TOA (Tubo-Ovarian Abscess): Three letters you don’t want to hear

Case presentation

An 11-year-old female presents with severe right-sided abdominal pain that began 5 days ago. The patient reports that she was in her usual state of good health until she experienced the pain, which initially seemed generalized, intermittent, and achy but has become more constant, sharp, and now is located primarily in the right lower quadrant. She developed a fever to 102 degrees Fahrenheit 2 days ago. She reports nausea but no emesis, diarrhea, hematuria, or trauma; she endorses dysuria. She also states that she had right flank pain several days ago, which has now resolved. She is generally healthy but does have a history of frequent urinary tract infections and at the age of 2 years had ureteral reimplant surgery on the right side for vesicoureteral reflux. She began her menses several months ago, but this has been somewhat irregular and occasionally associated with bilateral lower quadrant pain.

Examination reveals a visibly uncomfortable child who complains of right lower quadrant pain. She is afebrile, has a heart rate of 118 beats per minute, a respiratory rate of 20 breaths per minute, and a blood pressure of 120/80 mm Hg. She has focal right lower quadrant pain to palpation, with moderate guarding and rebound. There is no costovertebral tenderness. There are no signs of trauma.

Laboratory values demonstrate a total peripheral white blood cell (WBC) count of 11,000 cc/mm, a C-reactive protein level of 2.4 mg/dL, and a urinalysis with + nitrite, 1+ leukocyte esterase, few WBCs, and few bacteria.

Imaging considerations

Since the diagnosis of tubo-ovarian abscess (TOA) requires the presence of an inflammatory mass, imaging is usually employed.