Fallopian tubes & broad ligament
Fallopian tube tumor-like lesions
Tubo-ovarian abscess
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Deputy Editor-in-Chief: Gulisa Turashvili, M.D., Ph.D.
Last staff update: 15 July 2024 (update in progress)
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PubMed Search: Tubo-ovarian abscess
Table of Contents
Definition / general | Essential features | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Radiology description | Radiology images | Prognostic factors | Case reports | Treatment | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Virtual slides | Cytology description | Positive stains | Negative stains | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Li JJX, Ip P. Tubo-ovarian abscess. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/fallopiantubessalpingitis.html. Accessed July 15th, 2024.
Definition / general
- Inflammatory mass forming lesion of the fallopian tube or ovary
Essential features
- Commonly associated with pelvic inflammatory disease but may also arise from other intrapelvic sources of infection or inflammation
- Usually polymicrobial with the presence of anaerobes but uncommon organisms such as Mycobacterium, fungi and parasites have been reported
Epidemiology
- Most common in nulliparous and sexually active women of reproductive age (20 - 40 years) (J Microbiol Immunol Infect 2012;45:58)
- Risk factors (Fertil Steril 2004;82:498)
- Diabetes mellitus
- Endometriosis
- Immunocompromised state
- Intrauterine contraceptive device
Sites
- Fallopian tube
- Ovary
Pathophysiology
- Most commonly occurs as a complication of pelvic inflammatory disease (Am J Emerg Med 2022;57:70)
- Initial infection from cervix or vagina in the form of sexually transmitted infections such as Chlamydia trachomatis or Neisseria gonorrhoeae
- Ascending infection involving the uterine corpus and fallopian tube results in pelvic inflammatory disease, which may be complicated by tubo-ovarian abscess formation
- Abscess formation due to direct spread of infection from other adjacent structures (e.g., diverticulitis) and hematogenous spread are rare but have been described (Best Pract Res Clin Obstet Gynaecol 2009;23:667, Rev Esp Enferm Dig 2016;108:100)
Etiology
- Commonly associated with pelvic inflammatory disease and sexually transmitted infections
- Other reported causes include
- Appendicitis (Cureus 2023;15:e41226)
- Diverticulitis (Best Pract Res Clin Obstet Gynaecol 2009;23:667)
- Inflammatory bowel disease (Rev Esp Enferm Dig 2016;108:100)
- Systemic infections (hematogenous spread) (BMC Infect Dis 2016;16:527)
- Causative organisms
- Associated sexually transmitted infections include Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium (TOG 2018;20:11)
- Abscesses are typically polymicrobial with the presence of anaerobes (Best Pract Res Clin Obstet Gynaecol 2009;23:667)
- Less common organisms include Actinomyces, Mycobacterium, fungi, parasites (J Obstet Gynaecol Can 2015;37:426, Radiographics 2004;24:1575)
Clinical features
- Presenting symptoms
- Fever
- Pelvic / abdominal pain
- Vaginal discharge
- Physical examination (Infect Dis Obstet Gynecol 2019;2019:4161394)
- Abdominal tenderness
- Adnexal tenderness / cervical motion excitation
Diagnosis
- Diagnosis is based on clinical, serological and radiological findings
- Operative findings, microbiological and histological examination for confirmation
Laboratory
- Sexually transmitted infections and anaerobes are most commonly detected but not necessarily in every case (J Clin Microbiol 2015;53:357)
- Elevated white cell count, C reactive protein and erythrocyte sedimentation rate
Radiology description
- Ultrasound (TOG 2018;20:11)
- Complex solid / cystic mass due to adhesion of the ovary to the fallopian tube
- Pyosalpinx
- Thickened endosalpingeal folds (Ultrasonography 2015;34:258)
- Computed tomography and magnetic resonance imaging are more often used to exclude other intra-abdominal pathologies, when suspected (TOG 2018;20:11)
Radiology images
Images hosted on other servers:
Thickened endosalpingeal folds
Tubo-ovarian complex
Prognostic factors
- Adverse outcomes include infertility and need for surgical intervention
- Mortality is extremely rare since the introduction of antibiotic treatment (Obstet Gynecol 2006;107:611)
- Poor prognostic factors include
- Large lesion size (Infect Dis Obstet Gynecol 2019;2019:4161394)
- High body mass index (Infect Dis Obstet Gynecol 2019;2019:4161394)
- High C reactive protein level (J Microbiol Immunol Infect 2012;45:58)
- Multiparity (J Microbiol Immunol Infect 2012;45:58)
Case reports
- 17 year old girl with tubo-ovarian abscess causing pneumoperitoneum (Case Rep Womens Health 2020;26:e00181)
- 38 year old immunocompromised woman with bilateral tubo-ovarian abscess (Cureus 2022;14:e29631)
- 45 year old woman with Brucella tubo-ovarian abscess (IDCases 2020;23:e01029)
- 60 year old woman with ruptured ovarian tumor mimicking tubo-ovarian abscess (World J Clin Cases 2023;11:3852)
- 68 year old woman with chronic sigmoid diverticulitis causing tubo-ovarian abscess (J Surg Case Rep 2023;2023:rjad659)
Treatment
- Intravenous antibiotics as first line treatment (Infect Dis Obstet Gynecol 2019;2019:4161394)
- Surgical intervention for patients failing medical therapy
- Laparotomy and fertility preserving conservative surgery have been reported to reduce infertility rate (Obstet Gynecol Surv 2009;64:681)
Clinical images
Images hosted on other servers:
Peritonitis and false membranes
Adhesion to sigmoid colon
Gross description
- Dilated or thickened fallopian tube (IDCases 2020;23:e01029)
- Fallopian tube filled with pus (pyosalpinx) or blood (hematosalpinx)
- Cystic change and abscess formation within the ovary
- Adhesion of the ovary to the fallopian tube and other adjacent structures
Gross images
Images hosted on other servers:
Gonorrheal tubo-ovarian abscess
Microscopic (histologic) description
- Neutrophils filling the lumen of the fallopian tube with transmural infiltration
- Mucosal ulceration and fused fallopian tubal plicae
- Inflammation involving ovarian parenchyma
- Abscess formation within the ovary and fallopian tube
- Granulomatous inflammation may be seen in association with specific microorganisms such as mycobacteria
- Xanthogranulomatous inflammation has been reported to present in tubo-ovarian abscesses secondary to diverticultis (Gynecol Obstet Invest 2000;49:70, Hum Path Case Rep 2021;25:200539)
Microscopic (histologic) images
Contributed by Joshua J.X. Li, M.B.Ch.B. and Philip P. C. Ip, M.B.Ch.B.
Luminal neutrophils
Fused plicae
Ulcerated tubal epithelium
Abscess formation
Transmural inflammation
Ovarian abscess
Granulation tissue
Virtual slides
Images hosted on other servers:
Abscess formation
Inflamed, ulcerated fallopian tube
Cytology description
- Rarely obtained for diagnosis
- May show reactive mesothelial cells and neutrophils (World J Surg Oncol 2022;20:188)
Positive stains
Negative stains
- Immunohistochemical stains may be used to exclude neoplasms but are not routinely used for the diagnosis of tubo-ovarian abscess
Sample pathology report
- Ovary and fallopian tube, salpingo-oophorectomy:
- Tubo-ovarian abscess (see comment)
- Comment: Sections of the ovary and fallopian tubes show extensive neutrophilic infiltrates with abscess formation. The fallopian tube is distended and contains inflammatory exudates. Serositis is noted. There is no evidence of malignancy.
Differential diagnosis
- Ovarian neoplasms with rupture, torsion or abscess formation:
- Lesional neoplastic cells should be identified
- Hemorrhage, inflammatory exudates, infarction / torsion and rupture may obscure lesional cells
- Examples include infected endometriotic cyst, ruptured teratoma and high grade serous carcinoma with cystic areas (Acta Med Litu 2021;28:360, World J Clin Cases 2023;11:3852, Int J Gynecol Cancer 2005;15:1131)
- Ectopic pregnancy:
- Products of gestation are present
- Hydrosalpinx:
- Lack of significant inflammation
- Ovary not involved
- Other infective / inflammatory lesions of abdomen / pelvis:
- Appendicitis or appendiceal abscess
- Diverticulitis or diverticular abscess
- Inflammatory bowel disease
Board review style question #1
Which of the following is a risk factor for the development of tubo-ovarian abscess?
- Human immunodeficiency virus infection
- Human papillomavirus infection
- Multiparity
- Postmenopausal age
- Usage of barrier contraception
Board review style answer #1
A. Human immunodeficiency virus infection. An immunocompromised state increases the risk of developing tubo-ovarian abscess. Answer D is incorrect because tubo-ovarian abscess is more common during reproductive age. Answer E is incorrect because barrier contraception reduces the risk of sexually transmitted infection and thus tubo-ovarian abscess. Answer B is incorrect because not all sexually transmitted infections are associated with tubo-ovarian abscesses, in particular those that do not ascend to the fallopian tubes. Answer C is incorrect because parity does not increase the risk of developing tubo-ovarian abscess.
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Reference: Tubo-ovarian abscess
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Board review style question #2
Which of the following is an unfavorable prognostic factor for tubo-ovarian abscess?
- Culture positive for Escherichia coli
- History of gonorrhea infection
- Large lesion size
- Low C reactive protein level
- Nulliparity
Board review style answer #2
C. Large lesion size. A larger lesion is associated with failure of conservative antibiotic treatment requiring surgical intervention. Answer E is incorrect because multiparity is associated with adverse outcomes. Answers A and B are incorrect because there is no evidence supporting poor outcomes with specific infective organisms. Answer D is incorrect because a high C reactive protein level is an unfavorable prognostic factor.
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Reference: Tubo-ovarian abscess
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