A pelvic abscess is the end stage in the progression of a genital tract infection and is frequently an unnecessary complication. Intensive medical management including the use of broad-spectrum antibiotics, posterior colpotomy, and major surgery involving a hysterectomy and bilateral salpingo-oophorectomy, all have their place in the management of this condition. Such surgery, however necessary, is associated with profound physical and emotional effects in addition to the economic consequences associated with such therapy. It is hoped that with a better understanding of the epidemiology of PID and with the advent of improved diagnostic and therapeutic modalities for early genital tract infection, a pelvic abscess will eventually become a great rarity on gynecology services.
PIP: A pelvic abscess is the end stage in the progression of a genital tract infection and is frequently preventable. The abscess may fill the pelvis and occasionally the lower abdomen, and is usually posterior to the uterus and bound by the sigmoid colon, loops of small bowel, cul-de-sac, and sidewalls of the pelvis. A tubo-ovarian abscess may occur in the acute stage of pelvic inflammatory disease (PID) but is more common with chronic or subacute PID. An abscess occurs when pus from the fallopian tube spills onto the ovary and infects it at the site of follicular rupture or by direct penetration. Pelvic and abdominal pain which is bilateral and aggravated by motion and intercourse, and fever possibly exceeding 103 degrees fahrenheit with leucocytosis, tachycardia, and prostration are the most common symptoms of pelvic abscess. The pelvic examination may reveal all gradations of pathology, but because of the degree of guarding and tenderness it elicits, the abscess may elude the examiner. The rectal examination, computerized tomography, and ultrasonography are useful in diagnosis. Other disorders such as acute appendicitis and ecoptic pregnancy may be mistaken for abscess. Patients with pelvic abscesses should be immediately admitted to hospital regardless of the size of the abscess because the broad-spectrum anerobic antibiotic coverage needed is most effectively provided there. Preservation of normal tubal function is rarely possible in patients developing tubal abscesses. Bed rest, fluid and electrolyte replacement, nasogastric suction when indicated, and antibiotics are the basis of medical treatment. Controversy exists regarding appropriate antibiotic therapy, but the probable presence of anaerobic organisms should be kept in mind. Patients with pelvic abscesses are frequently given a triple antibiotic regimen including clindamycin, gentamicin, and aqueous penicillin. Guidelines for the failure of medical management in patients with a pelvic abscess include persistent fever, increase in size of abscess, persistent ileus, suspicion of rupture, septic shock, and uncertainty of the diagnosis. A posterior colpotomy is preferable to a laparotomy if surgical treatment is necessary, but it is only suitable for selected patients. Removal of a pelvic abscess frequently involves a total abdominal hysterectomy. Operating instructions and diagrams are included. Rupture of a pelvic abscess is life threatening and requires immediate surgery.