Pelvic Abscess: Understanding the Causes, Symptoms, and Treatment Options

               PELVIC ABSCESS

Encysted pus in the pouch of Douglas is called 

pelvic abscess.

           Types of pelvic abscess 

Etiology:

Pelvic causes (common)

 Postabortal and puerperal sepsis.

 Acute salpingitis.

 Perforation of an infected uterus such as attempted 

uterine curettage in septic abortion or pyometra.

 Infection of pelvic hematocele usually following 

disturbed tubal pregnancy.

 Postoperative pelvic peritonitis following 

abdominal or vaginal operation.

 Irritant peritonitis following contamination of 

urine, bile, vernix caseosa, meconium (spilled 

during cesarean section), iodine containing dye 

used in hysterosalpingography or contents of 

ruptured ovarian cyst (sebum in dermoid cyst), etc.

Extrapelvic causes (rare)

Appendicitis, diverticulitis, ruptured gallbladder, 

perforated peptic ulcer usually produce generalized 

peritonitis. The condition may ultimately settle to 

the dependent pouch of Douglas and produces pelvic 

abscess.

  Meckel diverticulum in per abdomen 

Clinical features: 

Symptoms

- Spiky rise of high temperature with chills and

rigor.

- Rectal tenesmus—frequent passage of loose

mucoid stool.

- Pain lower abdomen—variable degrees.

- Urinary symptoms—difficulty or even retention

of urine.

Signs

General: The face is flushed with anxious look. Pulse

rate is raised out of proportion to temperature.

Per abdomen:

- Tenderness and rigidity in lower abdomen.

- A mass may be felt in the suprapubic region—

tender, irregular, soft, and resonant on percussion.

Per vaginam:

- The vagina is hot and tender.

- The uterus is pushed anteriorly; the movement of

the cervix is painful.

- A boggy, fluctuant, and tender mass is felt in the

pouch of Douglas.

-  A separate mass may be felt through the lateral

fornix.

Rectal examination defines precisely the mass in

the pouch of Douglas.

Investigations

Blood: There is high leukocytosis with increased

polymorphs.

Ultrasonographic view of pelvic abscess 

Bacteriological study: Swabs are taken from high

vagina, endocervical canal and from the pus. Culture is

done for both aerobic and anaerobic microorganisms.

Sensitivity of the microorganisms to antibiotics is also

to be detected.

 

Diagnosis

The diagnosis is easy in most of the cases but at

times confusion arises between pelvic hematocele

and pelvic abscess. Pelvic ultrasonography reveals

  Ultrasonographic view of pelvic abscess 

accumulation of fluid in the pouch of Douglas.

Examination under anesthesia (EUA) and puncture

of pouch of Douglas (culdocentesis) give the correct

diagnosis. Old blood comes out in the former and pus

in the latter.

Treatment

General:Systemic antibiotics should cover anaerobic

as well as aerobic microorganisms (broad spectrum):

Cefoxitin 1–2 gm IV every 6–8 hours and gentamicin

2 mg/kg IV per 24 hours and metronidazole 500 mg

IV 8 hourly are started. Antibiotic regimen may have

to be changed depending upon the sensitivity report.

Surgery: Posterior colpotomy is the definitive

surgery to drain the pus through posterior fornix. The

loculi should be broken with finger.

Laparotomy is done when the patient’s condition

deteorates despite aggressive management. In patients

with recurrent infection and with loss of reproductive

function total abdominal hysterectomy with bilateral

salpingo-oophorectomy is the preferred treatment.

The pus should be sent for culture and drug

sensitivity test.

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