Tubo-ovarian abscessMANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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530 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Dialysis access complications Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian hyperstimulation syndrome Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Peritoneal dialysis peritonitis Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Renal transplant complications and rejection Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp43

Immediate priorities

›Stabilization and early escalation

›Airway and breathing

›Hypoxemia

›Increased work of breathing

›Aspiration risk

›Circulation

›Two large bore IV

›Cardiac monitoring

›Point of care glucose mmol/l

›Sepsis screening

›Suspected infection plus organ dysfunction

›Hypotension MAP < 65 mmHg

›Lactate mmol/l elevated

›Early antibiotics timing

›If septic shock then antibiotics within 1 hour

›If sepsis without shock then antibiotics within 3 hours

›Early source control planning

›IR and gynecology notification after imaging suspicion

›OR readiness if rupture concern

Hemodynamic targets and monitoring

›Perfusion goals

›MAP at least 65 mmHg

›If persistent hypotension after fluids then vasopressor

›Urine output at least 0.5 ml/kg/hour

›Foley catheter if severe illness or shock

›Lactate clearance trend

›Repeat lactate within 2 to 4 hours if elevated

02History/hx48

Focused symptom profile

›Presenting features

›Pelvic or lower abdominal pain

›Onset and progression

›Unilateral predominance

›Fever or chills

›Peak temperature at home

›Antipyretic use

›Vaginal discharge

›Purulent or malodorous

›New bleeding

›Gastrointestinal symptoms

›Nausea or vomiting

›Anorexia

›Urinary symptoms

›Dysuria

›Frequency

›Pregnancy possibility

›Last menstrual period timing

›Contraception use

Risk factors and exposures

›Infection and procedural risks

›Prior PID

›Prior TOA

›Recent STI exposure

›New partner

›Multiple partners

›IUD presence

03Physical Exam/exam42

Vital signs and general

›Systemic illness assessment

›Temperature

›Persistent fever

›Heart rate

›Tachycardia

›Blood pressure

›Hypotension

›Respiratory rate

›Tachypnea

›Oxygen saturation

›Hypoxemia

›Mental status

›Confusion

›Lethargy

Abdominal and pelvic

›Abdominal exam

›Suprapubic tenderness

›Rebound

›Guarding

›Peritonitis signs

›Rigid abdomen

›Diffuse tenderness

›Mass effect

›Palpable adnexal fullness

›Pelvic exam

›Speculum findings

›Mucopurulent discharge

04Differential Diagnosis/ddx42

Life threatening and surgical mimics

›Surgical emergencies

›Ectopic pregnancy ICD-10 O00

›Positive pregnancy test

›Free fluid

›Appendicitis ICD-10 K35

›RLQ peritoneal signs

›Ovarian torsion ICD-10 N83.5

›Sudden severe unilateral pain

›Ruptured hemorrhagic ovarian cyst ICD-10 N83.2

›Acute pain with hemoperitoneum

›Bowel obstruction ICD-10 K56

›Distension

›Obstipation

›Perforated viscus ICD-10 K63.1

›Free air

›Critical infections

›Sepsis source non pelvic ICD-10 A41.9

›Alternate focus

›Fournier gangrene ICD-10 N49.3

›Perineal necrosis

›Pyelonephritis ICD-10 N10

›CVA tenderness

›Urinalysis infection

Gynecologic and pelvic conditions

›Gynecologic causes

›PID without abscess ICD-10 N73.9

›Cervicitis plus pelvic tenderness

05Laboratory Tests/lt38

Core evaluation

›Initial labs

›Pregnancy test

›Serum beta hCG if urine equivocal

›Complete blood count

›Leukocytosis support

›Normal WBC does not exclude TOA

›CMP

›Creatinine for contrast planning

›Transaminitis possible in PID

›Lactate mmol/l if systemic toxicity

›Serial trend for resuscitation

›Blood cultures if febrile or septic

›Two sets before antibiotics if no delay

›Urinalysis

›Pyuria overlap common

›Culture if UTI concern

Microbiology and STI testing

›Genital infection testing

›NAAT gonorrhea and chlamydia

›Vaginal or endocervical specimen

›Trichomonas testing

›NAAT if available

›Vaginitis testing

›BV markers

›Candida if symptomatic

›HIV testing

›Offer per local policy

06Diagnostic Tests/dt57

Scoring Systems

›Severity and sepsis tools

›qSOFA

›Altered mentation

›Respiratory rate at least 22 per minute

›Systolic blood pressure at most 100 mmHg

›SIRS

›Temperature abnormal

›Heart rate more than 90

›Respiratory rate more than 20

›WBC abnormal

›Shock index

›HR divided by SBP more than 0.9 concern

›Clinical application

›High score then early ICU and source control planning

›Low score does not exclude TOA

MRI

›Pelvic MRI

›Indications

›Equivocal ultrasound and CT

›Contrast avoidance preference when stable

›Findings supporting TOA

›Complex thick walled adnexal collection

›Restricted diffusion

›Surrounding inflammatory change

›Limitations

›Limited availability emergently

›Time burden in unstable patient

07Disposition/dispo42

Level of care

›Admission indications

›Suspected or confirmed TOA

›Inpatient IV antibiotics default

›Pregnancy

›Inpatient management

›Severe illness

›High fever

›Persistent vomiting

›Inability to tolerate PO

›Sepsis or shock

›ICU consideration

›Failure of outpatient PID therapy

›No improvement within 48 to 72 hours

›ICU criteria

›Vasopressor requirement

›Norepinephrine infusion

›Lactate mmol/l persistently elevated

›Worsening organ dysfunction

›Altered mental status

›Airway concern

Consultation and transfer

›Specialist involvement

›Gynecology

›All TOA cases

›Interventional radiology

›Abscess drainage candidate

›General surgery

08Treatment/t98

Analgesia and supportive care

›Symptom control and monitoring

›Analgesia

›Acetaminophen 1000 mg PO or IV every 6 hours as needed

›Ibuprofen 400 to 600 mg PO every 6 hours as needed if no contraindication

›Hydromorphone 0.2 to 0.5 mg IV every 2 to 3 hours as needed

›Antiemetic

›Ondansetron 4 mg IV or PO every 6 to 8 hours as needed

›Fluids

›Crystalloid bolus 20 to 30 ml/kg if hypotension or lactate elevation

›Reassess after each bolus with MAP and urine output

›VTE prophylaxis if admitted

›Mechanical prophylaxis

›Pharmacologic prophylaxis per bleeding risk

Empiric IV antibiotics

›Broad spectrum pelvic infection coverage

›Coverage targets

›Gonorrhea and chlamydia

›Anaerobes including BV associated flora

›Gram negative enterics

›Streptococci

›Preferred inpatient regimens

›Ceftriaxone based regimen

›Ceftriaxone 1 g IV every 24 hours

›Dose 2 g IV every 24 hours if severe sepsis or high BMI per local protocol

›Doxycycline 100 mg IV or PO every 12 hours

›Switch to PO when tolerating

›Metronidazole 500 mg IV or PO every 12 hours

›Continue anaerobic coverage for TOA

›Cefoxitin based regimen

›Cefoxitin 2 g IV every 6 hours

›Alternative if ceftriaxone unavailable

›Doxycycline 100 mg IV or PO every 12 hours

›Switch to PO when tolerating

›Metronidazole 500 mg IV or PO every 12 hours

›Continue for TOA

›Clindamycin gentamicin regimen

›Clindamycin 900 mg IV every 8 hours

›Anaerobe coverage strong

›Gentamicin IV once daily dosing

›5 to 7 mg/kg actual body weight IV every 24 hours

›Dose adjust for renal function

›Beta lactam allergy considerations

›Clindamycin gentamicin regimen

›Clindamycin 900 mg IV every 8 hours

›Monitor for C difficile risk

›Gentamicin 5 to 7 mg/kg IV every 24 hours

›Trough monitoring per local policy

›If anaphylaxis history and gentamicin unsuitable then ID consult

›Alternative regimens based on local resistance

›Transition to oral therapy

›Clinical improvement and afebrile at least 24 hours

›Doxycycline 100 mg PO every 12 hours

›Continue to complete 14 days total

›Metronidazole 500 mg PO every 12 hours

›Continue to complete 14 days total

Source control and procedures

›Abscess management strategy

›Medical therapy first

›Hemodynamically stable

›No peritonitis

›Drainage indications

›No improvement after 48 to 72 hours IV antibiotics

›Large abscess size

›Persistent fever

›Persistent leukocytosis

›Surgical indications

›Rupture suspicion

›Generalized peritonitis

›Septic shock with uncontrolled source

›Concern for malignancy or torsion

›Drainage approaches

›Transvaginal ultrasound guided drainage

›Preferred when accessible

›CT guided percutaneous drainage

›Consider if transvaginal not feasible

›Intraoperative options

›Laparoscopy washout

›Tube and ovary preservation if feasible

›Salpingo oophorectomy

›If necrosis or rupture and unstable

›IUD management

›Do not remove immediately if improving on antibiotics

›Reassess at 48 to 72 hours

›If no improvement then consider removal

›Shared decision making with gynecology

Sepsis and shock therapies

›Hemodynamic support

›Vasopressor

›Initiate norepinephrine if MAP < 65 after fluids

›Start 0.05 to 0.1 mcg/kg/min

›Titrate every 2 to 5 minutes to MAP goal

›Second line vasopressor

›Add vasopressin 0.03 units/min if escalating norepinephrine

›Avoid titration above 0.03 units/min per typical protocol

›Steroid consideration

›If refractory shock then hydrocortisone 50 mg IV every 6 hours

›Class IIa recommendation based on sepsis guideline consensus

›Early reassessment

›Repeat lactate mmol/l

›Bedside ultrasound for volume status

›Urine output monitoring

09Special Populations/sp38

Pregnancy

›Pregnancy specific approach

›Risk profile

›TOA uncommon but higher maternal fetal risk

›Ectopic exclusion mandatory

›Imaging

›Ultrasound first line

›MRI preferred if further imaging needed and stable

›Antibiotics

›Avoid doxycycline

›Use pregnancy compatible regimen with OB and ID input

›Cephalosporin plus metronidazole options

›Tailor to gestational age and allergies

›Disposition

›Inpatient management

›Obstetrics involvement early

Geriatric

›Older adult considerations

›Atypical presentation

›Less fever

›Baseline leukopenia possible

›Malignancy concern with complex adnexal mass

›Lower threshold gynecologic oncology input

›Medication risks

›Renal dosing for gentamicin

›QT risks with antiemetics

›Disposition

›Lower threshold ICU for sepsis physiology

10Background/b40

Epidemiology

›Population patterns

›Relationship to PID

›TOA complication of ascending genital tract infection

›Risk factors

›Prior PID increases risk

›STI exposure increases risk

›Outcomes

›Infertility risk increases with recurrent PID

›Chronic pelvic pain risk increases after PID

›Microbiology patterns

›Polymicrobial common

›Anaerobes frequent

Pathophysiology

›Disease mechanism

›Ascending infection

›Cervix to endometrium

›Fallopian tubes

›Adjacent ovary involvement

›Abscess formation

›Tubal obstruction and pus accumulation

›Adhesions and loculations

›Systemic inflammation

›Cytokine mediated fever and tachycardia

›Progression to sepsis possible

›Complications

›Rupture with peritonitis

›Bacteremia

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge education and safety net

›Diagnosis

›Tubo ovarian abscess treated with antibiotics

›Medications

›Finish all antibiotics to complete at least 14 days total therapy

›Avoid alcohol while taking metronidazole and for 48 hours after last dose

›Activity and self care

›Hydration

›Rest

›No vaginal intercourse until symptoms resolved and treatment completed

›Partner and STI considerations

›Partners may need testing and treatment

›Avoid sex until partners treated if STI suspected

›Follow up

›Gynecology follow up within 48 to 72 hours after discharge or as directed

›Repeat imaging if instructed or if symptoms recur

›Return to ED immediately

›Worsening abdominal or pelvic pain

›New fainting or severe weakness

›Fever

›Vomiting with inability to keep fluids down

›Dizziness or low blood pressure symptoms

›New shoulder pain or severe bloating

›Vaginal bleeding heavy

›Trouble breathing

›Confusion

12References/r16

Guidelines and evidence sources

›Reference set

›CDC Sexually Transmitted Infections Treatment Guidelines PID and TOA sections

›ACOG guidance on PID and adnexal masses

›Sepsis management guidelines for shock and vasopressor targets

›SNOMED CT concept

›Tubo ovarian abscess

›ICD-10 codes

›Tubo ovarian abscess N70.93

›Acute salpingitis and oophoritis N70.0

›PID unspecified N73.9

›Sepsis unspecified organism A41.9

›Evidence level notation

›ACEP Level C for ED process guidance when specialty guidelines not ACEP specific

›Class I for rupture or peritonitis requiring urgent operative management

›Class IIa for drainage consideration after 48 to 72 hours non response

›Source file

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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