Pelvic Abscesses

Last updated by Peer reviewed by Dr Laurence Knott
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A pelvic abscess most commonly follows acute appendicitis, or gynaecological infections or procedures. It can also occur as a complication of Crohn's disease, and diverticulitis or following abdominal surgery. An abscess contains infected pus or fluid, and is walled off by inflammatory tissue. A pelvic abscess may grow quite large before making a patient ill, or causing obvious signs, and so may be easily missed.

  • In males the abscess is usually located between the bladder and the rectum.
  • In females the abscess usually lies between the uterus and the posterior fornix of the vagina, and the rectum posteriorly.
  • A tubo-ovarian abscess is one type of pelvic abscess which is found in women of reproductive age, and may be a complication of pelvic inflammatory disease. In this case it is an inflammatory mass which involves the ovary and Fallopian tube[1, 2].
  • Uncommon.
  • Predisposing factors include Crohn's disease, diabetes mellitus, immunodeficiency and pregnancy. In Crohn's disease, abscesses may occur either spontaneously or as a complication of surgery[3].
  • Systemic features of toxicity: fever, malaise, anorexia, nausea, vomiting, pyrexia.
  • Local effects: eg, pain, deep tenderness in one or both lower quadrants, diarrhoea, tenesmus, mucous discharge per rectum, urinary frequency, dysuria, vaginal bleeding or discharge.
  • Rectal or vaginal examination: may reveal tenderness of the pelvic peritoneum and bulging of the anterior rectal wall.
  • Partial obstruction of the small intestine: this may sometimes occur.
  • FBC: raised white cell count often but not invariably[1].
  • Ultrasound.
  • CT/MRI scanning may be more effective at identifying the origin of the abscess[4].
  • Arrange urgent admission to hospital.
  • Management is usually by drainage of the abscess along with antibiotic treatment. Antibiotics used alone are occasionally effective for very early, small abscesses.
  • Antibiotic choice is guided by the likely cause and local resistance patterns and guidelines, but usually needs to be broad-spectrum until the pathogens are determined. 
  • Image-guided pelvic abscess drainage has high clinical success and low complication rates. The only factor affecting the clinical success rate is the presence of fistula[5]. Procedures used for drainage of the abscess include:
    • Ultrasound-guided aspiration and drainage: usually the abscess would be rectally drained in men, and in females it would be drained vaginally[6, 7].
    • CT-guided aspiration and drainage. Percutaneous drainage often uses a trans-gluteal approach[8].
    • Endoscopic ultrasound-guided drainage (EUS-guided drainage). Evidence supporting this as an effective, minimally invasive option is growing[9, 10].
    • Laparotomy or laparoscopy with drainage of abscess may be required in some cases.
  • An abscess which is enlarging suprapubically needs draining urgently.
  • In females the abscess is more difficult to diagnose if coils of bowel lie between the abscess and the posterior fornix and it may have to be drained suprapubically.
  • Abscess drainage with adjuvant thrombolytic treatment, such as tissue plasminogen activator (tPA), has been used to aid drainage[11, 12].
  • Definitive surgery may be required after initial drainage for some causes of pelvic abscess, such as appendicectomy for abscesses due to appendicitis, or salpingo-oophorectomy for tubo-ovarian abscess.

The prognosis will depend on the aetiology of the abscess, underlying well-being of the patient and the speed of diagnosis and effective management. An abscess may sometimes drain spontaneously into the rectum.

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Further reading and references

  1. Chappell CA, Wiesenfeld HC; Pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and tuboovarian abscess. Clin Obstet Gynecol. 2012 Dec55(4):893-903. doi: 10.1097/GRF.0b013e3182714681.

  2. Granberg S, Gjelland K, Ekerhovd E; The management of pelvic abscess. Best Pract Res Clin Obstet Gynaecol. 2009 Oct23(5):667-78. doi: 10.1016/j.bpobgyn.2009.01.010. Epub 2009 Feb 20.

  3. Richards RJ; Management of abdominal and pelvic abscess in Crohn's disease. World J Gastrointest Endosc. 2011 Nov 163(11):209-12. doi: 10.4253/wjge.v3.i11.209.

  4. Kalish GM, Patel MD, Gunn ML, et al; Computed tomographic and magnetic resonance features of gynecologic abnormalities in women presenting with acute or chronic abdominal pain. Ultrasound Q. 2007 Sep23(3):167-75.

  5. Akinci D, Ergun O, Topel C, et al; Pelvic abscess drainage: outcome with factors affecting the clinical success. Diagn Interv Radiol. 2018 May-Jun24(3):146-152. doi: 10.5152/dir.2018.16500.

  6. Saokar A, Arellano RS, Gervais DA, et al; Transvaginal drainage of pelvic fluid collections: results, expectations, and experience. AJR Am J Roentgenol. 2008 Nov191(5):1352-8.

  7. Sudakoff GS, Lundeen SJ, Otterson MF; Transrectal and transvaginal sonographic intervention of infected pelvic fluid collections: a complete approach. Ultrasound Q. 2005 Sep21(3):175-85.

  8. Robert B, Chivot C, Fuks D, et al; Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature. Abdom Imaging. 2013 Apr38(2):285-9. doi: 10.1007/s00261-012-9917-z.

  9. Prasad GA, Varadarajulu S; Endoscopic ultrasound-guided abscess drainage. Gastrointest Endosc Clin N Am. 2012 Apr22(2):281-90, ix. doi: 10.1016/j.giec.2012.04.002. Epub 2012 Apr 25.

  10. Hadithi M, Bruno MJ; Endoscopic ultrasound-guided drainage of pelvic abscess: A case series of 8 patients. World J Gastrointest Endosc. 2014 Aug 166(8):373-8. doi: 10.4253/wjge.v6.i8.373.

  11. Gervais DA, Brown SD, Connolly SA, et al; Percutaneous imaging-guided abdominal and pelvic abscess drainage in children. Radiographics. 2004 May-Jun24(3):737-54.

  12. Beland MD, Gervais DA, Levis DA, et al; Complex abdominal and pelvic abscesses: efficacy of adjunctive tissue-type plasminogen activator for drainage. Radiology. 2008 May247(2):567-73. doi: 10.1148/radiol.2472070761. Epub 2008 Mar 27.