Case Study Reports: Pelvic Pain

PELVIC PAIN

History

A 21-year-old student presents with left iliac fossa and lower abdominal pain. The pain is present intermittently and there is no pattern to it 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 common 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 not had any 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.

Questions

·             What is the diagnosis?

·              How would you manage this woman?

ANSWER

The woman has a left 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 pres- ence 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 pre- sent 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 recur- rent pain.