Pelvic abscesses occurring after gynecologic pelvic surgery are uncommon. We describe the case of a woman who, after undergoing such a procedure, was found to have pelvic abscesses infected with methicillin-resistant Staphyloccocus aureus . The purpose of this report is to raise awareness of a life-threatening complication of gynecologic pelvic surgery.
Polypropylene mesh use during the surgical repair of pelvic organ prolapse and stress urinary incontinence is becoming increasingly popular. Mesh kits that replace the weakened suspensory ligaments in the pelvis have been developed and effectively act as support during straining maneuvers.
Midurethral slings are now commonly used to stabilize the urethra in patients with stress urinary incontinence. A rare complication that can occur after sling placement is a pelvic abscess. Because of their heightened potential for hematagenous spread and direct infection to surrounding organs, pelvic abscesses require extra attention, especially if they are infected with a drug-resistant organism such as methicillin-resistant Staphyloccocus aureus (MRSA).
Case Report
A 62 year old female had a worsening pelvic organ prolapse. To have a bowel movement, the patient routinely used her fingers to reduce the prolapse (splinting). During this time, the patient, using the same fingers, was also changing the dressings of her husband’s MRSA-infected leg abscess without using sterile procedure.
Because of the symptomatic prolapse, the patient underwent total vaginal hysterectomy, bilateral salpingo-oophorectomy, anterior and posterior culporrhaphy with repair of enterocele, sacrospinous ligament fixation with the placement of a polypropylene mesh in the anterior vaginal compartment (Uphold; Boston Scientific, Natick, MA), and placement of a suburethral sling for the treatment of stress urinary incontinence (Prefyx; Boston Scientific).
Her initial postoperative course was complicated by urinary retention. The patient was discharged home on postoperative day 1 with a Foley catheter in place, with the urinary retention resolving on postoperative day 3. However, on postoperative day 8, the day of admission, the patient presented with nausea, vomiting, abdominal pain, fever, and recurrent urinary retention.
Her past medical history was notable for bipolar disorder, for which she took lithium. She was G 2 P 2 . She had no known drug allergies.
Her physical examination was notable for tenderness in the left lower quadrant of the abdomen and a malodorous vaginal discharge. Urinalysis was normal and urine culture was negative. Computed tomography (CT) of the abdomen and pelvis showed multiple fluid collections consistent with pelvic abscesses. Piperacillin/tazobactam was started.
On the second hospital day, the largest fluid collection was drained. Blood cultures grew out Staphyloccocus aureus in 1 of 4 bottles, and MRSA in 1 of the same 4 bottles. Urine culture and pelvic abscess culture also showed MRSA with a sensitivity profile that matched what was found in the blood cultures.
Piperacillin/tazobactam was discontinued, and intravenous vancomycin and rifampin were started. Subsequent blood cultures were negative. On the fifth hospital day, CT of the abdomen and pelvis showed a marked improvement in the primary abscess cavity as well as a decrease in size of the multiple satellite lesions. The next day the patient continued to be afebrile, with reduced abdominal pain. She was discharged home and completed a 4 week course of antibiotics. One year later she still continues to be in good health.
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