What is a tubo-ovarian abscess (TOA) associated with Pelvic Inflammatory Disease (PID)?

From the Guidelines

A TOA associated with a PID should be treated with broad-spectrum antibiotics, and patients who do not respond to antibiotics should undergo surgical drainage, as recommended by the 2017 WSES guidelines for management of intra-abdominal infections 1. The treatment typically involves broad-spectrum antibiotics such as ceftriaxone 2g IV daily plus doxycycline 100mg orally twice daily plus metronidazole 500mg orally twice daily for 14 days. Some key points to consider in the treatment of TOA associated with PID include:

• The use of broad-spectrum antibiotics to cover likely pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, Gram-negative facultative bacteria, and streptococci.
• The consideration of surgical drainage for patients with TOA who do not respond to antibiotics.
• The importance of prompt diagnosis and aggressive treatment to prevent long-term reproductive complications.
• The use of imaging studies, such as ultrasound or CT, to diagnose TOA and guide treatment.
• The potential need for hospitalization and close monitoring of patients with TOA, particularly those who are pregnant or have severe illness. It is also important to note that the treatment of TOA associated with PID should be individualized based on the patient's specific needs and circumstances, and that consultation with a specialist may be necessary in some cases. Some of the key evidence-based recommendations for the treatment of TOA associated with PID include:
• The use of broad-spectrum antibiotics, such as ceftriaxone and doxycycline, to cover likely pathogens 1.
• The consideration of surgical drainage for patients with TOA who do not respond to antibiotics 1.
• The importance of prompt diagnosis and aggressive treatment to prevent long-term reproductive complications 1.

From the FDA Drug Label

GYNECOLOGIC INFECTIONS, including endometritis, endomyometritis, tubo‑ovarian abscess, and postsurgical vaginal cuff infection, caused by Bacteroides species including the B. fragilis group, Clostridium species, Peptococcusniger, and Peptostreptococcus species. Gynecological infections including endometritis, nongonococcal tubo-ovarian abscess, pelvic cellulitis, and postsurgical vaginal cuff infection caused by susceptible anaerobes

A tubo-ovarian abscess (TOA) is associated with Pelvic Inflammatory Disease (PID), which can be caused by various bacteria, including anaerobes such as Bacteroides species and Clostridium species 2 3.

• Key points:
  • TOA is a type of gynecologic infection
  • PID can lead to the formation of a TOA
  • Anaerobic bacteria, including Bacteroides and Clostridium species, can cause TOA and PID
  • Treatment of TOA and PID typically involves antibiotics, such as metronidazole and clindamycin, which are effective against anaerobic bacteria.

From the Research

Definition and Association of TOA with PID

• A Tubo-ovarian abscess (TOA) is a rare but serious condition that carries with it a high rate of morbidity and even mortality 4.
• TOA is associated with pelvic inflammatory disease (PID) as well as other factors such as intrauterine devices, uterine procedures, multiple sexual partners, diabetes mellitus, and immunocompromised states 4.
• PID is one of the most common serious infections of nonpregnant women of reproductive age, and TOA represents a severe form of PID 5, 6.

Characteristics and Diagnosis of TOA

• TOA usually arises from a gynecologic infection, but can be associated with a gastrointestinal source 4.
• History and physical examination are limited, demonstrating predominantly lower abdominal pain, but a minority of patients will present with vaginal symptoms 4.
• Laboratory evaluation may reveal elevations in white blood cell count and other inflammatory markers, and transvaginal ultrasound and computed tomography (CT) may be utilized for diagnosis 4.
• CT has higher sensitivity and can differentiate TOA from similarly presenting gastrointestinal pathology 4.

Management and Treatment of TOA

• Initial medical management of TOA includes antibiotics, and surgical intervention is indicated in those who fail initial medical therapy 4.
• The choice of an antibiotic regimen used to treat PID, and subsequently TOA, relies upon the appreciation of the polymicrobial etiology of this ascending infection 5.
• Clinically severe PID, which may include TOA, should prompt hospitalization and imaging to rule out a tubo-ovarian abscess, and parenteral broad-spectrum antibiotic therapy should be implemented 5.
• For women who desire fertility, management options for TOA include medical management alone, medical management with immediate laparoscopic drainage, and fertility-preserving conservative surgery 7.