PELVIC ABSCESS
Encysted pus in the pouch of Douglas is called
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.
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.
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
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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