Tubo-ovarian abscess is an acute purulent infectious and inflammatory disease of the uterine appendages, in which their melting occurs with the formation of a lumped formation. It is manifested by acute unilateral pain in the lower abdomen, nausea, vomiting, hyperthermia, dysuric disorders. For diagnosis, vaginal examination, transvaginal ultrasound, pelvic CT, laboratory methods are used. Drug treatment regimens involve the appointment of antibiotics, NSAIDs, immunomodulators, infusion therapy. In case of severe course and ineffectiveness of conservative therapy, the abscess is surgically removed.
General information
Tubo—ovarian abscess (tubo-ovarian purulent formation, inflammatory adnextumor) is the most severe form of gynecological inflammation. In the structure of infectious and inflammatory diseases of the pelvic organs in women, its share, according to various authors, reaches 6-15%. Pathology is detected mainly in young patients under the age of 20 with a low socio-economic status, which is most likely due to their high sexual activity. In the last decade, erased forms of inflammation have been occurring more often: in almost a third of patients, an acute clinical picture develops against the background of a chronically ongoing inflammatory and destructive process.
Causes
The formation of a voluminous purulent-inflammatory formation in the area of the uterine appendages often becomes possible with a combination of several factors and is a complication of already existing gynecological diseases. Primary abscesses of the tubo-ovarian region are extremely rare. According to experts in the field of gynecology, a combination of two or three conditions is usually required for the occurrence of the disease:
- The presence of aggressive associative flora. Several microorganisms are usually present in the sowing from the abscess focus. Gonococci are detected in 25-50% of patients, trichomonas in 25-30%, aerobic-anaerobic associations of gardnerella, bacteroids, peptostreptococci, streptococci, enterobacteria, mobilunci, and other conditionally pathogenic infectious agents in 25-60%.
- Adhesions in the pelvis. Suppuration of appendages is more often detected in patients with long-term chronic oophoritis, salpingitis, adnexitis, external genital endometriosis, complicated by the adhesive process. The presence of inter-organ synechiae simplifies and accelerates the formation of a pyogenic membrane, which restricts tubo-ovarian formation from the outside.
- Weakening of immunity. Activation of microflora usually occurs when the body’s defenses decrease. The causes of immunosuppression are exacerbation of genital and extragenital pathology, severe colds, stress, physical exertion, prolonged use of corticosteroids, acetylsalicylic acid derivatives, cytostatics, etc.
The risk of developing an abscess in the tubo-ovarian region is increased in patients who frequently change sexual partners, who have suffered bacterial vaginosis or sexually transmitted diseases. The probability of pathology increases after performing intrauterine manipulations (abortions, separate diagnostic curettage, installation of a spiral, in vitro fertilization, hysterosalpingography, removal of endometrial polyps, etc.).
Pathogenesis
The penetration of infection into the appendages usually occurs in an ascending (intracanalicular) way from the vagina, cervix and uterine cavity. In rare cases, inflammation begins due to contact infection with the serous cover of the tube. Before the final formation of tuboovarial purulent formation, the pathological process goes through several stages. First, the mucous membrane becomes inflamed in the fallopian tube under the action of infectious agents, and subsequently the inflammation spreads to the remaining layers of the wall ‒ a picture of acute purulent salpingitis develops. Obliteration of the lumen of the tube ends with the formation of a pyosalpinx.
From the fallopian tubes, microorganisms enter the surface of the ovary and penetrate into its tissues, which leads to the development of acute purulent oophoritis with the formation of multiple purulent cavities, the walls of which are represented by granulations and connective tissue. As a result of the fusion of abscesses, a baggy formation occurs — piovar. The formation of a tubo-ovarian abscess is completed by partial destruction of the walls of the pyosalpinx and piovar with fusion within a common pyogenic connective tissue membrane. The disease can occur chronically with an increase in the pathological conglomerate during exacerbation, fibrosis and tissue sclerosis in remission.
Symptoms of tubo-ovarian abscess
Clinical symptoms usually develop acutely. The patient has severe paroxysmal pains on the left or right in the lower abdomen. Painful sensations can radiate into the lumbar region, rectum, inner thigh from the corresponding side. A woman is worried about fever, chills, nausea and vomiting are possible. The temperature is usually raised to 38 ° C or more. Typical are whitish, yellowish, yellow-green purulent vaginal whites, soreness during urination, intestinal irritation in the form of frequent loose stools. Due to general intoxication, emotional lability, weakness, fatigue, loss of appetite, general lethargy occur.
Complications
The most threatening consequence of tubo-ovarian abscess is the rupture of the adnextumor with the appearance of an acute abdominal clinic, the development of peritonitis, septic shock, multiple organ failure, the formation of interstitial, rectal—vaginal, urethro-vaginal, vesicovaginal fistulas in the long term. Almost two-thirds of patients have functional disorders of the urinary system, and in half, the spread of inflammation to the pre-bubble and pelvic tissue causes the development of hydroureter and hydronephrosis. Involvement of adjacent organs in the infectious process is accompanied by the appearance of secondary parametritis, appendicitis, sigmoiditis, rectitis, omentitis, pelvic abscesses, etc. In the future, such women are more likely to have dishormonal conditions, ectopic pregnancy, infertility, chronic pelvioperitonitis, chronic pelvic pain, pelvic thrombophlebitis, ovarian vein thrombosis.
Diagnostics
The symptoms of tubo-ovarian abscess are similar to the manifestations of other conditions in which signs of an “acute abdomen” are observed. Therefore, taking into account the high probability of a complicated course of the infectious and inflammatory process, the diagnostic search is aimed at quickly confirming or excluding pathology. The most informative methods are:
- Examination on the chair. Bimanual palpation is difficult to perform due to intense pain and peritoneal phenomena. A typical sign is an increase in soreness during the examination of the lateral and posterior vaginal arches, attempts to shift the cervix. Mucus and pus are secreted from the cervical canal. Sometimes it is possible to palpate a painful conglomerate located to the right or left of the uterus.
- Transvaginal ultrasound. On the side of the lesion, a multi-chamber formation with dimensions of 5-18 cm of irregular ovoid shape with signs of an inflammatory process is determined. The walls of the pipe are thickened to 5 mm or more. Unlike the pyosalpinx, pus accumulations are located outside the fallopian tube. The adhesive process in the pelvic cavity is pronounced. There are signs of endometritis. The ovary is not visualized.
- CT of pelvic organs. Tomographically, purulent tuboovarial formation has the form of an oval or rounded volumetric pathological structure adjacent to the uterus and displacing it. Indistinctness of contours, heterogeneity of the conglomerate structure with the presence of cavities of reduced density are characteristic. The capsule can be either thickened or thinned. The informative value of the method reaches 99-100%.
Invasive methods (puncture of the posterior vaginal arch, laparoscopy) are used only because of the widespread adhesive process and the risk of damaging the capsule of tubo-ovarian abscess. Indirect confirmation of the acute inflammatory process is the characteristic changes in the general blood test: an increase in the number of leukocytes, acceleration of ESR, a shift of the leukocyte formula to the left. It is recommended to conduct a pregnancy test, microbiological smear examination for gonorrhea and chlamydia. The disease is differentiated with salpingoophoritis, rupture of an ovarian cyst or twisting of its leg, ectopic pregnancy, septic abortion, appendicitis, acute cholecystitis, diverticulitis, pyelonephritis, an attack of urolithiasis, peritonitis, intestinal obstruction, other acute surgical pathology. A surgeon, a urologist, an oncologist, an infectious disease specialist, an anesthesiologist-resuscitator are involved in the diagnosis.
Treatment of tubo-ovarian abscess
If purulent melting of the uterine appendages is suspected, emergency hospitalization, rest and bed rest are indicated. With stable pulse and pressure indicators, conglomerate sizes up to 9 cm, and the presence of reproductive plans in the patient, conservative therapy is indicated, which allows 75% of cases to refuse surgery. For the treatment of tuboovarial purulent formations are recommended:
- Antibiotic therapy. When choosing a drug, it is desirable to take into account the sensitivity of the pathogen. But since the disease is usually caused by a polymicrobial association, even before receiving the results of bacteriological smear culture with an antibioticogram, combinations of cephalosporins, semi-synthetic tetracyclines, penicillins, lincosamides, aminoglycosides, etc. are prescribed.
- Nonsteroidal anti-inflammatory drugs. NSAIDs by inhibiting the isoforms of the enzyme cyclooxygenase reduce the production of prostaglandins, thromboxane and other inflammatory mediators. At the same time, the drugs have an analgesic effect by increasing the pain threshold of peripheral receptors. Especially effective in the form of rectal candles.
Taking into account the clinical picture and to reduce possible complications of the main drug therapy, other pathogenetic and symptomatic agents are also used — eubiotics, immunomodulators, diuretics, infusion solutions, sedatives, vitamins. In the absence of the effect of antibacterial treatment for 48-72 hours (further deterioration of the patient’s condition, an increase in temperature and leukocytosis), surgical intervention is recommended to drain the abscess.
When choosing a method of surgical treatment, the prevalence and dynamics of tubo-ovarian inflammatory process, the severity of the woman’s condition are taken into account. In milder cases, the abscess is drained through a puncture of the abdominal wall, rectum or vagina, followed by rinsing of the cavity with antimicrobial agents. In cases of common abscesses and severe course of the disease, an operation is performed to remove the tubo-ovarian inflammatory conglomerate and excision the affected appendages. The laparoscopic approach is justified if the disease is no more than 3 weeks old and there is no pronounced adhesive process. The presence of a closed thick-walled abscess and the chronic course of the disorder are indications for laparotomy. Extirpation of the uterus and appendages is performed in the most difficult cases — with the detection of multiple ulcers, fistulas, sepsis, diffuse peritonitis. In the postoperative period, antibacterial and detoxification therapy are indicated.
Prognosis and prevention
Early diagnosis and adequate therapy of tubo-ovarian abscess allows to preserve reproductive function in 70-90% of patients. Primary prevention of the disease involves the rejection of unprotected sex with casual partners, reasonable appointment and technically accurate performance of invasive gynecological manipulations, regular observation by a gynecologist, timely treatment of genital infections. To strengthen the immune system, sufficient physical activity, rational nutrition, adherence to sleep and rest, exclusion of excessive psychological and physical exertion, cessation of smoking and alcohol abuse are recommended.
