Ruptured tuboovarian abscess

ABE MICKA)" M.D.

ADOLPH 1[. SF.LLM:\:\:\. M.l> .
J :\ C K S 0 ~ ).. BEE BE. \1 . » .
Nnt' Orlea/H, Loui,iana

Active and al(greHilJf 1Il1I1Ia.llt1llent vf patient, with ,u,puted rupturrd tubuu .·a/illn
ab .ICeS.> begi,,, in the nller""ncy ",,,111 with the ai1ll .. f fxplori"" tht patin"
surgically as soun aI condition .. :t'arrfl1lt. Thi, ,egim"n ha, bun I""d ,ino 1!.I51
in 93 patients with a murtalit), rate of H.1i po CNII. Thi, "p,(,tnt, a ",a,ktd
impruve1llenl ill r(JUlls o v a vur pre,·iou.\ CUnl(11 (/ti, '( 1II1111ag"lIoll vf tlzi, di"al'e
proceH.

R U P T l) R~: of the tuboo\'ariall ahsc('ss is sn'ss('s ; in (n I 1+.06 per cent) patients the
a grave gynecologic ellJngl'lIcy dl'lIIandinl.( ah'l'l'SS had rllpturl'd.

prompt recognition and surgical trcatml'nt.
Prior to 1951, we treated this condition with
the antibiotics then a\'ailable, bed rest in the
semi- Fowler's position, and drainage by col-
potomy. The results from this nl('lhod of
manageillent were comparahle to those ill
othlT reported studies when'in the mortality
rates varied from 80 to 100 per cenLI." Sincl'
1951, we have prrfonned celiotomy on pa-
tients with ruptuf(~d tuboovarian abscess and
have becoille steadily more aggressive with
this method of treatment, as n'll\oval of the
contents of the abscess as well as its walls is
technically feasible and assures better re-
covery for the patient than llIere drainag-t'.
Material and methods
The clinic popUlations at Charity Hospital
of Louisiana in New Orlc'ans and Lafayette
Charity Hospital together alTOI'd an appro-
priate study group since infection of the
pelvic organs and sequelae are common in
these patients. From July 1,1959, to Dec. 31 ,
1964, there were 28,938 consecutive admis-
sions to the Louisiana State University Gyne-
cological Service at both hospitals. Six hun-
dred and sixty-one patients (2.28 per cent)
had clinically diagnosed tuboovarian ab-
From the Department 0/ Obstetrics and
Gynecology, Louisiana State Uni versity
School of Medicine.
432
Allah'sis of the signs and symptoms of the
~n patiellts with rupturt'd tuhlK)varian ab~
sn'ss is listed ill Tables I and II. In general,
tht·st' patiellts are seH'rely ill; however, this
is not always trut'. A high index of sllspicion
coupled wilh the clinical and laboratory
findillgs is needed for the final diagnosis.
Management
E\'aluation of the patit'nt hegins in the
elllergent}' roOIll and is actin>ly purslled to
a pn,sLllllptin' or definite diagnosis. A com~
plelt' hisl<H)' is not always availahle due to
the illness of the patient or lack of infonna_
tion by the informant. The process of physi-
cal evaluation is ht'gun and continued to
compil'tion on the h'ynecologic wards. This
included {'xaminations, e\'aluation of blood
and urine with cultures and x-rays of the
abdoOlc'1l and thest. Culdo(:entesis is a valu-
able diagnostic aid and was positive in 65
( iO per cent) of the 93 cases.
Concomitant with evaluation of the pa-
tit'nt, corrective and supportive treatment is
started. Nasogastric sllction is IIsed for de-
compression and an indwelling catheter is
placed in the hladder for measuring urinary
Olltput. Nasal oxygen is started in the more
seriously ill and corticosteroids (0.5 to 1.0
Gill.) are uS{'d ewry 4 to 6 hours intra-
venously or intramuscularly in shock and
Volume 100
Number :1
Table I. SymptollIs
Symptom InridnlCt' (%)
Lower ahdominal pain
Fever
Vomitill,l(
Nausea
Chills
Vaginal discharge
Diarrh!'a
Table II, Si~ns
incidence
Signs I (~I, )
Pelvic tenderness 9:1
Temperature elevatN] over
101 0
F, 71l
Rc-bound ahdominal t!'IH\!'rrlt'ss III
Pulse over 110 p('r minute 5:1
PPivic mass 41l
Absent or decn'ased p{'ristalsis :! (when
recordc-d)
shocklike states. Fluids and antibiotics are
given intravenously, our regimen being 1,000
c.c. every 6 to 8 hours with each liter con-
taining 10 to 20 million units of aqueous
penicillin and 0.5 to 1.0 Gm. of chloram-
phenicol. In addition, 2.0 Gm. streptomycin
is given daily intramuscularly in divided
doses. This regimen is continued throughout
operation and the postoperative period and
is intensified or decreased as the clinical
condition warrants, with antibiotics being
changed as dictated by results of culture and
sensitivity studies.
When the presuIlIptive diagnosis is reached
and the condition of the patient permits,
emergency laparotomy is performed. Sixty-
four patients (68.8 pt'r cent) were operated
upon within 4 to H hours of admission, 12
(12.9 per cent) within 48 hours and 8 (8.6
per cent) within 96 hours. In 9 instances
(9.7 per cent), operation was ddayed beyond
96 hours because of the additional time re-
quired to establish the diah'l1osis and prepare
the patients for operation. Cultures are rou-
tinely taken during operation and Table III
shows the results.
Our policy is to remove only the involved
Ruptured tuboovarian abscess 433
()q~ans, as this disease procpss is more COI11-
mon in the young and low parity group.
Fifty-fi\"{' patients (59 per cent) had 0 to I
!III)
child; how('wr, no age group is exempt, as
71
4f1 one of our patients was 57 years of age. In
:19 most instances, a total abdominal hysterpc-
:1:1 tom), and n'rno\'al of both adnt'xa are neces-
9
5 sary. Table IV lists the surgical procpdures
Plllploy('d and the results. The poor clinical
condition of 5 patients precluded any further
treatment than laparotomy, aspiration of
purulent exudate, and drainage. Subtotal
hysterectomy was performed on one pa-
tient whose preoperative condition was grave.
She deteriorated progressively and did not
SIlIYI\'('.
SllhseqlU'nt operation was 1H'l'l'ssary in If)
instan(,cs (Tablc \'). Tweln~ of these pro-
cedures WI'I'{' in those patients where total
abdominal hysterectomy and bilateral sal-
pingo-oophorectomy were done. I t is illtpr-
esting to note that only 5 incisions dehisced
when obviolls and copious infection was
present. We routinely use a large rubber dam
drain in the vaginal vault with loose closure
of the angles. Also supra- and infrafascial
abdominal rubber dam drains are used and
left in place as long as drainage persists. They
arc advanced and ultimately removed by the
fifth or sixth day. Flank drainage is of
qucstionablc value and IS infrequently
used.
Additional pathology
A variety of interesting pathology was en-
countered in the surgical specimens (Table
VI). The following cases are of particular
interest.
A 29-ypar-old Npgro woman, para 2, was ad-
mittpd to New Orleans Charity Hospital for in-
vestigation of a positive cervical cytologic smear.
A biopsy was diagnosed as carcinoma in situ
with microscopic invasion. While the patient was
on the ward being prepared for operation, a
Idt tuhoovarian ahsc('ss ruptured and she was
taken to the operating room where a total ab-
dominal hysterectomy and bilateral salpingo-
oophorectomy were done. Six years after opera-
tion she is doinJl: well.
A 40-year-old Negro nulliparous woman had
a total abdominal hysterectomy and bilateral
 .... h, ua, y I, 1968
434 Mickal, Sell mann, and Beebe ,\111. J. Ollst. & Gynec.

Table III. R!'sults of cultur('s

Group Arrobic l' Ilk 1l1l1l'n Anaerobic Group total

Coliform 25
Aerubacter aFTOf.!pnt'J 9
t· nknown sp('cif's 16
Staphylococcus and Micrococcus 13
~)
Staph)'lococcul Pro.~eTle\ aureu,
Staphylococcus PYO/ieTltS a/bus 2
Staphylococcul epiderlllidis
A1icroc()CC1H tetr{J.~ene.,
Strepl()l"()lTUS II
"-helllolytic illreplot'ocelll py"genel 2
r~-helllolytic Streptococ(U.I pyogene.1 I
y-hplIlolytic SI re Plococcux pyo/iellfs 1
Ent('romcclls (Group D) 4
Streptococcus Sp. 1 2
:-';('isspria
N eix.,tria /:<!Tlorrhoeae
Protl'US 4
Proteul mirabilis
Proteul morgani;
Pspudomonas 3
P.\l'udo1llonas aeruj.!iuo.I(l 3
l'ndiff('r('ntiatpd 3
(;ralll-positi\"(' harilllls
Crarn-nr-g;ati\,e hacillus
C;ratll-positivc coccus
No growth 43
Tntal :16 19 5 103

Table IV. Operative procedures

Subsequent
No. a! CaSf.l RecoT'ued operation Ditd
Total hysterectomy, adnexa both sides 62 59 12 3
Total hysterectomy, adnexa one side 17 15 1 2
Adnexa, both sides I I n ()
Adnexa, one side 7 6 I I
Laparotomy-aspiration drainage 5 -l '2 1
Subtotal hystprectomy, adnexa hoth sides () () t

salpingo-oophon'ctomy for a rupturf'd right tubo-
ovarian ahs("f'ss. l'hc c('lvix contain('d carcinoilla
in situ. WIH'1l last Sf'C'n 18 months following
hystl'l'ectomy she was in good condition al-
thollgh she had hf'en trf'atl'd for multiple myelo-
mas 6 months after opl'ratioll.
A 39-year-old Nf'gro woman was rf'port('d to
have low grad(' adc'noear<"inoma of the utf'rinf'
tuhe in addition to a ruptun,d tuhoovarian ah-
S('('ss. The patient was sC'c'n rf'gulariy in ollr
clinic for 9 yC'ars after opf'ration and she has
rell1itill!'d in good health.
A 29-ypar-old Negro woman had a total ab-
dominal hystPrf'ctomy and bilatnal salpingo-
oophorectomy for a right ruptttr('d tuboovarian
abscess. A granulosa c('11 tumor was found in the
l..rt ()\·ary. SIlO' was Ilt'riodically ohsel"\'t'd in the
clinic for :~ p'ars aftn opt'ration with nf'gative
p"h'ic findings.
All ('ariy impbntt'd prt'gnane}, was found in
a J I-year-old :-';c'gro woman, para 4. The occur_
n'nel' of a rupturrd tuho()\'arian absc('ss in early
pregnancy was a surpris(' finding and the patho-
gl'nl'sis of this is dilTicult to ulldl'rstand. The only
nthc'r instance of pn'.gnancy cOllliJin('d with rup-
turt,d tllhoo\"arian abs('('s.~ is in a 32 w('('k gesta-
tion rf'ported hy Lowrie and Kron. 3
Comment
We concur with the rcported works of
Collins, Nix, and Ccrrha,l Pcdowitz and
Volume 100
Number :J
Table V. Subsequent opcrative procedures
Ligation inferior vena cava, septic throm-
bophlebitis
Laparotomy- --obstruction; lysis of adhe-
sions-3; small bowel resec tioll - I
Total hyster{'ctomy-- adnexa both sidl's
( pn'vious laparotomy. aspiration. drain-
age)
Incision and drainage' of left flank abscess
Dl'hiscencc
Bilateral ncphrnstomy. ureteral occlusions
Subtotal gastrpctomy-·ulcer (massive
hemorrhage)
Laparotomy-removal of rl'maining adnexa
Table VI. Additional pathology in ruphtn'd
tuboovarian absccss
No,
Uterine fibroids 26
Chronic pe'lvic inflammatory disease J.l
Carcinoma in situ 2
Polycystic ovaries 2 have played as a primary invader. Thc pres-
Diabetes mellitus 5 ence of a sterile abscess (no growth) in these
Subarachnoid hemorrhage
Adenomyosis
Endometriosis
Teratoma of ovary
Carcinoma of tube
Granulosa cell tumor of ovary
Early pregnancy
Pyeioneph ri t is
Cholelithiasis
Bloomficld,2 and Lardaro 4 that activc surgical
intervention is necessary in patients with
ruptured tuboovarian abscess. If the diag-
nosis is suspected but cannot bc confirmed
and the patient's clinical condition deteri-
orates under adequatc Illedical thcrapy,
thcn operation should be performed never-
theless.
Diffcrcntiating thc rupturcd tuboovarian
absccss from other acute abdominal and pel-
vic diseases is difficult un1e5s a high indcx of
suspicion is present. Our data reveal that
laboratory findings w('re of questionable
value. The hematocrit percentages rangcd
from 15 to 46 per cent. Although leuko-
cytosis was the rule, 3 patients had white
blood counts below 8,000. Roentgenography
Ruptured tuboovorion abscess 435
of the abdomen usually revcaled features of
adynamic ilrus but aided little in defining a
peh'ic mass or establishing a diagnosis. The
sin~le most helpful proccdure was the find-
4
ill!{ of purulent exudate by culdocentesis.
This is a simple, cffective diagnostic aid in
diagnosing intra-abdominal disease of in-
2 flammatory or hemorrhagic origin. It is not
I
n~(,OIlIllI('nd('d if large, well-defined, Ilon-
5
inflammatory ova nan masses are pres-
I
ent.
Forty-thrce (-t I. 7 per cent) of the cultures
yidded no growth as compared with 31.4
per cent reported by Pedowitz and Bloom-
field ." We arc in agrcemcnt with the results
of ()thcrs~' r•• G that the coliform organisms
ac('ounted for thl' largest group of bacterial
agents cultured from the absccss contcnts.
N c;I'Jt'I'ia {:ollOrr/lIJl'aC was directly implicated
in but OIlC case; howe\'Cr, it is difficult to
deterlllille the role that this organism could
sevcrely ill patients is difficult to in-
terpret.
At the time of operation, purulent exudate
in the abdomen must be removed as well as
the affected pelvic organs. A search must be
made for pocketing of such exudate in in-
1
testinal loops, the diaphragmatic area, and
7
the liver and splenic area.
4
A large portion of our patients with rup-
tured tuboovarian absccss revealed a history
of prcvious treatment for pelvic infections
which by our standards seemed inadequate
in dosage and duration. Indced, the typical
disease pattern was one of relapse, reinfec-
tion, abscess formation, and rupture. It has
been our expericnce that specific antibiotic
therapy must be continued beyond the abatc-
mcnt of symptoms, lasting at least 2 to 3
weeks. Discontinuance of antibiotics as symp-
toms regress frequently leads to subsequent
exaccrbations.
In 1959 we intcnsified our efforts toward
an earlier operative approach to this prob-
lem and in the 39 cascs handled through
1964 we were rewarded with a reduction in
the mortality rate to 5.12 per cent, compared
to the over-all mortality of 8.6 per cent.
436 Mickal, Sell mann, and Beebe
REFERENCES
1. Collins, C. G., Nix, F. (; .. and Cerrha. II. T.:
AM. J. OUST. & Gy:o-:t:r. . 72: 820, 19'>6.
2. Pedowitz, P .. and Bloomfil'ld, R. D.: A~1. J.
OUST. & GYNEC. 88: 721. 1964.
3. Lowrie, R. J., and Kron, W. L.: AM. J. OUST.
& GYNEC. 62: 454.1951.
4. Lardaro, H. H.: J A. M. A. 156: 699, 195·L
Ft"b.llary I , 1968
.-\111. j. Ob•• . & Gyntt.
",. Anden"n. (;. \' .. and BlIl'klcw, W . B.: West.
J. Sur~. 70: 67. 1962.
6. Schril'r. P. c.. :\dams. J 0 .. and E\'('rt'tt, B. E.:
South . ~f. J. :,0: 1·17:1, 19'>7.
1542 Tulan, Avmue
X'IL' O,ltanl, Louisiana iOll2