132 Pelvic Inflammatory Disease with Tubo-ovarian Abscess

Clinical Presentation

A 32-year-old woman presents with abdominal tenderness and fever.

Fig. 132.1 (A,B) Contrast-enhanced axial CT images of the pelvis demonstrate a heterogeneously enhancing area associated with mild fat stranding in the left adnexal region with an associated oval-shaped fluid density structure (arrow). There is free fluid in the pelvis.

Radiologic Findings

Contrast-enhanced axial computed tomography (CT) images of the pelvis (Fig. 132.1) demonstrate a heterogeneously enhancing area associated with mild fat stranding in the left adnexal region with an associated oval-shaped fluid density structure. There is free fluid in the pelvis.

Diagnosis

Pelvic inflammatory disease with tubo-ovarian abscess

Differential Diagnosis

Ovarian torsion
Endometrioma/endometriosis
Ectopic pregnancy
Ovarian malignancies
Appendicitis
Diverticulitis

Discussion

Background

Pelvic inflammatory disease (PID) represents a common and potentially life-threatening disease among women of childbearing age, mostly occurring in their 2nd to 3rd decade (peak incidence: 20–24 years). This condition typically results from ascending infection of the female genital tract and is typically caused by Neisseria gonorrhoeae or Chlamydia trachomatis, although 40% of cases are associated with polymicrobial agents. PID usually begins with a cervicitis that subsequently extends to the endometrium and fallopian tubes; the infection may spread via tubal spillage to the peritoneum, leading to a local peritonitis. Tubo-ovarian abscess is the result of postinflammatory fusion of an infected fallopian tube and ovary (tubo-ovarian complex).

Clinical Findings

Clinical diagnosis is often inaccurate, as patients may experience multiple nonspecific symptoms, including abdominal and pelvic pain, high fever, nausea, vomiting, vaginal discharge, uterine bleeding, dysuria, dyspareunia, and adnexal or cervical tenderness. Conversely, ˜35% of patients with PID have no noticeable symptoms. Laboratory findings are suggestive of infection such as leukocytosis, elevated erythrocyte sedimentation rate, and elevated C-reactive protein.