AJR 2003; 181:498-500
© American Roentgen Ray Society
Sonographically Guided Transgluteal Drainage of Pelvic Abscesses
Eric Walser1,
Syed Raza,
Alberto Hernandez,
Orhan Ozkan,
Manoj Kathuria and
Devrim Akinci
1 All authors: Department of Radiology, University of Texas Medical Branch, 301
University Blvd., Galveston, TX 77555-0709.
Received September 13, 2002;
accepted after revision January 28, 2003.
Address correspondence to E. Walser.
Introduction
Pelvic abscesses are sometimes difficult to drain percutaneously because of
their proximity to the bowel and bladder, proximity to vascular structures,
and enclosure by the bony pelvis. Transvaginal and endorectal routes are two
methods used to circumvent these access problems. The transgluteal posterior
approach to pelvic abscess drainage has traditionally been done with CT.
Although CT guidance for these procedures is technically straightforward
[1], it takes up valuable time
on a busy CT schedule and exposes the pelvis and gonads to radiation,
especially in women. We report an alternative access to pelvic abscess
drainage using the transgluteal approach with sonography rather than CT.
Materials and Methods
A consecutive series of 12 patients during 1 year were referred to the
interventional radiology department for drainage of deep pelvic fluid
collections that were not accessible by anterior percutaneous approaches. The
cause of these fluid collections included pelvic abscesses (n = 7) in
patients with diverticulitis (n = 3), tuboovarian abscess,
necrotizing fascitis, acute pancreatitis, and an infected colon carcinoma.
Five patients developed postoperative abscesses: after hysterectomy
(n = 2), appendectomy, ileoanal anastomosis, and radiofrequency
ablation of a rectal carcinoma.
Abdominal CT resulted in initial diagnoses in all patients with a pelvic
fluid collection. Coagulation parameters and platelet counts were normal in
all patients. Fluid collections ranged from 3 to 10 cm in diameter, and all
were situated far posteriorly necessitating a transgluteal approach. A curved
3-5–MHz transducer was used to scan the pelvis with the patient in a
prone position from parasacral regions. Continuous sonographic guidance was
used for needle placement with the patient under local anesthesia and
conscious sedation (Figs. 1 and
2). The coccyx was palpated as
a landmark, and whenever possible, the puncture site was caudal and close to
this landmark to avoid damage to the neurovascular bundle and piriformis
muscle. Oblique sagittal or axial sonographic imaging through the area of the
greater sciatic foramen was used to guide the needle into the fluid collection
(Fig. 3). On aspiration of
fluid, a guidewire was placed, and after serial dilatation, a 10- to 14-French
pigtail catheter was advanced into the fluid collection. Fluoroscopy was used
where necessary for final catheter placement. Gram staining and cultures were
performed on the fluid that was drained. Follow-up abscessograms were obtained
as output diminished to less than 20 mL per day. If no fistula or residual
cavity remained, the catheter was removed. IV antibiotic therapy was guided by
culture and sensitivity results. Two patients had no organisms but many
polymorphonuclear cells in their aspirates, consistent with a sterile
abcess.
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Fig. 1. —Photograph shows caudal, paramedian, transgluteal approach using
hands-free technique on model in prone position. Sterile drape cover and
continuous sonographic guidance were used for needle placement.
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Fig. 2. —Sagittal sonogram of deep pelvic abscess in 85-year-old woman with
diverticulitis using transgluteal window. Shadowing (arrow) at
cranial end of image is from coccyx. Transgluteal drainage route should be as
close to midline as possible.
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Results
Catheters were left in place for 3–90 days (mean drainage time, 18
days). One patient with prolonged drainage had a colonic fistula that
eventually sealed after 3 months. One technical failure occurred. This patient
had a recurrent rectal carcinoma, which was treated with radiofrequency
ablation. She developed a low-density collection containing air that was
thought to represent an abscess. Sonographically guided transgluteal puncture
yielded no fluid, and the patient underwent a transgluteal CT-guided
procedure. Again, no fluid was aspirated and a biopsy revealed necrotic,
noninfected tumor.
One minor complication occurred. During the procedure, a patient complained
of radiating pain in the left leg that resolved and did not recur during
drainage or after catheter removal. The pain was thought to represent sciatic
nerve irritation due to the proximity of the catheter to the sciatic nerve at
the lateral portion of the sacrospinous ligament
(Fig. 4).
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Fig. 4. —Unenhanced helical CT scan through pelvis of 16-year-old girl with
postappendectomy pelvic abscess. Pigtail catheter was placed into pelvic
abscess using transgluteal sonographic guidance. Patient had radiating left
leg pain during drain placement. Notice proximity of catheter to sciatic nerve
(arrow). Air-distended rectum hindered sonographic visualization of
abscess at sacral border, and catheter entry site was more lateral than
desired.
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Discussion
Drainage of deep pelvic abscesses is often more difficult than drainage of
abdominal abscesses. The difference is due to the bony pelvic ring, which
almost completely surrounds the internal pelvic organs. In addition, fluid
tends to collect and become infected in the space between the rectum and the
bladder, where percutaneous access from the anterior and posterior routes can
be difficult. The main percutaneous routes for abscess drainage are in the
anterolateral pelvis, especially if the fluid collection arises out of the
pelvis and contacts the lower abdominal wall. With the patient in the prone
position, a second window exists between the sacrum and the ileum, through the
greater sciatic foramen. Percutaneous drain placement from the posterior
approach requires that the catheter be close to the sacrum or coccyx to avoid
injury to the sciatic nerve or gluteal vessels that course laterally through
the greater sciatic foramen anterior and superior to the piriformis
muscle.
Whenever possible, the catheter route should pass inferiorly in the
foramen, through the sacrospinous ligament or below it, because the incidence
of pelvic and leg pain increases as the catheter is placed more superiorly,
through the piriformis muscle and near the sacral plexus
[1–3].
The published success rate for CT-guided pelvic abscess drainage is 81% with a
complication rate of 20% [2].
The most common complication is significant buttock pain, but more severe
complications have been reported, such as radiating leg pain, numbness, and
pelvic hemorrhage, which may require transcatheter embolization
[1–4].
To avoid these sometimes difficult percutaneous routes, transvaginal,
endorectal, and transperineal sonographic guidance has been used to drain
pelvic abscesses with good success and minimal complications
[5–7].
Although these routes are efficacious because of their proximity to the pelvic
fluid collections, sometimes they are not available because of the patient's
refusal. In addition, most pediatric patients are unsuitable for the
endorectal or transvaginal approach.
We elected to overcome the necessity of CT guidance for drainage of these
fluid collections by using transgluteal sonography from a parasacral approach.
The use of transgluteal sonography for diagnosis and biopsy of posterior
pelvic masses has been described
[8], and we believe that this
method is also useful for identification and drainage of posterior pelvic
abscesses. This technique is not, however, suitable for obese patients or for
patients with very small fluid collections, because of the excessive
soft-tissue path that hinders sonographic guidance.
Any coagulopathy should be corrected with appropriate blood products. Also,
a large amount of gas in a distended rectum can make sonographic guidance
difficult in this area and force the catheter into a more lateral position, as
it did in our one patient who experienced irritation of the sciatic nerve from
too lateral an approach. Placing a rectal tube before the procedure may help
in such cases.
Advantages of the sonographic approach include less time in the CT-imaging
area, less procedural time, less radiation exposure, and the ability to avoid
blood vessel puncture by real-time color Doppler imaging during needle
placement. An immediate sinogram can also be obtained if the drainage
procedure is performed in a fluoroscopic room.
Disadvantages other than those already mentioned include the occasional
difficulty in separating the fluid collection from the bladder. This
distinction is usually easy, but inserting a Foley catheter into the bladder
can help in confusing cases. Additionally, sonographic penetration may be poor
in the deep pelvic tissues of even an average-sized adult. Therefore, we
recommend that patients for transgluteal drainage be selected judiciously when
the diagnosis of a pelvic abscess has been established by another imaging
modality such as CT or MR imaging and a sonographic window through the greater
sciatic foramen is available in a nonobese patient.
In conclusion, sonographically guided transgluteal abscess drainage is an
alternative route for the drainage of pelvic abscesses, particularly in
patients who are unwilling or unable to undergo endorectal or transvaginal
drainage. This procedure is safe and effective for moderate to large fluid
collections in nonobese patients and eliminates the need for using valuable CT
time to perform these procedures.
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Introduction
Materials and Methods
