Ovarian cyst

Background

• Most common are functional or follicular cysts
• Less common include PCOS, cystadenomas, and dermoid cysts
• Cysts are generally >1cm in size
• Cysts are at risk of torsion when >4cm
• Cysts <2cm are virtually risk free from torsion

Relative incidences of different types of ovarian cysts.

Clinical Features

• Most tend to be asymptomatic
• Can cause:
  • Dull pelvic pain or fullness; they can be significantly painful if ruptured
  • Dyspareunia
  • Pressure on the bladder
• If there is bleeding into the cyst and it ruptures, it can be life threatening, with signs of peritonitis, shock

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Pregnancy-related
  • Ectopic Pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Acute Infections
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

RLQ Pain

• Appendicitis
  • Perforated appendicitis
• Peritonitis
• Abdominal aortic aneurysm
• Crohn's disease (terminal ileitis)
• Diverticulitis (cecal, Asian patients)
• Ectopic
• Endometriosis
• Epiploic appendagitis
• Herpes zoster
• Inguinal hernia
• Ischemic colitis
• Kidney stone
• Meckel's diverticulum
• Mesenteric lymphadenitis
• Mesenteric ischemia
• Mittelschmerz
• Neutropenic enterocolitis (typhlitis)
• Ovarian cyst
• Ovarian torsion
• PID
• Pyelonephritis
• Psoas abscess
• Testicular torsion

LLQ Pain

• Diverticulitis
• Kidney stone
• UTI
• Pyelonephritis
• Ectopic pregnancy
• Infectious colitis
• Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
• Inguinal hernia
• Mesenteric ischemia
• Epiploic appendagitis
• Mittelschmerz
• Ovarian cyst
• Ovarian torsion
• PID
• Psoas abscess
• Testicular torsion
• Appendicitis
• Abdominal aortic aneurysm
• Herpes zoster
• Endometriosis
• Colon cancer
• Irritable bowel syndrome
• Small bowel obstruction

Evaluation

Ultrasound demonstrates a simple ovarian cyst greater than 3 cm in size consistent with a follicular cyst.

Transvaginal ultrasound showing ovarian cyst

Ruptured hemorrhagic cyst. (a) CT with bilateral low-density cystic lesions (white arrows). There is extensive hyperdense free pelvic fluid representing hemorrhagic ascites (black arrow). (b) Trans-abdominal ultrasound shows free fluid containing low level echoes in the pelvis (black arrow). There is an adnexal cyst in the pelvis representing the right hemorrhagic ovarian cyst (white arrow).

Workup

• CBC, chemistry
• UA, urine pregnancy
• Pelvic ultrasound
• Consider CT A/P to rule out other etiologies (e.g. appendicitis)

Diagnosis

• Typically diagnosed on ultrasound, with same side of pain and absence of other concerning etiologies (e.g. negative UA, not pregnant)
• Check hemoglobin level to assess for blood loss

Management

• NSAIDs
• Oral contraceptives
  • No benefit has been found though gynecology may suggest them
• Ensure that patient does not have significant anemia/free fluid in pelvis
  • Consider repeat hemoglobin of observation period if concern for ruptured cyst with significant bleeding

Disposition

• Home, unlessed ruptured with concern for significant blood loss
• Follow up with OBGyn

See Also

• Abdominal Pain