Pelvic inflammatory disease presenting 16 months after vaginal hysterectomy

A report describes a case of a 52-year-old postmenopausal, multiparous woman who presented with a 2-day history of lower abdominal pain refractory to oral analgesia and fever up to 39 °C. She described no nausea, vomiting, diarrhea, or urinary symptoms but white vaginal discharge in the previous hours.

She had a medical history of vaginal hysterectomy due to pelvic organ prolapse 16 months before this presentation. Her abdominal examination revealed low abdominal pain, with voluntary guarding but no rebound tenderness.

Laboratory tests revealed a white blood cell count within the normal range, although her acute phase reactants were increased.

Her abdominal ultrasound and computed tomography (CT) scan ruled out Appendicitis and diverticulitis. However, the CT scan revealed an elongated 76 × 33 mm predominantly cystic mass in the right iliac region, suggesting a right tubo-ovarian abscess (TOA).

Her pelvic examination revealed vaginal cuff tenderness and purulent discharge but no sign of dehiscence. The transvaginal sonography findings were compatible with bilateral TOA, without any evidence of free fluid in the pouch of Douglas that would suggest ruptured TOA.

The patient received intravenous antibiotic treatment for Pelvic inflammatory disease (PID) with cefixime, doxycycline, and metronidazole. She displayed a clear reduction in pain, with a decrease in inflammatory markers. However, her temperature persisted around 37–38 °C despite antibiotic treatment, and she thus received exploratory laparoscopic surgery. 

 Surgery confirmed a bilateral TOA. The right tube (6 × 8 cm) was firmly attached to the vaginal cuff and fistulized to the right margin, while the left tube (3 × 4 cm) was attached only to the pelvic peritoneum. Both fallopian tubes were removed by laparoscopy, and the patient's postoperative recovery was uneventful. She received a discharge home with oral antibiotics.

 Six weeks after discharge, the patient recovered completely. Pathologic examination showed chronic and acute salpingitis, with negative blood and abscess cultures.

Cabello-Garcia E, Ferriols-Pérez E, Urpí-Tosar B, González-Comadran M. Pelvic inflammatory disease presenting 16 months after vaginal hysterectomy: A case report and literature review. Case Reports in Women's Health. 2021;31. https://doi.org/10.1016/j.crwh.2021.e00335.