Pelvic actinomycosis: diagnostic challenges and management strategies based on a retrospective case series and literature review

Abstract Background Pelvic actinomycosis is a rare, chronic infection caused by Actinomyces species, most associated with prolonged intrauterine device (IUD) use. Due to its nonspecific clinical presentation, it is frequently misdiagnosed as malignancy or other inflammatory conditions. This study aims to analyze the clinical features, diagnostic approaches, and outcomes of pelvic actinomycosis through a retrospective review of four cases and a supporting literature review. Case description We reviewed the medical records of four female patients diagnosed with pelvic actinomycosis between 2021 and 2025. Diagnostic modalities included imaging, physical examination, cervical cytology, endometrial biopsy, and histopathological analysis. Empirical antibiotic therapy was administered to confirmed cases. All patients had a history of prolonged IUD use. Imaging frequently revealed pelvic masses with inflammatory features. In all cases, Actinomyces was identified via cytology or histopathology. Three of the four patients were diagnosed preoperatively, thus preventing unnecessary surgical interventions. Long-term antibiotic therapy led to clinical resolution in most patients. Conclusion Pelvic actinomycosis should be considered in women with chronic pelvic symptoms and a history of long-term IUD use. Early identification through cytology or biopsy can reduce surgical morbidity. Increased awareness and its inclusion in the gynecologic differential diagnosis may improve patient prognoses.