TOA, a serious complication of PID, results in significantly high morbidity and mortality. A patient diagnosed with TOA is usually given parenteral antibiotics as the first-line treatment for at least 24 h, and when the desired response is obtained, outpatient treatment with oral antibiotics can be continued [7]. If there is no response within 48–72 h, surgery or drainage may be considered [9]. Although the use of broad-spectrum antibiotics is usually the first-line option in unruptured TOA, the optimal treatment of TOA is unclear and should be considered individually according to each patient’s clinical and laboratory findings. Approximately 70% of patients with TOA are known to respond to conservative medical treatment with broad-spectrum antibiotics, while the remainder requires an invasive intervention [10]. This is consistent with the results of our study, in which 70.2% of patients were successfully treated with antibiotic therapy. Identifying the clinical and laboratory findings that will determine the need for surgery in advance may allow for early surgical interventions and shorten the length of hospital stay.

In the current literature, although different factors that cause medical treatment failure are mentioned in relation to TOAs, there is no consensus on this issue. High gravidity and parity, old age, and menopausal status have been shown as epidemiological risk factors for medical treatment failure [11, 12]; however, this may be considered as an emphasis on surgical preference. Many studies have shown that patients receiving medical treatment are significantly younger than those undergoing surgery [11,12,13]. Similarly, medically treated patients in the current study were statistically significantly younger than the patients who needed surgical intervention.

In patients with large adnexal masses, the success rate of antibiotics alone is particularly low [14]. Some studies have reported the failure of conservative treatment and prolonged hospital stay in patients with TOAs larger than 6–9 cm [11, 14, 15]. Large TOA sizes in patients were associated with an increased rate of surgical treatment [16, 17]. In the current study, we also found an increased mean abscess volume and abscess size in surgically treated patients, and furthermore medical treatment failure and need for surgery were more common in patients with a large abscess (volume, > 40 cm3, or diameter, > 5 cm).

This study demonstrated that the WBC count, CRP levels, ESR, and body temperature of the patients with TOA were significantly higher among patients in the surgically treated group; however, they did not have any additional value for predicting the need for surgical treatment. There are many reports investigating the relationship between laboratory findings and the need for surgery [18,19,20,21]. Gungorduk et al. and Devitt et al. showed that the CRP levels and ESR were higher in surgically treated patients [11, 22]. Fouks et al. [23] stated that a simple risk scoring using the abscess size, age, and inflammation markers could similarly predict antibiotic failure in the treatment of TOA.

In cases where medical treatment is unsuccessful, invasive methods should be preferred based on the patient’s age and menopausal status, facilities of the clinic, and the surgeon’s experience. Computer tomography or ultrasound-guided TOA drainage with concomitant antibiotics is effective and safe for the primary or secondary treatment of TOA with some researchers even demonstrating that drainage may be a more successful treatment [24, 25]. TOA patients being mostly in the reproductive age group should not be overlooked in the treatment decision. With the development of minimally invasive methods, laparoscopy is frequently used in the safe surgical treatment of TOA [20]. According to Doğanay et al., laparoscopy presents as the best treatment option in selected cases [26]. In the current study, we performed laparotomy in all patients in the surgically treated group. This was due to either the general health status of the patients not allowing to perform laparoscopy (hemodynamic instability, sepsis, severe chronic obstructive pulmonary disease, huge adnexal mass, etc.) or the preference of the surgeon.

There were certain limitations to our study. Firstly, it was a single-center study which was retrospectively designed, and secondly, the long-term medical data of the included patients was missing.

The main limitations of the current study are the retrospective design and inclusion of patients treated in a single medical center. Also, long-term data regarding the included patients is missing.