Purpose or Case Report: Tubo-ovarian abscesses are uncommon and are usually associated with pelvic inflammatory disease secondary to sexually transmitted disease; however, there has been a small number of reported cases occurring in non-sexually active girls. A series of six virginal girls with tubo-ovarian abscesses is presented for discussion of the clinical circumstances, imaging findings and diagnostic difficulties encountered in this uncommon diagnosis.
Methods & Materials: The PACS database was queried for the words “tubo-ovarian abscess” resulting in finding of 5 cases between August 2011 and 2015. An additional case from this time period was retrieved from the teaching file of one investigator (SG). The charts and imaging studies of each patient were reviewed.
Results: Six girls were found with imaging or surgical documentation of tubo-ovarian abscess. The patients ranged in age from 8-15 years old at time of presentation and each denied ever engaging in oral, vaginal or anal sexual intercourse. Five of six cases were associated with appendicitis. Two of these cases were associated with acute ruptured appendicitis. The other three cases occurred in patients with prior ruptured appendicitis with recent appendectomy 2-3 weeks prior to presentation. The sixth case was felt to be due to poor hygiene with resulting ascending E. coli infection. Four of six abscesses were correctly diagnosed by imaging alone. Ultrasound, computed tomography, and magnetic resonance imaging were helpful in making the diagnosis, and the imaging findings are described. Two cases were not diagnosed until laparoscopy performed for complex adnexal mass/cyst thought to be of ovarian origin, but abscess was not included in the preoperative differential diagnosis.
Conclusions: Tubo-ovarian abscess is an uncommon diagnosis, but should be included in the differential diagnosis of a complex adnexal mass even in non-sexually active girls. Correct diagnosis by imaging can be difficult given the number of more common potential causes of complex adnexal masses and the reluctance to suggest this diagnosis without a history of sexual activity. However, a delay in diagnosis can result in chronic pelvic pain and increased risk of infertility. Further evaluation for a ruptured appendix should ensue in a girl with a tubo-ovarian abscess who denies sexual activity.