Women under the age of 25 years, who are sexually active, are the most common patients affected by a TOA. The clinical presentation varies, but the most frequently reported symptoms include pain in the lower region of the abdomen or pelvis, vaginal discharge, and fever. The pain tends to arise after menstruation has terminated, it is described by the patients as dull and cramp-like and is exacerbated by exercise or sexual intercourse; it also tends to disappear after a week. Fever is usually around 38° C and in cases of advanced disease, it may be accompanied by nausea and vomiting. Tubo-ovarian abscesses develop on the grounds of pelvic inflammatory disease (PID) in the vast majority of cases, with rare occurrences diagnosed without PID or in women who are not sexually active [1] [2].

Upon palpation, patients affected by a TOA usually report adnexal tenderness, that is unilateral. The finding of rebound tenderness suggests a potential peritonitis and is a sign of severe disease that requires immediate surgical intervention; Fitz-Hugh-Curtis syndrome is another potential complication [3] [4] [5] [6] [7]. In general, both PID and a TOA present with identical symptomatology; however, in a TOA case, the abscess can be identified by means of ultrasonography, plain radiograph or a magnetic resonance imaging scan.

Given the fact that tubo-ovarian abscesses develop on the grounds of pelvic inflammatory disease and can be complicated with sepsis upon their rupture, the Centre of Disease Control stipulates that antibiotics should be empirically administered for pelvic inflammatory disease, in patients who:

• Are high-risk patients for sexually transmitted diseases
• Present with pelvic or lower abdominal pain
• Have a disease that cannot be identified as non-PID
• Present with cervical, uterine or adnexal tenderness (one required)

A tubo-ovarian abscess can be diagnosed using various imaging modalities, such as ultrasonography (US), MRI, plain radiographs and a CT scan. Should the aforementioned imaging modalities fail to definitively depict a tubo-ovarian abscess, laparoscopy can also help to diagnose the abscess.

Physicians many times differentiate between a tubo-ovarian abscess and a tubo-ovarian complex. The former occurs when the ovary and fallopian tube are clearly discernible via imaging modalities, something that does not apply in the case of a tubo-ovarian complex. As far as radiographs are concerned, they are usually non-specific but may illustrate masses, reduced concentration of fat in the pelvic area and the radiographic picture of paralytic ileus. A transabdominal or endovaginal ultrasound is the imaging modality of choice for the diagnosis of a TOA and can clearly illustrate abdominal masses and debris that are usually bilateral. Ultrasonography is also opted for due to its low cost, high sensitivity and lack of ionizing radiation exposure [8]. Lastly, a CT scan is used to define the extent of the condition and an MRI scan can be useful when ultrasonography fails to illustrate an abscess.

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