Tubo-ovarian abscess (TOA) image

Tubo-ovarian abscess (TOA)


  • Tubo-ovarian abscess is an infectious complex in one adnexa or both
    • Can involve structures beyond the tube and ovary, including bowel and bladder  
    • Most commonly from a polymicrobial ascending genital tract infection   
  • TOA commonly presents with abdominal pain, fever, leukocytosis and vaginal discharge and, if severe, can be life-threatening  
  • Differential includes  
    • Appendicitis | Diverticulitis | Ovarian torsion | IBD | Ectopic pregnancy | Ovarian mass | Pyelonephritis 
  • Historically, IUD was thought to be an independent risk factor  
    • Recent studies negate IUD as an independent risk factor  
    • Only slightly increased risk at the time of insertion and subsequent 1 to 3 weeks 
  • Untreated TOA can result in sepsis, tissue necrosis and agglutination of pelvic structures causing long term scarring and adhesive disease 

Note: TOA requires urgent inpatient medical treatment 



  • Tubo-ovarian abscesses commonly result from a lower genital tract infection making its way from vagina or cervix into the uterus and then out to fallopian tubes and ovaries 
  • Common organisms include
    • E. coli | Streptococci | Prevotella | Bacteroides |Peptostreptococcus 
  • Rare organisms include
    • Mycobacterium | Actinomyces | Gonorrhea | Chlamydia 
  • The infection is almost always polymicrobial 
  • Most often a consequence of untreated PID
  • Risk Factors include
    • Reproductive ages between 15 to 40 | Sexually active | Prior history of PID | Rarely, can occur in postmenopausal patients and in patients without risk factors 


  • Acute onset of abdominal pain localized to lower quadrants | often worse with coitus or movements  
    • Systemic signs: Fever | Leukocytosis | Nausea | Dysuria | Vaginal discharge and/or bleeding   
  • Fitz-Hugh-Curtis: Rare, right upper quadrant pain worse with movement or breathing indicates disease that affects the peritoneum and adhesions on the liver capsule  
  • Symptoms can be subtle and fever is sometimes not present 

PID without TOA  

  • Ascending infection but has not yet resulted in abscess of the tubes or ovaries 
  • Managed outpatient unless the following is present
    • Surgical emergency such as appendicitis cannot be ruled out 
    • Pregnancy (early, after 12 weeks of pregnancy ascending infection is unlikely and appendicitis should be the lead differential) 
    • Severe illness with nausea, vomiting and high fever 
    • Unable to tolerate outpatient regimen 
    • Not responsive to oral treatment  
    • Unable to follow or tolerate an outpatient regimen 
    • Not responding to oral antimicrobial treatment 


  • Physical Exam findings 
    • Abdominal Exam | Tenderness to palpation in right/left or bilateral lower quadrants, rebound, guarding, or distension of the abdomen  
    • Pelvic Exam | Exquisite cervical motion tenderness | Cervical mucopurulent discharge, pain on pelvic exam 
    • If a ruptured TOA, patient can present with rigid abdomen and signs of sepsis 
  • Laboratory Studies  
    • Pregnancy test to rule out ectopic | CBC to assess leukocytosis | Blood cultures if concern for sepsis | Gonorrhea and chlamydia (from urine or cervix) 
    • Can consider erythrocyte sedimentation rate or c-reactive protein to confirm bacterial infection 
    • Possible endometrial biopsy if group A strep suspected or saline vaginal microscopy to confirm white cells 
  • Imaging Studies 
    • Ultrasound (transvaginal or abdominal) will show multilocular and complex tubo-ovarian masses or complexes with debris, septations and irregular wall thickness with possible debris in the pelvis 
    • CT (better when excluding appendicitis or other gastrointestinal etiology) demonstrating fluid-filled tubo-ovarian masses and thickened walls 
    • MRI similar findings to CT 

Medical Treatment  

CDC Guidelines for First-Line Parenteral Treatment 

  • Ceftriaxone 1 g IV every 24 hours PLUS doxycycline 100 mg orally or IV every 12 hours PLUS metronidazole 500 mg orally or IV every 12 hours


  • Cefotetan 2 g IV every 12 hours PLUS doxycycline 100 mg orally or IV every 12 hours


  • Cefoxitin 2 g IV every 6 hours PLUS doxycycline 100 mg orally or IV every 12 hours

CDC Alternative Parenteral Regimens

  • Ampicillin-sulbactam 3 g IV every 6 hours PLUS doxycycline 100 mg orally or IV every 12 hours


  • Clindamycin 900 mg IV every 8 hours PLUS gentamicin loading dose IV or IM (2 mg/kg body weight), followed by a maintenance dose (1.5 mg/kg body weight) every 8 hours | Single daily dosing (3–5 mg/kg body weight) can be substituted

After Hospitalization Discharge and Outpatient Considerations 

  • Transition to outpatient regimen following clinical improvement to complete 14 days of therapy
  • Following first-line parenteral treatment
    • Doxycycline 100 mg 2 times/day and metronidazole 500 mg 2 times/day
  • If using clindamycin and gentamicin alternative parenteral regimen
    • Clindamycin (450 mg orally 4 times/day) or metronidazole (500 mg orally 2 times/day) should be used to complete 14 days of therapy with oral doxycycline
  • Discharge criteria following inpatient admission 
    • Afebrile for 24 to 48 hours and able to meet activities of daily living 
  • Quinolone agents  
    • Due to quinolone-resistant N. gonorrhoeae, regimens with a quinolone agent are no longer routinely recommended for treatment    

Medical Treatment Failure

  • Proceed to surgical management if medical management fails
  • Signs of failed medical management include  
    • Signs of sepsis including respiratory or cardiac compromise or persistent fever  
    • Mass enlarging or markedly more painful  
    • Concern for malignancy especially in postmenopausal women presenting with presumed TOA 
    • Group A Strep infection requires hysterectomy (can be diagnosed on culture or endometrial biopsy) 

Percutaneous Drainage versus Surgical (Laparoscopy or Laparotomy) 

  • Percutaneous drainage has higher success rates if TOA is unilocular vs multilocular 
  • Laparotomy versus laparoscopy dependent on the skills and preference of the surgeon 
    • Obtain anaerobic and aerobic cultures 
    • Remove as much of the abscess cavity and surrounding debris  
    • Irrigate throughout the peritoneal cavity  
    • May consider a TAH/BSO in patient who has completed childbearing 
    • Close fascia with monofilament non-absorbable or delayed-absorbable suture and place closed suction drain like a Jackson-Pratt until fluid collection from drainage is minimal  

Long Term Sequelae 

  • Infertility, increased risk for ectopic pregnancy, pelvic thrombosis and chronic pelvic pain due to adhesive disease.  


Gil et al. Tubo-ovarian abscess in postmenopausal women: A systematic review. Gynecol Obstet Hum Reprod. 2020  

This systematic review assessed 9 studies to determine the prevalence rate of TOA in postmenopausal women 

  • Results 
    • The prevalence of TOA in this population was 6% to 18%  
    • Most common risk factor was a recent endometrial biopsy or a longstanding IUD (reported in up to 50% of cases) 
    • The rate of patients presenting with TOA and eventually diagnosed with malignancy varied from 2.5% to 47% 

Goje et al. J Minim Invasive Gynecol, 2020 

This systematic review assessed 10 studies to compare conservative management of TOA with antibiotics versus image-guided drainage versus laparoscopic drainage in a cohort of 975 patients  

  • Results 
    • Laparoscopic drainage: 11%  
    • Image-guided drainage: 42%  
    • Conservative management: 47%  
    • Authors found image-guided TOA drainage had the highest success, the lowest complication rate, and the shortest hospital stay  

Shigemi et al. Obstet Gynecol, 2019 

This retrospective cohort study compared laparoscopy vs laparotomy to manage patients with severe PID, including those with TOA 

  • Results 
    • 27,841 patients with PID | 749 women had laparoscopy and 3,670 had laparotomy 
    • Laparoscopic group had shorter operation duration, fewer blood transfusions, and shorter length of hospital stay vs laparotomy group 
    • There were no significant differences between groups for in-hospital deaths, surgical complications, and revision surgery 

Fouks et al. J Minim Invasive Gynecol, 2019 

The authors of this retrospective cohort study constructed a clinical risk score for TOA conservative treatment failure using a cohort of of 335 patients diagnosed with a TOA 

  • Results 
    • Their validated risk factors determined predictive of conservative treatment failure were: Age >35 | WBC count level > 16k | Largest TOA diameter >7cm | Presence of bilateral abscess on admission 


ACOG Practice Bulletin 174 

  • Aspiration of an adnexal mass may be appropriate in cases of tubo-ovarian abscess (although antibiotic therapy is first-line treatment)


  • TOA necessitates inpatient management 
  • Parenteral antibiotics should continue for 24 to 48 hours, or until afebrile and clinically improved 
  • Outpatient antibiotics should include metronidazole or clindamycin in addition to doxycycline to facilitate anaerobic coverage for minimum 14 days 


CDC: Pelvic Inflammatory Disease (PID)

ACOG Practice Bulletin 174: Evaluation and Management of Adnexal Masses

Surgical Intervention in Patients with Tubo-Ovarian Abscess: Clinical Predictors and a Simple Risk Score (Fouks et al. J Minim Invasive Gynecol, 2019)

Computed tomographic features of tuboovarian abscess (Hiller et al. J Reprod Med, 2005) 

Effectiveness and Adverse Events of Early Laparoscopic Therapy versus Conservative Treatment for Tubo-Ovarian or Pelvic Abscess: A Single-Center Retrospective Cohort Study (Chu et al. Gynecol Obstet Invest, 2019) 

Tubo-ovarian abscess management options for women who desire fertility (Rosen et al. Obstet Gynecol Surv, 2009) 

Pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and tuboovarian abscess (Chappell et al. Clin Obstet Gynecol, 2012) 

Early ultrasound-guided transvaginal drainage of tubo-ovarian abscesses: a randomized study (Perez-Medina et al. Ultrasound Obstet Gynecol, 1996)  

Outcomes of Minimally Invasive Management of Tubo-ovarian Abscess: A Systematic Review (Goje et al. J Minim Invasive Gynecol, 2020) 

Tubo-ovarian abscess in postmenopausal women: A systematic review. (Gil et al. J Gynecol Obstet Hum Reprod, 2020) 

Laparoscopic Compared With Open Surgery for Severe Pelvic Inflammatory Disease and Tubo-Ovarian Abscess (Shigemi et al. Obstet Gynecol, 2019)