Tubo-Ovarian Abscess Tubo-ovarian abscesses, a complication of acute salpingo-oophoritis, are usually unilateral and multilocular (20). The symptoms and signs are similar to those of acute salpingitis. A ruptured tubo-ovarian abscess is a life-threatening surgical emergency because gram-negative endotoxic shock can develop rapidly.
Vital signs reveal fever, tachycardia, and low blood pressure if the patient is septic. Tuboovarian abscesses can often be palpated on bimanual examination as firm, exquisitely tender, bilateral fixed masses. The abscesses can be palpated or “point” in the pelvic cul-de-sac and are appreciated on rectovaginal examination. Approximately 90% of patients will have abdominal or pelvic pain and 60% to 80% will present with fever and/or leukocytosis (21).
The diagnostic imaging of choice for tubo-ovarian abscesses is ultrasound. CT with and without contrast can be used to establish the diagnosis. The differential diagnosis of a unilateral mass includes tubo-ovarian abscess and adnexal torsion, ectopic pregnancy, endometrioma, leaking ovarian cyst, and periappendiceal or diverticular abscess. If physical and ultrasound examination results are not definitive, laparoscopy or laparotomy must be performed.
Tubo-ovarian abscesses should always be treated as an inpatient, and conservative medical therapy with broad spectrum antibiotics can be attempted (see Chapter 18). In one study, this yielded a treatment success rate of 75% (22). If the patient is persistently febrile or not improving clinically, CT or ultrasound-guided drainage of the abscesses should be undertaken. CT-guided percutaneous drainage can be achieved transabdominally or transvaginally. Drainage along with intravenous antibiotics is considered first-line therapy (23). If fertility is not desired, bilateral salpingo-oophorectomy and hysterectomy will provide definitive therapy.
A ruptured tubo-ovarian abscess rapidly leads to diffuse peritonitis, evidenced by tachycardia and rebound tenderness in all four quadrants of the abdomen. With endotoxic shock, hypotension and oliguria ensue, and the result can be fatal. Exploratory laparotomy with resection of infected tissue is mandatory (24) (see Chapter 18).
Uterine Leiomyomas Leiomyomas (fibroids) are uterine smooth muscle tumors, as discussed in detail in Chapter 15. Discomfort may be present when myomas are in the broad ligament or encroaching on adjacent bladder, rectum, or supporting ligaments of the uterus. The discomfort is usually reported as noncyclic pressure or pain symptoms and less often, urinary frequency, dysmenorrhea, dyspareunia, or constipation. There is no association between degree of pain and fibroid volume or number (25).
Acute pelvic pain caused by uterine leiomyomas is rare but can develop if the myoma undergoes degeneration or torsion (26). Degeneration of myomas occurs secondary to loss of blood supply, usually attributable to rapid growth associated with pregnancy. In a nonpregnant woman, degenerating uterine leiomyoma is often a misdiagnosis, because it can be confused with subacute salpingo-oophoritis. A pedunculated subserosal leiomyoma can undergo torsion with ischemic necrosis and can be associated with pain similar to that of adnexal torsion. When a submucous leiomyoma becomes pedunculated within the endometrial cavity, the uterus contracts forcefully as if to expel a foreign body and the resulting pain is similar to that of labor. The cramping pain is usually associated with vaginal hemorrhage.