Bratisl Lek Listy 2011; 112 (4)
200 – 203
CLINICAL STUDY
Treatment approaches in tubo-ovarian abscesses according to
scoring system
Doganay M1, Iskender C2, Kilic S2, Karayalcin R2, Moralioglu O2, Kaymak O2, Mollamahmutoglu L1
Zekai Tahir Burak Mother Health Training and Research Hospital, Clinical Assistant Chief, Ankara, Turkey.
[email protected]
Abstract: Background: The aim of this study was to define treatment modalities in tubo-ovarian abscesses
(TOA) using a scoring system. As there is no scoring system for TAO there is still a controversy on the
management. In our opinion, as there is no evidence based TAO management strategy, a scoring system is
needed in the management of these patients. For this purpose we prospectively tried to define that may be
useful for favoring a treatment modality and the effects of the parameters on the outcome.
Methods: The study group comprised of hundred and eighty-four patients hospitalized between May 2001 and
June 2008. Patients were divided in three groups according to the treatment modality- laparotomy (group 1,
n: 122), medical treatment, (group 2, n: 34), and laparoscopic surgery (group 3, n: 28). Antibiotic regimens
or other means of treatment strategies were directed according to our scoring system.
Results: Of the patients, 122 underwent laparatomy, 34 received medical treatment and 28 had operative
laparoscopy. Intraoperative complications in the group of 122 patients who underwent laparatomy were bowel
injury in 8 patients (6.5 %) and ureteral injury in six (4.9 %). Fourteen patients (11.4 %) in the laparatomy group
suffered from morbidity related to abdominal incision. In the laparoscopy group two patients (7.1 %) had bowel injury.
Conclusion: With this study, we propose a scoring system in TOA cases and define treatment strategies accordingly. According to the results of our study, laparoscopy serves the best treatment option. Medical treatment,
despite longer follow up, may be suitable in well-selected cases (Tab. 3, Ref. 39). Full Text in free PDF www.bmj.sk.
Key words: tubo-ovarian abscess, scoring system, treatment, pelvic inflammatory disease.
TOA is one of the main causes of pelvic masses in women of
reproductive age (1–4). It is the most important consequence of
pelvic inflammatory disease (1, 5, 6). TOA’s are
polymicrobial infections and E coli, B fragilis, peptococci,
peptostreptococci, and mix flora are frequently encountered microorganisms in abscess cavity (6–8).
In this study, we would like to point out the importance of
IUD use and age >40 in the etiology of TOA except for other
risk factors like adolescence, null parity and multiple sexual partners. Currently, there is no consensus on optimal treatment method
and optimal antibiotic regimen in the management of TOA. Thus,
we aimed to develop a scoring system for the patients presenting
with TOA, which we believe will be helpful in treatment and
follow up.
Methods
One-hundred eighty-four patients hospitalized with TOA at
the gynecology clinic of Zekai Tahir Burak women’s hospital
Zekai Tahir Burak Mother Health Training and Research Hospital, Clinical Assistant Chief, Ankara, Turkey, and 2Zekai Tahir Burak Mother
Health Training and Research Hospital, Clinical Specialist, Ankara,
Turkey
1
Address for correspondence: M. Doganay, MD, Cukurambar Mah.
38. Cad. Ozalp Apt. No: 7/39, Yuzuncuyil-Ankara, Turkey.
Phone: +90.312.3812127, Fax: +90.312.3812127
between May 2001 and June 2008 were involved in this prospective study. The study was approved by an ethic committee
and all patients were asked for filling an informed consent form.
Patients were divided into three groups. Group 1 consisted
of patients who underwent a laparotomy (n: 122). Group 2 comprised of patients with medical treatment (n: 34). The patients
who underwent a laparoscopic surgery composed group 3 (n: 28).
Patients were evaluated according to our scoring system, body
temperature, heard rate, bowel movements in auscultation, cervical motion tenderness, evaluation of adnexes and uterus,
ultrasonographic adnex size, white blood cell count (WBC),
erythrocyte sedimentation rate (ESR), and C-reactive protein
(CRP) were scored according to our scoring system.
Each of the parameters was evaluated separately. Scoring was
done accrding to our evaluation. Each parameter in 0–10 range
was pointed as 1, 11–20 as 2 points, and 21–30 as 3 points. The
treatment approaches were directed according to the aforementioned scoring system (Tab. 1).
Age, gravidity, history, ultrasonographic findings, laboratory
findings, duration of IUD use, patients with morbidity related to
previous abdominal incision, and length of hospital stay were
recorded (Tab. 2).
All the patients in this study had low socioeconomic status,
single sexual partners and no history of OCP use. Patients having 30 or more points according to our grading system were given
ofloxacin (400 mg every 12 hours) plus metranidazole (500 mg
Indexed and abstracted in Science Citation Index Expanded and in Journal Citation Reports/Science Edition
Doganay M et al. Treatment approaches in tubo-ovarian abscesses according to scoring system
Tab. 1. Scoring System for tubo-ovarian abscesses.
Sign
(0–10)
(11–20)
(21–30)
Body temperature
<37°
37–37.5°
>37.6°
Pulse/min
< 90
90-100
>100
Bowel sounds
Normal
Minimal
Absent
Cervical motion
tenderness
(+)
(++)
(+++)
Uterine tenderness
(+)
(++)
(+++)
Adnexal tenderness (+)
(++)
(+++)
Adnexal size
<4cm
4-6 cm
6–10cm or greater
WBC/ mm3
<10000
(10000-20000)
>20000
ESR (mm/h)
<20
20–30
>30
CRP (ng/dl)
<15
15–20
>20
Tab. 2. Clinical features of patients with tubo-ovarian abscess.
Group 1
Number of patients
122
Age (mean)
43.07
Parity (mean)
3 ± 0.4
Body temperature °C
38.2°
WBC/ mm3
18.45
ESR (mm/h)
55.4 ± 9.7
CRP (mg/dl)
21.3 mg/dl
Abscess diameter*(cm)
6.48
Hospital stay (day)
7.43
Operative morbidity (%)
25.4
IUD use
76
Duration of IUD use (years)
8.3
Group 2
Group 3
34
27.04
2 ± 0.8
37.7°
14.15
31 ± 8.2
14.8 mg/dl
3.68
11.06
12
4.1
28
33.08
1 ± 0.6
37.95°
15.35
37.6 ± 17.5
19.7 mg/dl
4.32
2.07
7.1
9
3.6
* Ultrasound finding
Tab. 3. Classification of patients according to scoring system.
30<
20–30
<20
Patients having double
antibiotic regimen (IV)
Patients having triple
antibiotic regimen (IV)
Febrile period (days)
Group 1
Group 2
Group 3
62
50
10
62
8
14
12
8
10
14
4
10
60
26
18
2.6±3.1
5.8±2.0
3.2±5.0
every 8 hours) intravenously. Patients with less than 30 points
received ampicilin (1 g every 6 hours), clindamycin (900 mg every 8 hours) and gentamicin (1.5 mg/kg every 8 hours following a
loading dose of 2 mg/kg) combination intravenously. The same
physician examined all patients with complete physical examination twice a day and pelvic examination in every three days. In
addition, ultrasonographies were carried out in all patients in every three days with the same device and by the same physician.
Patients whose score did not decrease after 3 days of antibiotic
treatment or those with an abscess diameter of 10 cm or more
(especially patients with persistent fever and pelvic pain) underwent laparotomy (group 1). Patients with total lyses of fever, dis-
appearance of pelvic organ tenderness, normalization of laboratory parameters and diminished abscess diameter after 72 hours of
parenteral antibiotic course were discharged from the hospital under
oral doxycycline (100 mg twice daily for 14 days) treatment.
The patients in group 2 had follow up for 1 year (every 2
weeks for the first three months and then monthly). Group 3 who
are 35 or younger with an abscess diameter of 10 cm or less and
desiring fertility received laparoscopic treatment following 3 days
of parenteral antibiotic treatment.
Cervical or endometrial cultures were not routinely taken
however; tissue cultures were obtained from the patients who
had intraabdominal abscesses detected at laparotomy and
laparoscopy.
Variant analysis and chi square tests were used for statistical
analysis. P value less than 0.05 was accepted to be significant.
Results
From the 184 patients involved in this study, 122 patients
underwent laparatomy, 34 patients received medical treatment,
and 28 patients underwent operative laparoscopy. From the 122
patients who underwent laparotomy, unilateral adnectomy was
performed in 38 (31 %) patients and 84 (68.8 %) patients had
hysterectomy and bilateral salpingo-oophorectomy. From the
patients in the laparotomy group, nine patients (7.3 %) had bowel
injury and eight patients (6.5 %) had ureteral injury. Fourteen
patients (11.4 %) in the laparotomy group suffered from morbidity related to abdominal incision. Two patients (7.1 %) had bowel
injury in the laparoscopy group.
Treatment scheduling according to the point of the patients
assessed via scoring system is shown in Table 3.
A shorter recovery period was observed in patients who received ofloxacin (400 mg every 12 hours) plus metranidazole
(500 mg every 8 hours) via IV route (p>0.5). With this antibiotic
regimen patients having normal body temperatures within 36
hours had 4 days shorter length of hospital stay.
Microbiologic examination of abscess samples revealed E.coli
in 42 patients (28 %), B. fragilis in 24 patients (16 %),
peptostreptococcus in 10 patients (6.6 %), other bacteroides species in 6 patients (4 %) and A. israeli in 2 patient (1.3 %), mix
flora in 22 patients (14.6 %). No microorganisms were cultured
from tissue samples of 44 patients (29.3 %).
Ninety-seven patients in the study groups had IUD. Average
length of IUD use was 4.3 years. Forty-six percent of patients
having IUD had a history of PID attack. Primary complaint in
our patients at the onset was abdominal pain (82 %). Thirteen
patients with previous laparotomy had pelvic operation. Nine
had cesarean section, one had para-ovarian cystectomy sixteen
years ago and the in other one salpingectomy was performed.
Patient who had para-ovarian cystectomy was nullipara and silk
found to be the suturing material in previous operation. A. israeli
growed in the cultures of silk suture.
In patients underwent laparotomy for suspicious TOA, six
endometriomas, four infected intraligamenter myomas, and a
colon cancer diagnosed intraoperatively.
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Bratisl Lek Listy 2011; 112 (4)
200 – 203
Discussions
In our study, we aimed to find out the optimal therapeutic
approach in TOA patients. Conservative treatment should be the
choice in young patients desiring fertility (9–13). Of the 66 patients with an IUD for contraception (average age >40), 54 patients had unilateral abscess and 12 patients had bilateral abscess. This is consistent with the study of Fiorin at al (14). Reed
at al. reported the necessity of laparatomy in 60 % of patients
with abscess diameter ³ 10 cm, and in 20 % of patients with an
abscess diameter <5 cm (13). In our study, laparatomy was performed in 72 % of patients with an abscess diameter ³10 cm and
in 26 % of patients with an abscess diameter <5 cm. This result
is concordant with literature (15).
There was no difference among the three groups in terms of
body temperature, ESR and CRP. The increments in ESR and
CRP values were used to measure the severity of infection in
TOA cases following PID (16–18). As mentioned before, clinical response to antibiotic treatment in patients with TOA emerges
within 72 hours (19–23). We initiated the antibiotic regimen according to our scoring system for TOA. In cases where an inadequate clinical and laboratory response to initial antibiotic regimen within 24–48 hours was seen, the antibiotic regimens were
changed.
Patients receiving double antibiotic regimen had clinical response in 12 hours that was shorter than patients under triple
antibiotic regimen. The length of hospitalization was 2.06 days
shorter and morbidity related to abdominal incision was less frequent (2 %) in this group.
We also found that age >40 is an important risk factor in
addition to adolescence, multiple sexual partners and history of
a PID attack (3, 23, 24). The average age of laparotomy group
was older than 40.2, patients in laparotomy group were postmenopausal and had no concomitant pelvic pathology. Recent
studies reported 1.7 % incidence of TOA among postmenopausal
women (25–28). Laparoscopic approach is the best diagnostic
modality for TOA (9–12, 29–31). Complication rate is less than
4 % (10–12, 32). Pelvic exposure is better in laparoscopic procedures, and it further allows microbiologic sampling and drainage (9–12, 29, 33). Complete remission with medical treatment
is possible in TOA’s. Advantages of medical treatment are absence of operative morbidity and preservation of fertility (10,
13, 16, 34–36).
Microorganisms obtained from abscess material were mixed
anaerobic and facultative bacterias. E coli, B. fragilis, anaerobic
streptococci, and peptostreptococcus were the isolated pathogens
in our study, similar to previously isolated microorganisms in
TOA’s (8, 13, 22, 23, 37–39).
As a result, prolonged IUD use especially after 40 years of
age increases TOA occurrence. Delay in the diagnosis of PID
would also predispose to TOA. Using our scoring system for
defining the treatment modality might be beneficial for both the
patient and the physician. According to our study, operative
laparoscopy seems to be the optimal treatment modality since it
has no morbidity related to abdominal incision, shortens hospi202
tal stay, and preserves fertility. Medical treatment, despite a
need of long follow up may be a reasonable alternative in wellselected cases since it does not carry a risk of operative complications.
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Received February 24, 2009.
Accepted November 26, 2010.
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