Diagnosis

Ruptured ovarian cyst

Etiology

Cause [afp]

• Follicular cyst and corpus luteum cyst from a normal growing monthly follicle

• Theca lutein cyst (overstimulation by hCG in pregnancy)

• Polycystic ovary syndrome

• Dermoid cyst (embryonal stem cells)

• Cystadenomas (ovarian tissue)

• Endometriomas (result of endometriosis)

• Neoplastic cysts: Serous/mucinous adenoma, stromal/germ cell tumors, malignancy (serous carcinoma, mucinous carcinoma, endometrioid carcinoma, clear cell carcinoma, and malignant Brenner tumors, immature teratoma, endodermal sinus tumors, embryonal carcinoma, and polyembryoma)

Pathophysiology [afp]

1. Ovarian cysts are fluid-filled structures that may be simple or complex

2. A mature ovarian follicle ruptures every month and releasing an ovum

3. After ovulation, follicular remnants form a corpus luteum (produces progesterone)

4. Ovarian cysts can cause complications:

   • Rupture

   • Hemorrhage

   • Torsion

5. Clinical presentation of a ruptured ovarian cyst:

   • Asymptomatic

   • Acute unilateral lower abdominal pain

Epidemiology

Incidence per 100.000 [moh][7a4]

Approach

• Pelvic exam

• Blood test: hemoglobin, hematocrit, hCG, Ca-125, LH, FSH, estradiol, testosterone

• Urine stix: hCG, rule out urinary tract infection and urolithiasis

• Transvaginal ultrasonography

• Abdominal ultrasonography

• Endocervical swabs to assess for pelvic inflammatory disease

• CT abdomen

• MRI abdomen

• Laparoscopy

Treatment

1. Most cysts resolve spontaneously without intervention --> Symptomatic support: [xy7]

   • Oral analgesics: acetaminophen, NSAIDs, IV morphine

   • Observation with serial:

     • Abdominal examinations

     • Laboratory testing

     • Transvaginal ultrasound

2. Surgery: Laparoscopy or laparotomy [afp]

   • Hemodynamic unstable

   • Suspected ovarian torsion

   • Acute abdominal pain

   • Persistent adnexal mass

   • Suspicious of malignancy: Cyst size greater than 10 cm, complex multilocular mass, papillary excrescences or solid components, irregularity, thick septations, evidence of ascites, and increased vascularity on color doppler

3. Prophylaxis: multiple episodes of ruptured physiologic cysts

   • Consider suppression of ovulation with oral hormonal contraception

Differential diagnoses

Aortic dissection, Appendicitis, Colorectal cancer, Diverticulitis, Endometriosis, Internal hemorrhage, Liver injury, Myoma uteri, Ovarian abscess, Ovarian cancer, Ovarian torsion, Pelvic inflammatory disease, Perforated ulcer, Rectus sheath hematoma, Retroperitoneal hemorrhage, Ruptured aortic aneurysm, Ruptured ectopic pregnancy, Splenic injury, Teratoma, Urinary tract infection, Urolithiasis