Objective. To evaluate the association between abscess size and duration of hospitalization and need for surgical intervention. Methods. We collected data from patients admitted with ICD-9 codes 614.9 (PID) and 614.2 (TOA) from January 1, 1999-December 31, 2005. We abstracted data regarding demographics, diagnostic testing/laboratory testing, imaging, treatment, and clinical course. Two abscess groups were created: </=8 cm or >8 cm. Descriptive statistics were calculated, and duration of hospitalization and surgical intervention for women with large abscesses were compared to women with smaller collections. Results. Of the 373 charts reviewed, 135 had a TOA and 31% required management with drainage and/or surgery. The average abscess size for those treated successfully with conservative management was 6.3 cm versus those requiring drainage and/or surgery (7.7 cm, P = .02). Every 1 cm increase in abscess size as associated with an increase in hospitalization by 0.4 days (P = .001). Abscesses greater than 8 cm were associated with an increased risk of complications (P < .01). Conclusions. Larger tubo-ovarian abscesses are associated with an increased duration of hospitalization and more complications including an increased need for drainage or surgery. Additional research to determine the most efficacious antibiotic regimen management strategy is needed.