A 25-year-old woman treated for pelvic inflammatory disease (PID) 2 years ago now presents with right-sided pelvic pain and a tender right adnexal mass. Ultrasound shows a thick-walled, fluid-filled right adnexal structure 6 cm with internal echoes. WBC is 14,000/µL and CRP is 85 mg/L. The diagnosis is tubo-ovarian abscess (TOA). According to current BASHH guidelines, which is the preferred initial management?
- A Immediate surgical drainage (laparoscopy or laparotomy)
- B Outpatient oral doxycycline + metronidazole for 14 days
- C Parenteral broad-spectrum antibiotics (IV cefoxitin + doxycycline or IV ceftriaxone + metronidazole + doxycycline) with reassessment at 72 hours ✓
- D Ultrasound-guided percutaneous aspiration as first-line in all cases > 3 cm
Correct answer: C. Parenteral broad-spectrum antibiotics (IV cefoxitin + doxycycline or IV ceftriaxone + metronidazole + doxycycline) with reassessment at 72 hours
Explanation
Per BASHH and ACOG guidelines, the initial management of tubo-ovarian abscess involves inpatient admission and IV broad-spectrum antibiotics targeting the polymicrobial aetiology (including anaerobes, gram-negatives, and STI pathogens). Recommended regimens include IV cefoxitin + doxycycline, or ceftriaxone + metronidazole + doxycycline. Surgical intervention (drainage via laparoscopy or image-guided aspiration) is reserved for failure to improve within 72 hours of antibiotics, rupture, or deterioration. Most TOAs (70–80%) respond to conservative antibiotic therapy.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.