It was a 39-year-old patient, married under the monogamous regime, third gesture et third part admitted for abdominal-pelvic pain of 48 hours duration and occurring five days after a hysterosalpingography (Figure 1) performed as part of an infertility assessment.

On admission, she presented with an infectious syndrome and signs of peritoneal irritation (guarding at the right iliac fossa, umbilical tenderness).

Paraclinical examinations revealed a non-specific biological inflammatory syndrome: CRP = 48 mg/l, WBC = 8000/mm³, HGB = 10.8 g/dl, PLT = 200,000/mm³.

A pelvic ultrasound highlighted at the level of the left ovary a heterogeneous formation measuring 85.9 × 50.9 mm with mixed component with predominance of rounded areas with hypoechoic content (Figure 2). It also revealed

tubal dilation with hypoechoic content, thickened tubal fimbriae in favor of a pyosalpinx and an effusion of medium abundance in the cul-de-sac of Douglas (Figure 3).

The diagnosis of upper genital infection was suspected.

Bi-antibiotic therapy made of Ceftriaxone 2 g/d by direct intravenous and Metronidazole 500 mg × 3/d by infusion last 10 days and symptomatic treatment with Paracetamol 4 g/d by infusion last 7 days was instituted.

The exploratory laparotomy revealed a left pyosalpinx and a collection of pus in the pouch of Douglas and dystrophic multi-cystic ovaries.

A left salpingectomy, bilateral ovarian drilling, drainage and collection of pus were performed.

The cytobacteriological examination of the pus made it possible to isolate a strain of Pseudomonas aeruginosa and the vaginal sample a bacterial vaginosis with Gardnerella vaginalis. The evolution was favorable with apyrexia after 4 days of antibiotic therapy and 3 days after surgery. The hospitalization lasted 11 days and the postoperative course was unremarkable.

It was a 40-year-old female patient, nulligravida, married under the regime of polygamy referred for acute abdominal-pelvic pain lasting for 7 days after a hysterosalpingography carried out as part of an infertility assessment.

On admission, she presented an acute abdominal-pelvic pain, abdominal guarding, exquisite pain in the right iliac fossa, umbilical tenderness and pain provoked in the pouch of Douglas.

Additional biological examinations revealed a non-specific biological inflammatory syndrome: CRP = 119 mg/l, WBC = 9830/mm³, HGB = 11.7 g/dl, PLT = 493,000/mm³ and an elevation of CA 125 = 196.8 U/ml (N < 35).

Pelvic ultrasound revealed a right hydrosalpinx with a biloculated left ovarian cyst measuring 56 × 35 mm. The abdominal & pelvic computed tomography was in favor of a right pyosalpinx associated with ipsilateral grade I hydronephrosis and an effusion in the cul-de-sac of Douglas.

The diagnosis upper genital infection was suspected.

Dual antibiotic therapy consisting of Ceftriaxone 2 g/day by direct intravenous and Metronidazole 500 mg × 3/day by infusion last 10 days and symptomatic treatment with Paracetamol 4 g/day by infusion last 7 days were instituted.

Laparotomy revealed utero-grelic, vesico-uterine and utero-parietal adhesions, a right tuboovarian abscess, a left hydrosalpinx and a purulent effusion of approximately 200 cc.

A right adnexectomy, a left salpingectomy, peritoneal washing and drainage were performed.

The cytobacteriological examination of the pus was sterile and the histopathological examination of the surgical specimen was in favor of a bilateral tubo-ovarian abscess.

The evolution was favorable with improvement in clinical signs and an 80% drop in CRP after 10 days of antibiotic therapy and 7 days after surgery.

The hospitalization lasted 26 days and the postoperative course was unremarkable.

It was a 27-year-old patient, nulligravida, single with a notion of multiple sexual partners, referred for acute abdominal-pelvic pain and diffuse abdominal distension.

On admission, she presented with diffuse abdominal tenderness, abdominal distention with shifting dullness of the flanks and a well-tolerated anemic syndrome.

A urine pregnancy test was performed and came back negative.

Additional examinations revealed a non-specific biological inflammatory syndrome: CRP = 96 mg/l, WBC = 26,000/mm³, HGB = 6.1 g/dl, PLT = 567,000/mm³, an increase in CA 125 to 48.3 U/ml (N = 35) and negative retroviral serology.

A pelvic ultrasound was performed and revealed two hypo-echoic, heterogeneous intrapelvic collections with a thick wall, measuring 98 × 75 mm and septate as cites suggestive of pelvic peritonitis.

The abdominal & pelvic computed tomography done was in favor of two right lateral-uterine cystic masses probably ovarian measuring 41 × 51 × 52 mm and 100 × 118 × 89 mm without obvious signs of malignancy suggesting a serous cyst adenoma (Figure 4).

Diagnosis of upper genital infection was suspected and antibiotic therapy based on Ceftriaxone 2 g/day by direct intravenous lasts 7 days, Metronidazole 500 mg × 3/day by infusion last 15 days and symptomatic treatment with Paracetamol 4 g/d by infusion last 7 days were started as well as a transfusion of packed red blood cells.

Laparotomy revealed adhesive magma, false membranes, a right tuboovarian abscess and an effusion of pus in the cul-de-sac of Douglas.

Adhesiolysis, right adnexectomy, drainage, abdominal washing and pus sampling were performed.

The cytobacteriological examination of the pus was sterile and the pathological

examination of the surgical specimen was in favor of an abscessed ovarian cyst without signs of malignancy.

The evolution was marked by the occurrence of febrile pneumonia on the 3rd day after laparotomy. A chest CT scan revealed ground glass images. Ceftriaxone was replaced by Ciprofloxacine 500 mg/day per os, which resulted in a pyrexia on the fifth day after surgery and a decrease in leukocytes is from 24,000 to 16,000/mm³. On the 12th postoperative day, C-reactive protein was normal (CRP = 6 mg/l) and without any particular finding on clinical examination.

The hospitalization lasted 15 days and the surgical consequences were unremarkable.

It was a 23-year-old female patient, nulligravid, single with the notion of multiple sexual partners, referred for acute abdominal-pelvic pain associated with food and bilious vomiting.

Examination at admission revealed a tender, distended abdomen with shifting dullness of the flanks, and umbilical and Douglas pouch tenderness.

The urine pregnancy test came back negative.

Additional biological examinations revealed a non-specific biological inflammatory syndrome: CRP = 81 mg/l, WBC = 18,000/mm³, HGB = 9.1 g/dl, PLT = 570,000/mm³.

A pelvic ultrasound done revealed a lateral heterogeneous cystic mass to the right of the uterus measuring 73 × 52 mm, suggestive of a dermoid cyst (Figure 5).

With this clinical picture, the diagnosis of upper genital infection was suspected.

Bi-antibiotherapy with Ceftriaxone 2 g/d by direct intravenous, Metronidazole

500 mg × 3/d by infusion last 10 days and symptomatic treatment with Paracetamol 2 g/day by infusion last 7 days was instituted as well as a transfusion of packed red blood cells.

A laparotomy was performed and revealed false membranes on the pelvis and the intestinal loops, a right tuboovarian abscess and a diffuse intra-abdominal purulent collection.

The procedures performed were a right adnexectomy, a removal of pus, washing and drainage.

Cytobacteriological examination for pus was sterile.

The evolution was favorable with an 80% drop in CRP (24 mg/l) 11 days after surgery and antibiotic therapy.

The hospitalization lasted 13 days and the postoperative course was unremarkable.

It was a 52-year-old patient, married under the regime of monogamy, seventh gesture and fifth part and menopausal for one year. She was admitted for acute abdominal-pelvic pain on the ground of chronic pelvic pain and recurrent undocumented genital infection.

On admission, she presented with an infectious syndrome associated with signs of peritoneal irritation (guarding in the left iliac fossa and a Douglas pouch tenderness) and offensive leucorrhoea.

Paraclinical examinations revealed a non-specific biological inflammatory syndrome: CRP = 200 mg/l, HGB = 11 g/dl, WBC = 14,000/mm³, PLT= 272,000/mm³.

A pelvic ultrasound was performed and revealed two lateral-uterine cystic masses with raised walls, oval on the right and pseudo-tubulated on the left.

Abdominal & pelvic computed tomography highlighted aright adnexal liquid mass, salpingian in appearance in favor of a hydrosalpinx of about 8 cm, infiltration of the adjacent perineal fat without infiltration of the salpingian collection.

Diagnosis of upper genital infection was suspected.

Antibiotic therapy based on Ceftriaxone 2 g/d by direct intravenous, Metronidazole 500 mg × 3/d by infusion last 10 days and symptomatic treatment based on Paracetamol 3 g/d last 7 days was instituted.

A laparotomy was performed and revealed a bilateral tuboovarian abscess (Figure 6). A bilateral adnexectomy and lavage of the pelvic cavity were performed.

The cytobacteriological examination of the pus taken in traoperatively was sterile, as was the NAAT (nucleic acid amplification test) with research of Chlamydia trachomatis and Neissseria gonorrhoeae was negative.

The outcome was favorable with a pyrexia after 3 days of antibiotic therapy and on day 1 after surgery. Biologically, we noted a drop in CRP of 68% (63 mg/l) and a drop in white blood cell count to 7000/mm³.

The hospitalization lasted 14 days and the postoperative course was unremarkable.

It was a 45-year-old patient, married under the regime of monogamy, IVGIVP (fourth gesture and fourth part), referred for the management of an ovarian tumor. She presented with acute abdominal-pelvic pain associated with vomiting.

Physical examination revealed a firm, painful hypogastric mass and a Douglas pouch tenderness on vaginal examination.

Paraclinical examinations findings revealed a non-specific biological inflammatory syndrome: CRP: 192 mg/l, WBC: 20,000/mm³, HGB: 6.3 g/dl, PLT: 978,000/mm³.

Abdominal & pelvic CT scan revealed a mixed adnexal mass (liquid, solid, calcium and fatty) measuring 160 × 144 × 102 mm responsible for right ureterohydronephrosis, suggestive of a teratoma.

Bi-antibiotic therapy consisting of Ceftriaxone 2 g/day by direct intravenous, Metronidazole 500 mg × 3/day by infusion last 10 days and symptomatic treatment with paracetamol 3 g/day last 5 days last were instituted.

An exploratory laparotomy was carried out and revealed agglutination of the small bowel loops and part of the cecum around the two pyosalpinxes and bowel-parietal adhesions (Figure 7).

The procedures performed were an adhesiolysis allowing the discovery of the two pyosalpinxes attached to the uterus forming a mass of about 20 cm, a total hysterectomy with a bilateral annexectomy and a sample of pus.

Cytobacteriological examination of pus made it possible to isolate a strain of Enterobacter cloacke.

The evolution was favorable with clinical improvement and biologically, we noted a 67% drop in CRP (63 mg/l) and a decrease in white blood cells to 7000 elements/mm³ after 10 days of antibiotic therapy.

The hospitalization lasted 14 days and the postoperative course was unremarkable.

Our series consisted of relatively young patients, in accordance with Ka et al. [5] with other risk factors for upper genital infection clearly identified in most studies such as multiple sexual partners (2 cases), invasive endouterine procedures in particular hysterosalpingography (two cases) and bacterial vaginosis (1 case) [2] [6] . Bacterial vaginosis (1 case) is quite common in STIs and considered to increase the risk of upper genital infection (OR = 2.03, CI 95%: 1.16 - 3.53) [7] . However, we noted that two of our patients were over 40 years old and had no other identified risk factors, which confirms the new trend in the epidemiology of upper genital infection [8] .

Combination of antibiotic therapy and drainage is considered the best option by many studies compared to antibiotic therapy alone [22] [23] .

Bi-antibiotic therapy consisting of Ceftriaxone 2 g and Metronidazole 500 mg × 3/day was started at the time the diagnosis was suspected. Laparoscopy was not very accessible in our context as was radiological drainage and exploratory laparotomy was justified given the signs of acute peritonitis. The diagnosis of tubo-ovarian abscess complicated by pelvic peritonitis (2 cases) and acute generalized peritonitis (2 cases), bilateral tubo-ovarian abscess (1 case) and bilateral pyosalpinx (1 case) were found. The operators preferred radical surgery associated with drainage due to the severity of the lesions observed, with almost complete destruction of ovarian tissue. Ka et al. had adopted the same attitude [5] . Furthermore, many studies have shown that ultrasound-guided transvaginal puncture in the absence of major hemostasis disorders or severe sepsis is a less morbid alternative to surgery and offers high cure rates [22] [23] . However, it was not performed because the patients were admitted at the complicated stage and open surgery was the only alternative given the unavailability of laparoscopy.

The postoperative course was favorable in most patients, apart from the case we noted pneumopathy in the postoperative period that resolved under antibiotic therapy.

Hospitalization lasted an average of 15 days due to the delay in making the decision to operate. The decrease in CRP was well correlated with the clinical evolution of our patients in accordance with Ribak et al. [24] .

Mortality was zero, unlike Takongmo et al. in Cameroon, which found a mortality of 23% in a study of 30 cases of genital peritonitis [25] . This is due to the large number of voluntary termination of pregnancy which leads to massive dissemination of aerobic and anaerobic germs and associated digestive complications.