Posthysterectomy pelvic abscess
- David E Soper, MD
David E Soper, MD
- Professor and Director of Specialists in Obstetrics and Gynecology
- Medical University of South Carolina
- Oluwatosin Jaiyeoba, MD, MSCR
Oluwatosin Jaiyeoba, MD, MSCR
- Assistant Professor of Surgery
- Obstetrics, Gynecology and Women’s Health Institute
- Cleveland Clinic
Pelvic abscess occurs as an infectious complication of surgery (eg, hysterectomy, cesarean delivery, induced abortion) or the result of infectious processes (eg, pelvic inflammatory disease, inflammatory bowel disease, diverticulitis). This topic will review the diagnosis and management of pelvic abscess complicating hysterectomy.
Less than 1 percent of patients undergoing obstetric or gynecologic surgery develop an abscess . In a retrospective cohort study of 23,366 patients undergoing either laparoscopic or abdominal hysterectomy, 783 (3 percent) developed a surgical site infection . Most of these were wound infections, but approximately one-quarter were infections of the organ space (or 0.7 percent of the entire cohort [210/23,366]).
Risk factors for posthysterectomy pelvic abscess can be separated into pre-, intra-, and postoperative elements. Risk reduction is focused on eliminating as many factors as possible. We counsel women with multiple nonmodifiable risk factors about their increased risk for postoperative abscess and possible need for subsequent treatment.
●Preoperative risk factors for posthysterectomy abscess include untreated pelvic inflammatory disease (PID), bacterial vaginosis, endometrioma, hydrosalpinx, prior laparotomy, anatomic anomalies, nonwhite race, renal comorbidities, and American Society of Anesthesiologists class ≥3 [1-5]. Bacterial vaginosis at surgery increases the risk of both posthysterectomy cuff cellulitis [6,7] and subsequent pelvic abscess formation . (see "Anesthesia and anesthetic choices", section on 'Preoperative risk assessment' and "Bacterial vaginosis: Treatment", section on 'Women undergoing gynecologic procedures').
●Intraoperative risk factors include perioperative blood transfusion and operative time >180 minutes for laparoscopic hysterectomy . In addition, one retrospective review of 413 women undergoing hysterectomy at a single institution reported increased risk of postoperative pelvic abscess when gelatin-thrombin matrix was used during surgery .
- Mahdi H, Goodrich S, Lockhart D, et al. Predictors of surgical site infection in women undergoing hysterectomy for benign gynecologic disease: a multicenter analysis using the national surgical quality improvement program data. J Minim Invasive Gynecol 2014; 21:901.
- Sherer DM, Schwartz BM, Abulafia O. Management of pelvic abscess during pregnancy: a case and review of the literature. Obstet Gynecol Surv 1999; 54:655.
- Matsunaga Y, Fukushima K, Nozaki M, et al. A case of pregnancy complicated by the development of a tubo-ovarian abscess following in vitro fertilization and embryo transfer. Am J Perinatol 2003; 20:277.
- Al-Kuran O, Beitawi S, Al-Mehaisen L. Pelvic abscess complicating an in vitro fertilization pregnancy and review of the literature. J Assist Reprod Genet 2008; 25:341.
- Patounakis G, Krauss K, Nicholas SS, et al. Development of pelvic abscess during pregnancy following transvaginal oocyte retrieval and in vitro fertilization. Eur J Obstet Gynecol Reprod Biol 2012; 164:116.
- Watts DH, Eschenbach DA, Kenny GE. Early postpartum endometritis: the role of bacteria, genital mycoplasmas, and Chlamydia trachomatis. Obstet Gynecol 1989; 73:52.
- Soper DE. Bacterial vaginosis and postoperative infections. Am J Obstet Gynecol 1993; 169:467.
- Sweet RL, Gibbs RS. Soft tissue infection and pelvic abscess. In: Infectious Diseases of the Female Genital Tract, 5, Sweet RL, Gibbs RS (Eds), Lippincott Williams & Wilkins, Baltimore 2009. p.95.
- Anderson CK, Medlin E, Ferriss AF, et al. Association between gelatin-thrombin matrix use and abscesses in women undergoing pelvic surgery. Obstet Gynecol 2014; 124:589.
- Duff P, Park RC. Antibiotic prophylaxis in vaginal hysterectomy: a review. Obstet Gynecol 1980; 55:193S.
- Hsu WC, Lee YH, Chang DY. Tuboovarian abscess caused by Candida in a woman with an intrauterine device. Gynecol Obstet Invest 2007; 64:14.
- Pakish JB, West L. Actinomyces bacteremia in association with tubo-ovarian abscesses and hysteroscopic sterilization. Obstet Gynecol 2014; 124:451.
- Ilmer M, Bergauer F, Friese K, Mylonas I. Genital tuberculosis as the cause of tuboovarian abscess in an immunosuppressed patient. Infect Dis Obstet Gynecol 2009; 2009:745060.
- Jaiyeoba O, Lazenby G, Soper DE. Recommendations and rationale for the treatment of pelvic inflammatory disease. Expert Rev Anti Infect Ther 2011; 9:61.
- Cruse PJ. Surgical wound infection. In: Infectious Diseases, Wonsiewicz MJ (Ed), WB Saunders Co, Philadelphia 1992. p.758.
- Krizek TJ, Robson MC. Evolution of quantitative bacteriology in wound management. Am J Surg 1975; 130:579.
- Weinstein WM, Onderdonk AB, Bartlett JG, Gorbach SL. Experimental intra-abdominal abscesses in rats: development of an experimental model. Infect Immun 1974; 10:1250.
- Jaiyeoba O. Postoperative infections in obstetrics and gynecology. Clin Obstet Gynecol 2012; 55:904.
- Gynecologic Infection. In: Williams Gynecology, Schorge JO. Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG (Eds), 2008. p.79-82.
- Nezhat C, Farhady P, Lemyre M. Septic pelvic thrombophlebitis following laparoscopic hysterectomy. JSLS 2009; 13:84.
- Tawadros PS, Simpson J, Fischer JE, Rotstein OD. Abdominal Abscess and Enteric Fistulae. In: Maingot's Abdominal Operations, 12e, 12th, Zinner MJ, Ashley SW (Eds), 2013.
- Robert B, Yzet T, Regimbeau JM. Radiologic drainage of post-operative collections and abscesses. J Visc Surg 2013; 150:S11.
- Chappell CA, Wiesenfeld HC. Pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and tuboovarian abscess. Clin Obstet Gynecol 2012; 55:893.
- Cacciatore B, Leminen A, Ingman-Friberg S, et al. Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. Obstet Gynecol 1992; 80:912.
- Boardman LA, Peipert JF, Brody JM, et al. Endovaginal sonography for the diagnosis of upper genital tract infection. Obstet Gynecol 1997; 90:54.
- Nguyen TL, Soyer P, Barbe C, et al. Diagnostic value of diffusion-weighted magnetic resonance imaging in pelvic abscesses. J Comput Assist Tomogr 2013; 37:971.
- Eschenbach D. Glob. libr. Women’s med., (ISSN: 1756-2228) 2011; DOI 10.3843/GLOWM.10032. (Accessed August 30th 2012).
- Benoist S, Panis Y, Pannegeon V, et al. Can failure of percutaneous drainage of postoperative abdominal abscesses be predicted? Am J Surg 2002; 184:148.
- Greenstein Y, Shah AJ, Vragovic O, et al. Tuboovarian abscess. Factors associated with operative intervention after failed antibiotic therapy. J Reprod Med 2013; 58:101.
- Dewitt J, Reining A, Allsworth JE, Peipert JF. Tuboovarian abscesses: is size associated with duration of hospitalization & complications? Obstet Gynecol Int 2010; 2010:847041.
- To J, Aldape D, Frost A, et al. Image-guided drainage versus antibiotic-only treatment of pelvic abscesses: short-term and long-term outcomes. Fertil Steril 2014; 102:1155.
- Sudakoff GS, Lundeen SJ, Otterson MF. Transrectal and transvaginal sonographic intervention of infected pelvic fluid collections: a complete approach. Ultrasound Q 2005; 21:175.
- Walser E, Raza S, Hernandez A, et al. Sonographically guided transgluteal drainage of pelvic abscesses. AJR Am J Roentgenol 2003; 181:498.
- Beilman GJ, Dunn DL. Surgical Infections. In: Schwartz's Principles of Surgery, 9th edition, Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthwes JB, Pollock RE (Eds), 2010.
- Kassi F, Dohan A, Soyer P, et al. Predictive factors for failure of percutaneous drainage of postoperative abscess after abdominal surgery. Am J Surg 2014; 207:915.
- Subhas G, Rana G, Bhullar J, et al. Percutaneous drainage of a diverticular abscess should be limited to two attempts for a resilient diverticular abscess. Am Surg 2014; 80:635.
- Yang CC, Chen P, Tseng JY, Wang PH. Advantages of open laparoscopic surgery over exploratory laparotomy in patients with tubo-ovarian abscess. J Am Assoc Gynecol Laparosc 2002; 9:327.
- PEDOWITZ P, BLOOMFIELD RD. RUPTURED ADNEXAL ABSCESS (TUBOOVARIAN) WITH GENERALIZED PERITONITIS. Am J Obstet Gynecol 1964; 88:721.
- Lareau SM, Beigi RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am 2008; 22:693.
- VERMEEREN J, TE LINDE RW. Intraabdominal rupture of pelvic abscesses. Am J Obstet Gynecol 1954; 68:402.
- Sweet RL. Soft tissue infection and pelvic abscess. In: Infectious diseases of the female genital tract, 5th ed, Sweet RL, Gibbs RS (Eds), Lippincott Williams and Wilkins, Philadelphia 2009.
- Wiesenfeld HC, Sweet RL. Progress in the management of tuboovarian abscesses. Clin Obstet Gynecol 1993; 36:433.
- Rosen M, Breitkopf D, Waud K. Tubo-ovarian abscess management options for women who desire fertility. Obstet Gynecol Surv 2009; 64:681.
- RISK FACTORS
- PATIENT PRESENTATION
- DIFFERENTIAL DIAGNOSIS
- DIAGNOSTIC EVALUATION
- Hemodynamically unstable patients
- Hemodynamically stable patients
- - Antibiotic therapy
- Antibiotic regimen
- Antibiotic treatment duration
- - Decision for percutaneous drainage
- Percutaneous drainage
- Treatment failure
- - Risk factors
- - Management approach
- - Surgical technique
- SUMMARY AND RECOMMENDATIONS