Tubo-ovarian abscess


  • Typically a complication of PID, although inflammatory bowel, appendicitis, and hematologic nidius have been reported
  • Mortality if not ruptured: <1% if treated; 2-4% if untreated
  • Infections are often polymicrobial

Risk factors

  • Multiple sex partners
  • Age 15-25 years old
  • Prior history of PID
  • IUD (within 21 days of insertion[1])
  • HIV infection

Clinical Features

  • +/-Fever
  • Vaginal discharge
  • Dyspareunia
  • Disproportionate unilateral adnexal tenderness or adnexal mass or fullness
  • Suspect in patient who does not respond after 72hr of treatment for PID

Differential Diagnosis

Pelvic Pain

Pelvic origin

Abdominal origin


  • CBC
  • Transvaginal pelvic ultrasound (Sn 75-82%)
  • CT pelvis (Sn 78-100%) - preferred in patients in whom associated GI pathology must be excluded


  • OB/GYN consult for possible operative drainage.
  • Majority (60-80%) resolve with antibiotics alone
  • Predictors of antibiotic treatment failure and possible indications for IR drainage upon admission to Ob[4]
    • WBC > 16,000
    • TOA size > 5.2 cm


  • Ceftriaxone 250mg IM once PLUS doxycycline 100mg PO BID x14 days
  • Metronidazole 500mg PO BID x14 days now recommended empirically by European guidelines [5]. Supported by CDC. Definitely give if suspicion of bacterial vaginitis or gynecological instrumentation in preceding 2-3 wks



  • Decision should be made in conjunction with gynecological colleague
  • Patient with fevers, elevated WBC, abscess greater than 5 cm, or systemic toxicity demand admission
  • Hemodynamically stable, afebrile patients with a relatively small abscess can be safely discharged with close gynecological follow up on antibiotics

See Also

  • PID


  1. https://www.cdc.gov/std/tg2015/pid.htm
  2. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  3. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  4. Huma F et al. Inpatient Management of Tubo-Ovarian Abscesses: What Is the Threshold of Parenteral Antibiotic Treatment Failure? Obstetrics & Gynecology: May 2015
  5. Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
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