Management of Pelvic Abscess
Patients with pelvic abscess should be hospitalized and treated with surgical drainage plus parenteral broad-spectrum antibiotics as the primary management strategy. 1
Diagnosis and Assessment
- Clinical presentation: Pain is the most common symptom, often accompanied by fever, swelling, and tenderness
- Imaging options:
Treatment Algorithm
Step 1: Hospitalization
Hospitalization is strongly recommended when a pelvic abscess is suspected due to:
- Risk of sepsis progression
- Need for parenteral antibiotics
- Requirement for surgical drainage 1
Step 2: Antimicrobial Therapy
Initiate broad-spectrum antibiotics immediately with coverage for:
- Gram-positive organisms
- Gram-negative organisms
- Anaerobes 1
Recommended Inpatient Regimens:
Regimen A:
- Cefoxitin 2g IV every 6 hours OR cefotetan 2g IV every 12 hours
- PLUS Doxycycline 100mg orally/IV every 12 hours 1
Regimen B:
- Clindamycin 900mg IV every 8 hours
- PLUS Gentamicin loading dose IV/IM (2mg/kg) followed by maintenance dose (1.5mg/kg) every 8 hours 1
Continue IV antibiotics for at least 48 hours after clinical improvement, then transition to oral antibiotics to complete 10-14 days of total therapy 1
Step 3: Drainage Procedure
Drainage options should be selected based on abscess location and patient factors:
Surgical Drainage:
Image-Guided Percutaneous Drainage:
- Routes include transabdominal, transgluteal, transrectal, transvaginal, or transperineal approaches 1
- Select the most sterile route possible for potentially sterile collections 1
- Technical success rates approach 100% with clinical success rates of 80% 2
- Catheter drainage is superior to needle aspiration alone (lower recurrence) 2
Special Considerations
Tubo-ovarian Abscess (TOA)
- TOAs are common in women of reproductive age
- Initial treatment with broad-spectrum antibiotics
- If antibiotic therapy is insufficient, surgical drainage should be performed 1
- For women desiring future pregnancy, early drainage results in pregnancy rates of 32-63% compared to 4-15% with medical management alone 1
Anorectal Abscess
- Incision should be kept close to the anal verge to minimize potential fistula length 1
- Different types require specific approaches:
- Perianal and ischioanal: drain via overlying skin
- Intersphincteric: drain into rectal lumen (may require limited sphincterotomy)
- Supralevator: drain via rectal lumen or externally depending on origin 1
Follow-up Management
- Continue antibiotics for 10-14 days total 1
- After discharge, doxycycline 100mg orally twice daily is recommended to complete the course 1
- Treat sex partners of women with PID to prevent reinfection 1
- Routine imaging after drainage is not required unless there is recurrence, suspected inflammatory bowel disease, or evidence of fistula 1
Pitfalls and Caveats
- Avoid delayed drainage - can lead to sepsis progression and increased mortality
- Complete drainage is essential - inadequate drainage leads to high recurrence rates
- Don't neglect partner treatment - failure to treat partners of women with PID leads to reinfection
- Consider fertility implications - early drainage in women of reproductive age improves future fertility outcomes
- Don't rely on needle aspiration alone - catheter drainage has better outcomes with lower recurrence rates 2
The management of pelvic abscess requires prompt intervention with appropriate antibiotics and drainage to reduce morbidity, mortality, and preserve quality of life, particularly regarding future fertility potential in women of reproductive age.