Twenty two year old housewife para 1, living 1 came with complaints of pain in lower abdomen and low grade fever for 1 week. She also gave a history of loose motions for 3 days, there was no history of chronic pelvic pain, fever with chills and no history suggestive of bladder complaints.

Past menstrual cycles were regular 28 day lasting for 3 days with a moderate flow and painless.

She had a single live issue 3 yr old male child, preterm vaginal delivery at 8 months amenorrhoea.

She had a past history of multiple bowel surgeries for anorectal malformation:

Abdominal examination revealed an infraumbilical midline vertical scar of previous surgery. There was tenderness and guarding of lower abdomen. Speculum examination revealed normal cervix and vagina. Vaginal examination revealed a normal sized anteverted uterus, smooth, firm and mobile. Cervical movements were nontender. An 8 x 8 cms cystic mass was palpable in the left and posterior fornix.
Sonography revealed 8.3 + 8.3 + 2.5 cms uterus with endometrial thickness of 13 mm with minimal fluid within. Both the ovaries were normal. There was a 9.1 x 8.2 x 8.2 cms (200 ml) well defined anechoic collection in the left adnexa with multiple internal echoes and echogenic debris which was suggestive of left tubo ovarian pathology as shown in the figure (Fig. 1).

Fig.1

CT scan showed a hypodense cystic lesion with enhancing wall in the pelvis measuring 6.8 x 6.8 cms with surrounding bowel loops adherent.

Horse-shoe kidney with extra renal pelvis with dilated ureters noted. The findings were compatible with the impression of pelvic abscess.

Patient was kept nil by mouth. Intravenous third generation cephalosporins were given. In view of previous multiple bowel surgeries and adhesions with the pelvic mass, an exploratory laparotomy because, of the high risks of injury to the bowel was deferred. Colpotomy was not considered safe in view of previous rectovaginal fistula repair.
A decision for interventional radiological treatment was thought of and sonography guided pigtail drainage of the abscess considered.

Under USG guidance, point on the skin overlying a clear path to the abscess identified.

Local anaesthetic infiltrated at the point of incision.

2 cm incision made through which catheter was inserted.

Further imaging was done to confirm position of catheter tip

Outer end of catheter was connected to drainage bag.

Continuous dependent drainage of abscess was done for 48 hours when drain output was 10 ml.

200 ml of thick yellow pus drained with no faecal odour.

Continuous dependent drainage of the abscess through pigtail was done for 2 days.

Total drain output was 220 ml.

After the procedure patient was symptomatically better on day 2. Post-operative period was uneventful and liquids orally were started once bowel sounds returned and patient tolerated them well and passed stools and the lump decreased in size and finally disappeared in 3-4 days.

Pigtail catheter was removed on the 4th day of insertion.

The patient was discharged on day 5 on oral antibiotics.

In view of patient not affording investigations like ANA/TB IgM/DNA PCR could not be performed to rule out Koch’s.

March 2002 issue of interventional radiology reports the largest study on percutaneous abscess drainage reported by Dr. Debra Grevais Medical Director of interventional radiology, Boston.

It claims that in many cases of pelvic abscess, percutaneous abscess drainage and intravenous antibiotics clear the infection, sparing the patient from surgery.

Should the patient require surgery at a later data to remove the diseased segment of bowel, the surgeon would be working in clean field.

Different routes for drainage of pelvic abscesses are transvaginal drainage of pelvic abscess, transrectal sonographically guided drainage of deep pelvic abscess, transgluteal rectal drainage of pelvic abscess.1-4

With percutaneous abscess drainage the success rate is quite high and the morbidity is low.5

Percutaneous abscess drainage6 performed in the interventional radiology suites of the medical centres is less costly than a surgical drainage.