Ovarian Cysts

Diagnosis

Investigations

Management

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Ovarian cysts may twist (torsion), rupture, bleed, or expand suddenly – cyst ‘accidents’. Cyst torsion is the most frequent & is a common presentation of benign cysts with sudden pain. Pain with a palpable mass or a cyst on sonar in the absence of pyrexia is suggestive of a cyst accident rather than PID. If a cystic swelling is not round but sausage shaped it may be a chronic hydrosalpinx. Consider ectopic pregnancy if there is amenorrhoea & a positive pregnancy test. Heteroptopic pregnancies do occur. A cyst may coexist with a threatened miscarriage.  Malignant cysts more frequently present in older patients with vague symptoms, chronic pain weight loss often accompanied by ascites.

A benign cyst may be a serous or mucinous cystadenoma, a benign mature cystic teratoma (a dermoid), an endometrioma or a follicular or functional cyst. Patients have, rarely, bled over 2 litres from a simple corpus luteum rupture in a normal menstrual cycle. On ultrasound, encysted peritoneum from adhesions or a hydrosalpinx, both associated with previous PID, may look like ovarian cysts.

Diagnosis

• A normal pre-ovulatory follicle grows up to 2.5 cm in diameter. Do not confuse this as pathological
• Larger cysts - torsion or rupture causes a sudden onset of severe constant or intermittent pain (torsion-untorsion)
• Gradual expansion may cause a slower-onset dull ache
• Weakness & dizziness from hemorrhage occur unusually
• Gastrointestinal and urinary symptoms are minimal
• Amenorrhoea is usually absent in the absence of an intrauterine pregnancy
• Pregnancy-associated cysts usually undergo torsion at 14-16 weeks or in the puerperium when the uterus shrinks to this size (they roll on the pelvic brim)
• There is usually no pyrexia with a cyst event
• Abdominal & pelvic signs are variable; a mass may or may not be palpable
• A pleural effusion is rare (if associated with a benign cyst this is ‘Meig’s Syndrome’)

Investigations

• Ultrasound - record the cyst diameter, appearance (simple, or solid/cystic, septate), & bilaterality, look for ascites or haemoperitoneum,
• A collapsed cyst may appear as fluid in the pouch of Douglas
• Urinary pregnancy test if there is ANY possibility of ectopic pregnancy
• If needed, pre-operative routine blood tests – U&E, FBC, Group & Hold
• CA-125 in women >35 years old
• hCG & AFP in pre-menstrual girls
• CEA is associated with mucinous cystadenocarcinoma
• Abdominal X-rays may show the teeth of a benign cystic teratoma, but are no longer performed

Management

This depends on the presentation

If there is not an acute abdomen, & the cyst is simple and ≤6 cm in diameter

1. Explain to the patient that the ovary normally makes cysts & that these may resolve
2. Repeat the ultrasound scan in 2-4 weeks
3. Advise the patient to return if they are unwell or if the pain worsens
4. Give simple analgesics, e.g. Paracetamol 1 g orally 6 hourly
5. If >35 years, take blood for CA-125
6. Do not prescribe combined oral contraceptives; randomized trials have shown they do not shrink cysts that have already formed

If there is a simple or partly solid cyst & an acute abdomen

1. Urgent laparotomy/laparoscopy is required
2. Following untwisting of a torted cyst the ovary sometimes may be saved, but if the adnexum remains dusky adnexectomy must be done
3. If the cyst has ruptured or is expanded by bleeding, it should be removed & the ovary properly reformed (surgical technique)
4. Washout of all blood & fluid with good haemostasis is essential before closing the abdomen. This is especially true after rupture of a dermoid or mucinous cyst to prevent post op adhesions. Ovarian cystectomy is the pelvic procedure most associated with adhesion formation

If the cyst has solid elements, or if it is ≥7 cm in diameter, in the absence of an acute abdomen

1. Laparotomy/laparoscopy should be done as soon as conveniently possible
2. Take blood for tumor markers if indicated – hCG, AFP, CA-125, LDH