Diagnosis and management of tubo-ovarian abscesses TOG 2018

Question 1

What proportion of TOA are in nulliparous women?

Answer 1

60%

Question 2

TOA + severe sepsis risk mortality

Answer 2

5-10%

Question 3

What proportion of TOA are polymcrobial?

Answer 3

30-40%

Question 4

Most common cause of TOA

Answer 4

Ascending infection from upper genital tract
Can also be secondary to any other intra-abdominal pathology - appendicitis, diverticulitis, pyelonephritis - direct of haemoatoegnous spread

Question 5

Risk factors for TOA

Answer 5

non-use of barrier contraception
Intrauterine contraceptive devices,
previous episode(s) of PID,
earlier age at first intercourse,
multiple sexual partners,
diabetes
immunocompromised state

Question 6

What proportion of women with proven PID will diagnosed with TOA

Answer 6

15-35%
Women with endometriosis more likely to have severe PID and TOA

Question 7

What proportion of women with TOA and PID have diarrhoea

Answer 7

TOA 90%
PID 60%

Question 8

What proportion of TOA in UK are +ve N. gonorrhea and C. trachomatis

Answer 8

1/4

Question 9

Differential for TOA

Answer 9

appendicular mass, an endometrioma (or other ovarian cyst), an extrauterine pregnancy, diverticulitis or underlying malignancy.

Question 10

What are the USS features of TOA

Answer 10

Complex solid/cystic mass
‘Cogwheel sign’
Lies in POD
Reactive ovary - polycystic

Question 11

When would you perform CT

Answer 11

If suspicion of GI pathology

Question 12

What is the most commonly effected proximal structured

Answer 12

Rectosigmoid
2nd ureter

Question 13

Which form of imaging most specific for TOA

Answer 13

MRI, however USS is 1st line

Question 14

Flow diagram for management of TOA

Answer 14

Question 15

If presented with sepesis, in no clinical improvement after which period of time on IV Abx should surgical/radiological management be considered?

Answer 15

24 hours

Question 16

What are poor prognostic factors for medical treatment

Answer 16

• Abscess > 5cm
• Age >40
• Higher WCC at booking
• Smoking

If >8cm requires surgical intervention

Question 17

What surgical options cab be considered?

Answer 17

Laparoscopic or Laparotomy - drainage of the abscess
- unilateral/bilateral sapping-oopherectomy

Can drain abscess with fertility desired - washout with large drain

Question 18

How common is TOA in postmenopausal women. What should be consideration in PM women with TOA

Answer 18

1.7% - risk of associated malignancy 47%

Question 19

What routes can USS or CT drainage be performed?

Answer 19

Transabdominal, tranvaginal, transrectal, transgluteal

Can perform as aspiration alone or catheter placement. Catheter if larger, bilateral, multiloculated abscess.

Question 20

Following drainage risk of requiring further surgery for TOA

Answer 20

7%

Question 21

What question to ask patient if removing IUCD?

Answer 21

Any sexual intercourse in last 5 days as will be at risk of pregnancy. May require emergency contraception.

Question 22

How common is pelvic pain agentry TOA
1) Overall
2) 1 episode
3) 2 episode
4) 3 episode

Answer 22

1) Overall 1/3
2) 1 episode 12%
3) 2 episode 30%
4) 3 episode 67%

Question 23

Difference in risk of chronic pelvic pain between surgical or non surgical

Answer 23

None

Question 23

What % of women achieved a pregnancy following TOA with -
1) Lap drainage of abscess
2) Abx alone

Answer 23

1) Lap drainage of abscess 32-65%
2) Abx alone 15%

Should consider Lap drainage of abscess for all women with TOAs who desire future fertility