Pelvic Cellulitis Vaginal cuff cellulitis is present in most patients who underwent hysterectomy. It is characterized by erythema, induration, and tenderness at the vaginal cuff. A purulent discharge from the apex of the vagina may be present. The cellulitis is often self-limited and does not require any treatment. Fever, leukocytosis, and pain localized to the pelvis may accompany severe cuff cellulitis and most often signifies extension of the cellulitis to adjacent pelvic tissues. In such cases, broad-spectrum antibiotic therapy should be instituted with coverage for gram-negative, gram-positive, and anaerobic organisms. If purulence at the vaginal cuff is excessive or if there is a ﬂuctuant mass noted at the vaginal cuff, the vaginal cuff should be gently probed and opened with a blunt instrument. The cuff can be left open for dependent drainage or, alternatively, a drain can be placed into the lower pelvis through the cuff and removed when drainage, fever, and symptoms in the lower pelvic region have resolved.
Intra-abdominal and The development of an abscess in the surgical field or elsewhere in the abdominal cavity is Pelvic Abscess an uncommon complication after a gynecologic surgery. It is likely to occur in contaminated cases in which the surgical site is not adequately drained or as a secondary complication of hematomas. The causative pathogens in patients who have intra-abdominal abscesses are usually polymicrobial in nature. The aerobes most commonly identified include E. coli, Klebsiella, Streptococcus, Proteus, and Enterobacter. Anaerobic isolates are common, usually from the Bacteroides group. These pathogens arise mainly from the vaginal tract but can be derived from the gastrointestinal tract, particularly when the colon was entered at the time of surgery.
Intra-abdominal abscess is sometimes difficult to diagnose. The evolving clinical picture is often one of persistent febrile episodes with a rising white blood cell count. Findings on abdominal examination may be equivocal. If an abscess is located deep in the pelvis, it may be palpable by pelvic or rectal examination. For abscesses above the pelvis, the diagnosis will depend on radiologic confirmation.
Ultrasonography can occasionally delineate ﬂuid collections in the upper abdomen and in the pelvis. Bowel gas interference makes visualization of ﬂuid collections or abscesses in the midabdomen difficult to distinguish. Computed tomography scanning is more sensitive and specific for diagnosing intra-abdominal abscesses and often is the radiologic procedure of choice.
Occasionally, if conventional radiologic methods fail to identify an abscess and the index of suspicion for an abscess remains high, labeled leukocyte scanning may be useful for locating the infected focus.
Standard therapy for intra-abdominal abscess is evacuation and drainage combined with appropriate parenteral administration of antibiotics. Abscesses located low in the pelvis, particularly in the area of the vaginal cuff, can be reached through a vaginal approach. In many patients, the ability to drain an abscess by placement of a drain percutaneously under CT guidance obviated the need for surgical exploration. With CT guidance, a pigtail catheter is placed into an abscess cavity via transperineal, transrectal, or transvaginal approaches. The catheter is left in place until drainage decreases. Transperineal and transrectal drainage of deep pelvic abscesses is successful in 90% to 93% of patients, obviating the need for surgical management (99,100).