AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Adnexal torsion

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab 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

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Drug Category: Antibiotic

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

Drug Name	Doxycycline (Vibramycin)
Description	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.
Adult Dose	100 mg PO bid for 14 d
Pediatric Dose	<8 years: Not recommended >8 years: Not established
Contraindications	Documented hypersensitivity, severe hepatic dysfunction
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
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

Drug Name	Cefoxitin (Mefoxin)
Description	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.
Adult Dose	2 g IV q6h until clinical improvement for 48-72 h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
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

Drug Name	Gentamicin (Garamycin)
Description	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.
Adult Dose	Loading dose: 2 mg/kg IV, then 1.5 mg/kg IV q8h; continue until clinical improvement for 48-72 h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, non–dialysis-dependent renal insufficiency
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)
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

Drug Name	Clindamycin (Cleocin)
Description	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.
Adult Dose	900 mg IV q8h; continue until clinical improvement for 48-72 h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity, regional enteritis, ulcerative colitis, hepatic impairment, or antibiotic-associated colitis
Interactions	Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
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

Drug Name	Ampicillin (Marcillin, Omnipen)
Description	Used in conjunction with gentamicin and clindamycin for added enterococcus coverage. Usually added if gentamicin and clindamycin do not yield the desired clinical result.
Adult Dose	2 g IV q6h
Pediatric Dose	None reported
Contraindications	Documented hypersensitivity
Interactions	Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
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

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

In/Out Patient Meds

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

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal 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

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Beigi RH, Wiesenfeld HC. Pelvic inflammatory disease: new diagnostic criteria and treatment. Obstet Gynecol Clin North Am. Dec 2003;30(4):777-93. [Medline].
• Centers for Disease Control. 2006 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR. 2006;55(RR11):1-94. [Full Text].
• Grimes DA. Deaths due to sexually transmitted diseases. The forgotten component of reproductive mortality. JAMA. Apr 4 1986;255(13):1727-9. [Medline].
• 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].
• 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].
• Soper DE. Surgical considerations in the diagnosis and treatment of pelvic inflammatory disease. Surg Clin North Am. Oct 1991;71(5):947-62. [Medline].
• Stenchever M, Droegemueller W, Herbst A. Comprehensive Gynecology. 4^th ed. Mosby Year Book; 2006:708-731.

Article Last Updated: Aug 14, 2007