Case 29: Pelvic pain

 

Case 29: Pelvic pain

CASE 29: PELVIC PAIN

History

A 21-year-old student presents with left iliac fossa and lower abdominal pain. The pain is

present intermittently with no pattern except that it is generally worse on exercise and so she

has stopped running to keep fit. The pain started about 6 months before and has gradually

become more frequent and severe. It is no worse with her periods and she is not currently

sexually active so cannot report any dyspareunia. Her periods are regular and not particularly heavy or painful. She has no previous gynaecological problems. She has had one sexual

partner who she was with for 4 years. She denies any sexually transmitted infections.

Medically she is fit and well, and has only been admitted to hospital for wisdom teeth removal

and for tonsillectomy as a child. She takes no medications.

Examination

The woman is slim and the abdomen is soft with a palpable mass in the left iliac fossa. This is

firm and feels mobile. It is moderately tender.

Speculum examination is normal. Bimanual examination confirms an 8 cm mass in the left

adnexa. The uterus is palpable separately and is mobile and anteverted. The right adnexa is normal.

INVESTIGATIONS

An abdominal X-ray is shown in Fig. 29.1.

Transvaginal ultrasound scan findings are shown in Fig. 29.2.

Questions

• What is the diagnosis?

• How would you manage this woman?

Figure 29.2 Transvaginal ultrasound image

showing a transverse view through the left

adnexa.

Figure 29.1 Abdominal X-ray.100 Cases in Obstetrics and Gynaecology

72

ANSWER 29

The woman has a palpable left adnexal mass, which is shown on ultrasound to be a complex

ovarian cyst. The ultrasound appearance shows an ovarian cyst. The appearance is of mixed

echogenicity with ‘acoustic shadowing’ and this appearance is typical for a dermoid cyst

(also known as a benign teratoma). The X-ray shows the presence of teeth in the left iliac

fossa region.

These cysts are common. Typically sebaceous fluid is present, often in association with

strands of hair or sometimes teeth. If active thyroid tissue develops the woman may present

with features of hyperthyroidism and the cyst is referred to as a struma ovarii.

The management is surgical with ovarian cystectomy, due to the size of the cyst and the

symptoms. Ideally this can be performed laparoscopically. In asymptomatic cysts there is

a possibility of expectant management (‘watch and wait’). However the risks of leaving the

cyst are:

• malignancy occurs in up to 2 per cent of dermoid cysts

• ovarian torsion is thought to be relatively common in women with dermoid cysts,

and if this occurs it is a medical emergency, which may involve oophorectomy.

The woman should be advised that the cysts are common and there is very little chance that

it is malignant or that removing it will affect her fertility. However recurrence may occur in

either ovary and she should seek further consultation if she develops recurrent pain.

KEY POINTS

• Dermoid cysts (mature cystic teratoma) are a common cause of ovarian cysts in

young women.

• They commonly display a classic appearance on X-ray or ultrasound scan.

• Surgery is usually recommended because of a small risk of torsion or malignant

transformation.