High risk and low prevalence diseases: Tubo-ovarian abscess

Introduction: Tubo-ovarian abscess (TOA) is a rare but serious condition that carries with it a high rate of morbidity and even mortality. Objective: This review highlights the pearls and pitfalls of TOA, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence. Discussion: TOA is associated with pelvic inflammatory disease (PID) as well as intrauterine devices, uterine procedures, multiple sexual partners, diabetes mellitus, and immunocompromised states. While usually arising from a gynecologic infection, TOA can be associated with a gastrointestinal source. History and physical examination are limited, demonstrating predominantly lower abdominal pain, but a minority of patients will present with vaginal symptoms. Half of patients will exhibit systemic illness to include fever, nausea, and vomiting. Laboratory evaluation may reveal elevations in white blood cell count and other inflammatory markers. Transvaginal ultrasound and computed tomography (CT) may be utilized for diagnosis, though CT has higher sensitivity and can differentiate this disease from similarly presenting gastrointestinal pathology. Initial medical management includes antibiotics. Surgical intervention is indicated in those who fail initial medical therapy, which is more likely in those with bilateral abscesses, large abscesses, and older patients. Conclusions: An understanding of TOA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.