Tubo-Ovarian Abscess, Sepsis and Diffuse Peritonitis in Pelvic Inflammatory Disease—A Diagnostic and Therapeutic Review

Background: Pelvic inflammatory disease (PID) is a common and potentially severe infection of the upper genital tract. Complications such as tubo-ovarian abscess (TOA), sepsis, and diffuse peritonitis contribute significantly to reproductive morbidity, particularly when diagnosis or treatment is delayed. Aim: The aim of this review is to present an updated, clinically relevant synthesis of the current evidence on the epidemiology, microbiology, diagnostic approach, imaging modalities, and management of PID, with a focus on severe forms including TOA, sepsis, and peritonitis. Content: PID is most frequently initiated by sexually transmitted pathogens—primarily Chlamydia trachomatis and Neisseria gonorrhoeae—which rapidly progresses to a polymicrobial infection involving anaerobic and enteric organisms. Diagnosis is predominantly clinical, supported by nucleic acid amplification tests, inflammatory markers, and imaging. Transvaginal ultrasonography remains the first-line diagnostic approach for suspected TOA, while CT or MRI is reserved for unclear cases or to assess rupture. Mild to moderate disease is managed with broad-spectrum combination antibiotics, whereas severe PID or TOA requires hospitalization, parenteral therapy, and timely source control through image-guided drainage or surgery. Ruptured abscesses and PID-associated sepsis demand urgent surgical intervention and multidisciplinary supportive care. Tailored approaches are necessary in pregnancy, adolescence, and immunosuppressed and postmenopausal patients. Conclusions: Prompt recognition, a low threshold for empiric antimicrobial therapy, the appropriate use of imaging, and decisive escalation to drainage or surgery are essential to limit morbidity and preserve reproductive health. Integrating guideline-based practice with structured clinical pathways may improve outcomes and reduce long-term sequelae of PID.