Continuing Education Activity

A pelvic abscess is potentially a life-threatening condition. It can lead to sepsis and rupture and poor prognosis, especially in women of reproductive age group if not treated promptly. This activity reviews the etiology, risk factors, complications, and new trends in the management and the treatment of pelvic abscesses, and highlights the role of the interprofessional team in providing quality care.

Objectives:

• Identify the risk factors involved in patients with pelvic abscess.
• Discuss the complications of pelvic abscess.
• Discuss the management and new advances in the treatment available for a pelvic abscess.
• Outline the significance of the involvement of the interprofessional team to identify and enhance the delivery of care and improves the patient outcome in the pelvic abscess.

Introduction

A pelvic abscess is a life-threatening collection of infected fluid in the pouch of Douglas, fallopian tube, ovary, or parametrial tissue.[1] Usually, a pelvic abscess occurs as a complication after operative procedures. It starts as pelvic cellulitis or hematoma spreads to the parametrial tissue.[2] It can also present as a result of the complexity of certain medical conditions like sexually transmitted infections, pelvic inflammatory disease, appendicitis, diverticulitis, and inflammatory bowel disease. Also, patients with pelvic abscess present with high-grade fever, leukocytosis, palpable pelvic mass, vaginal bleeding or discharge, and lower abdominal pain, often associated with elevated sedimentation rate or C-reactive protein.[3] A pelvic abscess responds well to adequate antibiotic treatment and hydration.[4] Its variable presentation requires early recognition, diagnosis, immediate hospitalization, and treatment, regardless of abscess size.[5] The current activity aims to explain the pathophysiology of pelvic abscess, elaborate on the importance of imaging techniques in diagnosing it, and illustrate the information needed to identify high-risk patients who require immediate surgical intervention.

Etiology

A pelvic abscess is a frequent complication of lower genital tract infection, including pelvic inflammatory disease. Other causes subsumed in the etiology of pelvic abscess are operative procedures like hysterectomy, laparotomies, cesarean sections, and induced abortion. Cancers of pelvic organs, trauma to the genital tract, Crohn disease complications, and diverticulitis are other significant causes.[6] In Crohn disease, the pelvic abscess may occur spontaneously or secondary to surgery.[7] In females, it usually lies between the uterus, the posterior fornix, and the rectum, which sometimes drains automatically into the rectum.

The risk factor for the pelvic abscess is the same as that of pelvic inflammatory disease, such as multiple sexual partners, sexually transmitted infection, intrauterine device, diabetes, and a low immune system. Other recognizable risk factors that have been studied in developing post-surgical abscess classify as preoperative, intraoperative, and postoperative causes. The preoperative risk factors involved in pelvic abscess formation are untreated pelvic inflammatory disease, hydrosalpinx, endometrioma, uncontrolled blood sugar with HbA1c greater than 6.5, renal comorbidities, obesity with BMI over 30, and congenital anomalies of the genital tract. Asymptomatic bacterial vaginosis is also a known documented risk factor for postsurgical vaginal cuff cellulitis and abscess formation.[8]

The perioperative risk factors include intraoperative blood loss of over 500 ml, prolonged surgical procedure exceeding 140 minutes, patients undergoing extensive surgeries like para-aortic lymphadenectomy, pelvic lymphadenectomy, pelvic exenteration for pelvic malignancies. The postoperative risk factors include uncontrolled blood sugar over 200 mg in the first 48 hours, and prolonged preoperative hospital stay also increases the incidence of surgical site infections and pelvic abscess formation. Postoperative hematoma is also a critical cause of pelvic abscess.

Epidemiology

In reproductive-age women, pelvic abscesses most frequently present as the progression of the end-stage of pelvic inflammatory disease, involving the fallopian tubes, the ovary, and the adjacent pelvic organs.[4][9] One-third of the women who are hospitalized with pelvic inflammatory disease are found to have a tubo-ovarian abscess. Notice that not all cases of abscess are associated with pelvic inflammatory disease. The incidence of pelvic abscess is less than 1% in patients undergoing obstetric and gynecological surgery.

Pathophysiology

The pelvic abscess is a circumscribed collection of infected exudate. It is formed by liquefaction necrosis. It develops due to an imbalance between host defense mechanisms and insufficient antibiotic coverage when a highly virulent bacterial inoculum is present. Necrotic tissue accumulates around the infective exudate, forming a thick fibrous wall. If the pus does not drain, it localizes microbes and toxins, which could be detrimental to the host and make it more difficult for antimicrobial agents to penetrate the fibrous inflammatory capsule and act on it. Enzymatic degradation of immunoglobulins and local complement release occur, resulting in persistent pus formation.

In young women, pelvic abscess occurs as a complication of pelvic inflammatory disease. It starts as an ascending infection from the vagina, cervix, and spreads to the uterus, fallopian tube, ovary, and peritoneum. It causes endothelial damage and edema of the fallopian tube and consequently leads to tubal blockage. Notably, it generally occurs in the follicular phase of the menstrual cycle. Likewise, high estrogen and cervical ectopy help link Neisseria Gonorrhea and chlamydia to the genital tract, which is a common cause of pelvic inflammatory disease and its complications.

In postoperative patients, the theory is that blood loss, serous fluid, lymphatic debris, necrotic tissue, and fibrillar hemostats accumulate in the lower pelvic area and vaginal vault. It results in a simple fluid collection. The fluid accumulation eventually becomes infected via skin contamination and vaginal opening and results in pelvic abscess formation. The pathogenic organism ascends from the vagina, endocervix, and via skin to the surgical site, including vaginal vault and abdominal incision. A compound and dynamic mixture of pathogenic and nonpathogenic bacteria that ascends from the vagina comprises anaerobic, facultative, gram-negative, and gram-positive bacteria. As a result of an imbalance between pathogenic and nonpathogenic bacteria, sterile tissue becomes infected, leading to a pelvic abscess. Infection is usually polymicrobial, with anaerobic bacteria predominating. The bacteria involved are Escherichia coli, Bacteroides fragilis, Peptostreptococcus, aerobic Streptococcus, and Peptococcus.[10]

History and Physical

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 a change in bowel habit. Leukocytosis with a left shift, along with an elevated erythrocyte sedimentation rate and elevated C-reactive protein, is present on the blood workup.[3] 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 by Landers and Sweet found that 35% of women with abscesses were afebrile, while 23% had a 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 tenderness 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 present as a fullness on the bimanual vaginal exam. On the rectal exam, tenderness and bulging of the anterior rectal wall may be present.

Evaluation

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 women of reproductive age. It can help differentiate between a fluid-filled lesion and a solid lesion. It is a relatively easy and inexpensive imaging method with no ionizing radiation. On ultrasound, an abscess appears as a collection of pus with varying-sized, delicate internal echoes. Transvaginal ultrasound is always superior to transabdominal ultrasound.[11] Multilocular abscess on imaging is likely to represent multiple inflamed tissues adherent to one another and a small collection of pus, most commonly seen in a tubo-ovarian abscess. A unilocular abscess typically appears as a localized mass on imaging.

Ultrasound is still the safe and first method of choice in women of reproductive age group for tubo-ovarian abscess. A study conducted by Hiller et al demonstrates that the majority of cases are multilocular (85%) and that 73% have internal fluid echoes; 95% have thick, enhancing, uniform abscess walls. Other common findings included mesosalpinx in 91% and fat infiltration. Less common findings on computed tomography included bowel thickening and infiltration of the uterosacral ligament.[12]

Other radiological techniques used in diagnosis include computed tomography and magnetic resonance imaging. Computed tomography and magnetic resonance imaging (MRI) are cross-sectional imaging methods often used in postoperative patients 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] A computed tomography scan with oral and intravenous contrast enhances the diagnostic accuracy. Oral contrast opacifies the bowel loop, while intravenous contrast enhances the vascularity of the mass and opacifies the urinary tract on contrast computed tomography. The pelvic abscess appears as a hypodense collection with peripheral round or oval enhancement on a computed tomography scan. Computed tomography demonstrates slightly higher sensitivity and specificity than ultrasound. Across several studies, computed tomography showed sensitivity for detecting abscesses ranging from 78% to 100%, compared with 75% to 82% for ultrasound. In some analyses, computed tomography achieved 100% sensitivity, compared with 92% for ultrasound.[14][15][16] Furthermore, MRI is usually recommended to clarify or supplement ultrasound findings, as it does not determine the mass's origin or 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.

Treatment / Management

All patients with suspicion of pelvic abscess and a 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 a tubo-ovarian abscess and substantially responds 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. A 2009 study by Granberg et al reported that 25% of patients fail to respond to conservative treatment.[4] A localized unilocular abscess is more likely to be referred to postsurgical complications and generally requires surgical drainage. Once diagnosed, a combination of parental antibiotics should be started to treat the mixed aerobic and anaerobic microbes. The gold-standard antibiotic regimen is a combination of clindamycin or metronidazole with an aminoglycoside, penicillin, or a third-generation cephalosporin. Aztreonam is a substitute for aminoglycosides in patients with renal impairment. Other antibiotics with high therapeutic efficacy that may be options as single agents include extended-spectrum antibiotics (cefoxitin, cefotetan, cefotaxime, ceftizoxime), beta-lactamase inhibitors (ticarcillin-clavulanate), carbapenems (meropenem, ertapenem), and extended-spectrum penicillins (piperacillin-tazobactam).[3][18][19] Parenteral antibiotics should continue for 24 to 48 hours after the patient becomes afebrile, then be switched to oral antibiotics. The ideal duration of antibiotics has not been rigorously studied. A 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 a 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 hospital stay and improves fertility outcomes. A study by Perez and Medina reported that surgical drainage is needed if the abscess is over 8 cm or if there is failure to respond to adequate antibiotic treatment within 2 to 3 days.[20] The criteria for treatment failure include: an increase in leucocyte count; a tense, tender abdomen despite antibiotic therapy; no reduction in abscess size; a new-onset fever; and an increase in abscess size.

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 drainage of the surgical abscess. Most gynecologists use vertical incisions to ensure adequate visualization of the abdomen and pelvis. The following steps should be done in the removal and surgical drainage of the abscess:

• Always confirm the diagnosis first with the appropriate backup.
• Cultures are obtained upon entering the peritoneal cavity and the 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 were sent for culture and histopathology.
• Leave the closed suction drain in place until the output is minimal and the patient improves clinically.

The laparoscopic approach is now being used for drainage. The laparoscopic approach is being used more successfully in a patient with no evidence of abscess rupture. The choice between laparotomy and laparoscopy depends on the surgeon's judgment and skill. However, antibiotic- and ultrasound- or computed tomography-guided drainage is the procedure of choice and has a success rate of 80% to 90%.[21][22] A study by Perez and Medina reports that these techniques have several advantages over laparoscopy, including no requirement for anesthesia, lower morbidity, and a shorter hospital length of stay.[23][24] Computed tomography-guided transgluteal percutaneous drainage is a safe procedure, especially for deep, postsurgical-type abscesses. 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 for draining pelvic abscesses that are not amenable to percutaneous drainage.[6][26] Some recent studies have shown the effectiveness and safety of intracavitary tissue plasminogen activator (tPA) for refractory and complicated abscesses.[27][28] Rupture of the pelvic abscess is always a life-threatening emergency in such patients, and immediate fluid resuscitation and surgery are required with antibiotic therapy.

Differential Diagnosis

Differentials diagnosis of the pelvic abscess include:

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

Prognosis

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

Complications

The complication of a pelvic abscess includes ectopic pregnancy; the scar tissue from the previous inflammation and infection prevents the fertilized ovum from implanting 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 been seen in one-third of the patients, and pain is related to scarring and adhesions from the previous abscess and infection.[9][30]

Postoperative and Rehabilitation Care

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 signs 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, including the drain, should be maintained and recorded. The drain can be removed a few days after drainage has become minimal and the patient has clinically improved. Appropriate analgesia should be given to control post-operative pain. Nausea control should be managed with anti-nausea medication as needed. Wound care involves keeping the dressing dry and clean. The parenteral antibiotic should be given for the first 24 hours or until the patient becomes afebrile, then switched to oral antibiotics to complete the course.

Deterrence and Patient Education

The most common cause of pelvic abscess in women of reproductive age is pelvic inflammatory disease. It is the duty of the provider, either a 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.

Enhancing Healthcare Team Outcomes

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 done 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 emergency room physician, nurses, pharmacists, and radiologists. Generally, the patient first presents to a primary care physician, nurse practitioner, or the emergency room with their chief complaint. The attending physician has to consider pelvic abscess in their differentials. The involvement of radiologists is essential for establishing the diagnosis, determining the cause, and planning 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 pressure-sore prophylaxis and encourage incentive spirometry. Pharmacists should assist with 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, can be administered by the nursing staff. A dietary consult is necessary since many patients have ileus and require short-term intravenous 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.

Outcomes

The outcome for patients with a pelvic abscess depends on the extent of the disease, prompt diagnosis, and response to 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 a pelvic abscess can present as sepsis or peritonitis, but fortunately, early recognition and expeditious treatment with appropriate antibiotics and surgical intervention can lead to successful treatment.

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References

1.

Akıncı D, Ergun O, Topel Ç, Çiftçi T, Akhan O. Pelvic abscess drainage: outcome with factors affecting the clinical success. Diagn Interv Radiol. 2018 May-Jun;24(3):146-152. [PMC free article: PMC5951203] [PubMed: 29770767]

2.

Faro C, Faro S. Postoperative pelvic infections. Infect Dis Clin North Am. 2008 Dec;22(4):653-663. [PubMed: 18954757]

3.

Benigno BB. Medical and surgical management of the pelvic abscess. Clin Obstet Gynecol. 1981 Dec;24(4):1187-97. [PubMed: 7333045]

4.

Granberg S, Gjelland K, Ekerhovd E. The management of pelvic abscess. Best Pract Res Clin Obstet Gynaecol. 2009 Oct;23(5):667-78. [PubMed: 19230781]

5.

Bugg CW, Taira T, Zaurova M. Pelvic inflammatory disease: diagnosis and treatment in the emergency department [digest]. Emerg Med Pract. 2016 Dec 22;18(12 Suppl Points & Pearls):S1-S2. [PubMed: 28745849]

6.

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. [PMC free article: PMC4133417] [PubMed: 25132921]

7.

Richards RJ. Management of abdominal and pelvic abscess in Crohn's disease. World J Gastrointest Endosc. 2011 Nov 16;3(11):209-12. [PMC free article: PMC3221952] [PubMed: 22110836]

8.

Soper DE, Bump RC, Hurt WG. Bacterial vaginosis and trichomoniasis vaginitis are risk factors for cuff cellulitis after abdominal hysterectomy. Am J Obstet Gynecol. 1990 Sep;163(3):1016-21; discussion 1021-3. [PubMed: 2403128]

9.

Lareau SM, Beigi RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am. 2008 Dec;22(4):693-708. [PubMed: 18954759]

10.

Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983 Sep-Oct;5(5):876-84. [PubMed: 6635426]

11.

Sayasneh A, Kaijser J, Preisler J, Smith AA, Raslan F, Johnson S, Husicka R, Ferrara L, Stalder C, Ghaem-Maghami S, Timmerman D, Bourne T. Accuracy of ultrasonography performed by examiners with varied training and experience in predicting specific pathology of adnexal masses. Ultrasound Obstet Gynecol. 2015 May;45(5):605-12. [PubMed: 25270506]

12.

Hiller N, Sella T, Lev-Sagi A, Fields S, Lieberman S. Computed tomographic features of tuboovarian abscess. J Reprod Med. 2005 Mar;50(3):203-8. [PubMed: 15841934]

13.

Koehler PR, Moss AA. Diagnosis of intra-abdominal and pelvic abscesses by computerized tomography. JAMA. 1980 Jul 04;244(1):49-52. [PubMed: 7382054]

14.

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. [PubMed: 23090458]

15.

Cacciatore B, Leminen A, Ingman-Friberg S, Ylöstalo P, Paavonen J. Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. Obstet Gynecol. 1992 Dec;80(6):912-6. [PubMed: 1448258]

16.

Boardman LA, Peipert JF, Brody JM, Cooper AS, Sung J. Endovaginal sonography for the diagnosis of upper genital tract infection. Obstet Gynecol. 1997 Jul;90(1):54-7. [PubMed: 9207813]

17.

Nguyen TL, Soyer P, Barbe C, Graesslin O, Veron S, Amzallag-Bellenger E, Tomas C, Hoeffel C. Diagnostic value of diffusion-weighted magnetic resonance imaging in pelvic abscesses. J Comput Assist Tomogr. 2013 Nov-Dec;37(6):971-9. [PubMed: 24270121]

18.

Duff P. Antibiotic selection in obstetric patients. Infect Dis Clin North Am. 1997 Mar;11(1):1-12. [PubMed: 9067781]

19.

Duff P. Antibiotic selection in obstetrics: making cost-effective choices. Clin Obstet Gynecol. 2002 Mar;45(1):59-72. [PubMed: 11862059]

20.

Reed SD, Landers DV, Sweet RL. Antibiotic treatment of tuboovarian abscess: comparison of broad-spectrum beta-lactam agents versus clindamycin-containing regimens. Am J Obstet Gynecol. 1991 Jun;164(6 Pt 1):1556-61; discussion 1561-2. [PubMed: 2048603]

21.

Fabiszewski NL, Sumkin JH, Johns CM. Contemporary radiologic percutaneous abscess drainage in the pelvis. Clin Obstet Gynecol. 1993 Jun;36(2):445-56. [PubMed: 8513638]

22.

Worthen NJ, Gunning JE. Percutaneous drainage of pelvic abscesses: management of the tubo-ovarian abscess. J Ultrasound Med. 1986 Oct;5(10):551-6. [PubMed: 3534287]

23.

Perez-Medina T, Huertas MA, Bajo JM. Early ultrasound-guided transvaginal drainage of tubo-ovarian abscesses: a randomized study. Ultrasound Obstet Gynecol. 1996 Jun;7(6):435-8. [PubMed: 8807761]

24.

Gjelland K, Ekerhovd E, Granberg S. Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases. Am J Obstet Gynecol. 2005 Oct;193(4):1323-30. [PubMed: 16202721]

25.

Robert B, Chivot C, Fuks D, Gondry-Jouet C, Regimbeau JM, Yzet T. 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. [PubMed: 22684488]

26.

Prasad GA, Varadarajulu S. Endoscopic ultrasound-guided abscess drainage. Gastrointest Endosc Clin N Am. 2012 Apr;22(2):281-90, ix. [PubMed: 22632950]

27.

Gervais DA, Brown SD, Connolly SA, Brec SL, Harisinghani MG, Mueller PR. Percutaneous imaging-guided abdominal and pelvic abscess drainage in children. Radiographics. 2004 May-Jun;24(3):737-54. [PubMed: 15143225]

28.

Beland MD, Gervais DA, Levis DA, Hahn PF, Arellano RS, Mueller PR. Complex abdominal and pelvic abscesses: efficacy of adjunctive tissue-type plasminogen activator for drainage. Radiology. 2008 May;247(2):567-73. [PubMed: 18372451]

29.

Graesslin O, Verdon R, Raimond E, Koskas M, Garbin O. [Management of tubo-ovarian abscesses and complicated pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]. Gynecol Obstet Fertil Senol. 2019 May;47(5):431-441. [PubMed: 30880246]

30.

Tao X, Ge SQ, Chen L, Cai LS, Hwang MF, Wang CL. Relationships between female infertility and female genital infections and pelvic inflammatory disease: a population-based nested controlled study. Clinics (Sao Paulo). 2018 Aug 09;73:e364. [PMC free article: PMC6077933] [PubMed: 30110069]

31.

Saokar A, Arellano RS, Gervais DA, Mueller PR, Hahn PF, Lee SI. Transvaginal drainage of pelvic fluid collections: results, expectations, and experience. AJR Am J Roentgenol. 2008 Nov;191(5):1352-8. [PubMed: 18941068]

Disclosure: Khalida Khaliq declares no relevant financial relationships with ineligible companies.

Disclosure: Noor Nama declares no relevant financial relationships with ineligible companies.

Disclosure: Richard Lopez declares no relevant financial relationships with ineligible companies.