The clinical presentation of the pelvic abscess is highly variable. Patients may present with a high-grade fever, general malaise, nausea, vomiting, tachycardia, lower abdominal pain, vaginal discharge, vaginal bleeding, retention of urine, and change in bowel habit. Leukocytosis with a left shift along with elevated erythrocyte sedimentation rate and high C-reactive protein is present in blood workup.[4] Ectopic pregnancy should always be ruled out on a urine pregnancy test. A diagnosis is conventionally made based on the presence of fever and palpable mass or fullness. In 1983 a study conducted by Landers and Sweet demonstrated that 35% of women with abscess present afebrile, while 23% had normal leucocyte count. In the same study, they reported that 50% of the patients with tubo-ovarian abscess present with fever, 28% with nausea, and 21% with vaginal bleeding.[10]

The complete physical exam includes a thorough abdominal, vaginal, and rectal examination. Superficial or deep abdominal tenderness on abdominal palpation may be indicative of peritonitis. The comprehensive vaginal examination consists of the bimanual and speculum exam. The bimanual vaginal exam should assess the size of the uterus, mobility, consistency, and adnexa. Usually, the cervical motion tender is present, the uterus is tender, boggy, and most likely pushed anteriorly.[9] An abscess can be unilocular or multilocular. It can be palpable as a well-defined fluctuant mass, and it can also be less distinct and presents as a fullness on the bimanual vaginal exam. On the rectal exam, tenderness and bulging of the anterior rectal wall may be present.

Different imaging techniques are the most effective way to determine the size and location of an abscess. Pelvic ultrasound is the first method of choice to evaluate a pelvic mass in the women of reproductive age group. It can help in differentiating between the fluid-filled lesion and solid lesion. It is a relatively easy and inexpensive method of imaging with no ionizing radiation. On ultrasound, an abscess appears a collection of pus with different sizes of delicate internal echoes. Transvaginal ultrasound is always superior to transabdominal ultrasound.[11] Multilocular abscess on imaging is likely represents as a multiple inflamed tissue adherent to each other along with a small collection of pus, mostly seen in a tubo-ovarian abscess. Unilocular abscess probably appears as an actual localized mass on imaging.

Ultrasound is still the safe and first method of choice in women of reproductive age group and tubo-ovarian abscess. In a study conducted by Hiller et al. demonstrates that the majority of cases are multilocular 85%, and 73% had internal fluid echos, 95% has thick enhancing uniform abscess wall. Other common findings demonstrated were mesosalpinx 91%, and infiltration into fat. Less common finding on CT was bowel thickening and infiltrated of the uterosacral ligament.[12]

Other radiological techniques used in diagnosis include computed tomography and magnetic resonance. Computed tomography (CT) and magnetic resonance imaging (MRI) are cross-sectional imaging methods often used in the postoperative patient with suspected abscess. In postoperative patients, the ultrasound is less likely to locate the pelvic abscess because of the collection of postoperative air, open surgical wounds, and abundant gas [13]. CT scan with oral and intravenous (IV) contrast enhances the diagnostic accuracy. Oral contrast opacify the bowel loop while the use of IV contrast enhances the vascularity of the mass and opacify the urinary tract in the contrast CT scan. The pelvic abscess exhibits as a hypodense collection with peripheral round or oval intensification on CT scan. CT scan has slightly better sensitivity and specificity than ultrasound.  In the review of a few studies in the past, it has demonstrated that sensitivity to detect abscess was 78 to 100 % as compared to ultrasound has the sensitivity of 75 to 82% and CT scan with the specificity of 100 vs. 92 % for an ultrasound.[14][15][16] Furthermore, the MRI is usually recommended to clarify or supplement ultrasound findings as it does not determine the origin of the mass and the extent of the disease. It does not provide any additional information.[17]

Moreover, other investigations include complete blood count, blood culture, exudate culture and sensitivity, wet mount test of vaginal discharge, and a urine pregnancy test to rule out an intrauterine and ectopic pregnancy.

All the patients with suspicious of pelvic abscess and diagnosis should be admitted to the hospital regardless of the size of the pelvic abscess. All patients should be monitored closely for sepsis and rupture. The initial approach to the treatment is Broad-spectrum antibiotics. A multilocular abscess usually represents tubo-ovarian abscess and substantially respond well to Antibiotic treatment alone.

CONSERVATIVE MANAGEMENT

The ideal candidates for conservative management alone are women with no sign of sepsis and rupture, hemodynamically stable and, pelvic abscess greater than 8 cm on imaging. In a study by Granberg et al. in 2009 stated that 25% of the patient fails to respond to conservative treatment.[5] A localized unilocular abscess more likely referred to postsurgical complications and generally requires surgical drainage.

Once diagnosed, a combination of parental antibiotic should be started to treat the mixed aerobic and anaerobic microbes. The gold standard antibiotics regimen is the combination of clindamycin or metronidazole with an aminoglycoside, penicillin, or third-generation cephalosporins. Aztreonam is a substitute for aminoglycoside in patients with renal impairment. Other antibiotics with high therapeutic efficacy which may be options as a single agent include extended-spectrum antibiotics (cefoxitin, cefotetan, cefotaxime, ceftizoxime), beta-lactamase inhibitors (ticarcillin-clavulanate and carbapenems, meropenem, ertapenem,)extended-spectrum penicillin (piperacillin-tazobactam).[4][18][19] Parental antibiotics should continue for 24 to 48 hours after the patient becomes afebrile and subsequently be switch to oral antibiotics. Vaginal cuff abscess is a likely complication of a post-hysterectomy infection that satisfactorily responds to dilatation and drainage of the vaginal cuff.

SURGICAL MANAGEMENT AND DRAINAGE OF THE PELVIC ABSCESS

Recent evidence suggests that it is acceptable and beneficial for the patient to perform primary surgical drainage along with appropriate antibiotic coverage. It decreases the length of stay of hospitalization and improves the fertility outcomes. In a study by Perez and medina reported that surgical drainage is needed if the size of the abscess is over 8 cm or failure to respond to adequate antibiotic treatment in 2 to 3 days.[20] The criteria for failure of treatment include; increase in leucocyte count, tense and tender abdomen, despite the antibiotic therapy there is no reduction in the size of the abscess, new onset of fever and increase in the size of the abscess.

Different techniques are available for surgical drainage of the pelvic abscess, but in the past, the preferred approach was laparotomy. Many gynecologists still prefer this surgical route for the removal and the drainage of the surgical abscess. Most of the gynecologist employs vertical incision in need for the proper visualization of abdomen and pelvis. Following steps should be done in the removal and surgical drainage of the abscess

Always confirms the diagnosis first with the appropriate backup.

Cultures are obtained upon entering into the peritoneal cavity and abscess itself.

Surgically remove the abscess as much as possible if the abscess is in the ovary, an adnexectomy is likely necessary.

Always irrigate the peritoneal cavity with normal saline to lessen the burden of infection.

All the tissues removed sent for culture and histopathology.

Leave in the closed suction drain until the output from the drain is minimal, and the patient improves clinically.

Now the laparoscopic approach is being used for the drainage. The laparoscopic approach is being used more successfully in a patient with no exhibition of the rupture of an abscess. The choice between laparotomy and laparoscopy depends upon the determination and skill of the surgeon.  However, the CT, MRI, or U/S guided drainage with antibiotics is the procedure of choice and has a success rate of 80 to 90%.[21][22] In a study conducted by Perez and medina, states that these techniques have several advantages over laparoscopy, it requires no anesthesia, less morbidity, decreases the length of stay in hospital.[23][24] CT guided transgluteal percutaneous drainage is a safe procedure, especially for deep abscess of postsurgical type. It is a successful procedure where the anterior approach to the pus collection is not feasible.[25] Endoscopic ultrasound (ESU)-guided drainage is another safe and effective method of draining in the pelvic abscess, which is not manageable to percutaneous drainage.[6][26] Some of the recent studies have shown the effectiveness and safe use of intracavitary tissue plasminogen activator (tPA) for refractory and complicated abscess.[27][28] Rupture of the pelvic abscess is always a life-threatening emergency in such patients immediate fluid resuscitation, and surgery required with antibiotics therapy.

Differentials diagnosis of the pelvic abscess includes:

• Pelvic inflammatory disease
• Ectopic pregnancy
• Sepsis following miscarriage 
• Appendicitis
• Renal colic
• Bowel obstruction
• Obturator hernia

The prognosis for the patients with a localized abscess is good; it usually depends on the timely diagnosis, prompt management, and etiology of the collection of pus. The prognosis is poor with regards to infertility in women of the reproductive age group who have had a pelvic abscess.[9]

The complication of a pelvic abscess includes ectopic pregnancy, the scar tissue from the previous inflammation and infection prevents the fertilized ovum to implant in the uterus and results in ectopic pregnancy.

Infertility is another prevalent complication, adhesion as a result of abscess and inflammation causes severe damages the fallopian tube and ciliary epithelium and ovary and results in infertility.[29] Chronic pelvic pain has seen in one-third of the patients, and pain is related to scarring and adhesions from the previous abscess and infection.[9][30]

Postoperative care is critical in the patient with surgical abscess removal and drainage. The patient must be monitored closely in the first 24 hours for any worsening of the condition. They are at a high risk of clinical deterioration. 

All patients require strict observation for any sign and symptoms of sepsis, hemorrhage, and shock.

Every patient's vital signs should be monitored and recorded periodically. It includes systolic blood pressure, pulse, temperature, and oxygen saturation.

The patient's intake and output should be maintained and recorded, including the drain. Drain can be removed in a few days after the drainage become minimal, and the patient improves clinically.

Appropriate analgesia should be given to control post-operative pain.

Nausea control should be with an anti-nausea medicine as per needed basis.

Woundcare will involve by keeping the dressing dry and clean.

The parenteral antibiotic should be given for the first 24 hours or until the patient becomes afebrile and then subsequently be changed to oral antibiotics to complete the course.

The most common cause of pelvic abscess in the women of reproductive age group is a pelvic inflammatory disease. It is the duty of the provider either nurse, primary physician or ob-gyn to provide education to the patient about safe sex, regular use of condoms and limiting the number of sexual partners especially in adolescents and teenagers.

The diagnosis and treatment of a pelvic abscess are very challenging. In a clinical setting, the presentation of the pelvic abscess is sometimes vague with high-grade fever, prostration, and vague lower abdominal pain. It requires prompt diagnosis and hospitalization. To avoid high morbidity, managing the condition is best when by an interprofessional team. It is coherent that the role of a gynecologist is dominant in the diagnosis and management of the patient. The integrated care includes primary care providers, The ED physician, nurses, pharmacists, and radiologists. Generally, the patient first presents to either the primary care physician, nurse practitioner, or to the ED with their chief complaints. The attending physician has to consider pelvic abscess in their differentials. The involvement of radiologists is essential in establishing the diagnosis, causes, and further treatment if imaging-guided drainage is needed.[31]

Close monitoring of these patients by nurses is vital because multiple complications can develop, including stress ulcers, sepsis, DVT, and pneumonia. Also, the nurses should provide prophylaxis against pressure sores and encourage incentive spirometry. Pharmacists should assist in the prophylactic and therapeutic dosing and administration of antimicrobial therapy, and consult with the physician staff if there are any concerns regarding therapy, which in many cases will be administered by the nursing staff.

A dietary consult is necessary since many patients will have ileus and require short term IV nutrition.  Bedside physical therapy is vital to prevent muscle contractures and wasting. Only with close interprofessional team collaboration and open communication can the outcomes be improved. [Level V]

Outcomes

The outcome of the patients with a pelvic abscess depends on the extent of the disease, prompt diagnosis, and response to the initial medical treatment. Sometimes the pelvic abscess drains spontaneously into the rectum. The rupture of the pelvic abscess is a life-threatening emergency and requires immediate surgery and frequent monitoring. The rupture of pelvic abscess can present as sepsis, peritonitis, but fortunately, early recognition and expeditious treatment with appropriate antibiotics and surgical interventional can lead to successful treatment.