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by the American Institute of Ultrasound in Medicine J Ultrasound Med 21:731-738 • 0278-4297 Single-Step Transvaginal Aspiration and Drainage for Suspected Pelvic Abscesses Refractory to Antibiotic TherapyDepartment of Radiology, University of California Davis Medical Center, Sacramento, California. Address correspondence and reprint requests to John P McGahan, MD, Department of Radiology, University of California Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817.
Objective. For treatment of suspected pelvic abscesses, the use of the trocar technique avoids many of the technical challenges of the Seldinger method. The purpose of this study was to evaluate the effectiveness and safety of sonographically guided transvaginal aspiration or drainage with the trocar technique in suspected pelvic abscesses that were refractory to antibiotic treatment. Methods. We retrospectively reviewed 22 patients with suspected pelvic abscesses refractory to antibiotic therapy who underwent single-step transvaginal pelvic aspiration or drainage between 1995 and 2000. Results. Transvaginal aspiration or drainage was successful in 19 (86%) of the 22 patients. Of the 3 patients in whom aspiration or drainage failed, all ultimately went on to have surgery despite undergoing repeated drainage procedures. Drainage catheters were placed in 15 (68%) of the 22 patients and left in place an average of 3.7 days. Aspiration alone resulted in a 100% success rate, whereas drainage with catheter placement resulted in an 80% success rate. No complications, including bleeding, bowel perforation, and death, were reported in any of the procedures. Conclusions. Transvaginal ultrasonographically guided aspiration or catheter placement with the trocar technique is a safe and effective treatment for suspected pelvic abscesses refractory to antibiotic therapy.
Key Words: aspiration • drainage • interventional sonography • pelvic abscess • sonographic guidance
Pelvic inflammatory disease usually occurs because of an ascending infection affecting the uterus, fallopian tubes, and surrounding structures, and it affects 1 in 10 women in the United States during the reproductive years.1 Because of the varying clinical appearance and lack of specific laboratory tests, 1 of 4 women with pelvic inflammatory disease has serious complications, such as acute morbidity, chronic abdominal pain, and infertility.2 Pelvic or tubo-ovarian abscesses occur in about 15% of cases of pelvic inflammatory disease. Pelvic abscesses can also result from other causes, such as diverticulitis, appendicitis, inflammatory bowel disease, and gynecologic or obstetric surgery. Pelvic abscesses usually respond to antibiotics, but surgical intervention is indicated when antibiotics fail. The traditional surgical approach to pelvic abscesses ranges from colpotomy to laparotomy to total abdominal hysterectomy and bilateral salpingo-oophorectomy.3 Although surgery can be effective, it usually involves a lengthy hospital stay and has associated morbidity and mortality. During the past decade, percutaneous image-guided drainage of pelvic abscesses has been shown to be an effective alternative to surgery.4 Various approaches have been described for pelvic abscess drainage, including transabdominal,5,6 transgluteal,7 transrectal,8,9 and transvaginal10–15 with the use of either computed tomographic or sonographic guidance. Transvaginal sonography may be used to guide drainage and delineates the uterine and ovarian anatomy well. This is due to the fact that the ultrasonic probe is placed in close contact with the uterus and ovaries, avoiding the overlying abdominal tissue and bowel and allowing the use of higher-frequency, higher-resolution ultrasonic probes.16,17 A transvaginal approach is often the most direct route to pelvic abscesses, and placement of a drainage catheter is simplified by not having to traverse the overlying bowel, uterus, or bladder. For a number of years, our institution has consistently performed sonographically guided transvaginal drainage of pelvic abscesses using the trocar technique rather than the Seldinger method.10 With the trocar technique, a drainage catheter with its inner stiffener and stylet (trocar) is inserted as a unit into the fluid collection with image guidance. The stylet is removed, and the collection is aspirated. On the basis of the collection appearance and aspirated material, a decision is made whether to place the drainage catheter. If deemed appropriate, then the drainage catheter is pushed off the stiffener into the cavity. For the Seldinger technique, an entry needle is advanced into the suspected abscess under image guidance, and then a guidewire is passed through the needle and into the collection. The needle is withdrawn, and the drainage catheter is placed over the guidewire. Although not as commonly used, the trocar technique is simpler, requires fewer steps, and avoids many of the technical difficulties associated with the Seldinger technique. The goal of this study was to retrospectively evaluate the effectiveness and safety of the trocar technique in draining suspected pelvic abscesses that were refractory to antibiotic treatment.
This retrospective study included a review of all patients who had transvaginal drainage of suspected pelvic abscesses from May 1995 through March 2000. The suspected abscesses in all patients included in this study were nonresponsive to antibiotics. Patients were not suitable candidates if they were younger than 18 years or had an uncorrectable coagulopathy. Most patients began receiving double-antibiotic treatment (gentamicin sulfate with metronidazole or clindamycin) or triple-antibiotic therapy (gentamicin sulfate, ampicillin, and metronidazole or clindamycin), which was modified as clinically dictated. Patients were monitored for clinical response and referred to radiology for evaluation of suspected abscesses if they had persistent pain, leukocytosis, or fever after at least 48 hours of antibiotic therapy and if diagnostic imaging studies showed a pelvic mass consistent with an abscess. Imaging studies were obtained in all cases within 24 to 48 hours before aspiration.
As described previously, suspected pelvic abscesses were drained by either needle aspiration of the fluid collection or catheter placement via the trocar technique.10 In short, the patient usually was sedated with propofol (Diprivan; AstraZeneca Pharmaceuticals LP, Wilmington, DE) given by an anesthesiologist or received deep conscious sedation with midazolam hydrochloride (Versed; Hoffmann-La Roche Inc, Nutley, NJ) or fentanyl citrate (Abbott Laboratories, Abbott Park, IL). An endoluminal transvaginal probe (Ultramark 9; Philips Ultrasound, Bothell, WA) was modified with a 6.7F McGahan drainage catheter (Cook Surgical, Bloomington, IN) mounted in the transducer groove.10 The ultrasonic probe was placed in the vagina, and the trocar technique was used to place the catheter in the fluid collection. The inner stylet was removed after entering the fluid collection and aspirating the contents. Then either the fluid was completely aspirated or a catheter was placed. The decision to place a catheter for drainage depended on multiple factors, including the size of the fluid collection, the presence of multiple abscesses, a simple versus multiloculated appearance, the viscosity of the aspirate fluid, and the amount of the aspirate fluid (Table 1
The medical records of each patient were retrospectively reviewed for this study. Details about the clinical and medical history, ultrasonographically guided aspiration, catheter placement, aspirate culture, and subsequent clinical course were noted. Treatment was considered unsuccessful if the patient became symptomatic, an infected fluid collection persisted despite treatment, or an abscess recurred in the region of previous drainage after catheter removal.
Twenty-two patients underwent aspiration or drainage for suspected pelvic abscesses. The mean age of the patients was 37.4 years (median, 37.0 years; range, 19–78 years). Purulent fluid was drained in 17 (77%) of the 22 patients, and cultures ultimately showed that these collections were abscesses. As shown in Table 2  , polymicrobial growth was seen with multiple species of organisms. In unimicrobial abscesses, the dominant organism was Escherichia coli in 4 cases, Enterococcus in 2, Klebsiella in 2, and Staphylococcus, Streptococcus, and Hemophilus influenzae in 1 each. On the basis of the clinical history and aspirate cultures, the final diagnoses of the purulent pelvic abscesses were salpingitis in 12 patients, post–gynecologic surgery infection in 4 patients, and post– abdominal surgery infection in 1 patient. Table 3 shows the final diagnosis of the pelvic collections versus the clinical outcome.
Of the 5 collections without bacterial growth, 2 were sterile cystic fluid collections, 1 was a postsurgical hematoma, and 1 was a sterile blood-tinged fluid collection. A catheter was left in place for this last collection, but cultures were negative for growth of any organisms. Treatment with triple antibiotics may have prevented bacterial growth in these cultures, and ultimately the patient became afebrile and improved clinically after drainage. One collection was ultimately shown to be an ovarian tumor. In this patient, the aspiration was considered successful because the aspirate fluid was sent not only for cultures but also for cytologic analysis, which helped lead to the final diagnosis of cancer.
The amount of fluid drained from each procedure ranged from 2.5 to 220 mL (average, 59 mL; SD, 64 mL). Given the difficulty of estimating abscess size, especially with irregular and multilocular abscesses, the volume of aspirated material was used as an estimate for abscess size. Abscesses treated with aspiration alone usually were smaller and averaged 7.5 mL in initial aspirate, whereas those that were treated with catheter placement averaged 45.1 mL. Table 4
Ultimately, transvaginal aspiration or drainage was successful in 19 (86%) of the 22 patients (Fig. 1 ). Of the 3 patients in whom aspiration or drainage failed, all ultimately went on to have surgery despite undergoing repeated treatment. One patient had a catheter placement yielding 70 mL of viscous fluid with mixed flora but had limited improvement. A second patient had improvement after 2 successful drainage placements, but recurrent symptoms developed 2 weeks later. A third patient underwent catheter drainage followed by a separate aspiration and was discharged home with antibiotics. However, 1 month later she had similar symptoms (Fig. 2). The first and second patients required abdominal hysterectomy, and all 3 patients required bilateral salpingo-oophorectomy.
Drainage catheters (Fig. 3 ) were placed in 15 (68%) of the 22 patients and were left in place for an average of 3.7 days (median, 3.5 days). Drains were usually reserved for larger fluid collections, multiple abscesses, multiloculated abscesses, and collections with viscous fluid, an amount of aspirate, and clinical history consistent with infection. Aspiration alone was successful in 7 (100%) of 7 cases, whereas drainage with catheter placement was successful in 12 (80%) of 15 cases. The 1 patient who underwent 2 unsuccessful procedures (1 aspiration and 1 drainage) was counted as having a drainage case for the purposes of this study. No complications, including bleeding, bowel perforation, and death, were reported in any of the procedures. The transvaginal catheters appeared to be well tolerated without any complications.
Pelvic inflammatory disease affects nearly 1 million women in the United States annually, and approximately 85,000 of these women eventually have pelvic abscesses.18 Left untreated, pelvic abscesses are associated with acute morbidity, adhesion formation, impaired fertility, and chronic pelvic pain. Although many pelvic abscesses respond to antibiotic therapy, surgery is often needed when antibiotics fail. However, laparotomy for pelvic abscesses is one of the more technically difficult gynecologic procedures and has associated surgical and anesthetic risks, hospitalization costs, and prolonged recovery times.19 The definitive surgical treatment of a total hysterectomy and bilateral salpingo-oophorectomy is highly effective. However, the surgical treatment leaves patients infertile and devoid of ovarian hormones, which are major problems in the young premenopausual women who tend to be affected by pelvic abscesses. Total abdominal hysterectomy is the alternative to failed aspiration or drainage of these abscesses. Given the drawbacks of surgery, interventional radiologic procedures have become the mainstay of treatment of pelvic abscesses. vanSonnenberg et al11 described successful treatment of 12 of 14 women by sonographically guided transvaginal and transabdominal aspiration with catheter placement mainly using the Seldinger technique. Casola et al6 reported success in 15 of 16 patients when using transgluteal, transvaginal, and transabdominal routes and a variety of techniques, including fine-needle localization, tandem trocar, and Seldinger methods. Feld et al12 reported 78% successful transvaginal sonographically guided drainage in 41 patients with catheter placement using the Seldinger technique. Nelson et al13 described an 84% success rate in 31 women having sonographically guided transvaginal drainage using mainly needle aspiration. Corsi et al14 reported successful abscess aspiration in 25 of 27 patients with transvaginal sonographically guided aspiration and catheter placement using an unspecified technique. Aboulghar et al15 described 100% success with sonographically guided transvaginal aspiration in 15 patients using needle aspiration. We found a similar success rate of 86% in 22 patients with transvaginal sonographically guided aspiration and catheter placement using the trocar technique. The use of aspiration alone versus catheter drainage for pelvic abscess therapy varies widely, and limited data comparing the 2 methods are available. vanSonnenberg et al11 reported success in 7 (88%) of 8 patients with aspiration alone compared with success in 5 (83%) of 6 patients with catheter placement. The benefits of needle aspiration include the ability for treatment to be completed in 1 session and avoidance of an indwelling catheter. A drawback of needle aspiration is the need for repeated punctures to fully aspirate complex abscesses. Also, multiple aspirations may be necessary for persistent or recurrent collections, and longer periods of antibiotic therapy may be needed to completely eliminate residual infections.20 Catheter placement allows repeated flushing of larger abscesses to help break down loculi and lower the viscosity of abscess contents. We generally reserved catheter use for larger collections, multiloculated abscesses, and collections with viscous fluid or if the clinical history was highly suggestive of infection. Of interest is the fact that multiseptate fluid collections were as successfully treated as simple cystic fluid collections. Catheters were placed by the trocar technique instead of the more common Seldinger technique reported in the literature. We experimented with the Seldinger technique previously but had difficulty with buckling when placing dilators or catheters through the vaginal musculature. The thick musculature of the vaginal vault can be extremely difficult to pierce and dilate, and the use of the Seldinger technique compounds this difficulty because of the necessity of repeated dilation and exchange over a guidewire. Other authors have reported similar difficulty with traversing the vaginal tissue with catheters, including Casola et al6 and vanSonnenberg et al.11 Eschelman and Sullivan21 recommended using a Colapinto needle as a dilator for the transvaginal approach, but Varghese et al20 reported that the Seldinger method was still difficult and timeconsuming even with the recommended modifications. The use of the trocar technique avoided many of the challenges of the transvaginal guidewire exchange technique.10 The single-step trocar technique can be completed safely, quickly, and effectively. In our experience, the actual procedure time for the trocar method usually took less than 30 minutes compared with considerably longer times for the Seldinger technique. The main challenge with the trocar technique was maintaining the catheter in the groove of the guide, which can be managed by the operator by using a finger to stabilize the catheter in place. Also, the use of the trocar technique allowed aspiration of the fluid after removal of the inner stylet of the trocar catheter. At this time, a decision could be made either to use aspiration alone or to place a catheter. There are several drawbacks of transvaginal catheter placement. The technique can be painful and often requires intravenous sedation. Also, the transvaginal approach may not be appropriate for young, prepubertal, or sexually inactive patients. Another potential drawback is that a small-bore (6.7F) catheter may not be sufficient for very viscous abscess collections; however, we did not find this to be the case. Also, depending on the location of the abscess, the collection may not be accessible by a transvaginal route. Careful imaging of patients is important, because the location will dictate whether a transvaginal approach may be safely used. For example, collections high in the false pelvis may be better accessed with a transrectal approach, whereas collections in the anterior abdomen may be more safely aspirated with a transabdominal approach. In our study, there were no complications from the procedures, such as bleeding, bowel perforation, and death. In conclusion, transvaginal sonographically guided drainage and catheter placement with the trocar technique is a safe and effective treatment for suspected pelvic abscesses. Our success rate of 86% is similar to those reported in the literature, and there were no complications in any of the patients. The use of the trocar technique greatly simplifies the procedure and avoids many of the technical difficulties of repeated dilation and exchange with the Seldinger technique. Further experience and investigation will allow greater insight into the use of transvaginal aspiration and drainage of suspected pelvic abscesses refractory to antibiotic therapy.
Received March 1, 2002, from the Department of Radiology, University of California Davis Medical Center, Sacramento, California.
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Abstract
Introduction
