INTRODUCTION — The female genital tract may be affected by ascending infection, either from sexually transmitted infections or vaginal flora. Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract, involving any or all of the uterus, fallopian tubes, and ovaries; this is often accompanied by involvement of the neighboring pelvic organs. It results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess (TOA).
PID may be complicated by a TOA, which is an inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs (eg, bowel, bladder); TOA may also occur without preceding PID . These abscesses are found most commonly in reproductive-age patients and typically result from upper genital tract infection. TOA typically occurs as a complication of PID.
TOA is a serious and potentially life-threatening condition. Aggressive medical and/or surgical therapy is required, and rupture of an abscess may result in sepsis. For patients with ruptured abscesses, current mortality rates have not been reported, but data from the 1960s suggest the rate may be as high as 1.7 to 3.7 percent [2-4]. The mortality rate approaches zero for abscesses that are not ruptured.
Treatment modalities for TOA include antibiotic therapy, minimally invasive drainage procedures, invasive surgery, or a combination of these interventions. The large majority of small abscesses (<7 cm in diameter) resolves with antibiotic therapy alone.
The management of TOA is reviewed here. The epidemiology, diagnosis, and evaluation of TOA are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)
Other manifestations of PID are discussed separately.
CLINICAL APPROACH — Antibiotics are the mainstay of treatment for TOA. In some patients, antimicrobial therapy must be combined with a minimally invasive drainage procedure or with surgery.
The availability of broad-spectrum antibiotics with excellent antimicrobial activity and abscess cavity penetration has revolutionized the primary treatment of nonruptured TOA. The advent of these antimicrobial agents reversed the dictum prior to the 1970s that all abscesses required drainage [5-8].
Patients who are immunosuppressed should be treated in the same manner as other patients; there are no data to support early surgical intervention in this patient population. Some data suggest that patients with HIV infection are more likely to have a complicated clinical course. However, treatment efficacy using the available approaches appears to be similar among HIV-infected and non-HIV-infected patients [9,10]. As an example, studies of TOA or pelvic inflammatory disease alone in patients with HIV infection do not suggest a benefit of early surgical treatment. (See "Pelvic inflammatory disease: Treatment in adults and adolescents", section on 'Patients with HIV'.)
Stable premenopausal patients — Most patients with TOA are candidates for management with antibiotics and are able to avoid surgery. We suggest antibiotic therapy alone as a highly successful strategy for patients who meet all of the following criteria:
●Hemodynamically stable with no signs of a ruptured TOA (acute abdomen, sepsis) that is maintained throughout the entire treatment course
●Continued clinical improvement while on the antibiotic regimen
●Abscess <7 cm in diameter
●Adequate response to intravenous antibiotic therapy
Abscess size is predictive of treatment success with antibiotics alone and of length of hospital stay. Early observational studies have reported that patients with abscesses measuring ≥9 cm in diameter on imaging appear to have a much higher likelihood of requiring surgical therapy compared with those with smaller masses (60 versus approximately 30 to 40 percent, respectively) [11,12]. Subsequent investigations have noted that the size of the abscess predictive of necessitating drainage is likely more in the range of 7 cm .
Thus, for most patients with a TOA ≥7 cm, we perform surgical exploration with incision and drainage. It is reasonable, however, to initiate antibiotic therapy alone in selected patients with large abscesses who are hemodynamically stable and have reasons to avoid surgery (eg, a history of pelvic surgery that suggests the presence of pelvic adhesions or desire to preserve fertility). In our practice, we evaluate these patients on a case-by-case basis and consider them candidates for antibiotics alone if there are no other indications for surgical intervention (eg, suspicion of abscess rupture, lack of response to antimicrobial therapy). In these cases, the patient should be counseled about the high risk that antimicrobial therapy will fail and that surgery will be required, as well as the risk of a worsening clinical condition while on antibiotics alone . In addition to antibiotics, these patient may benefit from image-directed drainage procedures. Drainage may lead to successful management, particularly when substantial amounts of inflammatory fluid can be drained from the abscess cavity.
Stable postmenopausal patients — The majority of TOAs are diagnosed in reproductive-age patients, but the finding of a TOA in a postmenopausal patient raises concern for the potential of an underlying malignancy.
Case series have reported that there is a high rate of malignancy among postmenopausal patients with TOA [14-17]. As an example, in one series, genital tract malignancy was found in 8 of 17 postmenopausal patients compared with 1 of 76 premenopausal patients .
Thus, postmenopausal patients with a presumed TOA should be counseled about the potential for malignancy and the possible need for a full staging procedure. For these patients, we suggest surgical exploration rather than treatment solely with antibiotics or a minimally invasive drainage procedure. For patients in whom there is a low suspicion of malignancy and who have been appropriately counseled about the possibility of malignancy, nonsurgical management is a reasonable option, and serial imaging studies are required to demonstrate complete resolution of the pelvic mass. If the mass does not resolve, surgery is required.
If a surgical approach is used in a postmenopausal patient, however, an intraoperative frozen section analysis of the adnexal mass should be performed. In addition, the pelvis and abdomen should be explored for evidence of metastatic disease. If malignancy is found, surgical staging should be performed by a surgeon with appropriate experience.
Patients with sepsis and/or ruptured abscess — Rupture of a TOA is a life-threatening emergency and requires prompt surgical intervention . Even in the absence of evidence of abscess rupture, surgical exploration and treatment are often advisable in any patient with overt signs of sepsis and a large abscess (≥7 to 9 cm).
Rupture is probably a misnomer, as the process is more like a leak, slow or fast; it is not typical for the abscess to burst open. Patients with a ruptured TOA classically present with an acute abdomen and signs of sepsis, although sepsis is not consistently present. Clinical findings suggestive of rupture include, but are not limited to, acute peritoneal signs, hypotension, tachycardia, tachypnea, or acidosis. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess", section on 'Ruptured abscess'.)
Antibiotics should also be started as soon as possible, either before or during the urgent operative intervention. In our experience, most patients who are acutely ill will not improve without surgical removal of the nidus of infection. Importantly, in an unstable patient with the presumptive diagnosis of abscess rupture, surgery should not be delayed for the administration of antibiotics.
ANTIBIOTIC THERAPY — TOA is treated with antibiotics, typically with initial therapy administered intravenously (IV) and as an inpatient . Outpatient and/or oral antibiotic therapy should be given to complete a course of therapy only if patients show substantial clinical improvement. Patients should be closely monitored to ensure successful treatment.
Antibiotic therapy alone (without image-guided drainage procedures and/or surgery) is effective in approximately 70 percent of patients [5-8,11,19-21]. This therapeutic approach is limited by the characteristics of abscesses (eg, relatively avascular, not easily permeated by antimicrobials, low pH). The rich ovarian blood supply may contribute to the relatively high rate of successful treatment with antimicrobial therapy.
Empiric regimen selection — While antibiotic regimens for TOA are similar to those for pelvic inflammatory disease (PID), there are additional considerations such as abscess wall penetration and data specific to TOA treatment. Thus, TOA treatment recommendations are not exactly the same as treatment recommendations for PID.
Treatment options include regimens using one, two, or three agents (table 1):
●Recommended parenteral regimens:
●Alternative parenteral regimens:
•Clindamycin (900 mg IV every 8 hours) plus gentamicin (2 mg/kg loading dose then 1.5 mg/kg every 8 hours IV or intramuscularly [IM]). For gentamicin dosing, single daily dosing may be substituted (3 to 5 mg/kg IV once per day).
These recommended and alternative regimens are consistent with those recommended by the Centers for Disease Control and Prevention (CDC) for the treatment of patients with PID .
●Additional regimens not listed above but that also provide appropriate coverage include:
•Ampicillin (2 g IV every 6 hours) plus clindamycin (900 mg IV every 8 hours) plus gentamicin (2 mg/kg loading dose then 1.5 mg/kg every 8 hours IV or IM). As above, a single daily dose of gentamicin may be used.
•Levofloxacin (500 mg IV once daily) plus metronidazole (500 mg IV every 12 hours). Consideration should be given to this regimen choice in areas with non-negligible rates of fluoroquinolone-resistant gonorrhea.
•Imipenem with cilastatin (500 mg IV every 6 hours).
All of the above listed regimens share the common characteristics of broad coverage for all associated bacteria, including coverage for the sexually transmitted pathogens (Neisseria gonorrhoeae and Chlamydia trachomatis, although these bacteria are rarely isolated from a TOA), as well as anaerobes, and superior abscess wall penetration [5,7,8,18,20-22]. It is still inconclusive whether additional antianaerobic coverage is needed above and beyond the second-generation cephalosporin. For this reason, the Centers for Disease Control and Prevention (CDC) guidelines for treatment of PID advise only selected use of metronidazole . If sexually transmitted pathogens are isolated from patients with TOA, clinicians should ensure that pathogen-specific therapy is included in the treatment regimen, and that sex partners are also treated. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess", section on 'Microbiology'.)
The majority of clinical data support the use of the regimens listed above and in the table (table 1). Data from head-to-head comparisons have shown nearly equivalent efficacy for the different regimens (approximately 70 percent and including patients with different size abscesses) [6,8,11,21]. Some data suggest that triple therapy is more effective than double therapy. A small series of patients with TOA reported that the treatment success rate was higher with a three-antibiotic regimen with ampicillin/clindamycin/gentamicin compared with two two-antibiotic regimens (clindamycin/gentamicin or cefotetan/doxycycline; 88 versus 47 or 34 percent) . Although this study did suggest higher efficacy among patients who received triple therapy, the small study size and noncomparative nature of the investigation suggest that further study is required before definitive conclusions can be made about superiority of three-antibiotic regimens.
Concern had been raised about potential resistance of bowel flora to cefotetan or to the closely related agent cefoxitin. Bowel flora are often involved in the TOA pathogenesis. This concern is based upon findings from a randomized trial that found that ertapenem was more effective than cefotetan at preventing surgical site infection in patients undergoing elective bowel surgery . However, even though infection with fluoroquinolone-resistant N. gonorrhoeae is theoretically a possible etiology of TOA, there are no data to support specifically targeting this pathogen. In addition, guidelines from the Infectious Diseases Society of America on management of intraabdominal infection suggest cefoxitin as a reasonable choice for cases with mild-moderate severity . Thus, cefotetan and cefoxitin remain first-line agents for treatment of TOA.
In addition to the standard regimens listed and suggested for use (due to years of data and successful use in clinical practice), newer agents that likely also have a role in the treatment of TOA, based on more limited investigation and known spectrum of action against pathogens causing serious intra-abdominal infections, include ertapenem (1 gram IV every 24 hours) or piperacillin-tazobactam (3.375 gram IV every 6 hours) [26-28].
The presence of drug hypersensitivities and risk factors for aminoglycoside toxicity (eg, renal insufficiency) are also relevant considerations when choosing a regimen. (See "Allergy evaluation for immediate penicillin allergy: Skin test-based diagnostic strategies and cross-reactivity with other beta-lactam antibiotics" and "Aminoglycosides", section on 'Toxicity'.)
Actinomyces or rare pathogens — Clinical experience suggests that pathogen-directed therapy should be included in the regimen in cases of TOA in which a culture demonstrates Actinomyces israelii. For patients with a TOA with this pathogen, we use one of the standard antimicrobial regimens for TOA (table 1) including a beta-lactam antibiotic (eg, ampicillin-sulbactam). When the standard regimen is complete, we continue treatment with penicillin for at least one additional month. Doxycycline may be used for patients with a penicillin allergy. There are no high-quality data regarding duration of therapy for this pathogen; most experts suggest three to six months of penicillin treatment.
Scattered case reports highlight the potential for an occasional unusual pathogen to be isolated from a TOA (eg, Candida spp., Pasteurella multocida, Salmonellae) [29-31]. These cases should be managed on a case-by-case basis, as these are not the usual endogenous genital tract flora found in the overwhelming majority of TOAs. Consultation with an expert in infectious diseases may be appropriate in such cases. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess", section on 'Microbiology'.)
Monitoring therapy — Patients require inpatient observation during initial therapy due to the serious nature of the infection, the potential for abscess rupture and ensuing sepsis, and occasional diagnostic uncertainty [5-8,19,23]. The CDC recommends at least 24 hours of inpatient observation; in our practice, we typically continue inpatient treatment and observation for 48 to 72 hours.
We generally perform daily white blood cell counts while we are monitoring response to therapy to assure our medical management is effective. We also repeat imaging studies approximately every three days and then less frequently if there is consistent clinical improvement. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess", section on 'Imaging studies'.)
Duration of therapy — The duration of antibiotic therapy required for treatment of a TOA is not well established. The duration depends upon several factors:
●When antibiotics alone are the chosen therapy, a minimum of 14 days is common practice. This is consistent with the CDC guidelines on the treatment for PID .
●When imaging-guided drainage procedures and/or extirpative surgery are used in combination with antimicrobial therapy, there are no data available to formally guide length of therapy. In our experience, 10 to 14 days of total antibiotic therapy is usually effective. The overall clinical scenario of each individual patient must also be taken into consideration in these decisions.
Most experts recommend continuation of antibiotic therapy until the abscess has resolved on follow-up imaging studies. This can sometimes require four to six weeks of total antibiotic therapy. In cases in which the patient is improving on antibiotics alone, but the abscess has not completely resolved, longer courses of outpatient antibiotics may be given. Cases that do not resolve with routine therapy are best managed in collaboration with an expert in infectious diseases.
Switching to oral therapy — Finishing the course of therapy with oral antibiotics as an outpatient is reasonable in select patients. When patients have demonstrated the criteria below, one can consider completion of the treatment in the outpatient setting. Candidates for outpatient therapy should meet all of the following criteria:
●Demonstrate clear clinical improvement – Afebrile for at least 24 to 48 hours, white blood cell counts that have normalized, improving abdominal symptoms with significantly less abdominal tenderness, etc.
●Able to tolerate oral medications.
●Able to comply with follow-up communication and appointments.
Oral antibiotic regimens for completion of TOA therapy in selected patients include (table 1):
●Amoxicillin-clavulanate XR (extended release: 2 g orally twice daily).
Patients who fail antibiotic therapy — After 48 to 72 hours of treatment with antibiotics alone, patients with TOA who do not respond or worsen require either minimally invasive abscess drainage or surgery. Antibiotics remain a cornerstone of therapy before, during, and after any abscess drainage procedure.
The criteria used to determine failure of treatment are:
●New onset or persistent fever
●Persistent or worsening abdominopelvic tenderness
●Enlarging pelvic mass
●Persistent or worsening leukocytosis
C-reactive protein (CRP) level trends can also be used as a determinant of failed medical therapy [32-34]. In a prospective cohort study of 94 patients with PID, CRP levels >49.3 mg/L were found to be a strong laboratory predictor of TOA (85 percent sensitivity and 93 percent specificity), and increasing CRP values during hospitalization were an indicator of failed medical therapy and the need for surgical intervention .
Models that predict the likelihood of antibiotic treatment failure for TOA have been described. In one such model, temperature >38.2°C at hospital admission, CRP level >243 mg/L, and TOA diameter ≥8 cm were all associated with higher rates of failed antibiotic therapy .
There are no high-quality data to guide whether to proceed with minimally invasive imaging-guided drainage procedures or surgery for patients who do not clinically improve. The largest clinical series evaluating failure of antibiotics for TOA used surgical intervention as the reference standard .
For patients who do not worsen, but fail to clearly improve on antibiotics alone, an imaging-guided percutaneous drainage procedure appears to be appropriate.
For patients who are clearly clinically worsening using the clinical parameters listed, in our institution, we generally move promptly to surgery. In addition, surgical intervention is required in patients who are not improving on antimicrobial therapy and in whom minimally invasive drainage is not feasible (eg, mass is multiloculated or difficult to access or a physician experienced in these procedures is not available) [36,37].
DRAINAGE AND SURGERY — Abscess drainage or surgery is required if a patient cannot be successfully treated with antimicrobials alone and/or there is suspicion of malignancy. This includes patients with one or more of the following characteristics: failed antibiotic therapy, ruptured abscess, suspected sepsis, or postmenopausal. The decision regarding drainage or surgery depends on the patient's clinical status. Suspected intra-abdominal rupture of a TOA is a life-threatening emergency and requires prompt surgical intervention . (See 'Clinical approach' above and 'Patients who fail antibiotic therapy' above.)
Minimally invasive drainage procedures — Since the 1970s, various methods have been used successfully to drain intra-abdominal abscess collections without requiring surgery [5,7,8,36,37]. Procedures guided by either computed tomography or ultrasonography have been used, and a 70 to 100 percent success rate for adequate TOA drainage has been reported in case series [36-44]. As an example, a retrospective study of imaging-guided drainage procedures in 49 patients with TOA reported successful treatment without subsequent need for surgery in 74 percent of patients . In addition, a separate small, retrospective investigation suggests that early drainage of collections via percutaneous methods combined with antibiotic therapy may result in higher efficacy and shorter overall treatment duration when compared with antibiotics alone . Definitive conclusions await controlled study.
Studies have used varied anatomic approaches, including percutaneous, transvaginal, transrectal, and transgluteal. The approach and imaging modality used vary depending upon the exact location of the abscess, available technology, and experience of the physician performing the procedure. In all settings, any fluid that is aspirated should be sent to the microbiology laboratory for aerobic and anaerobic cultures.
In general, studies have reported higher success rates (defined as clinical improvement without the need for surgery) for drainage procedures in smaller, unilocular fluid collections . Thus, the multilocular nature of many complex TOA collections may lessen the success rate in clinical practice. Nevertheless, this innovative approach can be highly successful and will continue to grow in popularity and efficacy as more radiologists acquire the necessary skills to perform these procedures and as the radiologic technology continues to improve.
Prior to the availability of modern imaging-guided drainage procedures, gynecologists drained pelvic abscesses transvaginally through a posterior colpotomy. This procedure is most appropriate for posthysterectomy vaginal cuff abscesses that are in the lower pelvis and dissect to the rectovaginal septum. However, the usual location of a TOA is more superior in the pelvis and makes this a less viable drainage approach. Reports have also highlighted occasional onset of peritonitis and sepsis after use of this approach for a TOA . Thus, in most patients with TOA, this approach should be avoided.
Surgery — Laparotomy is the surgical route used by most gynecologic surgeons for treatment of TOA. The decision of which incision to employ is important, given the need for complete pelvic visualization. We often use either a Maylard transverse or vertical midline incision, given the improved exposure afforded by these incisions. (See "Incisions for open abdominal surgery".)
Some data suggest that a laparoscopic approach can be used successfully, primarily among patients with no evidence of a ruptured abscess [3,48]. In addition, a few modestly sized case series suggest improved outcomes while using a laparoscopic approach (compared with laparotomy), but definitive data are lacking given there are no well-controlled prospective investigations . The choice between laparoscopy and laparotomy depends greatly on the skill of the surgeon. Even in patients without evidence of rupture, a laparoscopic approach should be undertaken only by an experienced laparoscopic surgeon. Surgical treatment of TOA is often a complex procedure, given the extensive, common involvement of varied intra-abdominal organs and inflamed nature of the involved tissues.
The importance of involvement of experienced gynecologic surgeons cannot be overstated. Regardless of an open or laparoscopic approach, surgical cases involving TOA are notoriously challenging, given the anatomic distortion and friable tissue planes that universally exist from the extensive inflammatory process. It is not uncommon to also require the assistance of a surgeon experienced with bowel surgery. Appropriate preoperative arrangements assuring availability of operators possessing these skills are prudent. When the clinical scenario allows, preoperative bowel preparation is encouraged.
The steps of surgical procedure for TOA are the following:
●Confirm the diagnosis of TOA (picture 1).
●Remove as much of the abscess cavity and associated infectious/inflammatory fluid and debris as possible.
●Copiously irrigate the peritoneal cavity, thereby lessening the overall infectious/inflammatory burden to the patient.
Anaerobic and aerobic cultures should be obtained from the peritoneal cavity upon entry and of the fluid in the abscess cavity itself. Tissue specimen cultures collected and sent from the abscess cavity can likewise provide accurate microbiologic information. All removed tissues should be sent for pathologic evaluation. As noted above, a TOA is sometimes associated with malignancy, particularly in a postmenopausal patient.
The traditional approach had been to perform a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) to remove all infected tissue. While in some situations this is still the optimal approach, further investigations have validated unilateral salpingo-oophorectomy alone as an accepted and appropriate management for unilateral TOA [2,6,7,19]. This more conservative procedure not only has the added benefit of preserving fertility and hormonal function but also is technically less involved with generally lower overall surgical morbidity. Thus, we suggest a conservative approach in most patients, particularly in those who are premenopausal and who wish to preserve fertility.
In patients who are acutely ill and who have completed childbearing, complete extirpative surgery (TAH-BSO) is often the procedure of choice. In our experience, this more aggressive approach hastens complete recovery compared with less extensive surgical approaches. In addition, this eliminates the possibility of repeat surgery that is required in 10 to 20 percent of patients who undergo more conservative surgical interventions [2,6,7,19]. Consultation with clinicians experienced with the management of complicated cases of TOA is often helpful, if possible.
Given the high rates of wound infection from contamination of the surgical field ("dirty wound") generated from abscess cavity disruption, we often use the following measures, when appropriate [2,5,7,8,50]:
●Close the fascia with monofilament nonabsorbable or delayed-absorbable suture, leaving the skin and subcutaneous wound open for at least the early postoperative period (72 hours). The wound can then be managed with a delayed closure procedure or can heal by secondary intention. Many gynecologic surgeons will opt for primary skin closure in such patients, and this may also be a reasonable option for patients with extensive TOA surgery, although no direct evidence suggests the superiority of either approach. (See "Complications of abdominal surgical incisions", section on 'Delayed closure'.)
●Leave in a closed suction drain (eg, Jackson-Pratt) postoperatively until the patient demonstrates clinical improvement and the output from the drain is minimal.
Pregnant patients — TOA has rarely been reported in pregnant patients [51-56]. The approach to a pregnant patient with a TOA is similar to nonpregnant patients. Care should be taken to avoid medications that are potentially teratogenic (eg, quinolones). In addition, decisions regarding surgical care will depend in part upon the safety of surgery at a specific gestational age. (See "Anesthesia for nonobstetric surgery during pregnancy".)
Treatment of sexual partners — For patients with TOA who test positive for sexually transmitted infection, sexual partners should be notified of the need for evaluation and treatment. (See "Pelvic inflammatory disease: Treatment in adults and adolescents", section on 'Management of sex partners'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic infectious diseases (non-sexually transmitted)".)
SUMMARY AND RECOMMENDATIONS
●Clinical significance – A tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs (eg, bowel, bladder). These abscesses are found most commonly in reproductive-age patients and typically result from upper genital tract infection. TOA is a serious and potentially life-threatening condition; aggressive medical and/or surgical therapy is required. (See 'Introduction' above.)
●Patients with ruptured abscess – Rupture of a TOA occurs in approximately 15 percent of cases. Patients suspected of having a ruptured TOA or who present with signs of sepsis require immediate surgical exploration. Laparotomy appears to be the best route in these emergency cases. (See 'Patients with sepsis and/or ruptured abscess' above and 'Drainage and surgery' above.)
●Premenopausal patients – For premenopausal patients who meet all of the following criteria: hemodynamically stable with no signs of a ruptured TOA, abscess <7 cm in diameter, and adequate response to antibiotic therapy, we suggest treatment with antibiotic therapy alone (table 1) rather than imaging-guided drainage or surgery (Grade 2C). Treatment with antibiotics alone is also reasonable in patients with an abscess that is ≥7 cm who meet these criteria and are aware of the decreased efficacy of this approach in their clinical situation. (See 'Stable premenopausal patients' above.)
●Postmenopausal patients – For postmenopausal patients with a presumed TOA, we suggest surgical diagnosis and/or treatment rather than treatment solely with antibiotics or a minimally invasive drainage procedure (Grade 2C). The risk of concurrent gynecologic malignancy appears to be much higher among postmenopausal patients with TOA. For patients in whom there is a low suspicion of malignancy and who have been appropriately counseled about the possibility of malignancy, nonsurgical management is a reasonable option, and serial imaging studies are required to demonstrate complete resolution of the pelvic mass. (See 'Stable postmenopausal patients' above.)
●Patients who fail antibiotic therapy – For patients treated with antibiotics alone who show no improvement, but are not worsening, we suggest a minimally invasive abscess drainage procedure (Grade 2C). For those on antibiotic therapy who are clinically worsening, we suggest surgical treatment (Grade 2C). Antibiotic therapy should be maintained in combination with these additional interventions. (See 'Patients who fail antibiotic therapy' above.)
●Surgery – The choice of an open or laparoscopic surgical approach in surgery for a nonruptured TOA is largely based on operator skill, experience, and ability to perform the necessary surgical maneuvers given the anatomic distortion. (See 'Surgery' above.)
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