6/9/04njm

**There are two questions**

**#1**

**Q.** Is percutaneous drainage of tubo-ovarian abscess standard of
care?

**A.** Yes, especially in women who have not completed their
child-bearing.

**#2**

**Q.** Does percutaneous drainage offered any benefit over the
established \"conservative\" treatment of cooling off with IV
antibiotics until afebrile 48 hours and then doxycycline for 6 weeks
with rescan at that point?

How do these two methods compare? It would seem that the less one
manipulates the fallopian tubes the better for fertility?

**A.** That question is more difficult to answer because PID's effects
are often unrelated to the initial severity of the episode. See the
second answer on page 3 below.

**TREATMENT CONSIDERATIONS** --- Potent new antibiotics, earlier
presentation for medical care, invasive imaging capabilities, and
appreciation of the distinction between TOA and TOC\* have all
contributed to a better therapeutic outcome for TOA in recent years.

\*Ultrasound is also the best way to differentiate between a TOA and a
tuboovarian complex (TOC), an important distinction only understood in
the last 15 years. TOC is an inflammatory pelvic mass representing
edematous, adherent, infected pelvic structures in PID. While sinus
tracts containing pus are often present in TOC, there is no devitalized
abscess wall or accumulation of pus within a cavity. The TOC is
perfused, living tissue, and although occasionally large, it is amenable
to medical therapy in over 95 percent of cases. TOC and TOA cannot be
differentiated on pelvic examination. Sonographically TOC is a markedly
heterogeneous, thick-walled mass with vague margins and no dominant
cystic component or symmetry.

Most studies of medical treatment of PID have identified TOA to be
responsible for 80 percent or more of treatment failures. We agree with
the proposal that therapy of TOA should be studied separately from that
of uncomplicated PID. The major controversy in the therapy of this
disorder is whether surgery (or some form of drainage procedure) is
required in the majority of cases. Some well-recognized experts in the
field continue to recommend a trial of medical therapy including
antimicrobials with anaerobic coverage, citing a 75 percent success rate
in their retrospective review of 119 cases of TOA .

**Surgical drainage** --- Drainage of pelvic cul-de-sac abscesses by
colpotomy incision has been used for many years. However, this procedure
should not be undertaken unless a fluctuant abscess is palpated in the
midline, adherent to the vaginal wall, and distends the upper one-third
of the rectovaginal septum. Patients with TOA rarely meet these criteria
now. Colpotomy has fallen into relative disfavor because of several
reports associating it with an unacceptable rate of major complications
including death, and a high rate of reoperation for progressive
infection.

Drainage of TOA using ultrasound guidance or laparoscopy is a major
therapeutic advance in the treatment of this disorder.

  **Ultrasonographic drainage** --- Studies have been performed with
ultrasound-guided drainage using a transvaginal or percutaneous
approach. Placement of a catheter or a single drainage procedure have
also been assessed.

  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} In one study 31 women with TOA who had
failed medical therapy underwent 34 ultrasound-guided transvaginal
drainage procedures. The initial treatment was successful in 26 (84
percent); however, 10 of the 18 patients (56 percent) who were available
for follow-up over the next 6 to 21 months remained well, while eight
(44 percent) developed sequelae of infection.\
\
  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} A second series evaluated percutaneous
drainage of 27 TOAs in 16 patients who had failed triple antibiotic
therapy; the route for the drainage was via the abdominal wall in 10,
buttocks in 11, and vagina in 6. Successful drainage was accomplished in
15 of the 16 patients (94 percent) but surgery was avoided long-term in
only 13 (81 percent).\
\
  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Another study reported success with
sonographically-guided drainage and antibiotic instillation into the
cavity in 10 women who had failed antibiotic treatment for TOA. The mean
time to discharge after drainage was 3.1 days although the average time
to resolution of the abscess by ultrasound was 10 weeks.\
\
  ![](media/image1.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Two small trials achieved cures with a
single transvaginal aspiration of the abscess followed by antibiotic
therapy; the patients in these studies in contrast to the others had not
failed previous medical treatment.

  **Laparoscopic drainage** --- Use of the laparoscope for preemptive
drainage also appears promising. In one report, laparoscopic drainage
with antibiotics as initial therapy resolved 20 of 21 (95 percent)
patients with TOA with four of seven patients, who desired pregnancies,
able to conceive. In a second study, laparoscopic drainage was
successful in 45 of 48 patients (94 percent).

**TREATMENT RECOMMENDATIONS** --- There is no current indisputable
standard of care for TOA. A physician should not be criticized for
immediate extirpative pelvic laparotomy for a patient with TOA
(particularly if she is unstable or has completed childbearing) or for
medical management alone with careful monitoring and potent
broad-spectrum antibiotics (particularly if she is young and in stable
condition). However, there are some boundaries for successful management
of this condition. Initial outpatient treatment of TOA is unsafe;
rupture and sepsis syndrome may occur unexpectedly and still carry a
mortality of approximately 25 percent. Oral antibiotic regimens and
those lacking coverage for facultative and anaerobic pathogens are
inadequate. TOC should first be treated medically.

Table 1 is a protocol which can serve as a general guideline for the
safe and cost effective treatment of TOA following first diagnosis
**(Table 1).**

If Actinomyces sp. is isolated from the TOA, consultation with an expert
is recommended. Patients initially treated medically for TOA should show
a clear clinical response within approximately four days, including
partial or complete resolution of fever, leukocytosis, pain, and ileus.

For those showing a good response to this conservative protocol,
comprehensive antibiotic treatment should be continued for at least a
total of 10 days. After a clear response has been established in the
hospital, the remainder of the treatment can be performed on an
outpatient basis. Patients should have weekly bimanual examinations for
two to three weeks after the initial resolution of the process. The mass
associated with the TOA may not fully resolve for several months; any
increase in its size should be evaluated carefully and additional
treatment considered. Sexually transmissible disease counseling should
be reinforced. Patients should be advised that pregnancy remains
possible, and they should be promptly evaluated for any episode of
amenorrhea or abdominal pain.

Almost all patients failing to respond within four days require surgery
although it is appropriate to review the antibiotic sensitivities of the
organisms isolated from the abscess, to image the abscess for
reaccumulation, to perform blood cultures and to consider water-soluble
contrast bowel studies and echocardiography. Laparotomy through a
vertical incision should be immediately performed for resection of all
infected tissues in the pelvis, if the pelvic infection is not resolved
by this protocol or if there is evidence of sepsis syndrome (hypotension
and dysfunction of two or more organ systems), which may occur at any
time during the treatment course with or without intraperitoneal rupture
of the abscess.

A careful search for metastatic abscesses should be undertaken
throughout the bowel loops and in the subphrenic and subhepatic spaces.
Closed suction drainage through the vagina may be a useful addition to
this surgery. A mass closure of peritoneum, muscle and fascia with
monofilament suture and retention stitches is advised. Closure of the
skin and subcutaneous layer primarily is appropriate only for those with
no free pus in the abdomen, and placement of a subcutaneous drain
brought through a separate stab incision may be beneficial.
Postoperative management in an intensive care unit should be considered
for those with septic shock, particularly if acute respiratory distress
syndrome is suspected

**Tuboovarian abscess**

Charles H Livengood, III, MD UpToDate Online 12.1

<http://www.uptodateonline.com/application/topic.asp?file=stds/5953&type=A&selectedTitle=10~35>

**Table 1: Treatment of Tuboovarian Abscess**

<http://www.uptodateonline.com/application/image.asp?file=id_pix/treatm2.gif>

**Question #2**

**Q.** Does percutaneous drainage offered any benefit over the
established \"conservative\" treatment of cooling off with IV
antibiotics until afebrile 48 hours and then doxycycline for 6 weeks
with rescan at that point?

How do these two methods compare? It would seem that the less one
manipulates the fallopian tubes the better for fertility?

**A.** That question is more difficult to answer because PID's effects
are often unrelated to the initial severity of the episode.

**Long term sequelae**

Symptomatic and asymptomatic PID produce indistinguishable permanent
injury to the fallopian tubes, most particularly their internal
epithelium. There is a continuum from loss of ciliary action through
patchy fibrosis to overt occlusion; these changes cause tubal factor
infertility proportional to the severity of the injury. Oral
contraceptives seem to confer some protection against tubal injury
during PID despite the evidence noted above that subclinical PID may be
more common in oral contraceptive users. The mechanisms for this
protection are unclear.

Delayed treatment for PID dramatically worsens future fertility. One
case control study of 76 women with infertility or ectopic pregnancy and
367 controls with intrauterine pregnancy found that delay in seeking
treatment for PID resulted in a threefold greater probability of
experiencing infertility or ectopic pregnancy. When patients experienced
PID due to chlamydia infection and treatment was delayed, the risk was
increased up to 20-fold.

The probability of infertility following PID correlates best with
laparoscopic severity of disease despite the fact that laparoscopic
findings do not always correlate well with clinical severity. The
approximate frequency of tubal factor infertility after mild, moderate,
and severe PID is 10, 25, and 50 percent, and each additional episode of
PID appears to decrease fertility further.

PID also seems to diminish the likelihood of a subsequent live birth by
increasing pregnancy complications. Among 1288 Swedish women followed
for twelve years after laparoscopically-graded PID, the cumulative
proportions of live births among those initially found to have mild,
moderate, and severe disease were 90, 82, and 57 percent. In addition,
recurrent PID among women with a history of severe disease decreased the
probability of a live birth eightfold compared to women with one mild
episode.

Here is some additional information on sequelae:

**SEQUELAE** --- Much of the morbidity, suffering, and cost of PID
arises from the scarring and adhesion formation which accompany healing
of damaged tissues after the infection itself is eradicated. These
effects take at least three forms: infertility, ectopic pregnancy, and
chronic pelvic pain. ([[See \"Chronic pelvic
pain\"]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/9373)
and [[see \"Incidence, risk factors, and pathology of ectopic
pregnancy\"]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/6639)).

**Infertility** --- Women with tubal factor infertility apparently
induced by past episodes of PID often give no history of PID
\[[[14-16]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=14~15~16&title=14-16)\].
([[See \"Clinical features and diagnosis of pelvic inflammatory disease
in
adults\"]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=stds/2470)).
As an example, in one study of 112 infertile women, 36 had adhesions or
distal tube occlusion suggestive of PID by laparoscopy but only 11 had a
history of this diagnosis
\[[[16]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=16&title=16)\].
In addition, up to one-third of women without a history of PID harbor
persistent Chlamydia trachomatis in the upper genital tract despite the
absence of clinical findings except infertility
\[[[17,18]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=17~18&title=17,18)\].
Thus, it seems clear that subclinical PID severe enough to produce
significant sequelae is common. Subclinical episodes are particularly
common among oral contraceptive users
\[[[19,20]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=19~20&title=19,20)\];
43 women with endometritis but no clinical signs of PID were four times
more likely to have used oral contraceptives than 111 control patients
with clinical PID and endometritis
\[[[20]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=20&title=20)\].

**Ectopic pregnancy** --- Almost 100,000 ectopic pregnancies occur
annually in the United States, and each costs at least one life (the
fetus) as well as almost \$10,000
\[[[27]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=27&title=27)\].
A case-control study in Los Angeles suggested that chlamydia-associated
PID alone caused almost one-half of ectopic pregnancies
\[[[28]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=28&title=28)\].
Approximately 10 to 15 percent of conceptions will be ectopic after
laparoscopically mild to moderate PID, and almost 50 percent after
severe PID
\[[[24]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=24&title=24)\].
Among women with a prior ectopic pregnancy and clinical PID, 60 percent
of conceptions were recurrent ectopic pregnancies
\[[[29]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=29&title=29)\].

**Pelvic pain** --- About one-third to one-half of women with
symptomatic PID develop chronic pelvic pain
\[[[24,30]{.underline}](http://www.uptodateonline.com/application/abstract.asp?TR=stds/4883&viewAbs=24~30&title=24,30)\].
This syndrome presumably results from adhesions and the resultant
tethering or fixation of organs intended to enjoy freedom of movement
and expansion during physical activity, coitus, and ovulation.

Some of these patients will benefit from ovulation suppression with oral
contraceptives and/or tricyclic therapy. We recommend
[[imipramine]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/129925&drug=true)
(25 to 50 mg QHS) and do not use serotonin reuptake inhibitors in this
setting unless the patient also has clear evidence of superimposed
depression.
[[Amitriptyline]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/14215&drug=true)
is also a reasonable choice but is more likely to cause weight gain.
Adhesiolysis seems to benefit some women, but many of these patients
come to surgical removal of the affected pelvic organs.

**Treatment and sequelae of pelvic inflammatory disease in adults**

Charles H Livengood, III, MD UpToDate Software, 12.1 2004

<http://www.uptodateonline.com/application/topic.asp?r=/application/topic.asp&file=stds/4883&app=utdol>

To look deeper into this topic,

RE: Success for long term fertility between the different treatment
methods, the following References may be a good jumping off point.

**References**

[[http://www.uptodateonline.com/application/topic.asp?file=stds/4883]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=stds/4883)