Pelvic Abscess

Pelvic abscesses are fluid filled masses of inflamed tissue that can occur within the female pelvis. The abscesses are caused by bacteria reaching the upper genital tract. The bacteria often originates from a separate genital tract infection, such as pelvic inflammatory disease (PID), or from otherwise healthy bacteria from the lower genital tract that has travelled up past the cervix.

Pelvic abscesses are exceptionally rare in men, and when they do occur they grow above the prostate. In women they are more common. The first area of the upper genital tract that is affected is the endometrial lining of the uterus. The infection can then spread through the fallopian tubes and to the ovaries, where they are called tubo-ovarian abscesses (TOA). The infection can also spread as far as the lining of the abdomen. Along this route the pelvic abscesses that form can cause a fever and a considerable amount of pelvic pain. The pelvic abscesses can grow to fill the pelvis, and painfully push up into the lower abdomen.

Pelvic abscesses are rare, but often require speedy treatment to recover with minimal damage done to the genital tract and other internal organs. Therefore, receiving a diagnosis and early treatment early is essential. To diagnose a pelvic abscess, your GP will do a pelvic and rectal examination, which may include ultrasounds. If left untreated, your fever will spike, your abscess will grow, and it can obstruct the intestines preventing normal function. In worst cases the abscess can rupture, leading to sepsis with a high risk of fatality. In most cases of TOA occurring, there will be permanent damage done to the reproductive system that can cause future issues with fertility.

If you've got a pelvic abscess you will feel poorly, you'll have a fever and a lot of pelvic pain. Treatment involves a course of antibiotics and a procedure to drain fluid from the abscess, followed by continued monitoring in an emergency unit to asses your recovery. Depending on the severity and location of your abscesses, an operation may be required to remove infected tissue to prevent it from causing any further damage.

What are the Symptoms of Pelvic Abscesses?

The most common symptoms of a pelvic abscess include feeling generally unwell with pain in the abdomen, fever and a mass visible through a pelvic examination. However, they can grow large with no obvious signs other than discomfort in the groin.

Other symptoms include:

• pain that gets worse as you move
• pain during and following sex
• an increase in the number of white blood cells (leucocytosis)
• a higher than normal resting heart rate, over 100 beats per minute in adults (tachycardia)
• physical weakness and emotional exhaustion
• abdominal bloating
• constipation or diarrhoea mixed with mucus
• limping or inability to raise the leg, depending on the position of the abscess
• vaginal discharge
• pain when passing wind or stool
• extreme pelvic pain and lower abdominal pain
• general feeling of being unwell
• a fever exceeding 39°C (103°F)

Conditions with similar symptoms include ovarian cysts, acute appendicitis, ectopic pregnancy, diverticulitis and Pelvic Inflammatory Disease (PID). Pelvic abscesses can go undiagnosed if they occur at the same time as the conditions above.

What Causes Pelvic Abscesses?

In women your risk of developing a pelvic abscess is highest when you are of reproductive age, if you have had multiple sexual partners and have previously suffered from Pelvic Inflammatory Disease (PID).

Pelvic abscesses are often avoidable through good pelvic hygiene and medical support during unrelated pelvic treatments.

• Gynaecological conditions - Including Pelvic Inflammatory Disease (PID) and rectal cancer, which can cause infections within the pelvis.
• Infection following abdominal/pelvic surgery - Pelvic abscesses can occur as a complication of a hysterectomy, caesarean section or another pelvic surgery which have allowed infection to enter the genital tract. The current estimated figure for pelvic abscesses occurring as a result of infection from gynaecological surgery is low at 1%. If you've had an operation or an infection in your pelvic area and start to feel ill afterwards, it's important to see your doctor if you think you have a pelvic abscess.
• Peritonitis - Peritonitis is an infection of the inner lining of the abdomen, which often spreads to the internal organs.
• Intestinal diseases - Complications from diverticulitis, appendicitis and Crohn's disease, can all lead to pelvic abscesses forming. 10-30% of people with Crohn's disease will develop a pelvic or abdominal abscess at some point. This occurs when the bowel wall becomes inflamed and a small hole occurs.
• Appendicitis - An infected appendix can spread over to the other pelvic organs, resulting in pelvic abscesses forming.
• Pelvic organ cancer - Any pelvic cancer can result in abscesses forming if it leads to infection.
• Intrauterine device (IUD) insertion - Although IUD's are an effective method of contraception and rarely have complications, when they do so they can be very serious. The IUD can move and perforate the uterus (occurring in between 1.3-1.6 per 1000 insertions) or intestines. This can allow infection to occur and enter the pelvis.
• HIV - Although HIV does not directly cause pelvic abscesses, those suffering from HIV are at a higher risk of developing abscesses. This is as they are slower to recover from infections due to their weakened immune system.

How to Treat Pelvic Abscesses

If you are diagnosed with any size of pelvic abscess you will be immediately admitted to hospital to avoid the abscess rupturing when emergency care is not available. If peritonitis is present, where the lining of the abdomen is also infected, the impact to the internal organs can be life-threatening and will require immediate medical treatment.

In women, with any degree of TOA there is a risk of losing normal function of your fallopian tubes and a risk of suffering with infertility as a result.

• Bed rest - Whilst admitted in hospital, you will be put on bed rest to avoid any further discomfort.
• Antibiotics - A broad spectrum of anaerobic antibiotics will be administered intravenously (through an IV) as well as orally whilst you are admitted to hospital, usually for 10-14 days. These may include clindamycin, gentamicin, and aqueous penicillin. Antibiotics can clear the infection but often are only part of the treatment as the abscesses also need to be drained if they do not shrink within 2-3 days. Antibiotics are most successful on abscesses 8 cm and smaller in diameter.
• Pelvic abscess drainage - A highly successful procedure, the infected abscesses are drained under local anaesthetic. The procedure will occur through the vagina (preferred for women) or the anus, usually through ultrasound guidance and with extra care to avoid the infection recurring. If the abscesses are unable to be drained through the vagina or anus, they can be drained through a long needle inserted through the skin of the abdomen or pelvis (percutaneous abscess drainage). The drain will be left in place for around two weeks to ensure all the infection is drained. You will continue on a course of antibiotics throughout.
• Surgery - If there is any risk of your abscess(es) rupturing, you will be taken into emergency surgery to remove it and any damaged organs.
• Hysterectomy - Removal of the uterus. Often the only solution to remove a large pelvic abscess. This surgery leaves you infertile.
• Bilateral salpingo-oophorectomy - Removal of the uterus, cervix, plus both ovaries and fallopian tubes. This surgery leaves you infertile.
• Laparotomy - If the abscesses have been unable to be drained through other means, a laparotomy may be required. This is when a surgical incision is made to the abdominal cavity to get access to it. This surgery is often required when the infection has spread to the lining of your stomach (peritonitis). Open surgery is required to drain abscesses and treat any damaged tissue or organs.
• Posterior colpotomy - Procedure to drain fluid through an incision in the vagina. Preferable to a laparotomy as it is completed through the vagina rather than abdomen.

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