We are aware that obtaining a good social history is important and asking about sexual activity may change the evaluation of a patient, particularly the teenage child. Certainly, our jobs would be easier if there were no concerns for alcohol / drugs, sexual transmitted diseases (ex, PID, Epididymitis), or firearms (or swimming pools, cars, or trampolines… geez, life is hazardous), but nevertheless these issues must be addressed. Does the lack of a concerning social history, however, rule-out pathology? Well, we all know that teenagers can “miraculously” become pregnant even having never had sexual intercourse… so the short answer is “no.” Another condition that may still need to be considered even when faced with a social history lacking sexual activity is Tubo-Ovarian Abscess (TOA). Let’s take a moment to digest a morsel on TOA:

Tubo-Ovarian Abscess: Basics

• Tubo-Ovarian Abscess (TOA) is an infection of the upper female genital tract:
  • Most often it is considered a severe complication of PID or,
  • Can be considered to be on the severe end of the PID spectrum, which includes:
    • Endometritis
    • Salpingitis
    • Tubo-ovarian abscess
    • Pelvic peritonitis
  • Adolescent females are at increased risk for developing PID compared to adults.
  • For sexually active females, presumptive diagnosis of PID can be made for those with: [Workowski, 2015]
    • Risk for STIs presenting with pelvic / lower abdominal painand no clear alternative diagnosis AND one or more of the following:
      • Cervical Motion Tenderness
      • Uterine Tenderness
      • Adnexal Tenderness
    • The following add support for the diagnosis:
      • Fever (>101°F / >38.3°C)
      • Mucopurulent cervical discharge or friability
      • Wet prep with abundant WBC

• TOA is RARELY encountered in adolescents diagnosed with PID in the ED. [Mollen, 2006]
  • Only 2.4% of one study population evaluating patients in the ED. [Mollen, 2006]
  • Higher rates reported in HOSPITALIZED patients with PID (17-20%).

• Unfortunately, TOA is difficult to detect on physical exam. [Mollen, 2006]
  • Many advocate for having lower threshold for imaging the ovaries in patients diagnosed with PID.
  • May not be warranted in those who are well enough for initial outpatient treatment, though. [Mollen, 2006]
  • Consider imaging those requiring hospitalization.

• TOA can occur unrelated to PID, however! [Mills, 2018; Goodwin, 2013; Vyas, 2008]

Tubo-Ovarian Abscess: The Causes

1. Predominantly a POLYMicrobial infection!
2. Chlamydia and Gonorrhea
   • Often considered to the be the culprits, particularly with PID
   • Not the only bugs though!
3. NON-Sexual Transmitted Infections
   • There are cases of TOA occurring in females who have never been sexually active. [Mills, 2018; Goodwin, 2013; Vyas, 2008]
   • E. Coli
   • Alpha-Hemolytic Streptococci
   • Coagulase Negative Staphylococcus
   • Bacteroides
   • Peptostreptococcus
   • Pasteurella

• Other pathways of infection to consider
  • A sexual transmitted infection ascending through the genital tract is one pathway that leads to TOA, but there are others:
  • Urinary tract infection and pooled urine leading to ascending infection
  • Translocation of bacteria from the bowel (ex, Severe Constipation)
  • Extension of local abscess (ex, Inflammatory Bowel Disease, Appendicitis) [Mills, 2018; Vyas, 2008]
  • Immunodeficiencies

Tubo-Ovarian Abscess: Management

There is no consensus on the management of TOA, particularly in patients who are not sexually active.

• Conservative management is often 1st choice [Goodwin, 2013]
  • Helps avoid surgery and preserve fertility
  • Broad Spectrum Antibiotics:
    • Cefoxitin or Cefotetan AND Doxycycline
    • May ADD Metronidazole, or Clindamycin and Gentamycin

• Surgical Management [Goodwin, 2013]
  • Usually reserved for patients with evidence of:
    • Hemodynamic instability
    • Peritonitis
    • Overt Sepsis
  • Also considered if conservative management did not resolve the issue.
  • May need to be considered based on proposed pathway of infection (ex, related to recent appendicitis) [Vyas, 2008]

Moral of the Morsel

• Get your Social History, but not being sexually active does not rule-out TOA!
• Most patients with PID that you discharge from the ED, do NOT need an ultrasound to evaluate for TOA.
• Consider TOA in the patient with PID who you are also considering hospitalization!
• Broad Spectrum antibiotics are going to be the primary choice of therapy for most patients with a TOA.

References