Interventional Radiology Case Conference

Massachusetts General Hospital Transvaginal Catheter Drainage of Tuboovarian Abscess Using the Trocar Method: Technique and Literature Review
Jose C. Varghese 1, Mary-Jane ONeill, Deborah A. Gervais, Giles W. Boland, Peter R. Mueller

A 30-year-old woman presented to the emergency department with a 2-week history of fever, nausea, headache, and lower abdominal pain. Physical examination revealed a pulse rate of 119 per minute, blood pressure of 110 over 60 mm Hg, and temperature of 101.4F (38.6C). Abdominal examination elicited marked lower abdominal pain with guarding but no rebound tenderness. Bimanual vaginal examination elicited generalized pelvic tenderness with fullness at the left adnexal region. She was gravida 0, para 0, with no signicant gynecologic history, including no history of sexually transmitted disease. Her last menstrual period started 2 weeks before admission, and her -human chorionic gonadotropin on admission was normal (<6 IU/L). Laboratory analysis revealed a WBC of 20,3000/mm3, hematocrit of 34.3%, hemoglobin of 11.4 g/dL, and platelets of 387,000/mm3. Chest radiographic ndings were normal. An unenhanced abdominal radiograph showed moderately dilated small- and large-bowel loops suggestive of ileus. Endovaginal sonography revealed a complex tubular structure 10 cm in diameter situated mainly at the left adnexal region and extending across the midline behind the uterus to the right adnexa. The mass

ase History

was separate from both ovaries and contained uiddebris levels. The uterus was retroverted but otherwise normal. On the basis of these imaging and clinical ndings, a diagnosis of tuboovarian abscess was made, and the patient was admitted for treatment by the gynecology service. After blood and cervical cultures were obtained, a peripherally inserted central catheter was placed, and the patient was started on IV antibiotic therapy using ampicillin, gentamycin, and clindamycin. Despite 24 hr of antibiotic treatment, the patient remained septic with an elevated temperature and WBC. In view of this, the possibility of radiologic drainage of the tuboovarian abscess was discussed between the gynecology and interventional radiology services physicians. Dr. Varghese. How is the diagnosis of tuboovarian abscess made on radiologic imaging? Dr. Boland. Transvaginal sonography is the rst-line imaging test used in the diagnosis of tuboovarian abscesses. It typically shows a well-dened thick-walled tubular structure, often containing uiddebris levels due to sedimentation of cells and debris within the abscess. The uterus and ovaries are usually seen as separate from the tuboovarian abscess. If the patient complains of generalized abdominal pain and there is evidence of peritonitis

on clinical examination or free uid on sonography, then CT of the abdomen and pelvis should be performed to fully evaluate for intraabdominal collections. If the tuboovarian abscess is perforated, sonography alone may miss signicant collections in the upper abdomen or pelvis that require drainage. Dr. Varghese. How are tuboovarian abscesses generally treated and what is the indication for radiologic drainage? Dr. Mueller. Most patients with tuboovarian abscesses will recover with IV antibiotic therapy. Drainage of the abscess is indicated in those that do not respond within 23 days of treatment. Drainage is traditionally performed using surgery [1]. Recent improvements in high-spatialresolution imaging capabilities and specialized interventional equipment have made radiologic drainage of tuboovarian abscesses possible [2]. Radiologic drainage is minimally invasive, easy to perform, and avoids the potentially higher risks associated with general anesthesia and surgery. Success rates of greater than 90% [3] have been achieved in the treatment of tuboovarian abscesses using radiologic techniques. The decision whether to use surgery or a radiologic technique to drain a tuboovarian abscess depends on local expertise and preference. Emergency surgery is required in patients with intraabdominal rupture of a tuboovarian ab-

Received November 6, 2000; accepted after revision January 9, 2001.

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All authors: Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Address correspondence to P. R. Mueller.

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Varghese et al. scess, and exploratory surgery is required when the diagnosis is unclear and other conditions, such as appendicitis or perforated viscus, cannot be excluded [1]. However, in the remaining patients with uncomplicated tuboovarian abscesses refractory to antibiotic therapy, the method of drainage should be chosen after joint discussion between physicians in the gynecology and interventional radiology services. In our institution, there is an increasing trend toward radiologic methods as the initial approach. Dr. Varghese. Why did you choose the transvaginal route and what other options did you consider for the drainage? Dr. Gervais. In general, pelvic collections can be drained using the transabdominal [35], transgluteal [3, 6], transrectal [7, 8] and, in female patients, transvaginal [2, 3, 916] routes. In this patient, the usual transabdominal route was not possible because of the deep location of the abscess and surrounding structures such as bowel, bladder, and bone. The transgluteal or the transrectal approach could have been used, but the easy localization of the abscess by transvaginal sonography made it ideal for a transvaginal approach. We thought that the transvaginal route provided the simplest, safest, and most direct access for drainage of this abscess situated close to the apex of the vaginal vault. There are limitations to the use of the transvaginal route for drainage of pelvic abscesses. In prepubescent or sexually inactive patients, the transvaginal route may not be appropriate and some other route would be preferable. Furthermore, collections situated in certain parts of the pelvis, such as the presacral space or ischiorectal fossa, are not accessible by the transvaginal route. Dr. Varghese. Some interventional radiologists note that patients report signicant pain associated with drainage using the transvaginal route [9, 10, 17]. Do you nd this to be your experience, and if so, how do you manage this problem? Dr. ONeill. The vaginal vault is made of thick muscular tissue that is tough to puncture and dilate without causing considerable discomfort to the patient. Furthermore, in patients with pelvic inammatory disease, there may be associated inammation of the vaginal wall adding to the discomfort. In one study [9], the procedure was terminated in up to 10% of patients before needle aspiration of the abscess could be completed. This problem can be avoided by routinely providing adequate analgesia and conscious sedation to all patients undergoing this procedure. At our institution, this is performed using IV fentanyl citrate (ElkinsSinn, Cherry Hill, NJ) and midazolam hydrochloride (Versed; Roche Laboratories, Nutley,
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NJ). In addition, administration of 1015 mL of 1% lidocaine at the site of vaginal vault puncture is also helpful. In following this practice, we nd most of our patients tolerate the procedure well, with little or no discomfort. Dr. Varghese. What are some of the complications that could occur when performing drainage using the transvaginal route? Dr. Boland. The complications that could occur include bleeding, infection, underlying organ damage, vaginal stula formation, and disruption of the vaginal vault suture line after surgery [11]. Although relatively large blood vessels, such as uterine arteries, course close to the vaginal vault, surprisingly, no major bleeding complications have been experienced or reported, to our knowledge, in the literature. Obviously, if the patient has signicant coagulopathy, this should be corrected before the procedure is done. Otherwise, it appears that with good technique, bleeding is a rare complication of transvaginal drainage. Similarly, introduction of infection into the pelvis or dissemination of infection within the pelvis as a direct result of transvaginal drainage has not been reported in the literature. The vagina is colonized by endogenous ora, and we routinely cleanse the vagina using povidone-iodine (Betadine) during the procedure as a reasonable precaution. Even with this cleaning, the vaginal environment is only semisterile. In fact, similar vaginal procedures have been performed safely without any special vaginal preparation [18], and, to our knowledge, there is no good data to suggest that any cleaning is necessary. We have noticed one complication resulting from transvaginal drainage. In this patient with an infected hematoma after a transvaginal hysterectomy, a partial disruption of the vaginal vault suture line occurred after catheter drainage. This resulted in no long-term sequelae, and the defect healed spontaneously after removal of the catheter. A similar complication has been reported [11] during needle aspiration of a pelvic collection; in that patient, the defect required surgical repair before healing. A colovaginal stula requiring surgery for cure has also been reported in one patient after transvaginal drainage of diverticular abscess [11]. Dr. Varghese. Some radiologists use needle aspiration alone [8, 1214] to treat pelvic collections; others also use catheter drainage [3, 5, 911, 15]. What are the merits of each, and when is catheter drainage indicated? Dr. ONeill. To our knowledge, there are no reported controlled trials comparing needle aspiration with catheter drainage in the treatment of tuboovarian abscesses. There are, however, a few reports of needle aspiration in the drainage

of pelvic collections arising from various causes [8] and those specically related to tuboovarian abscesses [1214]. The ideal collection for needle aspiration should be small, unilocular, and contain low-viscosity uid that can be easily aspirated. The needle sizes used have ranged from 16- to 22-gauge. The advantages of needle aspiration are that the treatment is completed in one session, it can be performed on an out patient basis [12], and it avoids the inconvenience of the patients needing an indwelling catheter. Short-term success rates as high as 100% have been reported [1214] in the treatment of tuboovarian abscess using needle aspiration alone. However, the disadvantages of needle aspiration are that multiple punctures are required to completely drain all loculi in a multiloculated complex collection, an extended period of antibiotic coverage is required to control residual infection, and repeated aspiration may be required if collections recur [8, 9]. Operators use varying thresholds for placing transvaginal catheters in pelvic collections arising from various causes. Nelson et al. [9] preferred needle aspiration and used catheter drainage only when the abscess material was too viscous to aspirate despite lavage or when the presence of a stula was suspected. In Nelsons study, catheter placement was required in only two of the 31 abscesses drained, with a success rate of 84%. Feld et al. [11] used a policy of placing catheters in all patients with clinical ndings highly suggestive of infection, irrespective of ne-needle aspiration ndings. In patients with a moderate suggestion of infection, catheters were placed only if purulent material was obtained on initial needle aspiration. This policy resulted in catheter drainage being used in 27 of the 41 collections drained, with a success rate of 78%. Patients in whom aspiration only was performed made good recovery, even when cultures were later positive for infection, provided that they were started on appropriate antibiotic therapy and that collections were initially completely aspirated. Thus, catheter drainage was recommended only in patients with a strong clinical suggestion of infection or when pus was aspirated in patients with a moderate clinical suggestion of infection. We tend to favor catheter drainage in all patients except those with noninfected uid or hematoma as conrmed by immediate Grams stain analysis obtained at the time of drainage. Catheters are always placed if the abscess is multiloculated or the aspirate is overtly purulent. Catheter placement allows frequent irrigation to break down the loculi and reduces viscosity of the abscess contents. Success rates
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Drainage of Tuboovarian Abscess Using the Trocar Method of 88% been recorded with catheter drainage [5]. In patients with catheter outputs greater than 100 mL per day, contrast material can be injected through the catheter to reveal any underlying stula [3]. Obviously, if the abscess cavity is too small (<34 cm) to accommodate a catheter or access for drainage is difcult, then needle aspiration alone is indicated [3]. Dr. Varghese. What type and size of catheters can be used for transvaginal drainage of collections? Dr. Mueller. Factors determining the choice of catheter include the size and complexity of the abscess and the nature and viscosity of the uid to be drained. Large-bore catheters are used in larger and more complex collections and in those containing more viscous uid. Typically, we use 8.3- to 12.0French catheters (Cook, Bloomington, IN), but others have used catheters ranging from 7-French all-purpose drainage catheters (Boston Scientic/Medi-Tech, Boston, MA) to 14.0-French vanSonnenberg sump catheters (Boston Scientic/Medi-Tech) [3, 5, 11]. Dr. Varghese. When catheter drainage is used, both the Seldinger [2, 3, 11, 16] and trocar [10, 15] techniques have been described for catheter delivery. Do you have any preferences? Dr. Boland. Yes, we have a strong preference for the trocar method in transvaginal drainage of tuboovarian abscess. It is a one-stick method that is quick, safe, and easy to perform. The entire procedure, including the puncture, catheter delivery, and abscess evacuation, can be continuously monitored using real-time sonography without resorting to uoroscopy. The Seldinger technique requires initial puncture using a thin needle and subsequent exchanges of guidewires and serial dilators before nal catheter delivery. This is especially hard to accomplish when using the transvaginal route because access is more difcult and the operator is farther from the point of puncture than when using the trocar method. These problems can lead to vaginal vault puncture, kinking of guidewires, and loss of access. To make dilation of the vaginal wall easier, using a Colapinto needle (Cook, Bloomington, IN) has been advocated [19]. Even with these modications and using uoroscopy for guidance, transvaginal catheter drainage using the Seldinger technique is frequently time-consuming and frustrating. Drainage using the trocar technique is best performed by two operators, one to hold the guidance mechanism and the other to perform the needle and catheter work. This way, the procedure is much easier to perform, and it should take no more than 30 min. In our view, choosing the trocar technique to perAJR:177, July 2001

form transvaginal catheter drainage is the key to making this a well-tolerated procedure by patient and operator alike. Dr. Varghese. When the trocar technique is used, what are the steps involved in setting up the probe and catheter-guidance mechanism for drainage? Dr. Gervais. The equipment required includes a transvaginal sonography probe, a catheter guide (we use either a short 12French, 15-cm peel-away sheath or the outer protective plastic tubing for the stylette that comes with the catheter set), two low-prole latex condoms or similar probe covers, coupling gel, a 10-French pigtail catheter, and rubber bands (Fig. 1). The transvaginal sonography probe is initially covered with a coupling-gellled condom, which is secured in position using rubber bands at the front and back (Fig. 2A). The peel-away sheath is then placed on the back of the condom-covered probe (where the needle guide is normally positioned) and secured in position using two more rubber bands (Fig. 2B). If the plastic tube is used as the guide, it must be modied in two ways. First, it should be shortened so that its tip sits 1 to 2 cm from the end of the probe. This ensures that the leading surface of the setup is as smooth as possible for easy insertion and that the tip of the needle is easily seen as it enters the sonographic beam during wall puncture. Second, the plastic tube should be slit along its entire length over one

surface to facilitate removal of the guide at the end of the procedure. Whichever catheter guide is used, it is most important to align the guide along the shaft of the transvaginal sonography probe and to attach it securely to the probe using rubber bands so that it does not move out of alignment during the procedure. When this is accomplished, the whole setup is covered with a second condom lled with coupling gel and secured at the front and back with more rubber bands (Fig. 2C). For easy insertion of the needle or catheter, the back of the outer condom should be rolled forward to expose the back of the guide. When the needle or catheter is rst advanced through the guide, the needle will perforate the outer condom before making contact with the vaginal mucosa. Once the catheter is delivered and locked in position, detachment of the guide and transvaginal sonography probe from the catheter requires careful manipulation. First, the outer rubber bands are cut. Following this, the outer condom is carefully rolled forward or slit to expose the underlying peel-away sheath. The latter is peeled away while the operator holds the probe steady. Further cutting of the outer condom and rubber bands may be required before the peel-away sheath is completely removed. Once this is done, it is relatively easy to slide the probe, with the covering inner condom, from the vagina while the catheter is left securely in position. If there is any resistance to probe removal, do not pull with excessive force; simply cut and

Fig. 1.Photograph shows materials required for performing transvaginal drainage of tuboovarian abscess using trocar technique: (a) transvaginal sonography probe (5-MHz end-re probe; Toshiba, Tokyo, Japan); (b) condom sheaths (Trojan; CWI Carter Products, New York, NY); (c) 12-French, 15-cm peel-away sheath (Cook, Bloomington, IN); (d) coupling gel (Triad Disposables; H&P Industries, Mukwonago, WI); (e) 10-French pigtail catheter (Cook); (f) rubber bands.

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B
Fig. 2.Diagrams illustrate setup of sonography probe and peel-away sheath required for transvaginal drainage of tuboovarian abscess. A, Diagram shows sonography probe covered with gel-lined condom held in position using rubber bands. B, Diagram shows peel-away sheath mounted on back of sonography probe, where needle guide is normally placed. Peel-away sheath is xed in position using additional rubber bands. Note strict longitudinal alignment of peel-away sheath along midline of back of sonography probe. C, Diagram shows gel-lined outer condom covering sonography probe and peel-away sheath combination. The catheter inserted through peel-away sheath will perforate outer condom before entering abscess cavity.

release any residual portions of the rubber band or condom attached to the catheter until the probe is released. Dr. Varghese. Can you give a detailed description of how the trocar technique was used to perform transvaginal drainage in this patient? Dr. Boland. The patient was brought to the radiology department and the procedure was carefully explained before consent was obtained. Antibiotics were not given because the patient was already receiving regular IV antibiotic therapy. The patient was placed in a lithotomy position with the legs in stirrups. Monitoring of the vital signs was initiated before IV conscious sedation was administered. A preliminary transvaginal sonography examination was performed using a 5-MHz endre probe attached to a sonography machine (SSH-140; Toshiba, Tokyo, Japan). The collection was identied as situated mainly toward the left adnexa, and a clear path for drainage was conrmed (Fig. 3A). The probe was then removed, and the perineum cleaned using povidone-iodine. The patient was sterilely draped and a vaginal speculum was inserted. The vaginal canal and cervix were further cleansed with povidone-iodinesoaked swabs held with surgical sponge holders. The speculum was then removed and the transvaginal sonography probe was reinserted with the guidance mechanism attached as previously described. The collection was brought into the center of view by angling the probe to the left vaginal fornix. Gentle forward pressure was applied to reduce the space and push away any intervening structures between the probe and the collection. Then the rst operator held the probe steady
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while a second operator administered local anesthesia to the vaginal mucosa using a 20-gauge, 20-cm needle. The vaginal wall indentation, mucosal inltration with anesthetic, and entry of the needle into the abscess cavity were continuously monitored using real-time sonography. The anesthetic needle was then removed and a new 20-gauge needle was advanced into the collection. After 5 mL of infected uid was aspirated, the needle was removed and a 10.2French catheter, mounted on a metal stiffening cannula and central stylet, was inserted through the guide. The catheter was advanced until the tip of the stylet was seen indenting the abscess wall. Once this point of entry was conrmed to be optimal, the catheter was advanced into the abscess cavity using a sharp forward thrust. After the catheter tip was conrmed by sonography to be within the abscess cavity (Fig. 3B), the inner stylet was removed, and a small quantity of pus was aspirated before the catheter was unlocked from the stiffener and released into the abscess cavity. The pigtail catheter was then formed and locked in position. Finally, the guidance system and probe were removed. The catheter was now attached to a threeway stopcock, connecting tubing, and a leg bag. Using a 60-mL syringe, approximately 150 mL of pus was aspirated immediately, and the cavity was irrigated until the returns were clear with 20 mL of saline for a total of 300 mL. The catheter was then xed to the anterior aspect of the left thigh using tape (Elastoplast; Beiersdorf, Norwalk, CT) and connected to gravity drainage. Dr. Varghese. In the technique you described, you placed the patient in the lithotomy position for the drainage. Others [17] perform this proce-

dure with the patient lying supine, knees exed, and legs gently opened to the sides. Is using the lithotomy position necessary? Dr. ONeill. We believe the lithotomy position is reasonably well tolerated by the patient and provides free access during the procedure. It allows easy placement of the speculum for cleaning and subsequent placement of the probe. Either positioning is acceptable as long as the patient is comfortable and does not impede the procedure. Dr. Varghese. Do you routinely catheterize the bladder after the procedure to help keep the catheter dry? Dr. Gervais. When a single transvaginal catheter is used, it can be kept away from the urinary stream. However, when more than one transvaginal catheter is placed simultaneously, urinary contamination of the catheters can be a problem. Bladder catheterization is often helpful to maintain sanitation. Dr. Varghese. Dislodgement of transvaginal catheters is a frequent problem. To avoid this, others have used specialized balloon catheters [20] or sutured the catheter to the lateral vaginal wall [15, 16]. Do you have problems with catheter dislodgement? What xation mechanisms do you use? Dr. Boland. We use a locking pigtail catheter, which is a self-retaining catheter with a tip that can be coiled within the cavity to prevent it from falling out. In addition, the catheter is carefully attached to the anterior aspect of the thigh using Elastoplast adhesive tape. The creation of a mesentery between the skin and catheter when applying the tape prevents the catheter from being easily detached if
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Drainage of Tuboovarian Abscess Using the Trocar Method

Fig. 3.30-year-old woman with left tuboovarian abscess. A, Initial diagnostic transvaginal sonogram shows well-dened tubular mass containing low-level echoes and uiddebris level (arrow ), strongly suggestive of tuboovarian abscess. B, Transvaginal sonogram obtained immediately before catheter delivery conrms position of tip of catheter (arrows) well within abscess cavity. C, Transvaginal sonogram obtained 3 days after drainage shows almost complete resolution of abscess. Note tip of catheter (arrow ) situated within residual collection.

B pulled. Patients seem to tolerate this well, and they are able to move without worry of catheter dislodgement. Dr. Varghese. How was the catheter managed on the ward, and how did you decide when it was time for removal? Dr. ONeill. Orders were given to the nursing staff to attach the catheter to gravity drainage, ush with 10 mL of sterile normal saline every 8 hr, and record all input and output volumes from the catheter. The patient was seen daily during the interventional radiology ward rounds to assess clinical condition, monitor catheter output, and detect any catheter complications [21]. Percutaneous catheters are generally removed when there is improvement in a patients condition, as evidenced by return of temperature and WBC to normal, combined with a reduction in catheter output to less than 20 mL over 24 hr. When these conditions are satised, the catheter can be removed without need of further imaging. If the patient continues to be septic, further imaging, usually using CT, is required to detect any undrained collections. In rare cases when catheter output continues to be high or there is sudden increase in
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C First, the abscess should be clearly visualized and be within easy reach of the endovaginal probe before the procedure is attempted. The probe should be adjusted until the abscess is brought within the center of the eld of view. Firm forward pressure should be applied on the probe to reduce distance and push away any structures between the probe and the abscess. The peel-away sheath should be maintained in perfect alignment with the probe during the entire procedure. Two operators should be available, the rst to hold the probe in position and the second to perform the catheter work. Before the abscess wall is punctured, the site of the puncture should be clearly located by sonographically identifying the place where indentation is made on the abscess wall by the catheter tip. Finally, after puncture and before the catheter is delivered, the position of the catheter tip within the abscess cavity should be conrmed using sonography and by aspiration of pus. In conclusion, radiologic drainage of tuboovarian abscesses is safe and easy to perform, and provides a viable alternative to surgery. Sonographically guided transvaginal drainage is well tolerated by patients and is associated
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output, catheter injection is performed to diagnose any potential stula. Dr. Varghese. A mixture of Escherichia coli, -hemolytic streptococcus, and Escherichia corrodens were cultured from the pus drained. Within 48 hr of drainage, the patients fever abated, and the WBC reduced to 13,100/mm3. By the third day of drainage, catheter output was reduced to less than 20 mL in 24 hr. A transvaginal sonogram obtained at this time showed marked reduction in the size of the tuboovarian abscess and a small amount of free uid in the cul-de-sac (Fig. 3C). The patient continued to improve over the next 48 hr, and the catheter was removed at the bedside on the fth day after the procedure. The patient was discharged 10 days after admission and remained well at follow-up 4 months later. In conclusion, can you summarize some of the key steps to consider when performing transvaginal drainage of abscesses using the trocar method? Dr. Mueller. Paying attention to a number of details from the planning stage to the nal catheter delivery will ensure that the procedure is performed as simply and safely as possible.

Varghese et al. with few complications. When catheter drainage is required, the trocar technique allows easy placement of the catheter.
7. Alexander AA, Eschelman DJ, Nazarian LN, Bonn J. Transrectal sonographically guided drainage of deep pelvic abscesses. AJR 1994;162:12271230 8. Kuligowska E, Keller E, Ferrucci JT. Treatment of pelvic abscesses: value of one-step sonographically guided transrectal needle aspiration and lavage. AJR 1995;164:201206 9. Nelson AL, Sinow R, Renslo R, Renslo J, Atamdede F. Endovaginal ultrasonographically guided transvaginal drainage for treatment of pelvic abscesses. Am J Obstet Gynecol 1995;172:19261935 10. McGhan P, Brown B, Jones C, Stein M. Pelvic abscesses: transvaginal US-guided drainage with trocar method. Radiology 1996;200:579581 11. Feld R, Eschelman DJ, Sagerman JE, Segal S, Hovsepian DM, Sullivan KL. Treatment of pelvic abscesses and other uid collections: efcacy of transvaginal sonographically guided aspiration and drainage. AJR 1994;163:11411145 12. Aboulghar MA, Mansour RT, Serour GI. Ultrasonographically guided transvaginal aspiration of tubo-ovarian abscesses and pyosalpinges: an optional treatment for acute pelvic inammatory disease. Am J Obstet Gynecol 1995;172:15011503 13. Teisala K, Heinonen PK, Punnonen R. Transvaginal ultrasound in the diagnosis and treatment of tubo-ovarian abscess. Br J Obstet Gynaecol 1990; 97:178180 Caspi B, Zabel Y, Or Y, et al. Sonographically guided aspiration: an alternative therapy for tuboovarian abscess. Ultrasound Obstet Gynecol 1996; 7:439442 Nosher JL, Winchman HK, Needell GS. Transvaginal pelvic abscess drainage with US guidance. Radiology 1987;165:872873 Abbitt PL, Goldwag S, Urbanski S. Endovaginal sonography for guidance in draining pelvic uid collections. AJR 1990;154:849850 Hovsepian DM. Transrectal and transvaginal abscess drainage. J Vasc Interv Radiol 1997;8:501515 King JC, Sherline DM. Paracervical and pudendal block. Clin Obstet Gynecol 1981;24:587595 Eschelman DJ, Sullivan KL. Use of a Colapinto needle in US-guided transvaginal drainage of pelvic abscesses. Radiology 1993;186:893894 Bangsboll S, Karstrup S. Technical note: ultrasound guided transvaginal drainage utilizing a 7 French pig tail balloon catheter. Br J Radiol 1994;67:389391 Goldberg MA, Mueller PR, Saini S, et al. Importance of daily rounds by the radiologist after interventional procedures of the abdomen and chest. Radiology 1991;180:767770

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