The Journal of Emergency Medicine, Vol. 40, No. 2, pp.
170 –175, 2011
doi:10.1016/j.jemermed.2010.02.033
Clinical
Communications: OB/GYN
SENSITIVITY OF ULTRASOUND FOR THE DIAGNOSIS OF TUBO-OVARIAN
ABSCESS: A CASE REPORT AND LITERATURE REVIEW
David C. Lee, MD and Anand K. Swaminathan,
Department of Emergency Medicine, New York University (NYU)/Bellevue Emergency Medicine Residency, NYU Medical Center, New
York, New York
Reprint Address: Anand Swaminathan, MD, Department of Emergency Medicine, Bellevue Hospital, NYU Medical Center, 462 1st Ave.,
New York, NY 10016
e Abstract—Background: Tubo-ovarian abscess is a seri-
ous complication of pelvic inflammatory disease, with a high
associated morbidity. Although tubo-ovarian abscess is not a
rare entity, its diagnosis presents multiple challenges. Prior
literature has suggested that pelvic ultrasound is now the
“gold standard” in the diagnosis of tubo-ovarian abscess.
Objective: Given the increasing use of ultrasound in the
emergency department, it is important to understand the
diagnostic value of transvaginal ultrasound in ruling in and
ruling out important gynecologic emergencies. Our objec-
tive is to review the literature to evaluate the sensitivity and
specificity of ultrasound in the diagnosis of tubo-ovarian
abscess. Case Report: We review a case of a 31-year-old
woman with frank peritonitis caused by a tubo-ovarian
abscess diagnosed by contrast-enhanced computed tomog-
raphy after an initial negative transvaginal ultrasound.
Conclusion: We found evidence for lower sensitivity and
specificity of ultrasound for the diagnosis of tubo-ovarian
abscess than generally reported in the emergency medicine
literature. © 2011 Elsevier Inc.
e Keywords—transvaginal ultrasound; tubo-ovarian ab-
scess; pelvic inflammatory disease
INTRODUCTION
Tubo-ovarian abscess (TOA) is a complication of pelvic
inflammatory disease (PID), which most commonly re-
sults from the spread of bacteria from the lower genital
RECEIVED: 13 August 2009; FINAL SUBMISSION RECEIVED: 11 December 2009;
ACCEPTED: 19 February 2010
170
Copyright © 2011 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$–see front matter
MD, MPH
tract. TOAs occur in up to one-third of women hospital-
ized with PID and represent the most common cause of
intra-abdominal abscess in pre-menopausal women (1–
3). TOAs have the potential to rupture, leading to a
surgical emergency. Also, many cases of TOAs are not
associated with PID but may be secondary to other
causes, such as infection related to intrauterine devices
(4). TOA presents a diagnostic challenge to the emer-
gency physician. Several studies have demonstrated the
difficulty in distinguishing PID from PID complicated by
TOA based on clinical presentation alone (2,5). Before
the wide availability of diagnostic imaging, laparoscopy
was required to confirm TOA (6). More recently, com-
puted tomography (CT) and ultrasound have allowed
clinicians to diagnose TOAs without invasive proce-
dures.
Ultrasound in the emergency department (ED) may
represent the ideal diagnostic tool for pelvic pathology
because emergency physicians (EPs) are achieving in-
creased levels of training in this imaging modality. In
addition, ultrasound machines are becoming ubiquitous
within EDs. Over the past decade, EPs have been in-
creasingly performing ultrasounds in female patients pre-
senting with undifferentiated abdominal pain (7). Al-
though there are no large emergency, gynecology, or
radiology studies evaluating the sensitivity and specific-
ity of ultrasound in PID or TOAs, there are many articles
stating that ultrasound is highly sensitive and highly
Ultrasound Sensitivity for Tubo-ovarian Abscess 171

Table 1. Studies Demonstrating the Sensitivity of Ultrasound for Tubo-ovarian Abscess

Study Date Population Study Type Sensitivity True Positives Specificity True Negatives

Taylor et al. 1978 Suspected pelvic Retrospective, 93% Surgery or autopsy 98.6% Surgery or autopsy
(13) abscess (n ⫽ 67) transabdominal not required
Landers and 1983 Admitting diagnosis of Retrospective, 93% Surgery or clinically
Sweet TOA (n ⫽ 98) transabdominal
(14)
Lande et al. 1988 Suspected adnexal Not defined, 75% Surgery, clinically,
(15) pathology receiving transabdominal follow-up U/S,
transabdominal and Not defined, 83% CT, MRI,
transvaginal transvaginal transvaginal U/S
ultrasound (n ⫽ 67) guided biopsy, or
culdocentesis
Patten et al. 1990 Severe PID requiring Retrospective, 100% Laparoscopy and 83% Laparoscopy and
(6) laparoscopy (n ⫽ 18) transvaginal biopsy biopsy
Tukeva et 1999 Clinically suspected Prospective, 56% Laparoscopy and 86% Laparoscopy and
al. (17) PID (n ⫽ 30) transvaginal MRI MRI
Varras et al. 2003 Severe PID requiring Retrospective, 100% Surgery
(16) surgery (n ⫽ 23) transvaginal

TOA ⫽ tubo-ovarian abscess; U/S ⫽ ultrasound; CT ⫽ computed tomography; MRI ⫽ magnetic resonance imaging; PID ⫽ pelvic
inflammatory disease.

specific for characterizing pelvic pathology (2,8,9). In
recent years, a number of articles published in emer-
gency medicine journals have made reference to a sen-
sitivity of 93% and specificity of 98% for ultrasound in
the diagnosis of TOA, with one even suggesting that
“short of laparoscopy, pelvic ultrasound is the ‘gold
standard’ for delineating answers regarding management
and disposition [of patients with PID]” (1,7,10,11).
Despite the numbers cited by these recent articles, it is
important to investigate the original literature regarding
the utility of ultrasound in diagnosing TOAs. In this
article we review the sensitivity and specificity of ultra-
sound for the diagnosis of tubo-ovarian abscess through
a case report and literature review.
CASE REPORT
A 31-year-old woman presented to the ED with the chief
complaint of diffuse abdominal pain for several hours
duration. She denied nausea, vomiting, diarrhea, dysuria,
or vaginal discharge, and otherwise had a negative gas-
trointestinal and urologic review of systems. Her last
menstrual period was 2 months prior. She had a recent
history of irregular menses and one prior elective termi-
nation of pregnancy. Her last sexual activity was 7
months prior. The patient was afebrile and hemodynam-
ically stable. The abdominal examination was remark-
able for diffuse tenderness to palpation, voluntary guard-
ing, and rebound most pronounced in the left lower
quadrant. The pelvic examination was remarkable for
cervical motion tenderness and bilateral adnexal tender-
ness without masses. The white blood cell count was
16.1 million cells per liter with a neutrophil predomi-
nance of 90%. Urinalysis was unremarkable and beta-
human chorionic gonadotropin was negative. Given the
patient’s peritoneal findings, the gynecologic consult ser-
vice was contacted before diagnostic imaging.
The gynecologic consult service evaluated the patient
in the ED and, under supervision of the attending gyne-
cologist, a transvaginal ultrasound was performed. The
patient’s right adnexa was reported as unremarkable and
fully visualized. The consulting service was unable to
fully evaluate the left adnexa. The initial consult recom-
mendation noted that the ultrasound did not reveal any
obvious pathology to suggest a gynecologic etiology for
the patient’s peritonitis. Thus, the EPs ordered an abdo-
men and pelvis CT scan with intravenous and oral con-
trast enhancement to aid in determining the etiology of
the patient’s abdominal pain.
The patient was immediately started on intravenous
ciprofloxacin and metronidazole for a presumed intra-
abdominal infection. The CT scan was performed and
demonstrated a 7.5 ⫻ 9.5 ⫻ 6.0-cm complex collection
in the pelvis superior to the uterine fundus with obscu-
ration of the left adnexa consistent with a large tubo-
ovarian abscess with associated ileus. The patient was
admitted to the gynecological service and treated with
intravenous gentamicin, clindamycin, and metronidazole
for 2 days, and discharged home on oral doxycycline and
metronidazole.
LITERATURE REVIEW
We identified articles through a systematic search of the
Medline (PubMed) database for relevant articles pub-
lished up to July 31, 2009 (Table 1). We used the
172
following text words and related Medical Subject Head-
ing terms: tubo-ovarian abscess, fallopian tube diseases,
ovarian diseases, pelvic inflammatory disease, female gen-
ital disease, and also ultrasonography and ultrasound.
Search results were reviewed to find articles with any data
demonstrating the sensitivity and specificity of ultrasound
in diagnosing tubo-ovarian abscess. References of reviewed
articles were also searched for relevant sources.
Our review revealed that the most commonly cited
study for the high sensitivity and specificity of ultra-
sound for diagnosis of TOA was by Taylor et al. (1,7,9 –
13). This study was performed in 1978 and retrospec-
tively assessed 67 patients with suspected pelvic abscess
who were scanned by transabdominal ultrasound. Pelvic
abscess was diagnosed by ultrasound in 33 of the 67
patients. Thirty-two of these 33 ultrasound diagnoses
were confirmed by surgery or autopsy, thus producing
one false positive, yielding the specificity of 98.6%. In
reference to the sensitivity, the authors state that the
subsequent clinical course of patients “seemed to con-
firm” the absence of a pelvic abscess in patients with a
negative ultrasound, without mention of what medical
interventions they received. One patient did not meet this
criterion, and on subsequent surgery or autopsy was
found to have an abscess, thus yielding the sensitivity of
93% (13).
Other articles in our review pointed to another study,
by Landers and Sweet, as reference for the high sensi-
tivity of ultrasound for the diagnosis of TOA (4,9,14). In
this study performed in 1983, authors reviewed 232
patients admitted with the diagnosis of TOA. Transab-
dominal ultrasound was performed in 98 of the patients,
and the authors were able to confirm the finding of an
adnexal mass on ultrasound in 91 of the 98 patients with
TOA, resulting in a sensitivity of 93%. Of these masses,
83 of the 91 were complex adnexal masses, whereas 8
were cystic adnexal masses. The study population of 98
patients represented a group of patients defined to have
TOA either by surgical confirmation (31 of the 98) or
clinical diagnosis (67 of the 98), and was defined as “the
presence of an adnexal mass(es) by pelvic examination
of patients with symptoms and signs consistent with a
diagnosis of acute pelvic inflammatory disease” (14).
These prior two studies reviewed the use of transab-
dominal ultrasound. In one study in 1988, Lande et al.
chose 67 patients for evaluation by transvaginal ultrasound
from a group of 354 patients who previously had transab-
dominal ultrasound for clinically suspected adnexal pathol-
ogy (15). The final diagnosis was determined by surgical
findings in 34 of these patients, with the rest confirmed by
clinical outcome, findings at sonographic follow-up, hys-
terosalpingography, CT scan, magnetic resonance imaging
(MRI), transvaginal ultrasound-guided biopsy, or culdocen-
tesis. Twelve of these 67 patients had a final diagnosis of
D. C. Lee and A. K. Swaminathan
tubo-ovarian abscess. In three cases, transvaginal ultra-
sound improved diagnostic sensitivity for TOA. However,
in two cases, the larger field of view in transabdominal
ultrasound was more helpful in locating adnexal masses and
differentiating uterine from adnexal structures when com-
pared with the transvaginal ultrasound studies, which were
non-diagnostic and compromised by their limited field of
view (15). Overall, these findings would translate into a
75% sensitivity of transabdominal ultrasound compared to
an 83% sensitivity of transvaginal ultrasound for the diag-
nosis of TOA.
Two other studies in our search retrospectively re-
viewed transvaginal ultrasound in patients who required
laparoscopy as part of the workup of their pelvic inflam-
matory disease. In 1990, Patten et al. reviewed 35 pa-
tients who had diagnostic laparoscopy and endometrial
biopsy for suspected PID, 18 of whom also had trans-
vaginal ultrasound (6). They reported six cases of tubo-
ovarian complex found by ultrasound, defined as either a
thickened fluid-filled oviduct fixed and tethered to the
ovary or distortion of the adnexal region without clear
distinction of tube from ovary. Ultimately, five of these
six tubo-ovarian complexes were confirmed by laparos-
copy, with one of the cases being a false positive for an
enlarged non-inflammatory cystic mass on laparoscopy
(6). In 2003, Varras et al. retrospectively reviewed the
ultrasound results of 25 women (23 ultrasounds were
transvaginal) with severe PID requiring surgical inter-
vention and TOA confirmed by surgery (16). In this
study, a mass was found in all cases, however, charac-
terization of the mass varied. At least two of these cases
demonstrated only a simple adnexal cyst.
In our literature search, we were able to identify only
one prospective study. In 1999, Tukeva et al. prospec-
tively enrolled 30 consecutive patients clinically sus-
pected to have PID (17). Inclusion criteria were a history
of acute pelvic pain of ⬍ 3 weeks duration, lower ab-
dominal tenderness, bilateral adnexal tenderness, cervi-
cal motion tenderness, elevated C-reactive protein, and a
negative pregnancy test. Each patient then had a bedside
transvaginal ultrasound in the ED performed by an ex-
perienced gynecologist. Patients subsequently underwent
MRI of the pelvis followed by laparoscopy. The original
intent of the study was to evaluate the sensitivity and
specificity of MRI as compared to ultrasonography in
reference to the gold standard of laparoscopic findings
for PID; however, published results also contain data on
the finding of abscess on ultrasonography, MRI, and
laparoscopy as well. Of the 30 patients, 21 were found to
have PID, and 9 of these patients were diagnosed with an
abscess on laparoscopy. Transvaginal ultrasound diag-
nosed 17 of the 21 cases of PID (81%); however, it
diagnosed only five of the nine abscesses, for a sensitiv-
ity of 56%. Two of the four abscesses missed were
Ultrasound Sensitivity for Tubo-ovarian Abscess
identified by ultrasound as ovarian tumors, and the other
two were diagnosed as salpingitis and pyosalpingitis
without mention of abscess. Additionally, in the 21 pa-
tients without abscess by laparoscopy, 3 were diagnosed
by ultrasound as having abscess, leading to a specificity
of 86%. MRI demonstrated 100% sensitivity for the nine
abscesses, but also diagnosed 2 patients with abscess
who subsequently were found by laparoscopy not to have
abscess, for a specificity of 90% (17).
DISCUSSION
In our literature review, we found two retrospective
studies of transabdominal ultrasound for the diagnosis of
pelvic abscess and tubo-ovarian abscess (13,14). These
two studies are the most often cited as evidence for the
high sensitivity and specificity of ultrasound for diagno-
sis of TOA, including four recent articles in emergency
medicine journals (1,7,10,11). We also found a prior case
report of a TOA not diagnosed by transabdominal ultra-
sound on a post-menopausal female with severe PID and
bilateral TOA (3). Transabdominal ultrasound alone may
result in equivocal and non-specific findings in TOA.
Transvaginal ultrasound has been proven to be superior
to transabdominal ultrasound in several studies of pa-
tients with PID (18,19). Specifically, transvaginal ultra-
sound leads to more detailed visualization of pelvic
structures, resulting in more clarity in assessing the se-
verity along the spectrum of acute PID (20).
Because early studies of ultrasound were performed
with less advanced technology and still were able to
achieve sensitivities of 93% for pelvic abscesses, the
assumption would be that with current technologies, the
sensitivities for diagnosing TOA by ultrasound would
be higher. However, this assumption is challenged by
Lande et al. in their study (15). The authors demonstrate
that although transvaginal ultrasound may increase the
visualization of specific pelvic structures over transab-
dominal ultrasound in the diagnosis of TOA, the more
limited field of view of transvaginal ultrasound makes it
more difficult to locate certain masses, when compared
to transabdominal ultrasound. This study, though notably
smaller, suggests a more modest sensitivity for transvag-
inal ultrasound (83%) in the diagnosis of TOA.
In reviewing any sensitivity, it is important to note the
methods for confirming the presence or absence of false
negatives as well as in which study populations a partic-
ular sensitivity was achieved. In the retrospective study
by Taylor et al., there is inadequate delineation of their
methods, although it seems that true positives and false
positives were confirmed only in those patients who
subsequently had surgery or autopsy performed (13).
False negatives were not all confirmed by a gold standard
173
such as surgery or laparoscopy, but instead, their “sub-
sequent clinical course confirmed absence of abscess”
(13). Based on their data, we interpret this to mean that
negative ultrasounds were confirmed to be negative if
these patients did not later require surgery or have au-
topsy performed. There is no comment on what inter-
ventions these patients did receive, such as antibiotics or
other medical management. Given that many patients
with tubo-ovarian abscess who are medically managed
do not necessarily require later surgery or autopsy, this
standard seems to be poor confirmation that these pa-
tients did not actually have a TOA.
Similarly, in the retrospective study by Landers and
Sweet, the study population in which a transabdominal
ultrasound sensitivity was determined was a group of
patients who had a TOA either surgically confirmed (31
of the 98 patients) or clinically diagnosed (67 of the 98
patients) (14). Clinical diagnosis was defined as “the
presence of an adnexal mass(es) by pelvic examination
with symptoms and signs consistent with a diagnosis of
acute pelvic inflammatory disease” (14). Not only were
the clinically diagnosed cases not confirmed by any gold
standard such as laparoscopy, but the study population
represented a specific subset of patients who presented
with PID, specifically those with the presence of an
adnexal mass by physical examination. According to one
study, a palpable adnexal mass on physical examination
was a finding detected in only 5 of 17 patients later
shown on pelvic ultrasound to have a TOA (9). Thus, this
sensitivity of 93% for the diagnosis of TOA on ultra-
sound refers to a subset of PID patients with a palpable
mass on physical examination, which does not capture all
TOAs. This subsequently makes the sensitivity less gen-
eralizable to a population of all patients who come to the
ED with PID.
In our literature review, we also found two smaller
studies that reviewed the use of transvaginal ultrasound
in patients who eventually required laparoscopy in the
work-up of their pelvic inflammatory disease. In one of
these studies, by Varras et al., the authors note that
although a pelvic mass was found in each of the 25
patients with TOA, the spectrum of sonographic findings
was not specific, and the variety of radiographic findings
may also increase suspicion for other disease processes
(16). It should be questioned whether simple cystic ad-
nexal masses that were included in the study by Landers
and Sweet as “positives” for TOA should instead be
characterized as false negatives, as did one of the other
reviewed studies (14,17). More importantly, both of
these smaller retrospective studies of transvaginal ultra-
sound only retrospectively reviewed patients who ended
up requiring laparoscopy or surgery in the work-up of
their PID. This subset of patients once again represents a
more specific subset of patients and may have included
174
patients who were more clinically ill and in whom find-
ings may have been more likely to be found, thus falsely
increasing the sensitivity of ultrasound in this more spe-
cific group of patients.
In our literature search, there was only one prospec-
tive study that analyzed patients with symptoms and
signs concerning for PID who all went on to have ultra-
sound followed by a confirmatory test. Tukeva et al.
studied 30 consecutively enrolled patients who were
clinically suspected to have PID (17). Transvaginal ul-
trasonography was performed in the ED by an experi-
enced gynecologist. These patients were then evaluated
by MRI and then laparoscopy. In our reanalysis of their
data, diagnosis of TOA by ultrasound occurred for only
5 of the 9 patients with abscesses found by laparoscopy.
Although it was a small study, these findings found a
sensitivity of transvaginal ultrasound for TOA of only
56%. It should be noted that two of the abscesses missed
were identified by ultrasound as ovarian tumors. It might
be argued that the finding of any adnexal mass by ultra-
sound in a patient with suspected PID should be suspi-
cious for TOA; however, including these findings as true
positives would still increase the sensitivity of transvag-
inal ultrasound to only 78%. Additionally, in our reanal-
ysis of their results, the specificity of transvaginal ultra-
sound for TOA was found to be 86%. This compares to
the superior sensitivity and specificity of MRI for TOA
found in the same study of 100% and 90%, respectively.
Ultimately, in those cases in which transvaginal ul-
trasound either fails to diagnosis TOA or results are
ambiguous or inconclusive, it may mean that further
imaging is required. There have been preliminary studies
investigating CT imaging for PID to develop character-
istic findings of disease (21). At least one reviewer has
noted that the prevalence of PID initially diagnosed by
CT imaging is increasing and that more mild inflamma-
tory changes may be better appreciated on CT scan than
ultrasound, though differentiation of the level of infec-
tion may be more difficult on CT scan than on ultrasound
(8). However, we were unable to find sufficient evidence
to state a given sensitivity and specificity of CT for PID
or TOA. Additionally, in our review we found evidence
that MRI may be more sensitive and specific in diagnos-
ing TOA when compared to ultrasound, although its
accessibility may limit its use in the ED.
CONCLUSION
Our case report demonstrates at least one instance of a
tubo-ovarian abscess that was not diagnosed by trans-
vaginal ultrasound and was then later diagnosed by CT
scan. Review of the emergency medicine literature notes
many references citing the high sensitivity and high
D. C. Lee and A. K. Swaminathan
specificity of ultrasound for the diagnosis of TOA. How-
ever, reviewing the sources and data in defense of these
statements reveals many retrospective studies that often
review more specific study populations. Overall, we
found results for the sensitivity of ultrasound for the
diagnosis of TOA that range from 56% to 93%, with a
specificity of 86% to 98%. The wide range is likely due
to differences in methods, including variability in the
technology used (transabdominal vs. transvaginal), the
person performing and interpreting the ultrasound (radi-
ologist vs. gynecologist), the study population (patients
with suspected PID, patients with a palpable adnexal
mass and suspected PID, vs. only patients eventually
requiring laparoscopy or surgery in the work-up of their
PID), the study design (retrospective vs. prospective),
and interpretation of positive results (inclusion of any
adnexal mass vs. limiting it to those specifically diag-
nosed as abscess). These retrospective studies may not
have included a group of patients who reflect a represen-
tative sample of those who come to the ED with signs of
PID. Furthermore, some of these studies had significant
issues in methodology that limit the reliability of their
results. The one prospective study that we found suggests
a lower sensitivity and specificity than previously re-
ported. As the use of ultrasound by emergency physi-
cians increases, it is important to be aware of the limi-
tations of ultrasound in diagnosing TOA. Our review
calls into question the ability to rule out tubo-ovarian
abscess by transvaginal ultrasound alone and demon-
strates the need for additional studies to determine the
utility of ultrasound for the diagnosis of tubo-ovarian
abscess.
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