O v arian ab scess w ith sp o n tan eo u s v ag in al d rain ag e
Departamento
de Obstetricia e Ginecologia da Universidade
Estadual de Campinas
- Campinas, Brazil
T h e o c c u rre n c e o f a ra re o v a ria n a b s c e s s , s p o n ta n e o u s ly d ra in e d th ro u g h th e v a g in a a fte r a n a b d o m in a l h y s te re c to m y is d e s c rib e d . T h e tre a tm e n t w a s a n o o p h o re c to m y . T h e v a rio u s fo rm s o f p rim a ry o v a ria n a b s c e s s a re d is c u s s e d in c o n n e c tio n w ith th e s e o b s e rv a tio n s . T h is c a s e illu s tra te s th e n e e d fo r a d e q u a te m a n ip u la tio n o f th e g o n a d d u rin g p e lv ic s u rg e ry in o rd e r to a v o id p a re n c h y m a l c o n ta m in a tio n a n d th e s u b s e q u e n t fo rm a tio n o f s u c h a b s c e s s e s .
U N IT E R M S : O v a ria n a b s c e s s o S u rg e ry . F is tu la . O v a ria n -to -v a g in a l.
IN T R O D U C T IO N
A
n o v a ria np ro c e s s o fa b s c e s sth e o v a ryis p rim a rilyw h ic h d iffe rsa n in fe c tio u sfro m th e tu b o o v a ria n a b s c e s s in w h ic h in v o lv e m e n t o f th eo v a ry is s e c o n d a ry to th e tu b e s . A n o v a ria n a b s e e s s w a s
firs t d e s c rib e d b y A itk e n in 1 8 6 9 (c ite d in re f. 4 ) . S in c e th e n
v a rio u s c a s e s o f s u c h a b s e e s s e s h a v e b e e n d o c u m e n te d ( 4 ) .
T h e firs t in s ta n c e o f d ra in a g e th ro u g h th e v a g in a w a s
re p o rte d in 1 9 7 2 b y A ltm a n (I)fo llo w e d b y a n o th e r c a s e b y
C la m a n e t a i ( 2 ) in 1 9 9 1 .
C A S E
R E P O R T
A 4 9 y e a r-o ld C a u c a s ia n , w id o w , g ra v id a 2 , p a ra 2 ,
c a rn e fo r c o n s u ltio n c o m p la in in g o f a e o p io u s p u ru le n t a n d
m a lo d o ro u s v a g in a l d is c h a rg e . S h e h a d u n d e rg o n e a to ta l
a b d o m in a l h y s te re c to m y fo r b le e d in g p ro b le m s e le v e n
m o n th s e a rlie r. A fte r s u rg e ry , s h e h a d fe v e r a n d in fe e tio n
A d d r e s s f o r c o r r e s p o n d e n c e :
G u s t a v o A . d e S o u z a
R u a A n t o n io L a p a , 3 0 3 . C a m b u i
C a m p in a s / S P . o B r a s il. C E P 1 3 0 2 5 - 2 4 0
o f th e s u rg ie a l w o u n d . O n th e 1 2 th d a y a fte r s u rg e ry s h e
d e v e lo p e d a n a b u n d a n t, p u ru le n t a n d fe tid v a g in a l d is c h a rg e
w h ie h p e rs is te d u n til c o n s u lta tio n . S h e re c e iv e d s e v e ra l
c o u rs e s o f a n tib io tic s w h ic h a p p a re n tly le d to th e h e a lin g
o f th e a b d o m in a l in c is io n in fe c tio n .
C lin ic a I e x a m in a tio n s h o w e d a p a tie n t in g o o d g e n e ra l
h e a lth w ith a m e d ia n in fra -u m b ilic a l s u rg ic a l s c a r a n d a n
e x te n d e d in c is io n a l h e rn ia . G y n e c o lo g ic a l e x a m in a tio n
re v e a le d a n e p ith e liz e d v a g in a l c u ff. A t rig h t a n g le s to th is ,
th e re w a s a s m a ll o rific e e x u d in g a p u ru le n t s e c re tio n . T h e
v o lu m e o f th is s e c re tio n in c re a s e d w h e n th e lo w e r a b d o m e n
w a s c o m p re s s e d . A c y s tic tu m o r w ith a m a x im a l d ia m e te r
o f 4 .0 c m , a tta e h e d to th e v a g in a l d o m e w a s d e te c te d b y
b i-m a n u a l p a lp a tio n . P e lv ic u ltra s o n o g ra p h y p e rfo rm e d
th re e d a y s la te r c o n firm e d th e p re s e n e e o f a c y s tic tu m o r,
w ith w e ll-d e fin e d , re g u la r b o rd e rs a n d in te rn a i e c h o e s
(7 .5 x 5 .5 e m ) (F ig . 1 ). U rin e a n a ly s is a n d th e h e m o g ra m
w e re n o rm a l.
A la p a ro to m y w a s p e rfo rm e d a n d a d h e re n c e o f th e
o m e n tu m to th e a b d o m in a l w a ll w a s o b s e rv e d . T h e
re m a in d e r o f th e a b d o m in a l c a v ity w a s re la tiv e ly fre e o f
o th e r a d h e re n c e . A n e n la rg e d rig h t o v a ry w ith a s m o o th
s u rfa e e w a s o b s e rv e d , fix e d to th e v a g in a l d o m e w h ile th e
tu b e p re s e n te d a n o rm a l a p p e a ra n c e . T h e le ft o v a ry
a p p a re n tly w a s n o rm a l. A n o o p h o re c to m y w a s p e rfo rm e d
a n d d u rin g th e d is s e e tio n th e a b s c e s s w a s o p e n e d a t its
e o m m u n ie a tio n w ith th e v a g in a . T h e in c is io n a l h e rn ia w a s
a ls o c o rre c te d .
F ig u re 1 - P e lv ie u ltra s o n o g ra p h y s h o w in g th e o v a ry (e y s tie ) c lo s e to th e v a g in a l d o m e .
A m ic a c in a a n d m e tro n id a z o l w e re u s e d a s p re - a n d
p o s t -o p e ra to ry a n tim ic ro b ia l th e ra p y . A s a m p le o f p u s fro m
th e a b s c e s s w a s c o lle c te d a n d a n a ly z e d b y m ic ro s c o p y a n d
c u ltu rin g . A s a re s u lt o f lim ite d fa c ilitie s , o n ly th e g ro w th
o f a e ro b e s w a s te s te d . G ra m -p o s itiv e c o c e i w e re o b s e rv e d
b y m ic ro s c o p y b u t n o b a c te ria l g ro w th w a s d e te c te d in
c u ltu re .
T h e p o s t-o p e ra tiv e p e rio d w a s u n e v e n tfu l. E x a m in a tio n
o f th e o v a ry re v e a le d a 5 ,0 x 3 ,0 e m c y s tic fo rm a tio n w ith a
y e llo w g ra n u lo u s in te rn a I s u rfa c e (F ig .2 ). U n d e r th e
m ic ro s c o p e , a la rg e n u m b e r o f p o ly m o rp h o n u c le a r
n e u tro p h ils , ly m p h o c y te s , p la s m o c y te s a n d h is tio c y te s w e re
s e e n . T h e d ia g n o s is w a s : " o v a ria n a b s e e s s " .
D IS C U S S IO N
O v a ria n a b s c e s s e s a re ra re a n d fo r th is re a s o n th e ir
e tió lo g y re m a in s p o o rly u n d e rs to o d . W e te h e r a ild D u n n4
c o n s id e re d th re e p o s s ib ilitie s to e x p la in in fe c tio n o f th e
o v a ry :
1 . T h e e n try o fb a c te ria in to th e p a re n c h y m a w h e n
th e o v a ria n c a p s u la is v io la te d .
2 . C o n ta m in a tio n v ia th e b lo o d s tre a m .
3 . C o n ta m in a tio n v ia th e ly m p h a tic s y s te m .
In th e ir re v ie w o f th e lite ra tu re , th e s e a u th o rs in d ic a te d
th a t th is in fe c tio n o c c u rre d in p re g n a n t w o m e n (1 2 c a s e s ),
in w o m e n u s in g in tra u te rin e d e v ic e s (1 2 c a s e s ), in th e p o s
t-1 5 9 7
F ig u re 2 • T h e e y s tie o v a ry a fte r th e s u rg e ry (rig h t) a n d o p e n e d
(Ie ft).
o p e ra tiv e p e rio d a fte r p e lv ic s u rg e ry (7 8 c a s e s ) a n d in o th e r
c a s e s c la s s ifie d a s " m is c e lla n e o u s " (5 7 c a s e s ).
T h e p o s t-o p e ra tiv e p e rio d is th e m o s t fre q u e n t a n d it
is e a s y to c o n tro l th ro u g h p ro p h y la c tic m e a n s . It d o e s ,
h o w e v e r, n e e d a p re c is e d ia g n o s is in p a tie n ts re c e n tly
s u b m itte d to p e lv ic s u rg e ry .
T h e in v a s io n o f b a c te ria in th e o v a ria n p a re n c h y m a
a fte r s u rg e ry m o s t lik e ly re s u lts fro m le s io n o f th e e p ith e liu m
b y a rtific ia l (s u rg ic a l) o r n a tu ra l (o v u la tio n a n d c o rp u s
lu te u m fo rm a tio n c lo s e to th e tim e o f s u rg e ry ) m e a n s .
L e d g e r e t a I (3 ) c o n s id e re d th e la tte r p o s s ib ility to b e th e
m o s t c o m m o n , s in c e p o s t-s u rg ic a l o v a ria n a b s c e s s e s o c c u r
m o s t fre q u e n tly in w o m e n s u b m itte d to v a g in a l s u rg e ry
(c o n s id e re d to b e c o n ta m in a te d ) a n d in p re -m e n o p a u s a l
w o m e n u n d e rg o in g o v u la tio n . T h e s e a u th o rs a ls o o b s e rv e d
th a t s u c h a b s c e s s e s o c c u r m o re fre q u e n tly in s u rg e rie s
p e rfo rm e d b y re s id e n ts . In th is re g a rd , in a d e q u a te
h e m o s ta s is m a y a ls o b e a c o n trib u tin g fa c to r s in c e it is
k n o w n th a t th e h e m o g lo b in re le a s e d b y re d c e lls in c re a s e s
th e v iru le n c e o f g ra m -n e g a tiv e m ic ro o rg a n is m s3 •
O v a ria n a b s c e s s e s a re fre q u e n tly a c c o m p a n ie d b y
fe v e r, a b d o m in a l p a in , s h iv e rin g , n a u s e a , d ia rrh e a , d y s u ria
e tc , a lb e it in s o m e c a s e s th e s e s y m p to m s m a y o n ly a p p e a r
la te r, u p to 1 0 0 d a y s o r m o re a fte r th e p e lv ic s u rg e ry in a
fe w c a s e s4 •
P ro p h y la x is is s till th e m o s t e ffe c tiv e m e a n o f
a v o id in g th is p ro b le m . T h e s u rg e ry m u s t b e p e rfo rm e d
p ro p e rly , w ith w e ll-c o n tro lle d h e m o s ta s is a n d m in im u m
m a n ip u la tio n o f th e a re a s u rro u n d in g th e o v a ry ,
p a rtic u la rly d u rin g p e lv ic s u rg e ry b y , th e v a g in a l ro u te . It
1598
is advisable to avoid the use ofblades
or needles previously
em ployed
for skin or vaginal
procedures,
w hen w ork in
the ovary is necessary.
F ixing the tubes and ovary in the
vaginal cuff should also be avoided, as it brings the gland
into proxim ity w ith the contam inated
vaginal environm ent.
In addition,
the infundibulopel
vic ligam ent
represents
a
w eak structural
support for the vagina.
T he recom m ended
treatm ent is to rem ove the affected
gland or to drain the abscess in patients presenting
a very
com prom ised
general
condition.
T he surgery
m ust be
follow ed
by proper
antibiotic
therapy
effective
against
aerobic and anaerobic
bacteria.
F inally, the general care
should be as for seriously ill patients, since fatalities have
been attributed to these abscesses
3•
R E S U M O
Descreve-se caso raro de abscesso ovariano, com o com plicação de histerectom ia abdom inal, e que drenou espontaneam ente pela vagina. O tratam ento realizado foi ooforectom ia. Discute-se as várias form as de abscesso prim ário do ovário sendo que a pós operatória parece ser a m ais com um . É necessário um a m anipulação adequada da gônada em cirurgias pélvicas para se evitar a contam inação do estrom a, o que propicia a form ação do abscesso ovariano.
REFERENCES
1 . A ltm an L C : O v arian ab scess an d v ag in al fistu la. O b stet
G y n eco I4 0 :3 2 1 -3 2 2 ,1 9 7 2 .
2 . C lam an P , D o v er M , S ag in u r R , T ao H an d O rizag a M :
S p o n tan eo u s o v arian -to -v ag in al fistu la: A case rep o rt. A m
J O b stet G y n eco l 1 6 4 ;7 1 -7 2 , 1 9 9 1 .
3 . L ed g er W J, C am p b ell C , T ay lo r D an d W illso n JR : A d n ex al
ab scess as a late co m p licatio n o f p elv ic o p eratio n s. S u rg
G y n eco lO b stet 1 2 7 :9 7 3 -9 7 8 ,1 9 6 9 .
4 . W etch ler S J an d D u n n L J: O v arian ab scesso R ep o rt o f a case
an d rev iew o f th e literatu re. O b stet G y n eco l S u rv 4 0 :4 7 6
-4 8 5 ,1 9 8 5 .
