QuestionSBA
QuestionChoice
Whilst ovarian torsion is a sensible differential, a ruptured ovarian cyst is more common. Combined with the fact she is mid-cycle and that the pain seems to have alleviated slightly, ovarian cyst rupture is the more likely diagnosis. Ovarian torsion often presents with worsening pain, sometimes associated with nausea and vomiting.
49925
d
Ovarian torsion
QuestionChoice
Whilst ectopic pregnancy is a possibility, this would be rare with a copper intrauterine device in situ.
49923
b
Ectopic pregnancy
QuestionChoice
Appendicitis typically presents with central periumbilical pain which localises to the right lower quadrant. This doesn't fit with her pain being on the left and sudden-onset.
49926
e
Appendicitis
QuestionChoice
Ovarian cyst rupture presents with a sudden-onset sharp unilateral pain.
49922
a
Ovarian cyst rupture
QuestionChoice
Whilst perforation of an intrauterine device can cause unilateral pain; this is usually within the first few days following insertion.
49924
c
Intrauterine device perforation
QuestionComment
quite hard to distinguish cyst rupture from torsion 
28649
User
subscriber
Sir Pep Guardiola
Concept
Chapter
# Summary
  
 
An ovarian cyst is a fluid-filled sac that can develop in the ovaries. They are often asymptomatic, but can cause acute unilateral pain and even intra-peritoneal haemorrhage in severe cases. The key differentials to consider are ovarian torsion, ectopic pregnancy and gastrointestinal conditions such as appendicitis. A pregnancy test is often the first investigation to exclude an ectopic pregnancy, and a diagnostic laparoscopy may be required if the patient is unstable. The management of ovarian cysts is mainly conservative, but surgery may be required in some cases.
  
 
# Definition
  
 
An ovarian cyst is a fluid-filled sac that develops within or on the surface of an ovary. They can vary in size and can occur as a normal part of the menstrual cycle or as a result of an underlying condition.
  
 
# Epidemiology
  
 
Ovarian cysts are a common condition, with most women experiencing at least one in their lifetime, although many are asymptomatic. They are most likely to occur during a woman's reproductive years, but can occur at any age.
  
 
# Aetiology
  
 
Ovarian cysts can be caused by a variety of factors, including hormonal imbalances, endometriosis, pregnancy and pelvic infections.
  
 
# Signs and Symptoms
  
 
Signs and symptoms of an ovarian cyst can include:
  
 
  - Asymptomatic presentation
  - Acute unilateral pain
  - Bloating and early satiety
  - Palpable adnexal mass
  
 
# Differential Diagnosis
  
 
The primary differentials to consider when diagnosing an ovarian cyst include:
  
 
  - **Ovarian torsion:** Characterised by sudden, severe pain, often accompanied by nausea and vomiting.
  - **Ectopic pregnancy:**Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.
  - **Appendicitis:** Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.
  
 
# Investigations
  
 
Investigations into a suspected ovarian cyst should include:
  
**Bedside:**

- Bimanual examination: To feel for any masses. 
- Pregnancy test: To exclude an ectopic pregnancy

**Bloods:**

In cases of diagnostic uncertainty consider performing:

- CA125: Especially in post-menopausal women, if suspecting cancer. However, specificity (and sensitivity) are below 80%. 

**Imaging:**

- Transvaginal Ultrasound Scan: First line and best test to visualise the cyst. 

**Invasive tests:**  

- Diagnostic laparoscopy, particularly in cases where the patient is unstable
  
 
# Management
  
**Conservative:**
 
Most ovarian cysts are managed conservatively, through monitoring and pain management, if they are simple or unilocular cysts. Exact management depends on their size: 

- If cyst is <5cm: no follow-up is required
- If 5-7cm: repeat TV USS yearly
- If >7cm: MRI with/without surgical intervention. 


**Medical:**

For recurrent or unresolved simple cysts.

- Combined oral contraceptive pill, as prevention of ovulation will also help prevent formation of new cysts. 



**Surgical:**

Used in cases of recurrent cysts, sustained cysts >5cm, and cysts that look suspicious or multiloculated.

- Laparoscopic cystectomy 
  
  
# Complications

- Cyst rupture: Most often seen in corpus luteum and dermoid cysts that are large, symptomatic and untreated. Rupture can lead to intra-peritoneal haemorrhage with haemodynamic compromise, or peritonitis in the case of dermoid cyst rupture leading to an inflammatory reaction. 
- Ovarian torsion: Most often seen with large cysts that are untreated, where the cyst twists around itself. Most commonly occurs with dermoid cysts and requires urgent surgical intervention to prevent ovary necrosis. 
- Dyspareunia: Can occur as a result of large cysts. 


 
# References
[Click here for RCOG Guidelines on Ovarian masses](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian-masses-in-premenopausal-women-management-of-suspected-green-top-guideline-no-62/)

  
[RCOG Guidance: Ovarian masses in premenopausal women](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian-masses-in-premenopausal-women-management-of-suspected-green-top-guideline-no-62/)

[RCOG Guidance: Ovarian cysts in postmenopausal women](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/ovarian-cysts-in-postmenopausal-women-green-top-guideline-no-34/)

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/660)

[NHS Website](https://www.nhs.uk/conditions/ovarian-cyst/)

[Patient Info](https://patient.info/womens-health/pelvic-pain-in-women/ovarian-cyst)
831
988
Ovarian cyst rupture
Topic
26
Gynaecology
10021
A 24-year-old female presents to accident and emergency with acute onset left iliac fossa pain.

She describes the pain as "stabbing" and of intensity 9/10. It came on suddenly while she was out for her daily jog approximately 1 hour ago. She thinks the pain has alleviated a little since then.

Her last menstrual period was 13 days ago. Her last sexual contact was 21 days ago. She has a copper intrauterine device in situ, which was inserted three months ago.

What is the most likely diagnosis?
a