. Women with either active infection or asymptomatic HSV shedding from normal-appearing skin can infect their infants during vaginal delivery. Those with a positive HSV test near term are advised to undergo caesarean section.
24
Q
HPV is spread by
A
skin-to-skin contact
25
Women with vulvar HPV lesions should be assessed for
cervical HPV lesions and infection
26
Appearance of cervical HSV lesions
The cervical lesions are flatter than typical genital warts (condylomata acuminata) seen on the vulva and perianal skin. In fact, they often are invisible to the naked eye, becoming visible only after application of a dilute solution of acetic acid (acetowhite epithelium) or by colposcopic examination (white epithelium, mosaicism, and coarse punctation).
27
Low risk HPV types
6, 11, 42, 43, 44, 54, 55 (associated with benign lesions of the cervix)
28
High risk HPV types
16, 18, 31, 33, 35, 39, 46, 56 (associated with intraepithelial neoplasia and invasive cancers)
29
What percent of HPV infections resolve in 1 year?
| In two years?
70% in one year
| 90% by 2 years
30
Persistent HPV infection may progress to
precancerous lesions and, over time, cervical cancer
31
Most important strategies for prevention of cervicitis
Abstinence
condoms
barrier methods
32
Which STIs should be screened for yearly in high risk populations, regardless of symptoms
gonorrhea and chlamydia--most prevalent in young adults aged 19-25
significant long-term complications
33
at risk populations for STI
```
multiple partners
19-25
inconsistent use of condoms or barrier
previous hx STI
current or prior drug abusers
```
34
when should pregnant women be screened for syphilis and HIV
at the first prenatal visit
35
Pregnant women with a history of HSV should be screened
near term
36
Women at high risk of premature delivery should be screened for
bacterial vaginosis
37
The prompt recognition and proper repair of cervical lacerations lessen the risk of
cervical stenosis and cervical incompetence in future pregnancies.
38
When hysterectomy is performed, if possible, the cervix should be
removed to minimize the risk of cervical diseases.
39
Common s/sx acute cervicitis
Purulent vaginal discharge
Some women have vaginal bleeding, most frequently after sexual intercourse, although intermenstrual bleeding and bleeding during examination can also occur.
burning and itching
40
In acute cervicitis, the pathogen may be determined by the appearance of
cervical discharge
41
thick and creamy discharge
gonorrheal infection
42
foamy and greenish-white discharge
trichomonal infection
43
white/curd-like discharge
candidiasis
44
thin and gray discharge
bacterial vaginosis
45
Amine or fishy odor when combined with KOH
bacterial vaginosis
46
purulent discharge from a reddened, congested cervix, or may be asymptomatic, without visible signs
Chlamydia
47
acutely inflamed, edematous cervix with purulent discharge from cervical os
N. gonorrhoeae
48
strawberry-like appearance covers the ectocervix and may extend to the adjacent vaginal mucosa.
trichomonal infection
49
white cheesy exudate may be difficult to wipe away and once wiped off usually leaves punctate hemorrhagic areas
candidiasis
50
which organisms of cervicitis may be accompanied by urethritis with frequency, urgency, and dysuria
Gonorrheal or chlamydial
51
If any infection is associated with acute salpingitis, the symptoms and signs will include
pelvic peritonitis
52
Postcoital bleeding or intermenstrual spotting may occur because of
hyperemia of the infected cervix associated with freely bleeding areas. Cervical friability with bleeding occurs when endocervical smears are obtained.
53
Colposcopic findings of acute cervicitis reveal
an altered microangioarchitecture with marked increase in the surface capillaries, which when viewed end-on may show a pattern of diffuse “punctation.”
54
characteristic double-hairpin capillaries
Trichomoniasis
55
Colposcopic picture in an inflammatory process
diffuse with ill-defined margins in contrast with the localized and sharply demarcated vascular changes associated with intraepithelial neoplasia
56
when colposcopic changes with malignancy are present alongside those associated with inflammation:
Invasive cancer with is secondarily infected
57
Chief sx of chronic cervicitis
leukorrhea
| Less diffuse as acute cervicitis, but may still cause vulvar irritation.
58
discharge in chronic cervicitis
The discharge may be frankly purulent and variable in color, or may simply be thick, tenacious, turbid mucus. Intermenstrual or postcoital bleeding may occur.
59
Associated sx of chronic cervicitis
lower abdominal pain, lumbosacral backache, dysmenorrhea, dyspareunia, urinary frequency, urgency, and dysuria.
60
Inspection of the chronically infected cervix often reveals
only abnormal discharge, with the upper vagina appearing normal.
61
Mucopurulent cervicitis is defined as
evidence of purulent material on inspection of an inflamed cervix along with 10 or more polymorphonuclear leukocytes per high-powered microscopic field seen on Gram's stain of the discharge.
62
In acute cervicitis with N gonorrhoeae, the sensitivity of Gram's stain for detection of diplococci is only
50%
63
In symptomatic patients, with signs suggesting Trichomonas, further testing of
nucleic acid amplification, culture testing may be necessary
64
Bacterial vaginosis can be seen on saline wet mount by
the coating of epithelial cells with bacteria called “clue cells.”
65
Bacterial vaginosis is diagnosed by using
Amsel criteria:
thin homogeneous white, yellow discharge,
presence of the “clue cells” on microscopy,
vaginal pH >4.5,
and fishy odor on adding alkaline 10% potassium hydroxide solution.
Presence of 3 of these criteria will confirm the diagnosis of bacterial vaginosis.
66
Candidal infections can be seen on potassium hydroxide preparations, with the distinctive presence of
hyphae
67
More recently, infection is detected more reliably than culture with
nucleic acid amplification methods such as polymerase chain reaction (PCR), transcription-mediated amplification, and strand displacement amplification.
high sensitivity and specificity (82–100%)
simultaneous detection of both N gonorrhoeae and C trachomatis from the same specimen.
68
Enzyme immunoassay and direct fluorescent antibody rely on
antigen detection and have a sensitivity ranging from 70–80%, but the specimen still requires invasive testing using a swab from the cervix or urethra.
69
HSV infection can be detected by
viral culture, PCR, and direct fluorescence antibody. Most laboratories are moving toward nonculture assays such as PCR, which offer high sensitivity and specificity.
70
Syphilis is detected by using
nontreponemal rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) tests and subsequent confirmation with microhemagglutination assay for Treponema pallidum (MHA-TP), fluorescent treponemal antibody-absorption (FTA-ABS) tests.
71
most effective strategy for detecting abnormal cervical pathology.
Combining HPV testing with cervical cytology
72
If cytology is abnormal
colposcopy with directed biopsy is advised.
73
In uncomplicated cervicitis not accompanied by salpingitis, the white count may be
normal
74
With salpingitis, a leukocytosis is
common with an elevated white count. The erythrocyte sedimentation rate may be slightly elevated.
75
cytologic cervical testing may delineate
Cellular changes of mild dysplasia (low-grade squamous intraepithelial lesion [SIL]), moderate or severe dysplasia (carcinoma in situ [CIS], high-grade SIL), and invasive cancer
76
Nuclear enlargement, clumping of chromatin, hyperchromatism, and nucleoli, as well as cytoplasmic eosinophilia and poorly defined cell membranes, are nonspecific findings of
cytologic atypia.
77
large numbers of polymorphonuclear leukocytes or histiocytes indicate
acute cervicitis.
78
When the inflammatory cells are so dense that the epithelial cells are obscured
the smear should be repeated after the inflammatory process has been treated.
79
HPV infection is characterized histologically by
squamous epithelial cell enlargement, multinucleation, and the perinuclear “halo” effect of koilocytosis.
80
Enlarged, multinucleated cells with ground-glass cytoplasm and nuclei containing inclusion bodies are indicative of
HSV infection
81
Both N gonorrhoeae and C trachomatis infections produce a nonspecific acute inflammatory reaction of
nonspecific acute inflammatory reaction of edema and increased vascularity, and the cervix becomes swollen and reddened. Gross appearance of acute cervicitis must be distinguished clinically and histologically from cervical ectopy.
82
Histopathology of cervical infections
- -visual inspection
- -microscopic inspection
- -post infection
Infection causes the glandular epithelium to hyperfunction, producing a copious purulent or mucopurulent exudate and mucus mixed with inflammatory cells.
Microscopically, stromal edema and infiltration by polymorphonuclear leukocytes are seen, and some mucous membrane may be denuded.
As the acute infection subsides, swelling and redness disappear, and polymorphonuclear leukocytes are replaced by lymphocytes, plasma cells, and macrophages—the histologic picture of chronic cervicitis.
83
Almost all parous women may have findings characteristic of chronic cervicitis on biopsy that are not significant unless
they also have clinical signs and symptoms of cervicitis.
84
Infectious cervicitis must be distinguished from
cervical intraepithelial neoplasia. Colposcopy is a useful adjunct. Cervical cytology and histologic examination by endocervical curettage and biopsy may help distinguish chronic cervicitis from cervical neoplasia.
85
N gonorrhoeae or C trachomatis cervicitis is often complicated by
salpingitis and pelvic inflammatory disease
86
salpingitis and pelvic inflammatory disease are associated with
an increased risk of
infertility,
ectopic pregnancy,
and chronic pelvic pain.
87
The occurrence of gonorrheal or chlamydial cervicitis in HIV-infected women has been reported to be associated with increased shedding of
HIV-1 that, in turn, increases the infectiveness of these women.
88
What is the risk of cancer in women with history of genital infection.
Not increased.
Although, hx of genital infection is more common among women with carcinoma of the cervix.
89
Considerations for treatment
Nature of infection
Pregnancy/breastfeeding
plans for future pregnancy
Severity of infection as indicated by: salpingitis/previous treatment
90
Instrumentation should be avoided during acute cervicitis to minimize the risk of
ascending infection.
91
Treatment for trichomoniasis
```
Metronidazole 2 grams PO, single dose
or
tinidazole 2 grams PO single dose
or
metronidazole 500 mg BID x 7 days.
Cure rate 90-95%.
```
92
What should be avoided while taking metronidazole or tinidazole?
alcohol--throughout treatment and for 24-72 hours afterward.
93
Treatment for pregnant/breastfeeding with thichomoniasis
Metronidazole 2 grams PO single dose.
If breastfeeding, stop breastfeeding for 12-24 hours after treatment.
Treat sex partners and avoid sex until both partners are cured.
Topical forms are available, but less efficacious.
94
Treatment for candidiasis
Topically applied azole drugs.
| Course may be 1,3,or 7 days, depending on severity of infection.
95
Specific medications for candidiasis
butoconazole 2% cream 5 grams intravaginally for 3 days
clotrimazole 1% cream 5 grams intravaginally for 7-14 days
clotrimazole 100mg vaginal tab for 7 days
miconazole 25 cream 5 grams intravaginally for 7 days
Miconazole 200 mg vaginal suppository for 3 days, or 100mg for 7 days
Single dose 150mg fluconazole by mouth
96
most prevalent genital ulcerative lesions in the United States.
Genital herpes, syphilis, and, less commonly, chancroid
97
the workup for all genital ulcers should include
serologic screening for syphilis, culture/antigen testing for herpes simplex virus (HSV)-1 and HSV-2, and culture for Haemophilus ducreyi in areas where chancroid is prevalent. More than 1 infectious etiology may be present in a single lesion.
98
Herpes Simplex
| Essentials of Diagnosis
Most commonly caused by HSV-2 but increasingly also caused by HSV-1
Painful genital ulcers
Chronic, lifelong, relapsing condition
Transmissible even in the absence of lesions
Antivirals improve symptoms, speed healing of lesions, and may decrease asymptomatic viral shedding
99
the majority of genital herpes infections are transmitted by persons
unaware that they have the infection or who are asymptomatic when transmission occurs.
100
Patients should be counseled that viral shedding
can occur during asymptomatic periods and that this can lead to transmission. Consistent condom use is associated with a decline in transmission of genital HSV infection.
101
For patients with symptomatic genital HSV-2 infection and an uninfected partner,
chronic suppressive therapy to reduce clinical recurrences and viral transmission should be considered.
Valacyclovir (500 mg daily) is the best-studied regimen for this specific indication and offers the convenience of once-daily dosing; however, acyclovir may be a reasonable alternative.
102
Symptoms and signs of genital herpes
Classically, patients present with multiple painful vesicular or ulcerative lesions on the genitals.
May be absent--especially if caused by HSV-1
103
Patients with a primary HSV infection may, in addition to painful ulceration, have
multiple constitutional symptoms such as fever, headaches, and malaise.
104
preferred tests for HSV in symptomatic patients
Cell culture and polymerase chain reaction (PCR)
105
Failure to detect HSV by culture or PCR does not indicate an absence of HSV infection, because
viral shedding is intermittent.
106
for serologically. Immunoglobulin (Ig)M testing for HSV is not useful, because
the IgM tests are not type-specific and might also be positive during recurrent episodes of herpes.
107
Type-specific HSV serologic assays may be useful in the evaluation of the following situations:
patients with recurrent genital symptoms or atypical symptoms with negative HSV cultures,
patients with a clinical diagnosis of genital herpes without laboratory confirmation,
and patients who have a partner with genital herpes.
108
during the first several weeks after HSV infection, what types of antibodies develop?
type specific and non-type specific
persist indefinitely
can be tested for serologically
109
The presence of type-specific HSV-2 antibody implies
anogenital infection
110
Lack of symptoms in an HSV-1 seropositive person does not distinguish
anogenital from orolabial or cutaneous infection.
111
Regardless of site of infection, persons with HSV-1 are at risk for acquiring
HSV-2.
112
Complications associated with HSV infection
Urinary retention due to severe dysuria with extensive genital lesions.
Rarely, can develop manifestations of disseminated infection, pneumonitis, hepatitis, or CNS complications such as meningoencephalitis.
Hospitalize for monitoring and IV antivirals.
113
Systemic treatment for herpes
help to control the symptoms of herpes episodes and may also be used as daily suppressive therapy.
Do not eradicate latent virus, nor affect the risk, frequency, or severity of recurrences after drug discontinued.
114
Medications for first episode of herpes
First clinical episode:
Choose one:
Acyclovir 400 mg orally 3 times a day for 7–10 days
Acyclovir 200 mg orally 5 times a day for 7–10 days
Famciclovir 250 mg orally 3 times a day for 7–10 days
Valacyclovir 1 g orally twice a day for 7–10 days
**May treat longer than 10 days if symptoms not resolved
115
Suppression therapy for genital herpes
# Choose one of the following:
Acyclovir 200 mg orally twice a day
Famciclovir 250 mg orally twice a day
Valacyclovir 500 mg orally once a day (may be less effective than the other regimens in patients with >10 episodes per year)
Valacyclovir 1g orally once a day
116
EPISODIC THERAPY FOR RECURRENT GENITAL HERPES
# Choose one of the following:
Acyclovir 400 mg orally 3 times a day for 5 days
Acyclovir 800 mg orally twice a day for 5 days
Acyclovir 800 mg orally 3 times a day for 2 days
Famciclovir 125 mg orally twice a day for 5 days
Famciclovir 1 g orally twice a day for 1 day
Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days
Valacyclovir 500 mg orally twice a day for 3 days
Valacyclovir 1 g orally once a day for 5 days
117
HSV Recommendations to pregnant women
Abstain from sex during third trimester with partners who are HSV positive.
All should be asked about history of HSV
At onset of labor, all women should be questioned carefully and examined for herpetic lesions.
Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally.
C-Section does not eliminate risk, but greatly reduces it.
118
Treatment of HSV-pregnancy
Acyclovir PO to pregnant women with first-episode genital herpes or severe recurrent herpes.
Reduces frequency of ceserean.
May be offered for suppression from approximately 36 weeks gestation
119
HSV with HIV treatment
# Choose one of the following:
a. Suppression
Acyclovir 400–800 mg orally 2–3 times a day
Famciclovir 500 mg orally twice a day
Valacyclovir 500 mg orally twice a day
B. Episodic Infection
Acyclovir 400 mg orally 3 times a day for 5–10 days
Famciclovir 500 mg orally twice a day for 5–10 days
Valacyclovir 1 g orally twice a day for 5–10 days
120
Chancroid essentials of diagnosis
Caused by gram-negative rod Haemophilus ducreyi
Painful, tender genital ulcer
Suppurative inguinal adenopathy
121
Exposure to chancroid is usually through
coitus, but accidentally acquired lesions of the hands have been reported. The incubation period is typically 4–10 days. Chancroid is a reportable disease.
122
If patient is diagnosed with chancroid, how is partner treated
Treat regardless of symptoms if they have had sexual contact in the 10 days preceding partner's onset of symptoms.
123
chancroid lesion
begins as an erythematous papule that evolves into a pustule and ultimately degenerates into a saucer-shaped ragged ulcer circumscribed by an inflammatory wheal. Typically, the lesion is very tender and produces a heavy, foul discharge that is contagious. Patients typically have more than 1 ulcer, and these are almost exclusively confined to the genital region.
124
Painful inguinal adenitis related to chancroid
The nodes may undergo liquefaction, producing fluctuant buboes that may become necrotic and drain spontaneously.
125
CIN
Cervical intraepithelial neoplasia (disordered growth)
126
VAIN
Vaginal intraepithelial neoplasia
127
VIN
vulvar intraepithelial neoplasia
128
PAIN
perianal intraepithelial neoplasia
129
5 categories of Pelvic infection
Pelvic inflammatory disease, including tubo-ovarian abscess (TOA)
Puerperal infections
Postoperative pelvic infection after gynecologic surgery
Abortion-associated infections
Secondary to other infections
130
Pelvic inflammatory disease essentials of diagnosis
Inflammation of upper female genital tract
usually polymicrobial
often diagnosed clinically based on the presence of cervical motion tenderness or uterine or adnexal tenderness
criteria exist to determine whether to manage patient as inpatient or outpatient
may result in pelvic scarring and infertility
131
Pathogenesis of PID
```
spectrum of inflammatory disorders of the upper female genital tract.
Any combination of:
endometriosis
salpingitis, tubo-ovarian abscess
pelvic peritonitis
STI (gonorrhoeae and trachomatis)
microorganisms from vaginal flora
```
132
normal vaginal flora
anaerobes, G vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae
133
Prevention of PID
Screening and treatment of sexually active women and their partners. (60 days preceding onset of symptoms)
Early diagnosis and eradication to prevent salpingitis
abstain from sex until no symptoms
134
PID clinical findings
Subjective:
may be subtle or mild, though early diagnosis important
Clinical diagnosis is appropriate, but often imprecise
c/o insidious or acute onset lower abdominal/pelvic pain--usually bilateral
sensation of pelvic pressure or back pain
offten associated with purulent vaginal discharge
Nausea with or without vomiting
HA with general lassitude.
No fever required for Dx
135
PID clinical findings
Objective:
Abdominal tenderness in both lower quadrants
somewhat distended abdomen
BS hypoactive or absent
Pelvic exam: inflammation of the periurethral (Skene) or Bartholin's glands as well as purulent cervical discharge.
Bimanual exam: extreme tenderness on cervical and uterine movement and palpation of the parametria.
136
CDC guidelines on when to start emperic tx of PID
sexually active young women and other woman at risk for STDs if
1. experiencing pelvic or lower abdominal pain
2. no cause other than PID can be identified
3. 1 of the following:
(a) cervical motion tenderness
(b) uterine tenderness
(c) adnexal tenderness
137
Labs for PID
Vaginal fluid: abundant WBC
Leukocytosis with shift to the left
ESR, CRP elevated
Endocervical swabs culture gonorrheoeae or trachomatis.
(BTW these might all be normal)
Endometrial biopsy is definitive, but hardly done.
138
Imaging for PID
Laparoscopy/salpingitis, endometriosis--useful adjuct
139
DDx PID
```
acute appendicitis
ectopic pregnancy
ruptured corpus luteum cyst with hemorrhage
diverticulitis
infected septic abortion
torsion of an adnexal mass
degeneration of a leiomyoma
endometriosis
acute UTI
regional enteritis
ulcerative colitis
```
140
Complications of PID
```
pelvic or generalized peritonitis
prolonged ilius
septic pelvic thrombophlebitis
abscess formation with adnexal destruction/infertility
intestinal adhesions and obstruction
Rarely: dermatitis
gonococcal arthritis
bacteremia with septic shock
```
141
Tx PID
All regimens should be effective against gonorrhea and chlamydia.
Outpatient Therapy
RECOMMENDED REGIMENS
Ceftriaxone 250 mg IM in a single dose (or other parenteral third-generation cephalosporin), plus
Doxycycline 100 mg orally twice a day for 14 days, with or without
Metronidazole 500 mg orally twice a day for 14 days
or
Cefoxitin 2 g IM in a single dose and probenecid 1 g orally in a single dose administered concurrently, plus
Doxycycline 100 mg orally twice a day for 14 days, with or without
Metronidazole 500 mg orally twice a day for 14 days
142
Hospitalize PID pt if:
Patient in whom surgical emergencies (eg, appendicitis) cannot be excluded
Patient who are pregnant
Patients who have not responded well to outpatient oral therapy
Patients who are unable to tolerate or comply with outpatient therapy
Patients who have severe illness, nausea and vomiting, or high fever
Patients with tubo-ovarian abscess
