Oophoritis

INTRODUCTION ¡@

Background: Oophoritis, which means “inflammation of the ovary,?is an uncommonly used term for pelvic inflammatory disease. This is an ascending infection of the ovaries that is a major cause of female infectious morbidity, ectopic pregnancy, and sterilization. Oophoritis is a clinically diagnosed disease that must be distinguished carefully from other causes of abdominal pain.

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Pathophysiology: Infection ascends from bacterial colonization of the cervix and extends to the uterus, fallopian tubes, and the ovary. Gonorrhea and Chlamydia typically are colonized from the cervix in cases of oophoritis, but these pathogens are rarely isolated in ovarian tissue. Rather, these organisms facilitate other bacteria to infect the adnexa. If left untreated, an abscess may form around the fallopian tubes and ovary, known as a tubo-ovarian abscess (TOA).

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Frequency:
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Mortality/Morbidity: Mortality statistics are unknown due to under-reporting of this disease. The major morbidities are the long-term risk of ectopic pregnancy, infertility, and chronic pelvic pain.

Age: Oophoritis most commonly occurs in women younger than 25 years.

CLINICAL ¡@

History:

Physical:

Causes:

DIFFERENTIALS Section 4 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic

Adnexal Tumors
Appendicitis
Cystitis, Nonbacterial
Diverticulitis
Ectopic Pregnancy
Gastroenteritis, Bacterial
Gastroenteritis, Viral
Mesenteric Lymphadenitis
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Other Problems to be Considered:

Adnexal torsion

WORKUP ¡@

Lab Studies:
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Imaging Studies:
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Other Tests:
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Histologic Findings: For cases evaluated by surgery, an abscess involving the fallopian tubes and ovaries may be seen.

TREATMENT ¡@

Medical Care: Outpatient treatment is appropriate for patients who are (1) hemodynamically stable, (2) reliable to return for follow-up care, (3) immunocompetent, (4) not pregnant, (5) cannot tolerate oral medication due to nausea and vomiting, or (6) have no evidence of a TOA.

Inpatient treatment is required for patients who (1) have already failed outpatient treatment, (2) are pregnant, (3) are infected with HIV, or (4) have evidence of a TOA.

Surgical Care: Oophoritis may be managed with surgery when medical treatment has shown no amelioriation of symptoms after 48-72 hours. Surgical options may include laparoscopy with drainage of the abscess, removal of adnexa, and total abdominal hysterectomy-bilateral sagittal oophorectomy (TAH/BSO). Factors that influence the type of surgery used include the extent of the abscess, the degree of immunocompromise of the patient, and preservation of fertility for future child bearing potential. Interventional radiology can sometimes be used for drainage of abscesses in patients who are not surgical candidates.

Consultations: Obstetrics and gynecology consultations can be made for follow-up care and surgical consultation, if needed.

Diet: No changes are necessary. Nothing is to be taken orally (NPO) if anticipating surgical treatment.

Activity: As tolerated

MEDICATION ¡@

The goals of pharmacotherapy are to reduce morbidity, prevent complications and eradicate the infection.
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Drug Category: Antibiotic -- Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Drug Name
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Ceftriaxone (Rocephin) -- Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Considered first-line treatment (in conjunction with doxycycline) for outpatient management of PID.
Adult Dose 250 mg IM once
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal impairment; caution in breast-feeding women and allergy to penicillin
Drug Name
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Doxycycline (Vibramycin) -- Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Used in conjunction with ceftriaxone or cefoxitin for outpatient treatment of PID.
Adult Dose 100 mg PO bid for 14 d
Pediatric Dose <8 years: Not recommended
>8 years: Not established
Contraindications Documented hypersensitivity, severe hepatic dysfunction
Interactions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy D - Unsafe in pregnancy
Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 years) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines
Drug Name
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Cefoxitin (Mefoxin) -- Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin. For inpatient treatment of PID, cefoxitin and doxycycline in conjunction are considered first-line therapy.
Adult Dose 2 g IV q6h until clinical improvement for 48-72 h
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
Drug Name
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Gentamicin (Garamycin) -- Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Gentamicin and clindamycin are second-line agents for inpatient treatment of oophoritis.
Adult Dose 2mg/kg loading dose IV, then 1.5 mg/kg IV q8h; continue until clinical improvement for 48-72 h
Pediatric Dose Not established
Contraindications Documented hypersensitivity, non–dialysis-dependent renal insufficiency
Interactions Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Drug Name
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Clindamycin (Cleocin) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Used in conjunction with gentamicin as second-line treatment for oophoritis.
Adult Dose 900 mg IV q8h; continue until clinical improvement for 48-72 hrs
Pediatric Dose Not established
Contraindications Documented hypersensitivity, regional enteritis, ulcerative colitis, hepatic impairment, or antibiotic-associated colitis
Interactions Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Drug Name
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Ampicillin (Marcillin, Omnipen) -- Used in conjunction with gentamicin and clindamycin for added enterococcus coverage. Usually added if gentamicin and clindamycin do not yield the desired clinical result.
Adult Dose 2 g IV q6h
Pediatric Dose None reported
Contraindications Documented hypersensitivity
Interactions Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
FOLLOW-UP ¡@

Further Inpatient Care:
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Further Outpatient Care:
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Transfer:
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Prognosis:
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MISCELLANEOUS ¡@

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Special Concerns:
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BIBLIOGRAPHY ¡@