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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, 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.
- 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.
- 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.
- 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.
- 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.
- 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 & 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 Dec;55(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 Oct;23(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 16;3(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 Ultrasound Q. 2007 Sep;23(3):167-75.
- Saokar A, Arellano RS, Gervais DA, et al; Transvaginal drainage of pelvic fluid collections: results, expectations, and AJR Am J Roentgenol. 2008 Nov;191(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 Sep;21(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 Apr;38(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 Apr;22(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 16;6(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-Jun;24(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 May;247(2):567-73. doi: 10.1148/radiol.2472070761. Epub 2008 Mar 27.
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Dr Colin Tidy
Dr Mary Harding
Dr Adrian Bonsall