Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: A study of 302 cases

American Journal of Obstetrics and Gynecology (2005) 193, 1323 30 www.ajog.org GENERAL OBSTETRICS AND GYNECOLOGY: GYNECOLOGY Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: A study of 302 cases Knut Gjelland, MD, a Erling Ekerhovd, MD, PhD, b Seth Granberg, MD, PhD c Department of Obstetrics and Gynecology, Ultrasound Laboratory, Haukeland University Hospital, a Bergen, Norway; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, b Go teborg, Sweden; Ultrasound Unit, Karolinska University Hospital, c Stockholm, Sweden Received for publication January 27, 2005; revised May 18, 2005; accepted June 1, 2005 KEY WORDS Transvaginal aspiration Ultrasonography Treatment Tubo-ovarian abscess Objective: Our purpose was to evaluate the effectiveness and safety of transvaginal ultrasoundguided aspiration together with antibiotic therapy for treatment of tubo-ovarian abscess. Study design: A review of women treated with transvaginal ultrasound-guided aspiration for tubo-ovarian abscess at Haukeland University Hospital, Bergen, Norway, between June 1986 and July 2003 was performed. Immediate clinical response and longer-term follow-up results were assessed. Results: A total of 449 transvaginal aspirations were performed on 302 women. A total of 282 women (93.4%) were successfully treated for transvaginal aspiration of purulent fluid, together with antibiotic therapy. In the other 20 women (6.6%), surgery was performed. The main indications for surgery were diagnostic or therapeutic uncertainty, such as suspected residual tubo-ovarian abscess or pain. No procedure-related complications were diagnosed. Conclusion: Transvaginal ultrasound-guided aspiration combined with antibiotics is an effective and safe treatment regimen for tubo-ovarian abscess. The high success rate indicates that it should be a first-line procedure. Ó 2005 Mosby, Inc. All rights reserved. Pelvic inflammatory disease refers to infection of the uterus, fallopian tubes, and adjacent pelvic structures. 1 It has been estimated that in the United States 10% to 15% of women in their reproductive years have at least 1 episode of inflammatory disease of the tubes. 2,3 If the infection is inadequately treated, complications such as pyosalpinx or tubo-ovarian abscess may occur. The classic treatment of tubo-ovarian abscess used to be hysterectomy with bilateral adnexectomy, a procedure which, though it offered high cure rates, resulted in hormone deficiency and left young women without Reprints not available from the author. reproductive potential. Today, with the availability of broad-spectrum antibiotics and the improvements of diagnostic techniques, treatment of tubo-ovarian abscess has changed dramatically. Because most women with tubo-ovarian abscess are of reproductive age, the primary aim of management is to be as conservative as possible. Medical treatment alone is successful in only 34% to 87.5% of patients with pelvic abscess. 4 Surgical intervention, either laparoscopy or laparotomy with drainage of abscess and excision of infected tissue, is normally performed in cases of diagnostic uncertainty or when medical therapy is inadequate. Ultrasound-guided drainage of pelvic abscesses has been described as an alternative to surgery. 5-9 0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.06.019

1324 Gjelland, Ekerhovd, and Granberg Figure 1 Tubo-ovarian abscess imagined by transvaginal ultrasonography. Presence of intraovarian fluid representing purulent material is seen. The dotted line is the guide line for transvaginal aspiration. Transvaginal ultrasonography, as part of the gynecologic examination, is normally performed on all women admitted to hospital with lower abdominal pain because it provides information of high diagnostic accuracy. The sonographic markers of a tubo-ovarian abscess are typical and reproducible, and have been described in detail. 10 The transvaginal approach provides a direct route from the vagina into the cul-de-sac or adnexal regions where tubo-ovarian abscesses are normally located. 11 Only a limited number of reports on transvaginal drainage of tubo-ovarian abscess have been published. 5-9 The number of patients examined in these studies is relatively low. It has also been suggested that transvaginal ultrasound-guided aspiration provides a less effective drainage of large abscesses compared with laparoscopy and that small pockets of pus are virtually nondetectable by ultrasonography. 12 Thus, at present there is controversy over the optimal treatment regimen when tubo-ovarian abscess is diagnosed. This report describes the effectiveness and safety of transvaginal ultrasound-guided aspiration combined with intravenous antibiotics for treatment of tubo-ovarian abscess during a period of 17 years. Material and methods The study population consisted of 302 consecutive women admitted to the Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway, between June 1986 and July 2003. All patients underwent ultrasonography in the emergency department or within 24 hours after admission to the hospital. The sonographic diagnosis of tubo-ovarian abscess was based on the demonstration of a unilocular or multilocular cystic mass filled with particulate fluid and with a maximal diameter of at least 3 cm in a patient with clinical signs and symptoms of a pelvic infection (Figure 1). Because many of the patients included in the study were treated for tubo-ovarian abscess before 1998, we were not able to use the sonographic criteria suggested by Timor-Tritsch et al. 10 The maximal diameter of the cystic structure was measured for assessment of tuboovarian abscess size. In addition, existence of bilaterality of abscesses was registered. Intravenous antibiotic therapy was initiated as soon as the diagnostic conclusion was reached. All patients were treated with 1 of the following 2 antibiotic regimens: (1) doxycycline 100 mg intravenously (IV) every 12 hours, plus metronidazole 500 mg IV every 8 hours, or (2) cefuroxim 1.5 g IV every 8 hours, plus metronidazole 500 mg IV every 8 hours. The duration of antibiotic treatment until transvaginal aspiration of pus ranged from a few hours to 5 days. Transvaginal ultrasound-guided aspiration of purulent abscess material was performed with the patient placed in the lithotomy position with the legs in stirrups. Sedatives or analgesics were administered only if the patient preferred such medication. The vagina was cleansed with chlorhexidine-soaked swabs held with surgical sponge holders. The endovaginal probe was covered with a sterile glove and a needle guide was mounted on the probe. A 300-mm long needle (SweMed, Mölndal, Sweden) with an outer diameter of 1.6 mm and a lumenal diameter of 1.3 mm connected to a syringe was in most cases used for the transvaginal aspiration. Purulent fluid was aspirated until no fluid could be visualized by ultrasonography. If the abscess could not be completely emptied or the pus was found to be too viscous for aspiration, 0.9% sterile saline solution was injected into the abscess. Injection of saline solution made the aspiration of pus easier, and irrigation of the abscess cavity was continued until it was completely emptied. Transvaginal aspiration was repeated if a substantial amount of abscess material was seen by ultrasonography 2 or 4 days after the initial aspiration. Aspirated volume of pus was in each case registered. Direct microscopy, cytologic examination as well as aerobic and anaerobic cultures of aspirated abscess material were routinely performed. For ultrasound examination and transvaginal aspiration of purulent fluid, a General Electric RT-3600 ultrasound machine (GE Medical Systems, Oslo, Norway) with a phased array 5 MHz vaginal probe was used until 1994. Between 1994 and 1998 a General Electric RT-400 machine (GE Medical Systems) with a 6.5-MHz curved vaginal probe was used. Since 1998 until July 2003, an ATL HDI 5000 (Philips Medical Systems, Oslo, Norway) with a 4-8 MHz curved vaginal probe was used. Pain relief, normalization of body temperature, and falling in white blood cell count, in addition to

Gjelland, Ekerhovd, and Granberg 1325 Figure 2 Transvaginal image showing 1 large intraovarian loculation (A). Image after transvaginal aspiration of purulent material (B). A small amount of the pyogenic material could not be aspirated as seen centrally in the image B. ultrasonographic findings were used as parameters for successful treatment. Parenteral therapy was continued until patients were afebrile for a minimum of 24 hours. Thereafter, oral therapy was administered for approximately 2 weeks. On the day of discharge, a complete pelvic examination was performed. Criteria for discharge from the hospital included the absence of or minimal residual adnexal tenderness, normal body temperature for at least 24 hours, and the ability to complete oral therapy. Treatment was considered to be unsuccessful if a patient continued to have significant pelvic pain or fever, a residual tubo-ovarian abscess was suspected, or a relapse of abscess was diagnosed within 3 months after aspiration. In these cases, surgery was performed under cover of IV antibiotic therapy. All patients were followed up for at least 3 years. For statistical comparison between women who were successfully treated with transvaginal aspirations and women who had surgery the c 2 test was used. Significance was set at P!.05. Results A total of 449 transvaginal aspirations were performed on 302 women (Table I). Purulent fluid was obtained in every case. The mean age of the women was 40.1 years, with a range of 15 to 86 years. Eighteen women (6.0%) were postmenopausal. The most common symptoms and clinical signs of pelvic inflammatory disease were lower abdominal pain (100%), adnexal or cervical excitation tenderness (94.4%), palpable mass at vaginal palpation (76.2%), and body temperature 38.0(C or higher (72.5%). Table I Location of abscesses, number of aspirations, mean volume of aspirated purulent fluid, and anesthetic used during transvaginal aspiration of tubo-ovarian abscesses in 302 patients Tubo-ovarian abscesses Location: Right sided (n) 109 (36.1%) Left sided (n) 110 (36.4%) Bilateral (n) 83 (27.5%) Mean size (cm) 7.3 (range 3.0-15.0) Number of aspirations: 1 197 (65.2%) 2 80 (26.5%) 3 15 (5.0%) O3 10 (3.3%) Volume of aspirated purulent fluid (mean; range): First aspiration (ml) 83.5 (10-1250) Second aspiration (ml) 65.4 (1-700) Third aspiration (ml) 26.8 (1-450) Total number of aspirations: 449 Anesthetic used during aspiration: No anesthetic (n) 153 (50.7%) Analgetic/sedative premedication 126 (41.7%) General anesthetic 20 (6.6%) Spinal/epidural anesthetic 3 (1.1%) The mean maximal diameter of the abscesses at ultrasonography was 77 mm, with a range of 30 to 150 mm. Thirty-three of the abscesses had a maximal diameter of more than 100 mm (Table I). In 197 women (65.2%), transvaginal aspiration was carried out 1 time only (Figures 2 and 3). Eighty women (26.5%) had 2 aspirations, whereas 3 aspirations were performed in 15 women (5.0%) and at least 4 aspirations

1326 Gjelland, Ekerhovd, and Granberg Figure 3 Transvaginal image showing 3 intraovarian loculations (A). Image after transvaginal aspiration of purulent material (B). The pyogenic material was completely aspirated as seen in image B. Figure 4 Days until normalization of body temperature after transvaginal ultrasound-guided aspiration of pus from tuboovarian abscesses in 302 women. Figure 5 Days until achievement of pain relief, defined as no use of analgesics, after transvaginal ultrasound-guided aspiration of pus from tubo-ovarian abscesses in 294 of 302 women. Data from 8 of the women could not be obtained. in 10 women (3.2%). The mean volume of aspirated material at the first aspiration was 83.5 ml, with a range of 10 to 1250 ml (Table I). Typically, in women who had 2 or more aspirations, the greatest volume of aspirated material was at the first aspiration. Thereafter, a decrease in volume of aspirated material was registered for each aspiration performed (Table I). Treatment with broad-spectrum antibiotics and transvaginal aspiration was successful in 282 women (93.4%). In 234 women (77.4%) body temperature was normalized within 48 hours after the first aspiration (Figure 4). Complete pain relief, defined as no use of analgesic medication, was found in 188 women (62.3%) within 48 hours after the first aspiration (Figure 5). No major procedure-related complications, such as bowel perforation or bleeding, were diagnosed. In 20 women (6.6%), despite 1 to 4 transvaginal aspirations of purulent material, surgery was performed. The main indications for surgery were diagnostic or therapeutic uncertainty, such as suspected residual tubo-ovarian abscess or pain (Table II). One of the women turned out to have bilateral tubo-ovarian abscesses and not a left-sided abscess as diagnosed at the initial transvaginal ultrasonography. Three women had both bilateral endometriomas and a unilateral tuboovarian abscess as correctly diagnosed by ultrasonography. In 2 women, what was originally thought to be a unilateral tubo-ovarian abscess and bilateral tuboovarian abscesses, respectively, turned out to be a unilateral endometrioma and bilateral endometriomas when laparotomy was carried out. Another woman had a rightsided endometrioma in addition to a left-sided tuboovarian abscess. The endometrioma was not seen by ultrasonography and it was ultimately diagnosed when laparotomy was performed. In another woman, a fistula communicating between the previously aspirated tuboovarian abscess and rectum was diagnosed when surgery was carried out. Another woman had a multicystic rightsided ovary at follow-up 4 weeks after transvaginal aspiration of a left-sided tubo-ovarian abscess had been performed. Ovarian cancer was suspected and the woman underwent surgery. Histopathologic diagnosis showed ovarian adenocarcinoma. In the remaining 11 women

Gjelland, Ekerhovd, and Granberg 1327 Table II Ultrasound assessment, number of aspirations, indication for surgery, and histopathologic diagnosis in cases in which transvaginal aspiration was unsuccessful Patient number Ultrasound assessment Number of aspirations Indication for surgery Histopathologic diagnosis 1. TOA dxt 1 Pain TOA dxt 2. Residual TOA sin 2 Pain/fever TOA sin 3. TOA sin 1 Peritonitis TOA sin 4. Residual TOA dxt 2 Peritonitis TOA dxt 5. TOA bilat 1 TOA bilat TOA bilat 6. TOA sin 1 TOA sin TOA sin 7. TOA bilat 1 Pain TOA bilat 8. Residual TOA dxt 2 Pain/fever TOA dxt 9. TOA dxt 1 Appendicitis? TOA dxt 10. Residual TOA dxt 2 Residual TOA TOA dxt 11. Residual TOA dxt 2 Residual TOA TOA dxt 12. TOA dxt/endm bilat 1 Sepsis/peritonitis TOA dxt/endm bilat 13. Residual TOA sin 3 Pain ENDM sin 14. TOA bilat 1 Pain ENDM bilat 15. TOA sin/endm bilat 1 Pain/fever TOA sin/endm bilat 16. TOA sin/endm bilat 1 TOA sin TOA sin/endm bilat 17. TOA sin 2 Pain/fever TOA bilat 18. Residual TOA sin 4 Pain TOA sin/endm dxt 19. Residual TOA sin 3 Pain TOA dxt with fistula to colon 20. Multicystic ovary dxt 1* (sin) Ovarian cancer? Adenocarcinoma TOA, Tubo-ovarian abscess; ENDM, endometrioma; dxt, dexter; sin, sinister; bilat, bilateral. * Aspiration initially performed because of TOA sin. who had surgery, the initial tentative diagnosis at ultrasonography and histopathologic diagnosis proved to be the same (Table II). None of the women had a relapse of tubo-ovarian abscess during a follow-up period of at least 3 years. Patient tolerance of the transvaginal procedure was satisfactory. During the initial years of the study period general, spinal, or epidural anesthesia were used. Gradually, we became aware that the transvaginal aspiration procedure was not as painful as initially expected and following information about the procedure, most patients preferred to have only IV analgesic or conscious sedation only, or even no analgesic at all. Totally, in 227 aspirations (50.6%) no anesthetic or analgesic was administered. The corresponding figures for analgesic/ sedative premedication, general anesthetic and spinal/ epidural anesthetic were 188 (41.6%), 30 (6.7%), and 4 (1.1%), respectively. No significant difference between patients who were cured by transvaginal aspiration and antibiotics and those who had surgery was found with respect to age, history of pelvic inflammatory disease, usage of intrauterine device, size of tubo-ovarian abscess, or volume of aspirated purulent material (Table III). In each case, aspirated purulent fluid contained white blood cells. Cultures of abscess material showed bacterial growth in samples from 194 women (64.2%). The dominant bacteria were Escherichia coli, Enterococcus, Klebsiella, Table III Comparison between women successfully treated with transvaginal aspiration for tubo-ovarian abscess and women in whom surgery was performed, mean diameter of abscesses, and mean volume of aspirated purulent material Successful treatment (n = 282) Surgery (n = 20) P-value Mean age (y) 40.1 40.8.76 Mean parity 1.6 1.7.5 Postmenopausal 16 (5.7%) 1 (5%).6 Earlier PID 85 (30.1%) 8 (40.8%).9 Mean diameter 7.3 7.2.75 of TOA (cm) Mean volume 84 72.68 of aspirate (ml) Bilateral abscesses 77 (27.3%) 6 (30%).8 PID, Pelvic inflammatory disease. Staphylococcus, Streptococcus, and Hemophilus influenza. Thus, most of the positive cultures grew bowel flora, suggesting progressive amplification of the initial infection by prolonged transmural contamination from adherent inflamed colon. Only 3 samples were positive for Actinomycosis. Cytologic examination did not show any sign of malignancy. For presence of gynecologic malignancy in women with tubo-ovarian abscess included in the current study, a review of data from the

1328 Gjelland, Ekerhovd, and Granberg Norwegian Cancer Registry, a national database where all cancers in Norway are registered, was conducted. No tubal or ovarian cancer had been diagnosed, except for the 1 ovarian cancer detected at the follow-up scan 4 weeks after transvaginal aspiration. Comment Approximately 100,000 women in the United States are annually hospitalized with tubo-ovarian abscess. 13 Even with modern broad-spectrum antibiotic therapy, as many as 25% of women who have tubo-ovarian abscess require surgery. 13 The current study shows that ultrasound-guided transvaginal aspiration of purulent material under cover of IV antibiotics provides a viable alternative to surgery. In fact, the high success rate of the treatment regimen indicates that it should be a firstline approach when tubo-ovarian abscess is diagnosed, and that surgery should be carried out only if this treatment fails. In the current study, surgery was performed in 20 of the 302 women (6.6%). Especially during the first 5 years of the study period, surgery was on several occasions carried out on the basis of physician preference. The main indications for surgery were diagnostic or therapeutic uncertainty, such as suspected residual tubo-ovarian abscess or pain. In retrospect, is seems clear that several of the laparotomies were not necessary, because the majority of them were performed only 0 to 5 days after the first transvaginal aspiration of purulent material. Over the years, diagnostic accuracy and clinical experience regarding treatment of tuboovarian abscess have both increased. Since 1998 all women with tubo-ovarian abscess admitted to the clinic have successfully been treated with transvaginal ultrasound-guided aspiration combined with broad-spectrum antibiotics. Women with concomitant endometriosis seem to constitute a diagnostic challenge. Endometrioma is in some cases difficult to distinguish sonographically from tubo-ovarian abscess. In addition, adequate pain relief after aspiration of purulent material did not occur in some of the women with endometriosis. Thus, in 4 of the women operated on for endometrioma as well as tuboovarian abscess were diagnosed at surgery (Table II). In 3 of these patients endometrioma was suspected at ultrasonography before surgery. In 2 other patients no tubo-ovarian abscess was found at surgery, but instead endometrioma was diagnosed. In these patients it can be concluded that transvaginal aspiration combined with antibiotics was successful because no sign of ongoing infection was seen at surgery. In 1 woman (patient 19, Table II), a fistula between the residual tubo-ovarian abscess and the large intestine was diagnosed when laparotomy was performed. This woman was 68 years old and had no previous medical history of gynecologic disease. The woman had diverticulitis for several years, and clearly, diverticulitis was the cause of the abscess. It is well known that tuboovarian abscesses can be the result of other causes than pelvic inflammatory disease, such as diverticulitis, appendicitis, inflammatory bowel disease, and surgery. In another women (patient 20, Table II), right-sided ovarian cancer was diagnosed 4 weeks after transvaginal aspiration of purulent fluid from a left-sided tubo-ovarian abscess had been performed. Before laparotomy, a multicystic ovary was clearly seen by transvaginal ultrasonography. Because purulent material had initially been aspirated, this woman, who was 80 years old, most likely had both a tubo-ovarian abscess and an ovarian cancer. An association between tubo-ovarian abscess and gynecologic malignancy in postmenopausal women has previously been documented. 14 Thus, when a tubo-ovarian abscess is diagnosed in a postmenopausal woman, a thorough investigation to exclude concomitant pelvic malignancy should always be carried out. The success rate of the transvaginal procedure was neither affected by the size of the abscess nor by the multilocularity of the abscess (Table III). As pointed out by others, it is often difficult to measure the precise size of an abscess, especially when irregular or multilocular abscesses are visualized. 15,16 Therefore, maximal diameter of the abscess as well as volume of aspirated purulent material was included for assessment of tuboovarian size in the current study. In fact, those who were cured by transvaginal aspiration together with antibiotics had a larger average volume of aspirated pus than the patients who had surgery (Table III). When transvaginal aspiration was performed on some multilocular abscesses or when the abscess content was found to be particularly viscous, irrigation with sterile saline solution was carried out to break down loculations and dilute abscess material. The aspiration procedure could be assessed by the volume of aspirated purulent material as well as by real-time ultrasonography. In most cases, irrigation was not necessary and a sequential collapse of multiple loculations during aspiration was seen. On the other hand, sonographic findings of residual debris, despite complete resolution of symptoms, could be seen for months after transvaginal aspiration. This finding is in agreement with a previous study, which found that masses of residual debris persisted from 1 to 6 months after drainage, with a mean time of 9.5 weeks. 17 In some pervious studies, an indwelling catheter for drainage of tubo-ovarian abscess has been used. 6,15,18,19 Various techniques, such as the Seldinger and the trocar techniques, have been described for catheter delivery. 18 Catheters are usually taped to the patient s thigh and attached to a tube and a leg bag. Suggested advantages of catheter placement are that it allows frequent irrigation to break down loculi and reduces abscess viscosity

Gjelland, Ekerhovd, and Granberg 1329 of the abscess content. 18 However, catheter delivery is often a rather time-consuming and difficult procedure, and it is normally performed by 2 operators, 1 to hold the guidance mechanism and 1 to perform the needle and catheter work. It also seems clear that catheter passage through the vaginal wall is a painful procedure. 6,15 In addition, dislodgement of transvaginal catheters is sometimes a problem, and complications such as disruption of the vaginal vault suture line and vaginal fistula after catheter drainage have been described. 15,18 The advantages of needle aspiration only, as in the current study, are that the treatment in most cases can be completed in 1 session, the procedure normally takes only 15 to 30 minutes, it avoids the inconvenience of the patient s needing an indwelling catheter, and it can even be performed on an outpatient basis. 7 Transvaginal ultrasound-guided aspiration of tubo-ovarian abscess is also a well-tolerated procedure and no vaginal vault sutures are needed. In the current study, analgesics were administered only if the patient preferred such medication (Table I). We also experienced that an increasing number of patients declined such medication when aspiration was performed more than once. The finding that transvaginal needle aspiration is not associated with pain of high intensity has previously been demonstrated by others. 7 Transvaginal ultrasound-guided aspiration seems to be as effective as catheter drainage for treatment of tuboovarian abscess. Van Sonnenberg et al 6 performed ultrasound-guided drainage for a variety of pelvic abscesses in 14 women, including 5 women with tubo-ovarian abscess and 1 woman with pyosalpinx. Of the 14 women, 12 were spared a major operation. However, 2 of the women with tubo-ovarian abscess underwent surgery to remove a tubo-ovarian phlegmon after the transvaginal procedure. Feld et al 19 reported an overall success rate of 78% in transvaginal sonographically guided catheter drainage of pelvic abscesses in 41 patients. Transvaginal ultrasound-guided aspiration of tuboovarian abscess under antibiotic treatment without the use of catheter drainage was first described by Teisala et al. 5 In 10 women 10 to 120 ml of pus was aspirated and recovery of all patients was quick and uncomplicated. Aboulghar et al 7 successfully treated 15 women with pyosalpinx or tubo-ovarian abscess with transvaginal aspiration. In that study, antibiotics were installed locally in addition to systemic antibiotic therapy. 7 Using both intracavitary antibiotic instillation and systemic antibiotic therapy in combination with ultrasoundguided transvaginal aspiration, Caspi et al 17 successfully treated eight women with tuboovarian abscess. Nelson et al 16 reported a success rate of 84% in 31 women with pelvic abscess refractory to antibiotic therapy after mainly transvaginal needle aspiration under endovaginal ultrasonographic guidance. Corsi et al 9 reported successful abscess aspiration in 25 of 27 patients (92.6%) with transvaginal sonographically guided aspiration and catheter placement using an unspecified technique. Transvaginal aspiration or drainage was successful in 19 (86%) of the 22 patients in the study reported by Lee et al. 15 Drainage catheters were placed in 15 (68%) of the 22 patients. Needle aspiration alone resulted in a 100% success rate, whereas drainage with catheter placement resulted in a success rate of 80%. During the last decade we have intensified the use of transvaginal ultrasound-guided aspiration not only for treatment of tubo-ovarian abscess but also when pyosalpinx is diagnosed. In our opinion, when either tubo-ovarian abscess or pyosalpinx is seen by ultrasonography, early aspiration of purulent material should be performed. Early interference makes aspiration easier because the purulent fluid has not yet become highly viscous and pain relief and normalization of body temperature usually occur shortly after transvaginal aspiration. In addition, no diagnostic approach is accurate enough to identify those who need aspiration and those who will be cured by antibiotic therapy only. In a prospective randomized study including 40 women with tubo-ovarian abscess, Perez-Medina et al 8 compared the outcome of treatment with IV broad-spectrum antibiotic therapy alone or in association with early ultrasoundguided transvaginal aspiration. They found that aspiration of pus combined with antibiotic treatment proved to be significantly more effective than medical treatment alone in regard to treatment success, mean hospital stay, and associated surgical morbidity. Although not examined in the current study, their conclusion is in agreement with our experience. The current study clearly shows that transvaginal ultrasound-guided aspiration combined with antibiotics is effective for treatment of tubo-ovarian abscess. This treatment regimen has several advantages compared with surgical intervention. Transvaginal aspiration normally takes 15 to 30 minutes. The procedure is well tolerated, inexpensive, minimally invasive, and avoids the potential risks associated with general anesthesia and surgery. Acknowledgments We thank Tore Wentzel-Larsen for assistance in data analysis. We also thank GE Medical Systems, Norway, and Philips Medical Systems, Norway, for technical support. References 1. McCormack WM. Pelvic inflammatory disease. N Engl J Med 1994;330:115-9. 2. Aral SO, Mosher WD, Cates W. Self-reported pelvic inflammatory disease in the United States, 1988. JAMA 1991;266:2570-3. 3. Cates W Jr, Wasserheit JN. Genital chlamydial infections: epidemiology and reproductive sequelae. Am J Obstet Gynecol 1991; 164:1771-81.

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