Postpartum septic symphysitis, a rare condition with possible long-term consequences: a cohort study with long-term follow-up.

BACKGROUND: Postpartum septic symphysitis (PPSS) is defined as acute onset of severe pain around the symphysis, restricted movement, fever, and elevated inflammatory parameters. It is a rare but serious condition requiring urgent diagnosis and treatment. The aim of this study was to describe the incidence, symptoms, diagnosis, treatment, and long-term follow-up of PPSS. METHODS: This follow-up study included 19 out of 21 women diagnosed with PPSS from 1989 to 2017 at one tertiary care hospital in Sweden. Clinical data were retrieved from hospital records and compared to those retrieved from a regional registry. Women completed a postal questionnaire, and those who reported lumbopelvic pain (LPP) were offered a clinical examination. RESULTS: 1) PPSS was diagnosed after a normal postpartum period of 24 to 50 h by blood tests (n = 19/19), ultrasonography (n = 9 /19), computer tomography (n = 8/19) or magnetic resonance imaging (n = 16/19) Treatment included aspiration of symphyseal abscesses, i.v. antibiotics and different physiotherapeutic interventions. Women with PPSS more frequently were primiparous (n = 14/19, p = 0.001), had an instrumental delivery (n = 14/19, p = 0.003), longer time of active labour (p = 0.01) and second stage of labour (p = 0.001) than women in the regional registry. 2) Ten out of 19 (52%) women reported LPP at follow-up. These women more often suffered impaired function related to LPP (Pelvic Girdle Questionnaire, 27 versus 0, p < 0.0001), a poorer health-related quality of life (EuroQol-5 dimensions p = 0.001 and EuroQol-visual analogue scale, 65 mm versus 84 mm, p = 0.022) and higher levels of anxiety and depression (Hospital Anxiety Depression Scale (HADS) HADS-Anxiety, 7 versus 2, p = 0.010; and HADS-Depression, 1 versus 0, p = 0.028) than women with no pain. 3). Of the eight women who were clinically assessed, one had lumbar pain and seven had pelvic girdle pain (PGP). CONCLUSIONS: In the largest cohort of patients with PPSS to date, primiparas and women with instrumental vaginal delivery were overrepresented, indicating that first and complicated deliveries might be risk factors. Approximately half of the women reported PGP at follow-up, with considerable consequences affecting health-related quality of life and function decades after delivery. Prospective multicentre studies are needed to establish risk factors, long-term consequences, and adequate treatment for this rare pregnancy complication.

[Comparison of antibiotics and saline irrigation with tube drainage in the treatment of postoperative abdominal and pelvic infectious effusion].

Objective: To compare the efficiency of saline irrigation, antibiotics irrigation and high-concentration antibiotics perfusion with tube drainage in the treatment of infectious effusion. Methods: Clinical and sonographic features of abdominal and pelvic infectious effusion of 64 patients with malignant tumor collected from September 2013 to September 2017 were retrospectively analyzed. The changes of effusion size and temperature, catheterization time were evaluated in saline irrigation group and antibiotics irrigation group. The catheterization time was compared between antibiotics irrigation group and high-concentration antibiotics perfusion group. Results: The effective rates of the saline irrigation group and the antibiotics irrigation group were 68.6% and 86.8%, respectively, and the times of catheterization were 11.9±8.4 days and 7.8±4.8 days, respectively, with significantly statistical difference (both P<0.05). However, the effective rates of the antibiotics irrigation group and the high concentration antibiotic perfusion group were 86.8% and 100.0%, respectively (P=0.067), while the times of catheterization were 7.8±4.8 days and 3.6±3.1 days, respectively (P<0.001). Conclusion: The antibiotic irrigation with tube drainage, especially the high concentration perfusion is more effective than saline in the treatment of abdominal and pelvic infection effusion.

Use of the Transrectal Ultrasound Probe in Aspiration and Drainage in Pediatric Patients: A Retrospective Observational Study.

PURPOSE: To retrospectively evaluate the safety and efficacy of transrectal ultrasound (TRUS) probe use for aspiration and drainage of pelvic abscesses in children. MATERIALS AND METHODS: Patient demographics, procedural details, technical success, safety, and clinical course of TRUS procedures were retrospectively analyzed. Between 2007 and 2016, 118 TRUS-guided procedures were performed in 115 children (60 males, 55 females); median age was 12.4 years (range, 2.4-17.9 years) and median weight was 45 kg (range, 12.6-112 kg). Ten children were 5 years of age or younger. RESULTS: In total, 113/118 procedures were performed under general anesthesia. The rectum accommodated the probe and needle guide without resistance in all children (technical feasibility, 100%). Abscesses were anterior to the rectum in 116/118 and posterior in 2/118. One hundred twelve collections were drained, 4 were aspirated, and 2 procedures were aborted, both subsequently successfully drained (2 and 3 days later). One patient underwent repeat drainage after 28 months. No major complications were reported. Median times to temperature normalization was 0 days (mean, 1.2; range, 0-13 days), catheter dwell time 5 days (mean, 6; range, 2-21 days), drain removal to discharge 1 day (mean, 2; range, 0-41 days), and follow-up 117 days (mean, 195; range, 5-2,690 days). CONCLUSIONS: TRUS-guided drainage using the TRUS probe and needle guide is a safe and effective method for aspiration and drainage of pelvic abscesses in children as young as 2 years.

Effectiveness and Adverse Events of Early Laparoscopic Therapy versus Conservative Treatment for Tubo-Ovarian or Pelvic Abscess: A Single-Center Retrospective Cohort Study.

BACKGROUND/AIM: We aimed to assess the value of early laparoscopic therapy in management of tubo-ovarian abscess (TOA) or pelvic abscess. METHODS: This was a retrospective study of all consecutive patients who were initially diagnosed with TOA or pelvic abscess at the local hospital between January 2010 and December 2014. The risks of operation and recurrence were analyzed using logistic analyses. RESULTS: The durations of body temperature > 38.0°C (p = 0.001) and hospitalization (p < 0.001) were longer in the conventional group versus the early laparoscopy group. In the conventional group, 15 (50%) patients finally underwent laparoscopic exploration. The abscess size in the late laparoscopic group was significantly larger than the successful antibiotic treatment group (6.3 ± 1.5 vs. 4.9 ± 1.2 cm, p = 0.010). Abscess > 5.5 cm was independently associated with antibiotic failure (OR 4.571; 95% CI 1.612-12.962). Compared with late laparoscopy, early laparoscopy was associated with a shorter operation time (p = 0.037), less blood loss (p = 0.035), and shorter durations of body temperature > 38.0°C (p < 0.001) and hospitalization (p < 0.001). The cost was the lowest in the patients successfully treated conservatively. CONCLUSION: Early laparoscopic treatment is associated with shorter time of fever resolution, shorter hospitalization, and less blood loss compared with conventional treatment for TOA or pelvic abscess.

Low Hartmann's procedure or intersphincteric proctectomy for distal rectal cancer: a retrospective comparative cohort study.

PURPOSE: Two non-restorative options for low rectal cancer not invading the sphincter are the low Hartmann's procedure (LH) or intersphincteric proctectomy (IP). The aim of this study was to compare postoperative morbidity with emphasis on pelvic abscesses after LH and IP. METHODS: All patients that had LH or IP for low rectal cancer were included in three centres between 2008 and 2014 in this retrospective cohort study. Follow-up was performed for at least 12 months. RESULTS: A total of 52 patients were included: 40 LH and 12 IP. Median follow-up was 29 months (IQR 23). There were no differences between groups in gender, age and ASA classification. Seven patients in the LH group (18%) and four patients in the IP group (33%) developed a complication within 30-day postoperative with a Clavien-Dindo classification grade III or higher (P = 0.253). Four out of 40 patients (10%) in the LH group and two out of 12 patients (17%) in the IP group developed a pelvic abscess (P = 0.612). Reinterventions were performed in 11 (28%) patients in the LH group and five (42%) patients in the IP group (P = 0.478), with a total number of reinterventions of 13 and 20, respectively. Six and 15 interventions were related to pelvic abscesses, respectively. CONCLUSION: Pelvic abscesses seem to occur in a similar rate after both LH and IP. Previous reports from the literature suggesting that IP might be associated with less infectious pelvic complications compared to LH are not supported by this study, although numbers are small.

Recurrent Pelvic Infections and Salpingitis after Perforated Appendicitis.

BACKGROUND: The effect of perforated appendicitis on the adnexa is an issue of concern and controversy. Long-term fertility studies have been conflicting. CASE: We present the case of a patient with chronic pelvic infections, salpingitis, and hydrosalpinx after perforated appendicitis. SUMMARY AND CONCLUSION: Magnetic resonance imaging was helpful in diagnosing a chronically obstructed fallopian tube, likely secondary to the dense adhesions from her previously treated perforated appendicitis. Salpingectomy relieved her symptoms of chronic pain and recurrent infections.

Comparison of outcomes between endoscopic ultrasound-guided transcolonic and transrectal drainage of abdominopelvic abscesses.

BACKGROUND: Transrectal endoscopic ultrasound (EUS)-guided pelvic abscess drainage has been reported, but data on transcolonic drainage are scant. AIM: To compare outcomes in patients undergoing transcolonic and transrectal drainage of abdominopelvic abscesses. METHODS: Retrospective study of all patients who underwent EUS-guided drainage of abdominopelvic abscesses over a 7-year period. Abscesses were drained by a standard single-step EUS-guided technique with deployment of double-pigtail stents ± catheters. Technical success was defined as successful placement of stents or drainage catheters within the abscess cavity. Treatment success was defined as resolution of abscess on follow-up computed tomography at 2 weeks with symptom improvement. RESULTS: Of 38 patients, 11 underwent transcolonic and 27 transrectal drainages. There was no difference in patient demographics, laboratory values, and median abscess size (65 vs 70 mm, P = 0.85) between the two cohorts. Etiology of abscess was postsurgical in 65.7%, diverticulitis in 13.1%, perforated viscus in 10.5%, and other causes in 10.5%. There was no difference in rates of technical success (100% in each cohort), treatment success (70% vs 96.3%, P = 0.052), or complications (none). Three patients in the transcolonic and one in the transrectal cohort underwent surgery for failed endoscopic drainage (27.3% vs 3.7%, P = 0.06). When evaluated by etiology, treatment success for diverticular abscess was significantly lower compared with others (25% vs 97%, P = 0.002). At a median follow-up of 1228.5 days (interquartile range = 131-1660), all patients with treatment success were doing well with no recurrence. CONCLUSION: Except for patients with diverticular etiology, treatment of abdominopelvic abscess under EUS guidance is highly effective and safe for both routes.

Early recognition of serious infections in obstetrics and gynecology.

Pelvic infections commonly occur in pregnant and postoperative women. Most of these infections are readily diagnosed because of their typical clinical manifestations and prompt antimicrobial therapy that leads to the resolution of disease. However, uncommon cases may escape detection and the severity of the process may also go unrecognized without a careful assessment of clues available through physical examination and laboratory testing. In some cases a particularly virulent pathogen can lead to severe infection, septic shock and its consequences, even death, despite clinicians acting appropriately.

Postoperative infections in obstetrics and gynecology.

Postoperative infection is the most commonly seen complication of surgery in obstetrics and gynecology. The use of antibiotic prophylaxis has greatly decreased though not completely eliminated this adverse outcome. Postoperative infections include wound cellulitis, wound abscess, endomyometritis, pelvic cellulitis, and pelvic abscess. Infections usually manifest as fever and greater than normal postoperative pain. Refractory fevers maybe because of septic pelvic vein thrombophlebitis or maybe noninfectious in origin. Broad-spectrum antibiotics should be initiated as soon as possible when diagnosis of postoperative infection is made; most patients will respond to treatment within 24 to 48 hours when appropriate antibiotics are selected.

Management of patients with huge pelvic actinomycosis complicated with hydronephrosis: a case report.

Actinomycosis is an uncommon, chronic, granulomatous disease caused by several species of the genus Actinomyces, a Gram-positive, filamentous bacterium that normally colonizes mucosal areas. Actinomycosis can be mistaken for malignant tumors, and in most cases the diagnosis is delayed or missed entirely until surgery. Actinomycosis in the abdomen or pelvis mostly results from prolonged use of an intrauterine device. We report the case of a 40-year-old female who presented with decreased urine production, poor appetite, marked loss of body weight and intermittent lower abdominal pain for 3 months. Abdominal computed tomography indicated a large infiltrative pelvic mass that was complicated by bilateral hydronephrosis, bladder compression and small bowel adhesions. Despite the elevated levels of cancer antigen 125, we suspected pelvic actinomycosis because of a 15-year history of an intrauterine device. The diagnosis was confirmed by histopathological examination of soft tissue obtained from a laparotomy biopsy. We successfully treated the patient with prolonged antibiotics instead of surgical eradication. Abdominal computed tomography obtained 1 year later showed almost complete resolution of the pelvic inflammatory mass.

[Pelvic actinomycosis: just think of it]. / Actinomycose pelvienne : est-ce prévisible ?

OBJECTIVES: Pelvic actinomycosis is a rare disease that can be diagnosed before, during or after surgical treatment of a suspected ovarian tumor, a suspected bowel obstruction, or acute peritonitis. The possibility of early detection of pelvic or abdominal abscess related to was evaluated through a personal series and literature review. PATIENTS AND METHODS: Our series of 11 cases of severe abdominal or pelvic actinomycosis is related and compared to 58 cases reported in the literature. RESULTS: Seven patients in this series were diagnosed with pelvic inflammatory disease and acute peritonitis with or without bowel obstruction, and four women were diagnosed after surgical treatment for suspected ovarian cancer. Fifty-two of the 58 cases of reproductive tract actinomycosis reported in the literature review and all our cases were associated with prolonged use of an intrauterine contraceptive device with a mean of eight years. The contribution of pelvic ultrasound and angioscanner in evaluating these patients should not be underestimated and MRI may be useful in some cases as well. Early diagnosis based on Actinomyces-positive cervical smears or abscess aspiration was accomplished only once in our series and was rare in literature. A histopathologic diagnosis during laparoscopy or laparotomy could avoid more difficult and extensive surgery. In our series of 11 patients, five women required abdominal surgery, five required salpingo-oophorectomy and three required hysterectomy. All women required surgical intervention. Effective treatment combined long antibiotic therapy with surgery. Correct preoperative diagnosis is rare but if achieved, long-term treatment with penicillin for at least two months and sometimes up to a year may completely eradicate the infection. Surgery may still be necessary to improve medical treatment or to resolve pelvic abscesses. DISCUSSION AND CONCLUSION: Any pelvic abscess occurring in a woman with a history of long-term use of an intrauterine device should be considered as possible pelvic actinomycosis. If there is no fever in association with an atypical adnexal tumor, frozen section should be obtained during surgery to rule out the diagnosis of actinomycosis.

Pelvic hydatid (echinococcal) disease.

OBJECTIVE: To study epidemiologic and clinical features of pelvic hydatid disease and discuss its management. METHOD: A retrospective analysis of 11 cases of pelvic hydatid disease managed over 7 years and 8 months at the Maternity and Neonatalogy Unit, Tunisian Medical Center La Rabta, Tunis, Tunisia. All cases were identified from histopathologic reports. RESULTS: The 11 affected patients had a mean age of 41.6years (range, 22-79 years), 6 had a history of surgery for hydatid disease, 8 presented for chronic pelvic pain, and 1 was admitted for acute surgical abdomen. On physical examination, 6 had a pelvic mass. An ultrasound examination suggested the diagnosis preoperatively in 6. All were treated surgically. Primary laparoscopy was performed in 5 patients. Unroofing (or partial cystectomy) was performed in 6 patients and complete cystectomy in 4. The postoperative course was uneventful in all cases. Recurrence occurred only in 1 patient, 6 months after initial surgery. CONCLUSION: Pelvic hydatid disease is rare and its diagnosis often difficult preoperatively. The treatment mainstay is surgery. The laparoscopic approach seems to be safe and effective, and may increasingly replace laparotomy.

Large gluteal abscesses as a complication of transgluteal drainage of pelvic abscesses: analysis of three cases and a search of the literature.

BACKGROUND: The percutaneous transgluteal approach is a well-accepted method for drainage of deep pelvic abscesses. Recently, in 3 patients, transgluteal drainage was complicated by the development of large gluteal abscesses requiring multiple surgical interventions. METHODS: This report describes these cases as well as a search of the literature. RESULTS: Three patients with a complicated clinical course after colon resection are described. After CT-guided percutaneous transgluteal drainage of the pelvic abscess, large gluteal abscesses were diagnosed after 2-6 weeks. Subsequent surgical interventions were needed to adequately drain these abscesses. In the literature, transgluteal drainage of pelvic abscesses is well described as a safe and efficient method. However, until now the development of gluteal abscesses has not been mentioned as a complication in the literature. CONCLUSION: In our own experience, a transrectally (radiologically or surgically performed) drainage route is recommended in patients who develop a deep pelvic abscess after bowel resection and suspicion of an anastomotic leak.

Pelvic actinomycosis: a malignant appearing mass. A case report.

Pelvic actinomycosis is a rare complication of a long-term intrauterine contraceptive device. Early diagnosis is important, as clinical and radiological imaging may mimic a malignant pathology and lead to radical and unnecessary surgery. We report a case of pelvic actinomycosis in a woman who had used an intrauterine contraceptive device for the last 13 years. The actinomycosis appeared as a malignant pelvic mass with invasion into the sigmoid and left ureter, with high-grade stenosis of these structures. Because of its rapidly developing obstructive character, an urgent Hartmann procedure with resection of the uterus and both ovaries was performed. Histology revealed actinomycosis. With this case we want to illustrate that for a woman presenting with an intrauterine contraceptive device and a malignant appearing mass in the pelvis, pelvic actinomycosis must be considered in the list of differential diagnosis, so that appropriate diagnostic work out and treatment can be made.

Pelvic sepsis after stapled hemorrhoidopexy.

Stapled hemorrhoidopexy is a surgical procedure used worldwide for the treatment of grade III and IV hemorrhoids in all age groups. However, life-threatening complications occur occasionally. The following case report describes the development of pelvic sepsis after stapled hemorrhoidopexy. A literature review of techniques used to manage major septic complications after stapled hemorrhoidopexy was performed. There is no standardized treatment currently available. Stapled hemorrhoidopexy is a safe, effective and time-efficient procedure in the hands of experienced colorectal surgeons.

Image-guided transvaginal drainage of pelvic abscesses and fluid collection using a modified Seldinger technique.

BACKGROUND: Transvaginal drainage using the trocar method is advantageous as a single-step procedure; however, the procedure may occasionally be difficult to perform, due to buckling of the catheter in the elastic vaginal tissues, despite the presence of a stiff stylet. PURPOSE: To evaluate the efficacy and the safety of image-guided transvaginal drainage of pelvic abscesses and fluid collection using a modified Seldinger technique. MATERIAL AND METHODS: Fifteen patients (mean age 43 years, range 24-82 years) who underwent transvaginal aspiration (n=1) or catheter drainage (n=14) guided by ultrasound and fluoroscopy were enrolled in this retrospective study. A small coronal incision was performed to facilitate puncture using an 18G needle, tract dilatation, and the insertion of a drainage catheter by the Seldinger technique. Outcome was analyzed with respect to clinical success, technical success, and procedure-related complications. RESULTS: The overall clinical success rate was 87% (13/15 cases). The success rate of catheter drainage was 86% (12/14 cases), and the use of aspiration alone was successful in one patient. Technical success was achieved in all patients, without procedure-related complications. CONCLUSION: Image-guided transvaginal drainage with a modified Seldinger technique can be a safe and effective alternative treatment for pelvic abscesses and fluid collection.