Background: This study aimed to evaluate the clinical utility of shear wave elastography (SWE) in assessing abscess wall stiffness and its potential contribution to predicting the need for surgical intervention in patients with tubo-ovarian abscess (TOA). Materials and methods: This prospective cross-sectional study included 34 women diagnosed with TOA who underwent SWE evaluation upon admission. Demographic characteristics, laboratory parameters, abscess size, abscess wall elasticity, and abscess content elasticity were recorded. These patients were categorized as either medically managed or surgically treated. Group comparisons, receiver operating characteristic (ROC) curve analysis, and multivariable binary logistic regression were performed to identify independent predictors of surgical intervention. Results: There were no significant differences between the operated and non-operated groups regarding age, body mass index, and laboratory parameters (p > 0.05). The median length of hospital stay was significantly longer in the operated group (15 vs. 12 days, p = 0.017). Abscess diameter was significantly larger in the operated group (6.75 ± 1.17 cm vs. 4.65 ± 1.20 cm; p = 0.001). Likewise, the median abscess wall SWE value was significantly higher in the operated group (3.12 vs. 1.47 kPa; p = 0.027). The optimal cut-off value for abscess wall SWE was 2.04 kPa (AUC: 0.721, 95% CI: 0.551–0.892, sensitivity: 64.7%, specificity: 70.6%). Abscess size demonstrated a higher predictive performance (AUC: 0.905, 95% CI: 0.796–1.000). However, in the multivariable logistic regression analysis, only abscess size remained an independent predictor of surgical intervention (OR: 4.14, 95% CI: 1.50–11.39, p = 0.006), whereas abscess wall SWE and baseline C-reactive protein were not independently associated with treatment failure. Conclusions: Increased abscess wall stiffness measured by SWE was associated with the need for surgical intervention in patients with TOA. Although SWE was not an independent predictor after adjustment for abscess size and baseline C-reactive protein, it may serve as a complementary imaging biomarker when interpreted together with established clinical, laboratory, and conventional ultrasonographic findings.