eMedicine Specialties > Obstetrics and Gynecology > Infections

Oophoritis

Arthur T Ollendorff, MD, Associate Professor of Clinical Obstetrics and Gynecology, Residency Program Director, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine; Chief of Gynecology, Veterans Affairs Medical Center, Cincinnati

Updated: Aug 14, 2007

Introduction

Background

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

Pathophysiology

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

Frequency

United States

One million cases are reported each year.

International

Worldwide incidence and prevalence rates are unknown.

Mortality/Morbidity

In the United States, the Centers for Disease Control and Prevention (CDC) estimate that 150 women die each year and 100,000 women become infertile due to oophoritis. The other major morbidities are an increased risk of ectopic pregnancy and chronic pelvic pain.

Age

Oophoritis most commonly occurs in women younger than 25 years. When oophoritis occurs in postmenopausal women, it is usually associated with an underlying gynecologic malignancy.

Clinical

History

• Abdominal pain
• Pelvic pain
• Vaginal discharge
• Dyspareunia
• Fever
• Chills
• Nausea/vomiting

Physical

• Temperature greater than 38°C
• Abdominal tenderness in lower quadrants
• Possible rebound tenderness on pelvic examination
• Mucopurulent discharge
• Cervical motion tenderness
• Adnexal tenderness
• Adnexal mass (if a tubo-ovarian abscess is present)

Causes

• Unprotected sexual intercourse
• Multiple sexual partners
• High-risk sexual behavior
• Immunosuppression
• Recent instrumentation of genital tract (endometrial biopsy, intrauterine device [IUD] placement)
• Gynecologic malignancy (in postmenopausal women)

Differential Diagnoses

Other Problems to Be Considered

Adnexal torsion

Workup

Laboratory Studies

• Elevation of the white blood cell (WBC) count to more than 10,000/µL is a nonspecific indicator of infection; however, the count may be within reference ranges soon after onset.
• Urinalysis is used to exclude cystitis.
• Urine pregnancy testing is used to exclude ectopic pregnancy.
• Wet preparation of cervical discharge shows numerous WBCs and bacteria.
• Cervical cultures for gonococcal and chlamydial species are used to help exclude, diagnose, and treat infection with these organisms. Immediate results will not be available.

Imaging Studies

• Pelvic ultrasonography may be needed if the patient cannot tolerate a thorough palpation of the adnexa because of pain. An ultrasonographic examination excludes the presence of a tubo-ovarian abscess (TOA). However, if a TOA is not present, ultrasonography will probably not be helpful.

Other Tests

• Diagnostic laparoscopy is the definitive test. The diagnosis is usually made clinically.
• 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

Surgical evaluation may reveal an abscess involving the fallopian tubes and ovaries.

Treatment

Medical Care

Outpatient treatment is appropriate for patients who are (1) hemodynamically stable, (2) sufficiently reliable to return for follow-up care, (3) immunocompetent, (4) not pregnant, (5) tolerant of oral medication, and (6) without clinical suspicion of a tubo-ovarian abscess (TOA).

Inpatient treatment is required for patients who (1) have already failed outpatient treatment, (2) are pregnant, (3) are infected with HIV or otherwise immunocompromised, (4) are exhibiting evidence of a TOA, (5) are hemodynamically unstable or appear septic, or (6) are unable to tolerate oral medications.

Surgical Care

Oophoritis may be managed with surgery when medical treatment fails to ameliorate symptoms after 48-72 hours. Surgical options may include laparoscopy with drainage of the abscess, removal of adnexa, and total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO).

Factors that influence the choice of surgery include extent of the abscess, degree of immunocompromise of the patient, and preservation of fertility for future childbearing potential. Interventional radiology can sometimes be used for drainage of abscesses in patients who are not surgical candidates or in patients who prefer a less invasive procedure than surgery.

Consultations

If needed, consultation with obstetricians and gynecologists can be made for follow-up care and surgical expertise.

Diet

No changes are necessary. Nothing is to be taken orally if surgical treatment is anticipated.

Activity

As tolerated

Medication

The goals of pharmacotherapy are to reduce morbidity, prevent complications, and eradicate the infection.

Antibiotic

Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

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.

Dosing

Adult

250 mg IM once

Pediatric

Not established

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

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.

Dosing

Adult

100 mg PO bid for 14 d

Pediatric

<8 years: Not recommended
>8 years: Not established

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

Contraindications

Documented hypersensitivity, severe hepatic dysfunction

Precautions

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 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

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.

Dosing

Adult

2 g IV q6h until clinical improvement for 48-72 h

Pediatric

Not established

Interactions

Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Contraindications

Documented hypersensitivity

Precautions

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

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.

Dosing

Adult

Loading dose: 2 mg/kg IV, then 1.5 mg/kg IV q8h; continue until clinical improvement for 48-72 h

Pediatric

Not established

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)

Contraindications

Documented hypersensitivity, non–dialysis-dependent renal insufficiency

Precautions

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

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.

Dosing

Adult

900 mg IV q8h; continue until clinical improvement for 48-72 h

Pediatric

Not established

Interactions

Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity, regional enteritis, ulcerative colitis, hepatic impairment, or antibiotic-associated colitis

Precautions

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

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.

Dosing

Adult

2 g IV q6h

Pediatric

None reported

Interactions

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

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

Continue IV antibiotics until the patient is 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. Metronidazole (Flagyl) may be substituted for clindamycin if a tubo-ovarian abscess (TOA) is present.

Further Outpatient Care

Arrange for a follow-up visit within 48-72 hours of treatment (outpatient) or discharge from hospital to evaluate the treatment's success. Pain may take 7-10 days to abate.

Inpatient & Outpatient Medications

Continue patients on doxycycline for a total of 14 days. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for pain control.

Transfer

Transfer is typically unnecessary.

Deterrence/Prevention

• Patients with oophoritis must be counseled about the use of condoms to prevent the future acquisition of sexually transmitted diseases (STDs).
• Fully evaluate the male sexual partner of a patient with PID for STDs. Initiate appropriate treatment based on test results.

Complications

• Ruptured TOA is a surgical emergency with a high mortality rate. Aggressive surveillance for the presence of a TOA and prompt inpatient medical management is required. Consider the diagnosis of a ruptured TOA if the patient has increased peritoneal signs and a rigid abdomen.
• Infertility occurs in 12-15% of women after a single episode of PID.
• The chances for ectopic pregnancy are increased with PID. Patients should be counseled regarding this fact, and they 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

Ninety percent of patients with PID respond to medical therapy if no TOA is present. Most patients respond to IV antibiotics alone if a TOA is smaller than 7 cm.

Patient Education

• See Deterrence/Prevention.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Pelvic Inflammatory Disease and Ectopic Pregnancy.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose pelvic inflammatory disease (PID) at an early stage may lead to tubo-ovarian abscess (TOA) and added morbidity.
• Missing a TOA when present or mistakenly treating one on an outpatient basis can lead to a ruptured TOA and the requirement for major abdominal surgery.

Special Concerns

• Pregnancy
  • Oophoritis in pregnancy is very uncommon.
  • A consultation with an obstetrician/gynecologist is immediately required if this diagnosis is suspected.
• Pediatrics
• Children rarely have this condition.
• The provider must have a high suspicion for sexual abuse if PID is suspected in an adolescent patient.
• Geriatrics: Elderly patients with PID are more likely to have an associated genital tract malignancy such as ovarian cancer or endometrial cancer.

References

1. Beigi RH, Wiesenfeld HC. Pelvic inflammatory disease: new diagnostic criteria and treatment. Obstet Gynecol Clin North Am. Dec 2003;30(4):777-93. [Medline].

2. Centers for Disease Control. 2006 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR. 2006;55(RR11):1-94. [Full Text].

3. Grimes DA. Deaths due to sexually transmitted diseases. The forgotten component of reproductive mortality. JAMA. Apr 4 1986;255(13):1727-9. [Medline].

4. Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial. Obstet Gynecol. Sep 2005;106(3):573-80. [Medline].

5. Reed SD, Landers DV, Sweet RL. Antibiotic treatment of tuboovarian abscess: comparison of broad- spectrum beta-lactam agents versus clindamycin-containing regimens. Am J Obstet Gynecol. Jun 1991;164(6 Pt 1):1556-61; discussion 1561-2. [Medline].

6. Soper DE. Surgical considerations in the diagnosis and treatment of pelvic inflammatory disease. Surg Clin North Am. Oct 1991;71(5):947-62. [Medline].

7. Stenchever M, Droegemueller W, Herbst A. Comprehensive Gynecology. 4^th ed. Mosby Year Book; 2006:708-731.

Keywords

oophoritis, pelvic inflammatory disease, PID, tubo-ovarian abscess, TOA, ectopic pregnancy, infertility, chronic pelvic pain, Gonorrhea, Chlamydia, inflammation of the ovary, infection of the ovaries, sterilization

Contributor Information and Disclosures

Author

Arthur T Ollendorff, MD, Associate Professor of Clinical Obstetrics and Gynecology, Residency Program Director, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine; Chief of Gynecology, Veterans Affairs Medical Center, Cincinnati
Arthur T Ollendorff, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Public Health Association
Disclosure: Nothing to disclose.

Medical Editor

Ronald Levine, MD, Director, Section of Gynecologic Endoscopy, Professor, Department of Obstetrics and Gynecology, University of Louisville School of Medicine
Ronald Levine, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Obstetricians and Gynecologists, American Medical Association, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Antonio V Sison, MD, FACOG, Program Director, Department of Obstetrics and Gynecology, Robert Wood Johnson University Hospital
Antonio V Sison, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

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