Suture-Induced Tubo-Ovarian Abscess: A Case Report with Literature Review

Abstract Introduction Suture is an underreported cause for tubo-ovarian abscess (TOA) that can cause significant morbidity. This report describes a case of TOA arising from a silk suture three years after bilateral tubal ligation. Case presentation A 38-year-old woman with a history of tubal ligation presented with persistent pelvic pain and fever. Imaging revealed a suspicious left adnexal mass with features concerning for malignancy or abscess. Surgical exploration revealed a TOA adherent to surrounding structures, containing a retained silk suture from prior surgery. The abscess and suture were removed, and histopathology confirmed chronic inflammation without malignancy. The patient underwent additional procedures for thorough management, including polypectomy and contralateral tubal ligation. Literature Review A total of nine cases of TOAs and suture-induced abscesses were reviewed. Of these, seven were TOAs, six of which occurred postoperatively. Three cases developed following tubal ligation procedures. The abscesses ranged in size from 1 to 7.6 cm. The interval between the presumed inciting event and abscess detection varied widely, with one case presenting more than three decades after surgery. Isolated microorganisms included Escherichia coli, Streptococcus pyogenes, and Peptostreptococcus anaerobius. All patients underwent surgical intervention via various approaches, and several also received adjunctive antibiotic therapy. Conclusion Suture-induced TOA following sterilization may result in considerable morbidity, and surgical intervention may provide favorable outcomes. Introduction Pelvic inflammatory disease (PID) is a polymicrobial infection resulting from the ascent of pathogens from the cervix or vagina to the upper genital tract. It is most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae, which together are responsible for approximately 60–75% of cases. Once these pathogens ascend, they can infect the endometrium, fallopian tubes, ovaries, and surrounding pelvic structures, triggering an inflammatory response [1]. A tubo-ovarian abscess (TOA) is a severe complication of PID, characterized by the formation of a purulent abscess involving the uterus, fallopian tubes, and ovaries [2]. This condition primarily affects women of reproductive age, with the highest incidence occurring in the fourth decade of life. Approximately 4.4% of sexually active women have a history of PID, placing them at increased risk for TOA development [3]. Given its non-specific clinical presentation, TOA can be challenging to diagnose, often requiring differentiation from other acute abdominal and pelvic conditions. The differential diagnosis includes ovarian torsion, ectopic pregnancy, appendicitis, gastroenteritis, constipation, and urinary tract infection, all of which can present with overlapping symptoms such as pelvic pain, fever, nausea, and gastrointestinal discomfort [2]. Although TOAs are commonly associated with PID, they can also develop from less common etiologies, such as the presence of surgical sutures. Reports of TOAs linked to surgical sutures remain scarce in the literature. This report highlights a unique case of a TOA that developed due to a silk suture three years after the patient had undergone bilateral tubal ligation, a procedure intended for permanent female sterilization. This case underscores the need for awareness of non-infectious etiologies in the differential diagnosis of TOAs, particularly in patients without a recent history of PID. The report was written according to the CaReL guidelines, and unreliable sources were excluded [4,5]. Case Presentation Patient information A 38-year-old female presented with a one-month history of worsening, persistent pelvic pain. Her medical history was unremarkable, and her surgical history included bilateral tubal ligation performed three years earlier. Clinical findings Physical examination revealed a high temperature, tenderness in the left suprapubic area, and the presence of an immobile pelvic mass upon palpation. Diagnostic assessment A pelvic ultrasound (US) showed a left-sided heterogeneous lesion measuring 44 x 30 mm. The mass was a vascular solid lesion with calcifications, exhibiting indistinct margins and evidence of invasion into the adjacent peritoneum and the left rectus abdominis muscle. Doppler imaging demonstrated high vascularity, with a score of 3-4. These characteristics were highly suspicious for a desmoid tumor or a primary peritoneal tumor; however, direct invasion of the left ovary could not be excluded (Figure 1). Computed tomography (CT) with IV contrast revealed a 6 x 4 x 3 cm, multilocular mass located in the left lower abdomen, arising from the left adnexa and attached to both the uterus and left ovary. The mass extended into the posterior aspect of the left rectus muscle. It was in proximity to the left inferior epigastric artery and a loop of small intestine, though no direct invasion was observed. Surrounding fat stranding raised the possibility of infection, such as a TOA, though malignancy could not be excluded. Mild pelvic free fluid was noted, and no suspicious lymph nodes were identified. The other abdominal organs, including the liver, spleen, pancreas, kidneys, and adrenal glands, appeared normal. The laboratory results revealed the following: Carcinoembryonic Antigen (CEA) was 0.471 ng/ml (normal range: 0-5 ng/ml), Cancer Antigen 125 (Ca125) was 33.6 IU/ml (normal range: <35 IU/ml), and Carbohydrate Antigen 19-9 (CA 19-9) was 5.73 IU/ml (normal range: <33 IU/ml), all of which fell within the normal reference ranges. Serum C-reactive protein (CRP) level was slightly elevated at 8.38 mg/L, above the normal range of <5.0 mg/L. Therapeutic intervention To ensure accurate diagnosis and appropriate management, consultations were held with oncology and gastrointestinal surgery specialists. After a thorough evaluation, an explorative laparoscopy was planned. During the procedure, a TOA was found, firmly adherent to the omentum and anterior abdominal wall. The abscess was carefully aspirated using suction, and a biopsy was taken for frozen section analysis. The preliminary histopathology report indicated inflammation and fibrosis, confirming the lesion's nature. As the surgery progressed, an unexpected finding was discovered: an unabsorbable silk suture embedded within the abscess. This suture, most likely a remnant from her previous procedure, was carefully excised along with the surrounding fibrotic tissue and sent for further histopathological analysis. To reduce the risk of recurrence, the contralateral fallopian tube was also removed and securely ligated. In addition to addressing the abscess and suture, a hysteroscopy and polypectomy were performed to ensure thorough treatment. The procedure was completed successfully, with all abscess material and pathological tissues removed. The histopathological examination revealed a hyperplastic endometrial polyp with background secretory changes consistent with progestin exposure, without evidence of atypia or malignancy. The left tubal mass showed chronic nonspecific salpingitis, and the attached omentum exhibited severe acute-on-chronic inflammation with fibrosis, consistent with an abscess wall. The right fallopian tube revealed para-tubal cysts and Walthard cell rests, while the right ovarian cyst was identified as a hemorrhagic corpus luteum. No malignancy was detected in any of the submitted specimens. Follow-up Post-operative treatment included intravenous Flagyl (Metronidazole) and Claforan (Cefotaxime), and there were no complications. After six months of follow-up, no significant complication was observed. Discussion The development of PID and TOAs has long been considered a rare complication of tubal sterilization. The most frequently isolated pathogens of these abscesses include Escherichia coli and Bacteroides species. Additional identified organisms in these abscesses comprise Peptostreptococcus, Peptococcus, and aerobic Streptococcus species [1]. Although rare, infections involving Staphylococcus species and Burkholderia pseudomallei have also been reported in the literature [6,7]. Among the reviewed cases, six patients developed TOAs following surgical procedures. Among the cases in which microbiological data were reported, Escherichia coli was identified in two patients, Streptococcus pyogenes in another two, and Peptostreptococcus anaerobius in one (Table 1) [1,2,8-12]. Table 1. Relevant variables of the reviewed cases. Author/year Age Sex Pregnancy Gynecological history Surgical history Comorbidities Symptoms Location Mass size (cm)* Treatment Presence of Foreign Body Identified pathogens Pathological findings Outcome Sun et al./2024 [9] 18 M N/A N/A Mucocele excision None Soft and tender nodule Lower lip 1 Total excision of the lesion Silk suture N/A Acute and chronic inflammation & multinucleated foreign body giant cells Recovery Linck et al./2023 [16] 51 F 3 Abnormal uterine bleeding D&C hysteroscopy & polypectomy None Heavy menstrual bleeding, fever & abdominal pain Right posterior pelvic area 5.1 Antibiotic, Interventional radiology percutaneous drainage, laparotomy, total hysterectomy & bilateral salpingo-oophorectomy None Escherichia coli Acute inflammation & acute serositis Recovery Campbell et al./2021 [2] 15 F None Unremarkable Appendectomy None Abdominal pain Right adnexa 7.1 Laparoscopy, drainage of the right pyosalpinx, removal of the stump appendix & antibiotics Stump appendix None Necrotic material with acute inflammatory debris Recovery Zein et al./2021 [13] 58 M N/A N/A Retinal detachment repair HIV infection Swollen conjunctivae, bulbar injection, and tearing Left eye 1 Corticosteroids, excision of the lesion, & Amnioti