Case 52

57 year old female s/p appendectomy (>20 years ago), s/p laparoscopic hysterectomy and b/l oophorectomy (3 mos ago) presents with foul-smelling vaginal discharge x 1 day.  She noted some mild left lower abdominal pain since surgery which recently worsened. She also notes some clear discharge from rectum. No similar sxs in the past. She denies fever, hematuria, dysuria, frequency, N/V/D,  other PMH. 

VS: HR 110; Temp: 97; RR: 20; BP: 105/76; O2 sat: 98 on RA

PE:
Gen: Well-appearing, non-toxic. No acute distress
Skin: warm, pink. No rash.
Card: RRR no murmurs, rubs or gallops. S1 S2 regular.
Resp: CTAB
Abdomen: soft, non-tender, non-distended. Mild LLQ TTP.
Neuro: Alert and oriented.

ultrasound image during a transverse view of the bladder

ultrasound image during a transverse view of the bladder

QUESTIONS

  1. What do you see in the video/images?
  2. How does this explain the patient’s symptoms?
  3. Where is the typical location for this kind of finding?
  4. What in this patient’s history puts her in increased risk for her condition?
  5. What are other risk factors for this condition?
  6. What are the different ways this condition can be managed?

ANSWERS

  1. There is a pelvic mass that appears to have purulent material inside it. Correlating with the clinical picture, this is a pelvic abscess.
  2. Many pelvic abscesses present with vaginal discharge due to fistula forming between the abscess and vagina
  3. The most common location for pelvic abscesses in females is between the uterus and the posterior fornix of the vagina and the rectum posteriorly.
  4. Post-hysterectomy state puts a patient at increased risk for pelvic abscess. Less than 1% of patients undergoing obstetric or gynecological surgery develop a pelvic abscess. Other risk factors: Complications of surgery, i.e. hysterectomy, cesarean delivery, induced abortions, or complications of inflammatory disease, i.e.  PID, inflammatory bowel disease, and diverticulitis
  5. Management depends on hemodynamic stability, size of the abscess and location of the abscess.
    1. An unstable patient is likely to have a ruptured pelvic abscess. This is life-threatening and requires emergent surgical intervention as well as aggressive fluid resuscitation and broad-spectrum antibiotics.
    2. A stable patient is started on broad spectrum antibiotics until the patient is afebrile x 48 hrs.
    3. Patients with an abscess >7cm need to be percutaneously drained as well via ultrasound or CT guidance.