INTRODUCTION
An ovarian cyst is a fluid-filled
sac within the ovary. Most cases of ovarian cysts are asymptomatic. Severe symptoms might result if the cyst ruptures, bleeds, or becomes infected or torted and presents with vague symptoms like vomiting, severe lower abdominal pain, dizziness, fever, or fainting.1 Ovarian cysts are common in the
reproductive age group aged 18-45 years and rare in premenstrual and postmenopausal age groups.2
A hemorrhagic ovarian cyst is a functioning cyst
that arises when a cyst bleeds. Abdominal discomfort on one side of the body is
a symptom of this cyst.1 Haemorrhagic cysts are commonly
detected by grey-scale ultrasound but are often misdiagnosed due to their
variable sonographic appearance, mimicking other organic adnexal masses. Most
haemorrhagic ovarian cysts are functional, and though a handful of them can be
neoplastic, they are universally benign.5
Though ovarian cyst torsions are rare gynaecological emergencies, they usually present
diagnostic challenges. The varied imaging features and nonspecific symptoms of
ovarian torsion can lead to a delay in identification,
with misdiagnosis being common. It refers to a complete or partial rotation of
the adnexal supporting organ, resulting in ischemic changes in the ovary.4
Mature cystic teratomas (MCT) of the ovary or dermoid cysts are commonly
encountered benign ovarian lesions accounting for approximately 70% of benign
tumours and originating from germ cells.5
Surgical intervention may be indicated in cases
of large cysts greater than 5 cm in diameter, severe persistent abdominal pain,
failure of the cyst to resolve spontaneously, masses that cannot be confirmed
to be benign by ultrasound criteria and
finally, the occurrence
of complications such as rupture and ovarian torsion.6
CASE PRESENTATION
A
28-year-old nulliparous businesswoman with a secondary level of
education. She presented to a private facility with complaints of severe abdominal pain of 24 hours duration before
presentation to the facility. The pain was of sudden onset, temporarily relieved by ingestion of analgesics, she graded the pain to
be eight on a scale of 0 to 10. At the onset of pain, she
presented to a pharmacy where some unknown
medications were administered, including
parenteral medicines. There was associated weakness and dizziness but no fainting
spells, and with worsening symptoms, she presented to the facility for proper
medical attention. Her menstrual history was not significant. She had noticed abdominal swelling of about one year duration, with
swelling described as painless and the size of
an orange in the lower abdomen. The swelling
had gradually increased, with no associated fever, vomiting, change in bowel habits, or
urinary symptoms. On examination at
presentation, she was in severe painful distress, marked pale, dehydrated, but
conscious, her pulse rate was 114 beats per minute, and her blood pressure
was 90/40mmHg. The abdomen was distended with generalised tenderness, and difficulty was observed in ascertaining abdominal organs due to tenderness. Pelvic
examination revealed normal vulva and vagina, difficulty performing a bimanual examination due to tenderness, a full pouch of Douglas and
positive cervical motion tenderness. A diagnosis of ruptured ectopic pregnancy
to rule out an ovarian cyst accident was
entertained.
The packed cell volume was 34%, the
serum pregnancy test was negative, and HIV 1 &2 were seronegative. An abdominopelvic ultrasound scan revealed normal
abdominal findings with pelvic organs that showed a normal-sized uterus with a subserous myoma nodule that measured 4.4 by
3.5 cm. There was a huge solid mass
with unclear exact origin. However, the location appeared more towards the right adnexum, extending to the upper abdominal region
and was suggestive of an ovarian tumour. The
dimensions of the mass were 14.70cm by 10.10cm,
with irregular
borders and a heterogeneous echotexture with
severe cystic degeneration. There were also a
few areas of vascularity on the colour doppler. In addition, there was associated marked irritation of the bowel loops, especially at the right ileac region, with associated inflammatory changes suggesting
acute appendicitis. The left ovary harboured a similar mass of size 3.6cm by 3.3cm with predominantly
hyperechoic echotecture. Furthermore, there was
also marked intraperitoneal fluid, which contained lots of debris but no
bowel dilatation.
She was counselled
on her condition, and informed consent was
obtained. She subsequently had an exploratory laparotomy. Findings were
haemoperitonium of about 1.5 litres, a huge
right ruptured ovarian cyst that measured 14cm by 30cm and weighed 5kg. She had
right ovariectomy, blood loss with haemoperitonium was 1.7 litres. She received
two units of whole blood intra-operatively and was managed with antibiotics and
discharged home on the 5th post operative day in stable clinical
state. The histology report showed mature
cystic teratoma with rupture. On follow-up visit, she was counselled on the
surgery, the histology and her concerns of future fertility.
DISCUSSION:
Ovarian
cyst torsion is a rotation of the ovarian vasculature, entirely or partially.
It occurs due to ovarian twisting over the infundibulopelvic and utero-ovarian
ligamentous support, obstructing blood flow.7 It commonly occurs
between the third and fourth decade of a woman’s life, though it can happen at
any age.8 Our patient was 28 years of age, falling in this age
bracket. Common symptoms include progressively worsening abdominal pain of
sudden onset with varying characteristics and may be intermittent if the ovary
is torting and detorting.9 Nausea and vomiting are also common
symptoms.10 Fever may be a pointer of ongoing ovarian necrosis,
while abnormal vaginal discharge may occur if a tubo-ovarian abscess is torted.
As seen in our patient, rupture
of ovarian cyst is generally either spontaneous or associated with torsion (figures
2&3). Very rarely, however, rupture may be a consequence of blunt abdominal
trauma11.
Most ovarian cysts happen on the right, usually due to more
extensive utero-ovarian ligaments on that side. The sigmoid colon on the left
also reduces the anatomical space in that region, leading to a higher incidence
of right-sided lateralisation.12 A right-sided mass was seen on
ultrasound and intra-operatively in our case. However, Pramana et al. reported
a left-sided torsion in a 19-year-old3, while Baradwan et al.
reported a case of a 20-year-old with bilateral ovarian torsion.13
This variability, however, affects the course of medical and surgical
intervention as the latter case was managed by performing a left-sided
salpingo-oophorectomy and right cystectomy.
The main risk factor for torsion and rupture is the presence
of an ovarian mass greater than or equal to 5cm in diameter. This large diameter increases
the chances of rotation on the axis of its supporting ligaments, leading to
reduced venous drainage and, ultimately, arterial supply9. Pregnancy
and vomiting are independent risk factors for ovarian torsion. Other risk
factors include history of abdominal surgeries, tubal ligation and pathologies
like dermoid cysts, which cause ovarian enlargement.3, 13 Our
patient had a massive ovarian mass with dimensions of 14.70cm by 10.10cm
that extended to the upper abdomen, which is a major risk factor for the
condition.
The diagnosis of ovarian cyst torsion is difficult due to
the generalised nature of presenting complaints that are usually associated
with a range of medical conditions, including ectopic pregnancy, appendicitis,
pelvic inflammatory disease, and tubo-ovarian abscess. A transvaginal Doppler
ultrasound scan (TVDUS] is the imaging modality of choice in ovarian torsion,
however, ruptures can be seen on pelvic scans.14 TVDUS usually have
high sensitivity, but this depends on many factors, including the operator’s
skill and the patient’s anatomy. The most sensitive ultrasound findings documented in studies are ovarian
oedema, abnormal ovarian blood flow, relative ovarian enlargement, and free
fluid or the whirlpool sign, which results from the twisting of the vascular
pedicle.9 There should be a high index of suspicion of ovarian cyst torsion
and rupture due to functional impairment and long-term complications without
prompt and adequate intervention.
An ovarian torsion with
rupture is a gynaecological emergency that requires urgent surgical
intervention. The desire for future fertility, the viability of the ovary, and
the patient’s clinical condition influence the choice of treatment. In women of
reproductive age, ovarian salvage should be the first management line. However,
necrotic ovaries beyond damage are often removed.9 A salpingo-oophorectomy
is also indicated in post-menopausal women and visualisation of malignant
cysts. Laparoscopy is the first line of treatment, but open laparotomy is
indicated in settings without resources for laparoscopy.15 The
ovaries are visualised for viability before the decision of salvage or removal
is made. Over 90% of ovaries were seen to be viable following ovarian
detorsion.16 For our patient, we did an exploratory laparotomy with
right ovariectomy on account of the ruptured huge ovarian cyst.
The primary
complication of ovarian torsion is the failure to salvage the ovary, which
often necessitates a salpingo-oophorectomy and affects fertility. Other
complications with bleeding and rupture include infection, usually following
necrosis, peritonitis, sepsis, adhesions, ovarian atrophy, and chronic pain.17
Follow-up care is critical following ovarian detorsion to monitor for potential
sequelae and ensure good recovery. Regular follow-up appointments also ensure
early detection of issues related to fertility, particularly if one or both
ovaries were affected or a salpingo-oophorectomy was done. Counselling is
necessary, especially with loss of ovarian function. Overall, ongoing follow-up
care supports the patient's recovery and addresses long-term concerns.
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