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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
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].
- 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.
- 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.
- Pelvic inflammatory disease.
- Diverticular disease.
- Generalised peritonitis - eg, from a perforated peptic ulcer.
- Sepsis following termination of pregnancy or miscarriage.
- FBC: raised white cell count often but not invariably.
- CT/MRI scanning may be more effective at identifying the origin of the abscess.
- 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. 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.
- 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.
Further reading and references
Incision and Drainage of Pelvic Abscess via the Vaginal Route; Atlas of Pelvic Surgery
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.