What is Pelvic Abscess?
A pelvic abscess is a serious condition where infected fluid collects in various parts of the pelvic area such as the pouch of Douglas (a space between the uterus and rectum), the fallopian tubes, ovaries, or surrounding tissues. This often happens as a follow-up issue after surgical procedures.
The abscess may start as an infection or a swelling filled with blood (also known as a hematoma) in the pelvic area that spreads to the surrounding soft tissues. Even unrelated health issues such as sexually transmitted infections, pelvic inflammatory disease, appendicitis, diverticulitis (a condition that causes small pouches in the digestive tract), and inflammatory bowel disease can lead to a pelvic abscess.
Patients with a pelvic abscess often have symptoms such as high fever, an increase in white blood cells (sign of infection), a detectable mass in the pelvic area, bleeding or discharge from the vagina, and lower abdominal pain. These symptoms often accompany an increase in the sedimentation rate or C-reactive protein, which are general indications of inflammation in the body.
Pelvic abscesses usually respond well to appropriate antibiotic treatment and keeping the patient well hydrated. However, early detection is key. Its symptoms can vary from person to person, making it necessary to quickly recognize, diagnose, and start treatment promptly. This holds true regardless of the size of the abscess. It’s important that the patients need to be hospitalized immediately for proper care.
Understanding how a pelvic abscess develops and progresses (its pathophysiology), the role of imaging techniques for diagnosis, and the factors that can lead to a high risk of needing immediate surgery are all crucial parts of managing this condition.
What Causes Pelvic Abscess?
A pelvic abscess, which is a pocket of pus that forms inside the pelvic area, can commonly occur due to an infection in the lower genital tract, such as pelvic inflammatory disease. Additional causes could be surgeries like hysterectomies (removal of the uterus), laparotomies (surgery in the abdomen), c-sections, or induced abortions. It can also occur as a result of cancers of organs in the pelvic area, injuries to the genital tract, complications from Crohn’s disease (a type of inflammatory bowel disease), or diverticulitis (inflammation in the digestive system).
In women, the abscess usually develops between the uterus, the posterior fornix (the area behind the vagina), and the rectum, and can sometimes drain into the rectum on its own.
The risk factors for getting a pelvic abscess are similar to those for pelvic inflammatory disease including having multiple sexual partners, sexually transmitted infections, using an intrauterine device, diabetes, and having a weakened immune system. Certain other factors before, during, and after surgery can also increase the risk of developing a post-surgical abscess.
Before surgery, the risk of developing an abscess increases if you have untreated pelvic inflammatory disease, hydrosalpinx (a condition where fluid fills and blocks the fallopian tubes), endometrioma (a type of ovarian cyst), uncontrolled blood sugar levels (above 6.5 HbA1c), kidney-related health problems, obesity (with a BMI over 30), congenital anomalies (birth defects) of the genital tract, or bacterial vaginosis but no symptoms, which is a risk factor for post-surgical cellulitis and abscess.
During surgery, risk factors can include losing more than 500ml of blood, undergoing a surgical procedure that lasts longer than 140 minutes, or having complex surgeries like para-aortic lymphadenectomy (removal of lymph nodes near the aorta), pelvic lymphadenectomy (removal of lymph nodes in the pelvic area), or pelvic exenteration (removal of organs in the pelvic area due to cancer).
After surgery, risk factors include uncontrolled blood sugar levels (above 200mg in the first 48 hours), a long hospital stay before surgery (which can increase the chances of surgical site infections and abscess formation) and postoperative hematoma (a collection of blood outside blood vessels), which is a significant cause of a pelvic abscess.
Risk Factors and Frequency for Pelvic Abscess
Pelvic abscesses often occur in women of childbearing age as a late stage of pelvic inflammatory disease, affecting the fallopian tubes, ovaries, and nearby pelvic organs. About one-third of women hospitalized due to pelvic inflammatory disease end up having a tubo-ovarian abscess. However, not all abscesses are linked to pelvic inflammatory disease. Pelvic abscesses are less common, with less than 1% occurrence in patients who undergo surgeries related to obstetrics and gynecology.
- Pelvic abscesses often occur as a result of pelvic inflammatory disease in women of reproductive age.
- They can affect the fallopian tubes, ovaries, and nearby pelvic organs.
- About one-third of women hospitalized for pelvic inflammatory disease can develop a tubo-ovarian abscess.
- Not all abscesses are associated with pelvic inflammatory disease.
- Less than 1% of patients undergoing obstetrics and gynecology surgeries may experience a pelvic abscess.
Signs and Symptoms of Pelvic Abscess
A pelvic abscess can show a variety of symptoms. Usually, people with this condition might feel very sick, have a high temperature, feel tired, and could have nausea or vomiting. They might also have fast heartrate, pain in their lower abdomen, unusual vaginal discharge, vaginal bleeding, difficulty urinating, and changes in bowel movements. A common sign of a pelvic abscess is a high white blood cell count, an increased rate of red blood cell settling, and high C-reactive protein levels in a blood test.
Doctors often make a diagnosis based on symptoms like fever and the presence of some fullness or lump that can be felt during a physical exam. Interestingly, many people might not show these typical symptoms. For instance, in a study conducted in 1983, it was found that 35% of women with an abscess didn’t have a fever and 23% had a normal white blood cell count.
- High body temperature
- Tiredness
- Nausea or vomiting
- Fast heart rate
- Pain in the lower stomach
- Unusual vaginal discharge
- Vaginal bleeding
- Difficulty urinating
- Changes in bowel movements
- High white blood cell count
- Increased rate of red blood cell settling
- High C-reactive protein levels
A comprehensive physical exam for this condition includes a detailed check of the stomach, vagina, and rectum. Pain during stomach examination might suggest an infection of the peritoneum, a thin tissue that lines the inside of the abdomen. The vaginal examination includes a bimanual check, where two fingers are inserted into the vagina while the other hand gently presses on the abdomen to feel the size and shape of the uterus and its mobility. It is common to find tenderness in the cervix or uterus, which may feel soft and expanded, and might be pushed toward the front.
The abscess can be a single or multi-chambered mass. It can either be felt as a distinct, elastic lump or less precisely, as general fullness during the vaginal examination. A rectal exam might show tenderness or bulging of the front wall of the rectum.
Testing for Pelvic Abscess
Different imaging techniques like ultrasound, Computed Tomography (CT) scan, and Magnetic Resonance Imaging (MRI) can help your doctor find out the size and exact location of an abscess – which is a collection of pus in a specific area of the body.
Starting with ultrasound – it’s typically the first choice for investigating a pelvic mass (which might be a lump or growth) in women of reproductive age. Ultrasound is a procedure that uses high-frequency sound waves to produce images of what’s going on inside the body. It can help differentiate between a lesion filled with fluid (like an abscess), and a solid lump. It’s a relatively simple and cheap procedure, and it doesn’t involve any harmful radiation. An abscess can show up as different sizes of delicate internal echoes on the ultrasound image. There are two types of ultrasound: transvaginal and transabdominal. The transvaginal ultrasound is superior in terms of detailing, as it can provide clearer images.
A study highlighted that in most cases, an abscess appeared to have multiple compartments (multilocular) and showed fluid echoes in about 73% of the cases. There were other common indicators, like thickening of the abscess wall and changes to the mesosalpinx – a part of the female reproductive system.
While ultrasound is usually the first go-to method, other imaging techniques like CT scans and MRI come into the picture when more detail is needed. These techniques are particularly useful in patients who have undergone surgery and are suspected of having an abscess; ultrasound isn’t as effective in these cases as it can be obstructed by post-surgery air and gases.
A CT scan includes you drinking a contrast liquid and also getting one via an IV. This enhances the accuracy of the scan. The drinking contrast illuminates the bowel, while the IV contrast increases the visibility of blood vessels and the urinary tract. The abscess will usually show up as a low-density mass with intensification around the edges in a CT scan.
CT scans have slightly better sensitivity (how well a test correctly identifies a condition) and specificity (how well a test correctly rules out a condition) in detecting abscesses as compared to ultrasounds. Various studies have shown that CT scans have revealed abscesses in about 78% to 100% of cases, while ultrasounds detected abscesses in about 75% to 82% of cases.
As for MRI, it’s typically recommended when ultrasound results are not clear and need to be clarified. However, MRI may not provide additional information about the origin and extent of the abscess.
Other tests that may be performed include a complete blood count, blood and pus cultures (to identify any bacteria), a vaginal discharge test, and a pregnancy test to rule out possible pregnancy-related conditions.
Treatment Options for Pelvic Abscess
When a doctor suspects a patient has a pelvic abscess, they usually need to be admitted to the hospital. This is crucial as it allows the doctor to closely monitor signs of infection spreading throughout the body (sepsis) and rupturing of the abscess.
The first step in treatment usually involves taking a wide-range antibiotic. If the abscess has many chambers, it points towards a tubo-ovarian abscess, which often responds well to just the antibiotics.
Doctors may suggest a conservative treatment plan for patients with no signs of sepsis or rupturing, stable vital signs, and a large pelvic abscess (greater than 8 cm). However, this approach may not always work, and about 25% of patients fail to respond to this approach according to a 2009 study.
When doctors confirm the diagnosis of a pelvic abscess, they typically use a combination of antibiotics to target both aerobic and anaerobic microbes (germs that can or can’t live in the presence of oxygen). The best combination of antibiotics often includes clindamycin, metronidazole, aminoglycosides, penicillin, or third-generation cephalosporins. If the patient has kidney disease, doctors may use Aztreonam in place of an aminoglycoside.
Patient should be given antibiotics for about 24 to 48 hours after their fever subsides. Then, they will be prescribed oral antibiotics. The preferred duration of antibiotics treatment is yet to be scientifically established.
A specific type of pelvic abscess, called vaginal cuff abscess, usually happens as a complication of post-hysterectomy infection. It’s often treated successfully by draining the infected area in the vagina.
Latest research suggests that performing surgical drainage along with giving appropriate antibiotics can be beneficial for the patient because it reduces the length of hospital stay and improves fertility outcomes in the future. Surgical drainage is usually recommended if the abscess is greater than 8 cm or if the antibiotics treatment doesn’t work within 2 to 3 days.
Several surgical methods are available to drain the pelvic abscess. The preferred method in the past was majorly performed through a large surgical cut in the abdomen (laparotomy), with many gynecologists still preferring this approach. These days, a laparoscopic method, which uses smaller incisions and a special camera, is commonly used. However, imaging-guided drainage using CT, MRI, or ultrasound, along with antibiotics, is usually considered the best method with a success rate of 80-90%.
For abscesses deep in the pelvis or difficult to access, an endoscopic ultrasound-guided drainage can be used as a safe and effective method. Recent studies have shown the safe use of a drug called tissue plasminogen activator (tPA) for complicated abscesses.
In situations when the pelvic abscess bursts open, it’s considered a life-threatening emergency. In such cases, immediate fluid replacement, surgery, and antibiotic therapy are required.
What else can Pelvic Abscess be?
When a doctor is trying to diagnose a pelvic abscess, there are several other conditions they must consider, as they can present with similar symptoms. These include:
- Pelvic inflammatory disease
- Ectopic pregnancy
- Sepsis following miscarriage
- Appendicitis
- Renal colic (kidney pain)
- Bowel obstruction
- Obturator hernia (a type of abdominal hernia)
What to expect with Pelvic Abscess
The recovery outlook for patients with a localized abscess, which is a pocket of pus in one area of the body, is usually good. This is especially true if it is diagnosed and treated promptly. The cause of the abscess also plays a crucial role in recovery. However, for women in their childbearing years who have had a pelvic abscess, there may be difficulties with becoming pregnant in the future.
Possible Complications When Diagnosed with Pelvic Abscess
Pelvic abscesses can lead to several complications. One significant complication is an ectopic pregnancy. If there is scar tissue present from previous infections or inflammation, it may stop a fertilized egg from attaching properly in the uterus, leading to an ectopic pregnancy.
Infertility is also a common issue. Scar tissue formed from the abscess and inflammation can cause severe damage to the fallopian tube, ciliary epithelium, and ovary, which can result in infertility.
Another issue is chronic pelvic pain, which about a third of patients endure. This pain is linked to the scarred and adhered tissue resulting from the previous abscess and infection.
Here are the potential complications:
- Ectopic pregnancy due to scar tissue
- Infertility caused by damage to the reproductive organs
- Chronic pelvic pain linked to the scarring and tissue adhesions
Recovery from Pelvic Abscess
After a surgery to remove and drain an abscess, it’s crucial to take care of the patient well. For the first 24 hours after the surgery, the patient needs to be watched closely to make sure they don’t get worse. They are at high risk of their health deteriorating quickly.
The patient needs to be closely observed for any signs and symptoms of sepsis (an extreme response to infection), hemorrhage (heavy bleeding), and shock (a life-threatening condition that needs immediate treatment).
It is key to regularly check and record the patient’s vital signs, which are measurements that show how their body is functioning. These include systolic blood pressure (the force of blood against artery walls when the heart beats), pulse (how often the heart beats), temperature, and oxygen saturation (how much oxygen is in the blood).
It’s also necessary to keep track of everything the patient eats and drinks and what comes out of their body, including any fluid from the drain. The drain is usually removed after a few days, once there’s only a little fluid coming out and the patient is feeling better.
Medicines should be given as needed to manage any pain after the surgery.
If the patient feels sick to their stomach, anti-nausea medicine should be given as needed.
To care for the wound, it’s important to keep the dressing clean and dry.
For the first 24 hours after surgery, or until the patient no longer has a fever, they should be given antibiotics through a needle in their vein. After that, they can switch to taking antibiotic pills until they’ve finished the full course of medicine.
Preventing Pelvic Abscess
The main reason why women of childbearing age might develop a pelvic abscess is due to a condition known as pelvic inflammatory disease. It’s important for healthcare providers, whether they be nurses, primary care doctors, or obstetrician-gynecologists, to talk to their patients about practicing safe sex. This includes regular condom use and being mindful about the number of sexual partners they have, particularly in young people and teenagers.
