Oophoritis

INTRODUCTION

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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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• In the US: One million cases are reported per year.

• Internationally: Unknown

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.

CLINICAL

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History:

• Abdominal pain

• Pelvic pain

• Vaginal discharge

• Dyspareunia

• Fever

• Chills

• Nausea/vomiting

Physical:

• Temperature greater than 38C

• Abdominal tenderness in lower quadrants

• Rebound tenderness (possible) on pelvic exam

• Mucopurulent discharge

• Cervical motion tenderness

• Adnexal tenderness

• Adnexal mass (if TOA present)

Causes:

• Unprotected sexual intercourse

• Multiple sexual partners

• High-risk sexual behavior

• Immunosuppression

• Recent instrumentation of genital tract (endometrial biopsy, intrauterine device [IUD] placement)

WORKUP

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Lab Studies:
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• CBC - Elevation of the white blood cell count (WBC) to more than 10 K is a nonspecific indicator of infection. Early in the onset, however, the WBC may be normal.

• Urinalysis - To rule out cystitis

• Urine pregnancy test - To rule out ectopic pregnancy

• Wet prep of cervical discharge - Shows numerous WBCs and bacteria

• Cervical cultures for gonococcus (GC) and Chlamydia - To rule out or diagnose and treat infection with these organisms (immediate results will not be available).

Imaging Studies:
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• Pelvic ultrasound may be needed if the physical exam does not allow for a thorough palpation of the adnexa. This occurs commonly because patients guard due to the pain they experience. An ultrasound examination will rule out presence of a TOA. However, if a TOA is not present the ultrasound will probably not be helpful.

Other Tests:
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• Diagnostic laparoscopy is the definitive test, usually reserved when diagnosis is unclear.

• Perform serologies for hepatitis B virus, hepatitis C virus, syphilis, and HIV, since these can be found in patients engaging in high-risk sexual behaviors.

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

TREATMENT

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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.

MEDICATION

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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.

FOLLOW-UP

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Further Inpatient Care:
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• Continue IV antibiotics until afebrile for 24 hours. If patients are placed on gentamicin and clindamycin and do not respond to this antibiotic coverage, add ampicillin to provide coverage for Enterococci.

Further Outpatient Care:
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• Arrange for follow-up visit within 5 days of treatment (outpatient) or from discharge from hospital (inpatient) to evaluate success of treatment. Pain may take 7-10 days to abate.

In/Out Patient Meds:
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• Continue patients on doxycycline for a total of 14 days. NSAIDs can be used for pain control.

Transfer:
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• Usually not necessary

Deterrence/Prevention:
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• Fully evaluate the male sexual partner of a patient with pelvic inflammatory disease (PID) for sexually transmitted disease (STD). Initiate appropriate treatment based on the results of the testing.

Complications:
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• Ruptured TOA is a surgical emergency with high mortality. Aggressive surveillance for the presence of a TOA and prompt inpatient medical management is required. Suspect ruptured TOA if the patient has increased peritoneal signs and a rigid abdomen.

• Infertility will occur in 12-15% of women after 1 episode of PID.

• Ectopic pregnancy is increased with PID. Patients should be counseled regarding this and should seek early prenatal care if they subsequently become pregnant.

• Chronic pelvic pain is a possible long-term consequence of PID. The mechanism of pain is presumably secondary to adhesive disease.

Prognosis:
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• If no TOA is present, 90% of patients with PID will respond to medical therapy. If a TOA is smaller than 7 cm, most will respond to IV antibiotics alone.

MISCELLANEOUS

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Medical/Legal Pitfalls:
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• Failure to diagnose PID at an early stage may lead to TOA and added morbidity.

• Missing a TOA when present and mistakenly treating on an outpatient basis can lead to a ruptured TOA and the requirement for major abdominal surgery.

Special Concerns:
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• Pregnancy

• Oophoritis in pregnancy is very uncommon.

• A consultation with an obstetrician/gynecologist is required immediately if this diagnosis is suspected in pregnancy.

• Pediatrics

• Children rarely have this condition.

• If PID is suspected in an adolescent patient, the provider must have a high suspicion for sexual abuse.

• Geriatrics: Elderly patients with PID are more likely to have an associated genital tract malignancy such as ovarian cancer or endometrial cancer.