IJG-08731; No of Pages 5

International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

The value of ultrasonographic tubo-ovarian abscess morphology in

predicting whether patients will require surgical treatment
Tugba Kinay , Eylem Unlubilgin, Derya A. Cirik, Fulya Kayikcioglu, Mehmet A. Akgul, Ismail Dolen
Etlik Zubeyde Hanim Womens Health Training and Research Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey

a r t i c l e

i n f o

Article history:
Received 7 January 2016
Received in revised form 29 March 2016
Accepted 8 June 2016
Keywords:
Morphology
Surgery
Tubo-ovarian abscess
Ultrasonography

a b s t r a c t
Objective: To determine if the ultrasonographic morphology of a tubo-ovarian abscess (TOA) could be used
to predict if a patient will require surgical treatment. Method: A retrospective cohort study reviewed medical
records from patients diagnosed with TOA via ultrasonography between January 2009 and January 2014 at a tertiary referral center in Turkey. Patients with pelvic inammatory disease and an inammatory adnexal mass,
identied during sonographic examination, were included in the study. Ultrasonographic morphology, demographic characteristics, and clinical and laboratory ndings were compared between patients who required surgical treatment and those who did not. Results: Records were included from 164 patients; medical therapy was
successful in 121 (73.8%) patients and 43 (26.2%) required surgical treatment. TOA morphology was identied,
using ultrasonography, as unilocular cystic, complex multicystic mass, or pyosalpinx in 56 (34.1%), 73 (44.5%),
and 35 (21.3%) patients, respectively. No correlation was present between ultrasonographic TOA morphology
and patients requiring surgical treatment (all PN 0.05). Multivariate analyses demonstrated that an abscess larger
than 6.5 cm in size (P=0.027), fever at admission (Pb 0.001), and parity greater than two (P=0.026) were independent predictors of patients requiring surgical treatment for TOA. Conclusion: Although increased TOA
size, fever at admission, and parity were associated with increased odds of patients with TOA requiring surgical
treatment, ultrasonographic TOA morphology was not.
2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
During the clinical course of pelvic inammatory disease (PID), nearly 15% of women develop a tubo-ovarian abscess (TOA) [1]. A TOA is an
inammatory mass that forms during infection of the adnexa and, sometimes, other adjacent organs [24]. TOA is a serious complication of PID
that can threaten both patients fertility and lives; consequently, prompt
diagnosis and treatment are crucial. Whereas PID is classically diagnosed
based on clinical and laboratory ndings, imaging is necessary to diagnose TOA and ultrasonography is the most commonly applied diagnostic
imaging modality for diagnosing a TOA. Ultrasonography is inexpensive,
non-invasive, widely available, and has demonstrated high specicity
(93%) and sensitivity (98.6%) in diagnosing TOA [1]. The ultrasonographic morphology of a TOA can demonstrate a unilocular cystic structure, a complex multicystic structure with thick walls and septation
(tubo-ovarian complex), or a pyosalpinx, a uid-lled sausage-shaped
cystic structure with incomplete septation [5].
Although rst-line medical treatment for TOA is the aggressive use
of intravenous broad-spectrum antibiotics, such treatment is ineffective
and surgery is required for approximately 25% of patients [6]; however,
Corresponding author at: Etlik Zubeyde Hanim Womens Health Training and
Research Hospital, Department of Obstetrics and Gynecology, Yeni Etlik Cd, No:55,
06010, Kecioren, Ankara, Turkey. Tel.: +90 0537 847 0624; fax: +90 312 323 8191.
E-mail address: tkinay@hotmail.com (T. Kinay).

few data exist on associations between clinical and biochemical variables, and whether a patient with a TOA will require surgery. Although
increased age, a high white blood cell (WBC) count, and a cyst larger
than 6 cm in size are thought to be associated with increased risk for
surgical treatment [7,8], whether TOA ultrasonographic morphology is
associated with the effectiveness of antibiotic therapy is unknown. It is
thought that antibiotic penetration into infected tissue could differ
based on abscess morphology. For example, it could be the case that
the thin wall of a pyosalpinx is easily penetrated by antibiotics, whereas
a tubo-ovarian complex, with thick walls and septae, could be less permeable for antibiotics. Consequently, the aim of the present study was
to determine if the ultrasonographic morphology of a TOA is associated
with whether a patient will require surgical treatment.
2. Materials and methods
In the present retrospective cohort study, medical records were
reviewed for patients diagnosed with a TOA who were hospitalized between January 2009 and January 2014 at a tertiary referral center in
Turkey. Patients with a pelvic ultrasonography-identied tubo-ovarian
inammatory mass fullling the US Centers for Disease Control and
Prevention criteria for PID [9] were included in the present study; patients were only excluded if the patient records included incomplete
data. The institutional review board approved the study protocol and

http://dx.doi.org/10.1016/j.ijgo.2016.04.006
0020-7292/ 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Kinay T, et al, The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will
require surgical treatment, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.006
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico julio 13, 2016.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.

T. Kinay et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx

written informed consent for future data use was obtained from all participants at the time of treatment.
Data retrieved from patient records included demographic characteristics; menopausal status; the presence of diabetes mellitus; history
and current use of an intrauterine device; history of curettage; history
of pelvic surgery including cesarean section, salpingo-oophorectomy,
ovarian cystectomy, myomectomy, and tubal ligation; laboratory and
pelvic ultrasonography ndings; treatment modality; and duration of
hospitalization. Association between patients requiring surgical treatment and ultrasonographic TOA morphology, demographic characteristics, and clinical and laboratory ndings were investigated. Patients
were grouped according to whether medical treatment was successful
or if surgery was required, and based on ultrasonographic morphology
(unilocular cyst, complex multicystic mass, or pyosalpinx [cyst with
incomplete septation]); examples of ultrasonographic morphology
ndings are presented in Fig. 1.
All patients underwent an ultrasonography examination using a
610-MHz transvaginal probe (Logiq P5; GE Healthcare Inc, Milwaukee,
Wisconsin, USA), with all examinations performed by one sonographer
who was not blinded to patient diagnoses. Patients were examined
in the lithotomic position, and the uterus and bilateral adnexa were
evaluated. The maximum diameter of each inammatory mass was considered the TOA size. In patients with a bilateral TOA, the maximum
diameter of the largest mass was considered to be the TOA size.
All patients diagnosed with a TOA were admitted to the hospitals
gynecology department. Upon admission, all patients underwent routine physical and pelvic examinations, and venous blood samples
were taken for laboratory testing. The serum WBC count, erythrocyte
sedimentation rate (ESR), and C-reactive protein (CRP) level were measured on the rst day of medical treatment, before being measured every
other day. Initially, all patients were treated with broad-spectrum antibiotics (clindamycingentamycin or ceftriaxonemetronidazole [10]).
Parenteral antibiotic treatment continued for 10 days, based on recommendations for PID treatment [11] and clinical experience treating
patients unable to complete followup or tolerate oral medication.
Patients in the present study were predominantly of low socioeconomic
status and, based on clinical experience at the study institution, were hypothesized to potentially experience difculties regularly complying
with the oral-medication dosing schedule.
Patients who did not experience clinical improvement after 72 hours
of antibiotic therapy [12], had positive peritoneal signs, or had a
suspected ruptured TOA had medical treatment withdrawn and
underwent surgery. Surgical treatment included ultrasonographyguided transvaginal abscess drainage, uni-/bi-lateral salpingectomy/
salpingo-oophorectomy via laparoscopy or laparotomy, or total abdominal hysterectomy combined with uni-/bi-lateral salpingectomy/
salpingo-oophorectomy. CT-guided abscess drainage was not available
at the study institution. Eligible patients underwent ultrasonographyguided transvaginal abscess drainage. In the lithotomic position, a 16G
aspiration needle attached to a 610-MHz transvaginal probe (Logiq
P5; GE Healthcare, Inc, Milwaukee, Wisconsin, USA) was inserted into
the abscess and purulent material was aspirated. Patients with a ruptured TOA, multilocular abscess, or an abscess that was difcult to access
using ultrasonography-guided transvaginal drainage underwent laparoscopy or laparotomy.
Data were analyzed using SPSS version 11.5 (SPSS Inc, Chicago,
IL, USA) and the normality of the data was analyzed using the
KolmogorovSmirnov test. Differences in normally distributed continuous data were analyzed using the independent samples t test, and data
without a normal distribution were analyzed using the MannWhitney
U test. The 2 test was used to evaluate categorical data. A one-way
ANOVA test with Bonferroni correction was used to make comparisons
between the three TOA morphology groups in terms of continuous
data with a normal distribution. The KruskalWallis test and one-way
ANOVA were used in the analysis of continuous data that was not normally distributed. Binary and multiple logistic regression analyses

Fig. 1. Examples of tubo-ovarian abscess ultrasonographic morphology. Unilocular

cystic structure (a). Complex multicystic structure with thick walls and septation (b).
Pyosalpinx (cystic structure with incomplete septation) (c).

were used to evaluate the effect of variables on the odds of a patient

with TOA requiring surgical treatment. Variables were included in the
multiple logistic regression analyses if Pb0.25 for comparisons between
patients treated successfully or unsuccessfully with medical treatment,
and if there was no correlation with other variables. A receiver operating characteristic curve was used to evaluate the optimal TOA-size
cut-off value for predicting requiring surgery for TOA treatment.
P0.05 was considered statistically signicant.

Please cite this article as: Kinay T, et al, The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will
require surgical treatment, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.006
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico julio 13, 2016.
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T. Kinay et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx

3. Results
During the study period, 173 patients were diagnosed with TOA.
There were nine patients excluded from the study owing to incomplete
data and 164 patients were included in the analyses. Medical treatment
was successful in 121 (73.8%) patients and failed, mandating surgical
treatment, in 43 (26.2%) patients. Of the 43 patients who required surgery, 11 (25.6%) underwent transvaginal abscess drainage, 18 (41.9%)
underwent uni-/bi-lateral salpingectomy/salpingo-oophorectomy, and
14 (32.6%) underwent total abdominal hysterectomy combined with
uni-/bi-lateral salpingectomy/salpingo-oophorectomy. Based on ultrasonographic imaging, TOA morphologies of unilocular cyst, complex
multicystic mass, and pyosalpinx were recorded in 56 (34.1%), 73
(44.5%), and 35 (21.3%) patients, respectively.
Demographic, laboratory, and ultrasonography data for the medical
treatment success/failure subgroups are presented in Table 1. Patients
for whom medical treatment was not successful were older and had
higher gravidity and parity compared with patients who responded to
medical therapy. The number of patients experiencing fever (temperature 38 C) at admission and the number of patients with a history of
curettage were also higher among patients who required surgical treatment. The mean serum WBC count at admission, ESR, and duration of
hospitalization were also signicantly higher among patients who
underwent surgery for TOA (Table 1).
There were nine parameters (age, parity, history of curettage, TOA
size, TOA bilaterality, WBC count, ESR, fever at admission, and the duration of hospitalization) included in the multivariate analyses; TOA size
smaller than 6.5 cm (odds ratio [OR] 2.56; 95% condence interval [CI]
1.245.28), fever at admission (OR 6.58; 95% CI 3.0114.37), and parity
greater than two (OR 2.30; 95% CI 1.144.76) were found to be independent predictors of patients requiring surgical treatment for TOA following the failure of medical therapy.
The only ultrasonography examination nding that was signicantly
associated with requiring surgical treatment was TOA size, which was
signicantly higher among patients who required surgical treatment
for TOA (7.09 1.72 cm vs 6.06 1.50 cm; P = 0.001). According to a
receiver operating characteristic curve analysis, the optimal TOA-size
cut-off value for predicting patients requiring surgical treatment was

6.5 cm (area under the curve 0.670; sensitivity 60.5%, specicity 66.9%;
Pb 0.001) (Table 1).
When the data were grouped by ultrasonography morphology, there
was no signicant difference in the number of patients requiring surgery between the three groups (Table 2). The TOA size, percentage of
patients with fever (38 C) at admission, ESR, and rate of intrauterine
device use were signicantly lower among patients with a pyosalpinx
TOA in comparison with the other patient subgroups; no other differences were observed between the patient subgroups.
4. Discussion
In the present study, the rate of successful medical treatment and
the rate of surgical treatment being required were similar regardless
of TOA morphology; however, higher parity, a TOA size above 6.5 cm,
and patients having fever at admission were found to be independent
predictors of patients requiring surgical treatment. To the best of our
knowledge, the present study is the rst to investigate associations between ultrasonographic TOA morphology and patients needing surgery
to treat TOA.
Although pelvic ultrasonography is the most common imaging
method used by gynecologists for the differentiation of pelvic masses
in patients with suspected TOA [7], the ultrasonographic assessment
of TOA morphology does present some shortcomings. Under ultrasonographic examination, TOA can mimic other adnexal masses, including
endometrioma and hemorrhagic cyst [13]. Varras et al. [14] examined
the ultrasonographic ndings from 25 patients with TOAs, reporting
that 60% had a mixture of cystic and solid elements, 16% had a thickened
tube-shaped cyst, 16% had a cyst with a diaphragm, and 8% had simple
cyst morphology. In the present study, three different morphologies
were observed using ultrasonography; a thickened unilocular cyst
(34.1%), a complex multicystic mass (44.5%), and pyosalpinx (21.3%).
The ultrasonographic morphology of TOAs was not indicative of the
success of medical treatment; however, the incidence of fever at admission and patients initial ESRs were signicantly lower, and the size of
TOAs was signicantly smaller in patients with pyosalpinx-morphology
TOAs. It is hypothesized that this could have resulted from an engorged
fallopian tube preventing the spread of micro-organisms to the peritoneal

Table 1
Clinical, laboratory, and ultrasonographic ndings of participants grouped based on the success of medical treatment of TOA. a
Variable
Demographic
Age, y
Gravidity
Parity
Menopause
Diabetes mellitus
History of curettage
Currently using an intrauterine device
History of tubal ligation
History of pelvic surgery
Sonographic
TOA size, cm
Bilateral TOA
TOA morphology
Unilocular cyst
Complex multi-cystic mass
Pyosalpinx
Clinical and biochemical
Fever 38 C
WBC count, cells/mL
ESR, mm/h
CRP, mg/L
Duration of hospitalization, d

Patients requiring surgical

treatment (n=43)

Patients treated successfully with

medical treatment (n=121)

Odds ratio (95% condence interval) of

patients requiring surgical treatment

P value

40.237.82
3 (18)
2 (18)
2 (4.7)
2 (4.7)
8 (18.6)
24 (55.8)
1 (2.3)
15 (34.9)

37.058.61
2 (09)
2 (06)
5 (4.1)
5 (4.1)
17 (14.0)
64 (52.9)
1 (0.8)
39 (32.2)

1.05 (1.001.09)
1.31 (1.071.59)
1.51 (1.132.00)
1.13 (0.216.06)
1.13 (0.216.06)
0.34 (0.563.52)
1.13 (0.562.27)
2.86(0.186.70)
1.13 (0.542.35)

0.037
0.005
0.007
0.885
0.885
b0.001
0.741
0.461
0.751

7.09 1.72
5 (11.6)

6.061.50
31 (25.6)

1.51 (1.191.90)
0.38 (0.141.06)

0.001
0.057
0.117

19 (44.2)
19 (44.2)
5 (11.6)

37 (30.6)
54 (44.6)
30 (24.8)

3.04 (0.90-9.26)
2.11 (0.726.23)
Referent

23 (53.5)
13 700 (620026 100)
75.4826.94
480 (0960)
9.84 4.83

18 (14.9)
12 500 (430027 900)
65.9625.64
480 (0960)
7.943.47

6.58 (3.0114.37)
1.07 (1.001.14)
1.01 (1.001.03)
1.00 (0.991.01)
1.12 (1.031.23)

b0.001
0.036
0.045
0.469
0.009

Abbreviations: TOA, tubo-ovarian abscess; WBC, white blood cell; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.
a
Values are given as meanSD, median (range), or number (percentage), unless indicated otherwise.

Please cite this article as: Kinay T, et al, The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will
require surgical treatment, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.006
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico julio 13, 2016.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.

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Table 2
Clinical and laboratory ndings of participants grouped based on TOA morphology, determined by ultrasonography. a
Variable

TOA ultrasonographic morphology

Age, y
Gravidity
Parity
Menopause
Diabetes mellitus
Currently using an intrauterine device
History of tubal ligation
Currently using condoms
History of curettage
History of pelvic surgery
Fever 38 C
Duration of hospitalization, d
TOA size, cm
Bilateral TOA
WBC count, cells/mL
ESR, mm/h
CRP, mg/L
Patients requiring surgical treatment

P value

Unilocular cyst (n=56)

Complex multicystic mass (n=73)

Pyosalpinx (n=35)

39.308.15
3 (17)
2 (16)
4 (7.1)
4 (7.1)
35 (62.5)
1 (1.8)
0
14 (25.0)
21 (37.5)
21 (37.5)
8.884.07
6.641.86
10 (17.9)
12 800(4300 24 230)
74.9526.38
480 (0960)
19 (33.9)

37.788.26
3 (08)
2 (08)
3 (4.1)
1 (1.4)
42 (57.5)
1 (1.4)
4 (5.5)
25 (34.2)
26 (35.6)
19 (26.0)
8.67 4.15
6.44 1.48
19 (26.0)
13 600 (540027 900)
69.2125.20
480 (0960)
19 (26.0)

35.839.33
2 (09)
2 (06)
0
2 (5.7)
11 (31.4)
0
3 (8.6)
14 (40.0)
7 (20.0)
1 (2.9)
7.263.07
5.601.24
7 (20.0)
11 400 (465019 200)
56.3124.57
480 (0960)
5 (14.3)

0.164
0.263
0.192
0.26
0.245
0.010 b
0.743
0.114
0.295
0.181
0.001 c
0.13
0.008 d
0.513
0.065
0.004 e
0.104
0.117

Abbreviations: TOA, tubo-ovarian abscess; WBC, white blood cell; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.
a
Values are given as mean SD, median (range), or number (percentage), unless indicated otherwise.
b
Comparison of unilocular cyst and complex multicystic mass (PN0.99); comparison of complex multicystic mass and pyosalpinx (P=0.031); comparison of unilocular cyst and
pyosalpinx (P=0.011).
c
Comparison of unilocular cyst and complex multicystic mass (P=0.163); comparison of complex multicystic mass and pyosalpinx (P=0.001); comparison of unilocular cyst and
pyosalpinx (P=0.001).
d
Comparison of unilocular cyst and complex multicystic mass (PN0.99); comparison of complex multicystic mass and pyosalpinx (P=0.032); comparison of unilocular cyst and pyosalpinx
(P=0.008).
e
Comparison of unilocular cyst and complex multicystic mass (P=0.624); comparison of complex multicystic mass and pyosalpinx (P=0.045); comparison of unilocular cyst and
pyosalpinx (P=0.003).

cavity, limiting infection within the tube. Kim et al. [15] recently reported
that pyosalpinx is a less severe form of PID, observing that patients with
pyosalpinx had smaller masses, a lower CRP level, and a shorter hospitalization period compared with patients with complex multilocular cystic
masses. In contrast to the present ndings, they also reported that
fewer patients with pyosalpinx required surgical treatment in comparison with patients with other TOA morphologies [15].
Broad-spectrum antibiotic therapy is often effective for the treatment of TOA, but it is unsuccessful in some patients and surgical treatment is then required. In the present study, 26.2% of the patients with
TOAs required surgical treatment, a nding consistent with earlier reports [9,16]. Clinical characteristics as well as laboratory and ultrasonographic ndings have been identied as predictors of patients requiring
surgical treatment for TOA [7,1619]. In a study that included 122 patients with TOA, Greenstein et al. [7] reported that older age, parity,
and a maximal WBC count were associated with increased risk of requiring surgery. Gngrdk et al. [10] reported that the CRP level and
ESR at admission were higher in patients who underwent surgery, and
Kuo et al. [16] observed that a CRP level above 8.0 mg/L is an important
indicator for surgical treatment being needed. In the present study
patients mean age, parity, WBC counts, and ESRs at admission were
signicantly higher among patients who required surgery, whereas
no correlation was identied between CRP levels and necessitating surgical treatment for TOA. Additionally, having a fever of at least 38 C at
admission was observed to be an independent predictor of requiring
surgical TOA treatment. As was expected, and similar to previous studies
[10,16], the duration of hospitalization was longer among patients who
underwent surgical treatment. In the present study, all patients were
hospitalized and received parenteral antibiotics owing to potential difculties in patient follow-up when using an oral treatment protocol.
Despite prolonged parenteral antibiotic treatment, the mean duration
of hospitalization recorded in the present study was not increased in
comparison with previous studies [10,16].
The nding in the present study that TOA size, measured using ultrasonography, was an independent predictor of the need for surgical
treatment is similar to ndings in previous studies. Dewitt et al. [8]

reported that patients with a TOA size above 8 cm required surgery

more often than patients with TOAs below this size and that as the
diameter of patient abscesses increased, the duration of hospitalization
increased. Greenstein et al. [7] observed that the mean TOA size in patients who responded to antibiotic therapy was 4.4 cm, compared
with 7.3 cm in patients who required surgical treatment. Similarly, the
optimal TOA size cut-off for predicting surgical treatment being required in the present study was TOAs being above 6.5 cm in size.
The major strength of the present study was that it was the rst,
to our knowledge, to investigate associations between ultrasonographic
TOA morphology and the need for surgical treatment. Additionally,
the present study was among the largest that have examined TOA.
Conversely, the retrospective design was a signicant limitation.
Another limitation was that TOA was diagnosed based on clinical,
laboratory, and ultrasonographic ndings, and not via laparoscopy,
which is considered the gold standard diagnostic tool for TOA [14].
Finally, the administration of empiric antibiotic therapy in all patients, and a lack of culture and antibiotic-sensitivity test results were
also limitations.
In conclusion, prompt medical treatment for TOA is essential but
surgical treatment could be required for some patients. Predicting
which patients with TOA will require surgical treatment early in the
course of medical treatment could facilitate improved patient and physician follow-up. Previously, only large TOA size was considered a predictor for patients requiring surgical treatment. In the present study,
higher parity, TOA size above 6.5 cm, and a fever at admission were independent predictors of the requirement for surgical treatment of TOA;
however, ultrasonographic TOA morphology did not predict the success
of medical treatment. Consequently, it is suggested that patients with
TOA who present with the risk factors identied in the present study
should be informed of the risks/benets of medical treatment compared
with surgical treatment.
Conict of interest
The authors have no conicts of interest.

Please cite this article as: Kinay T, et al, The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will
require surgical treatment, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.006
Descargado de ClinicalKey.es desde Universidad Nacional Autonoma de Mexico julio 13, 2016.
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References
[1] Taylor KJ, Wasson JF, De Graaff C, Roseneld AT, Andriole VT. Accuracy of grey-scale
ultrasound diagnosis of abdominal and pelvic abscesses in 220 patients. Lancet
1978;1(8055):834.
[2] Granberg S, Gjelland K, Ekerhovd E. The management of pelvic abscess. Best Pract
Res Clin Obstet Gynaecol 2009;23(5):66778.
[3] Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain:
spectrum of CT ndings. Radiographics 2002;22(4):785801.
[4] Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT ndings in acute pyogenic pelvic
inammatory disease. Radiographics 2002;22(6):132734.
[5] Callen PW. Ultrasonography in Obstetrics and Gynecology 5th ed. Philadelphia:
Saunders; 2008.
[6] Mirhashemi R, Schoell WM, Estape R, Angioli R, Averette HE. Trends in the management of pelvic abscesses. J Am Coll Surg 1999;188(5):56772.
[7] Greenstein Y, Shah AJ, Vragovic O, Cabral H, Soto-Wright V, Borgatta L, et al.
Tuboovarian abscess. Factors associated with operative intervention after failed
antibiotic therapy. J Reprod Med 2013;58(34):1016.
[8] Dewitt J, Reining A, Allsworth JE, Peipert JF. Tuboovarian abscesses: is size associated
with duration of hospitalization & complications? Obstet Gynecol Int 2010;2010:
847041.
[9] Centers for Disease Control and Prevention. Pelvic Inammatory Disease (PID) Statistics. http://www.cdc.gov/std/pid/stats.htm. Published 2014. Accessed January 5, 2015.
[10] Gngrdk K, Guzel E, Asiciolu O, Yildirim G, Ataser G, Ark C, et al. Experience of
tubo-ovarian abscess in western Turkey. Int J Gynecol Obstet 2014;124(1):4550.

[11] Sweet RL. Treatment of acute pelvic inammatory disease. Infect Dis Obstet Gynecol
2011;2011:561909.
[12] Ross J, Judlin P. Jensen J; International Union against sexually transmitted infections.2012 European guideline for the management of pelvic inammatory disease.
Int J STD AIDS 2014;25(1):17.
[13] Velcani A, Conklin P, Specht N. Sonographic features of tubo-ovarian abscess
mimicking an endometrioma and review of cystic adnexal masses. J Radiol Case
Rep 2010;4(2):917.
[14] Varras M, Polyzos D, Perouli E, Noti P, Pantazis I, Akrivis C. Tubo-ovarian abscesses:
spectrum of sonographic ndings with surgical and pathological correlations. Clin
Exp Obstet Gynecol 2003;30(23):11721.
[15] Kim HY, Yang JI, Moon C. Comparison of severe pelvic inammatory disease,
pyosalpinx and tubo-ovarian abscess. J Obstet Gynaecol Res 2015;41(5):7426.
[16] Kuo CF, Tsai SY, Liu TC, Lin CC, Liu CP, Lee CM. Clinical characteristics and treatment
outcomes of patients with tubo-ovarian abscess at a tertiary care hospital in Northern
Taiwan. J Microbiol Immunol Infect 2012;45(1):5864.
[17] Mizushima T, Yoshida H, Ohi Y, Ishikawa M, Hirahara F. Evaluating the risk factors
for developing resistance to parenteral therapy for tubo-ovarian abscess: a casecontrol study. J Obstet Gynaecol Res 2013;39(5):101923.
[18] Halperin R, Levinson O, Yaron M, Bukovsky I, Schneider D. Tubo-ovarian abscess in
older women: is the woman's age a risk factor for failed response to conservative
treatment? Gynecol Obstet Invest 2003;55(4):2115.
[19] Topu HO, Kokanal K, Gzel AI, Tokmak A, Erkln S, mit C, et al. Risk factors for
adverse clinical outcomes in patients with tubo-ovarian abscess. J Obstet Gynaecol
2015;35(7):699702.

Please cite this article as: Kinay T, et al, The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will
require surgical treatment, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.04.006
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