Tubo-ovarian abscess

Tubo-ovarian abscesses are one of the late complications of pelvic inflammatory disease.

Risk factors include 15:

Patients typically present with a combination of fever, elevated inflammatory markers, lower abdominal-pelvic pain, and vaginal discharge. Fever and leukocytosis may sometimes be absent.

Abscesses are often polymicrobial with a preponderance of anaerobic organisms 9.

Uncommon causes include actinomycosis, tuberculosis, and xanthogranulomatous inflammation19.

The clinical context is extremely important in radiological interpretation. Patients will experience tenderness with endovaginal scanning. Some differentiate between:

  • tubo-ovarian "abscess": ovary and tube cannot be separately distinguished within the inflammatory mass
  • tubo-ovarian "complex": if the tube and ovary are separately discernible structures within the inflammatory mass

Features are non-specific and may include:

  • soft tissue density mass
  • loss of normal pelvic fat planes
  • an adynamic ileus may be present

Transabdominal and endovaginal ultrasound are the preferred initial imaging investigations. Findings may include:

  • multilocular complex retro uterine/adnexal mass
    • debris, septations, and irregular thick walls
  • commonly bilateral
  • echogenic debris within the pelvis

Can be a helpful adjunct to ultrasound especially in determining the extent of disease 3:

  • fluid attenuation pelvic masses which may contain fluid-fluid levels or gas
  • usually shows a thick enhancing wall
  • a tubular configuration is more conclusive of a pyosalpinx

Can be useful especially when sonography is inconclusive or if the gas content is difficult to be differentiated from bowel gas 5.

Typically seen as thick-walled fluid-filled pelvic mass(es) 12

  • T1: abscess contents typically hypointense
  • T2: abscess contents typically heterogeneous signal or hyper-intense

Initial treatment can be with antibiotic therapy. Radiological guided drainage or surgery may be required in patients resistant to antibiotic treatment. Drainage may be performed from an endovaginal, transgluteal, or transabdominal approach, dependent on patient and operator preference 4.

Recognized complications include:

Clinical features of infection is a key to aid diagnosis as a number of other pathologies can give similar appearances 1:

Uncommon causes of TOA such as actinomyces and tuberculosis have many overlapping features with ovarian malignancy, such relatively vague presentation, solid/cystic ovarian masses, and peritoneal and serosal thickening and enhancement. There can be clues that favor uncommon causes of TOA over malignancy such as longstanding IUD as a risk factor for actinomyces, and smoother peritoneal enhancement more typical of peritonitis rather than carcinomatosis. In these cases, biopsy or fluid sampling is often most appropriate to guide therapy and avoid unnecessary surgical intervention19.

Ultrasound - gynaecology
Share article

Article information

rID: 9818
System: Gynaecology
Synonyms or Alternate Spellings:
  • Tubo-ovarian complexes
  • Tuboovarian abscess
  • Tuboovarian abscess (TOA)
  • Tubo-ovarian abscesses
  • Tuboovarian abscesses
  • Tubo-ovarian complex
  • Tuboovarian complex

Support Radiopaedia and see fewer ads

Cases and figures

  • Case 1
    Drag here to reorder.
  • Axial T2
    Case 2: on MRI with incidental uterine didelphys
    Drag here to reorder.
  • Pyosalpinx
    Case 3: with IUCD
    Drag here to reorder.
  • Case 4: on MRI - complication of IUCD (removed)
    Drag here to reorder.
  • Case 5: on ultrasound
    Drag here to reorder.
  • Case 6
    Drag here to reorder.
  • Case 7
    Drag here to reorder.
  • Case 8: bilateral
    Drag here to reorder.
  • Case 9
    Drag here to reorder.
  • Case 10
    Drag here to reorder.
  • Case 11
    Drag here to reorder.
  • Case 12
    Drag here to reorder.
  • Case 13
    Drag here to reorder.
  • Case 14: tuberculosis
    Drag here to reorder.
  • Updating… Please wait.

     Unable to process the form. Check for errors and try again.

     Thank you for updating your details.