Review Question - QID 103412

This patient has cervical motion tenderness, cervical purulence, and an ultrasound demonstrating a loculated fluid collection which are concerning for a tuboovarian abscess (TOA). The most appropriate initial step in management is cefoxitin, doxycycline, and metronidazole (for presence of TOA).

Pelvic inflammatory disease (PID) is diagnosed clinically with cervical discharge and cervical motion tenderness. A low threshold for diagnosis is typically kept due to complications of untreated PID, including infertility and adnexal scarring. Tuboovarian abscess should be suspected in the setting of PID and the appreciation of adnexal fullness. The diagnosis can further be confirmed with a transvaginal ultrasound or a CT scan. Treatment involves IV antibiotics such as cefoxitin and doxycycline which cover for anaerobes, Neisseria gonorrhoeae, and Chlamydia trachomatis while also penetrating the abscess wall effectively. Presence of TOA necessitates the addition of clindamycin or metronidazole to provide even more effective anaerobic coverage than doxycycline alone. If the lesion is large or persistent, surgical drainage may be indicated.

Figure A is the physical exam finding of cervicitis which demonstrates purulence exiting the cervix. Figure/Illustration B is an ultrasound with a loculated fluid collection (red circle) which is concerning for a tuboovarian abscess.

Incorrect Answers:
Answer 2: Ceftriaxone and azithromycin is the appropriate treatment of cervicitis which this patient has given her cervical motion tenderness and purulence draining from the cervix. It is insufficient coverage for a TOA as it does not cover anaerobes nor does it penetrate the abscess wall as effectively.

Answer 3: Levofloxacin and metronidazole is an outpatient treatment regimen for uncomplicated pelvic inflammatory disease; however, it would be insufficient in this ill patient with a TOA.

Answer 4: Metronidazole alone is appropriate treatment of bacterial vaginosis (foul and fishy odor from the vagina with a white discharge and clue cells) and trichomoniasis (frothy green discharge with a strawberry cervix and pruritus). It is also considered in PID if tuboovarian abscess is present.

Answer 5: Surgical drainage may be indicated for large or persistent TOAs; however, it would not be the preferred initial management of a TOA in this patient.

Bullet Summary:
Tuboovarian abscess should be treated with an appropriate antibiotic regimen (such as cefoxitin, doxycycline, and metronidazole/clindamycin) and surgical drainage if persistent or large.