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Low-Invasive Imaging Guided Treatment of Tubo-Ovarian Abscess Malkhaz Mizandari, MD, PhD Ultrasound Education Centre GEOJEFF State Medical University Tbilisi, Georgia

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Etiology-Pathogenesis TOA is a complication of PID (15.0 to 30.0% of cases) (15.0 to 30.0% of cases)Pathogenesis Ascending lower genital tract infection Ascending lower genital tract infection Tube epithelium inflammation and necrosis Tube epithelium inflammation and necrosis a) Altered pH a) Altered pH b) Devitalized or necrotic tissue from infection b) Devitalized or necrotic tissue from infection c) Impaired blood supply from edema c) Impaired blood supply from edema d) Pathogenic organism growth d) Pathogenic organism growth

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Diagnosis - Diagnosis - Clinical Findings Pain in Small Pelvis High Temperature Vaginal Discharge (Purulent) Painful Mass in Adnexal Region Tenderness or Pain of Cervix on Physical Examination

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Diagnosis - Imaging UltrasoundCT MR imaging

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Ultrasound Diagnosis Ultrasound Diagnosis Irregularly Shaped Mass in Adnexa Thick Walls Complex Mass (Predominantly Cystic) Internal Septi Internal Septi Fluid-Fluid Level Fluid-Fluid Level Fluid-Debris level Fluid-Debris level Gas (Gas-Forming Microorganizms) Gas (Gas-Forming Microorganizms) Often Adnexal Region Occupied Bilaterally Often Adnexal Region Occupied Bilaterally

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Microbiology The Most Common Primary Causes: a) Chlamydia trachomatis a) Chlamydia trachomatis b) Neisseria gonorrhea b) Neisseria gonorrhea Less Common Gardneralla vaginalis, Peptostreptococcus sp, Streptococcus agalectiae, Ureaplasma sp, Mycobacterium tuberculosis, Haemophilus influenzae, Actinomyces Gardneralla vaginalis, Peptostreptococcus sp, Streptococcus agalectiae, Ureaplasma sp, Mycobacterium tuberculosis, Haemophilus influenzae, Actinomyces Supplemented Infection Escherichia Coli Escherichia Coli

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Treatment Medical (Broad Spectrum Antibiotics for PID ) TOA - Content Evacuation: Surgery Surgery Surgical options include laparoscopy or laparotomy with unilateral adnexectomy or total abdominal hysterectomy with bilateral oophorectomy Surgical options include laparoscopy or laparotomy with unilateral adnexectomy or total abdominal hysterectomy with bilateral oophorectomy Low-Invasive Low-Invasive Intervention Intervention Imaging guided percutaneal or endocavity aspiration/drainage: Imaging guided percutaneal or endocavity aspiration/drainage: a) CT b) Ultrasound c)Combined (Ultrasound- Fluoroscopy) a) CT b) Ultrasound c)Combined (Ultrasound- Fluoroscopy)

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Invasive Ultrasound - Advantages No Ionizing Radiation Real-Time Technique Doppler Capability Puncture Aiming and Needle Movement Guidance Capability Abdominal and Endocavity Approach Cost-Saving

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Material and Methods TOA 28 patients Percutaneal approach (Drainage) 4 patients Perrectal approach (Aspiration, Rinsing) 4 patients Pervaginal approach (Aspiration, Rinsing) 22 patient (Note all patients received antibiotics according the findings of bacteriology of aspirated material)

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Procedures Rinsing (Saline and Antiseptics) was performed to all patients Proteolythic Enzyme Injection was performed to 6 patients because of inadequate rinsing due to TOA Septi and viscous content 6 patients because of inadequate rinsing due to TOA Septi and viscous content Single Procedure - 7 patients total (2 percutaneal drainages and 5 aspirations) 2 procedures 10 patients (among them 1 after percutaneal drainage) 3 and more procedures 11 patients (among them 1 after percutaneal drainage)

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Abdominal vs. endocavity approach - Indications Abdominal vs. endocavity approach - Indications Abdominal Approach Relatively Big Mass, Fixed to Anterior Abdominal Wall (advantage Drainage Easily Performed) Rectal Approach Big Amount of Purulent Vaginal Discharge, Painful Vaginal Examination, Virgo Patient Vaginal Approach Small Masses Easily Achievable for Puncture

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Needle Inserted in TOA

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Saline Injection

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Rinsing (Bubbles in TOA cavity)

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Betadine Injected

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Aspiration (Cavity is Collapsing)

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Aspiration (Cavity Collapsed)

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Results Positive Result was Achieved in 27 (96.6%) cases Open Surgery Required (Total Abdominal Hysterectomy with Bilateral Oophorectomy) 1 (3.4 %) case

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Summary Low-Invasive Treatment (LIT) under Imaging Guidance Control Is Safe, Effective and Cost- Saving Technique Low-Invasive Treatment (LIT) under Imaging Guidance Control Is Safe, Effective and Cost- Saving Technique LIT is Easily Tolerated by Patients (Multiple Procedures) Combination of Percutaneal Drainage and Endocavity Aspiration Might Be Helpful LIT Should Be Used as a First Choice Treatment Procedure in TOA Patients Management

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