Ruptured Ovarian Cyst – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Ovarian cysts are very common in reproductive-age women.Occasionally, once a cyst reaches a certain size or following an episode of strenuous activity or sexual intercourse, a cyst may rupture.A ruptured ovarian cyst may be asymptomatic or may cause extreme pain due to the presence of irritating fluid or blood in the abdominal cavity.A ruptured ovarian cyst may require surgical intervention.

Description

Types of ovarian cysts that may rupture fall into two groups: physiologic and pathologic (1)[C].

Physiologic or functional cysts form as a result of normal hormonal stimulation of the ovary. Most are asymptomatic and spontaneously resolve in 60–90 days. Follicular cysts form when a growing follicle fails to rupture and release an egg. Most common type of functional cystUnilateral and filled with serous fluidCorpus luteum cysts occur when an egg is released and pregnancy does not occur. The residual structure does not regress and may hemorrhage internally (hemorrhagic cysts).Theca-lutein cysts result from excessive stimulation of beta-human chorionic gonadotropin such as in infertility patients, molar pregnancies, or choriocarcinoma.Pathologic cysts are caused by a process other than normal hormonal stimulation. When followed, these cysts remain stable in size or may grow. Endometriomas are cysts or collections of blood clot that form as a result of cycling endometrial tissue on the ovary. Also called “chocolate cysts” due to their appearance.Mature cystic teratoma (dermoid) develop from totipotent germ cells. Most commonly, they contain mucinous material and hair.Up to 14% are bilateral and can grow very large.Less than 1% rupture spontaneously but may lead to shock, hemorrage, and acute peritonitis.Cystadenomas may have solid or mucinous areas and are usually benign but may have borderline malignant areas. They rarely rupture.Other cystic-appearing adnexal structures include paratubal cysts, tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy.

Diagnosis

A ruptured ovarian cyst may be asymptomatic or present as abdominal pain, varying from dull to acute.The broad range of presentations can prove to be a diagnostic dilemma for many physicians.

History

A general past medical and surgical history should be reviewed.Risk factors for gynecologic pain should be elicited: Possibility of pregnancyMenstrual history with attention to symptoms suggestive of endometriosis or history of cystsSexually transmitted disease historyLevonorgestrel-containing intrauterine device (up to 12% of users experience ovarian cysts) (2)[B]Infertility treatmentOther causes of acute abdominal pain should also be considered, including gastrointestinal and urologic etiologies.

Alert

Patients with bleeding diathesis or undergoing anticoagulation therapy may experience significant bleeding from hemorrhagic cysts.

Physical Exam

An uncomplicated ruptured ovarian cyst usually produces dull pain on palpation during the abdominal and pelvic exams. Enlargement of one of the adnexa may be present.A complicated ovarian cyst rupture may have more of an “acute abdomen” presentation due to the presence of blood or fluid in the abdominal cavity.

Diagnostic Tests & Interpretation

Lab

Serum quantitative beta-human chorionic gonadotropin (b-hcg) to rule out pregnancyComplete blood count (CBC) to evaluate for infection and monitor hemodynamic statusCervical cultures if pelvic inflammatory disease is suspectedUrinalysis to evaluate possibility of infection or stonesBlood type and cross matching if the patient is hemodynamically unstable and surgery is planned

Imaging

Transvaginal ultrasound: Most widely used and the gold standard of gynecologic imaging modality due to its cost-effectiveness and availability, and it is well-tolerated (1)[C],(3)[B] The presence of intraperitoneal fluid or blood in the absence of other gynecologic pathology is suggestive of a ruptured cyst.The ovaries may contain cysts, be slightly edematous, contain areas of hemorrhage, or appear normal.An ovarian cyst may be the causative factor in an episode of ovarian torsion. A torsed ovary is diagnosed by no blood flow to the ovary on ultrasound exam.

Alert

A torsed ovary requires immediate surgical intervention.

Follow-Up & Special Considerations

CT scan may be used if the ultrasound is unclear or the diagnosis is uncertain.

Diagnostic Procedures/Surgery

Traditionally, culdocentesis, or aspirating a small amount of peritoneal fluid transvaginally, has been used to diagnose the presence of fluid or hemoperitoneum from a ruptured cyst.Culdocentesis can also be used therapeutically as the removal of irritative blood or fluid from the abdominal cavity may relieve pain.

Differential Diagnosis

Should include all causes of acute abdominal pain, both gynecologic and nongynecologic, such as:

Ectopic pregnancyOvarian torsionPelvic inflammatory diseaseOvarian hyperstimulation syndrome (OHSS)AppendicitisDiverticulitisNephrolitiasisBowel perforation

Treatment

Medication

Pain due to an uncomplicated cyst rupture is usually self-limiting and can be managed on an outpatient basis with pain medication and rest (4)[B].

First Line

NSAID medications are the most effective at relieving pain due to peritoneal irritation.

Second Line

Narcotic pain medications may also be necessary acutely.

Additional Treatment

For patiets with painful, recurrent ovarian cysts, oral contraceptive pills can be prescribed to suppress ovulation. This may help prevent the formation of new cysts but will not impact cysts that have already formed (5)[A].

Issues for Referral

Referral to a gynecologic oncologist should be made in any postmenopausal female with an adnexal mass that has concerning ultrasound findings, an elevated CA-125, ascites, a nodular, fixed pelvic mass and a family history of breast or ovarian cancer. (1)[C],(3)[B]

Surgery/Other Procedures

If pain from a ruptured cyst is severe and persistent, the patient is unstable, or the diagnosis is uncertain, surgical evaluation is recommended (4)[B].

Laparoscopy is the better choice over laparotomy because it is less-invasive, better tolerated by patients, and can usually be done on an outpatient basis. (1)[C],(3)[B]Surgery includes suction-evacuation of any fluid or blood found in the pelvis as well as achieving hemostasis, if needed, at the site of the cyst. If a cyst wall is present, it should be removed.In the vast majority of cases, oophorectomy is not necessary.Laprascopic excision of the cyst and capsule of endometriomas substantially decreases risk of recurrence (6)[A].

Ongoing Care

Follow-Up Recommendations

Most functional cysts resolve spontaneously without treatment and “watchful waiting” with serial transvaginal ultrasounds for 2–3 cycles is appropriate.If cysts fail to resolve or develop concerning ultrasound findings (increasing size or complexity, nodules, septations, excrescences), they may be pathologic and surgical evaluation is recommended (5)[A].Concern for malignancy: The vast majority of ruptured ovarian cysts are a result of functional cysts in reproductive-age women and the risk of malignancy is very low. See “Issues for Referral” section.

Pregnancy Considerations

Ovarian cysts in pregnancy: With the widespread use of ultrasonography during pregnancy, up to 4% of pregnant women are found to have adnexal masses, most of which are follicular cysts which spontaneously resolve by 16 weeks’ gestation.Less than 2% will spontaneously rupture or torse during pregnancy; however, this can lead to preterm labor and delivery, which may cause poor obstetric outcomes.If they are painful, are large (>8 cm), or have ultrasound characteristics that are concerning for malignancy, elective surgical evaluation can be done during the 2nd trimester. (1)[C],(3)[B]

Patient Education

www.acog.org

References

1. Stany MP, Hamilton CA et al. Benign disorders of the ovary. Obstet. Gynecol. Clin. North Am. 2008;35:271–84, ix

2. Mirena [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2009.

3. Management of Adnexal Masses ACOG Practice Bulletin No. 83. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:201–14.

4. Bottomley C, Bourne T et al. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009;23:711–24.

5. Grimes DA, Jones LB, et al. Oral contraceptives for functional ovarian cysts. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006134. DOI: 10.1002/14651858.CD006134.pub3

6. Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004992. DOI: 10.1002/14651858.CD004992.pub3

Additional Reading

Raziel A, Ron-El R, et al. Current management of ruptured corpus luteum. Eur J Obstet Gynecol Reprod Biol 1993 Jun; 50:77–81.

Møller LM et al. [Complications of gynaecological operations. A one-year analysis of a hospital database] Ugeskr. Laeg. 2005;167:4654–9.

Saunders BA, Podzielinski I, Ware RA, Goodrich S, DeSimone CP, Ueland FR, Seamon L, Ubellacker J, Pavlik EJ, Kryscio RJ, van Nagell JR et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol. Oncol. 2010;118:278–82.

Huchon C, Staraci S, Fauconnier A et al. Adnexal torsion: a predictive score for pre-operative diagnosis. Hum. Reprod. 2010;25:2276–80.

Hoo WL, Yazbek J, Holland T, Mavrelos D, Tong EN, Jurkovic D et al. Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome?Ultrasound Obstet Gynecol. 2010;36:235–40.

Falcone T. Risk of complications from gynecological surgery is lower with laparoscopy than with laparotomy. Evidence Based Obstetrics and Gynecology 2004;4:185–6.

Codes

ICD9

620.2 Other and unspecified ovarian cyst

Snomed

95598005 ruptured cyst of ovary (disorder)

Clinical Pearls

Functional ovarian cysts are very common in reproductive-age women and usually resolve spontaneously in 60–90 days.If a cyst does rupture, the pain is usually self-limited and can be treated with oral pain medications on an outpatient basis.Surgery may be necessary if pain is extreme or if the patient is unstable. This usually involves laprascopically evacuating irritating fluid and blood from the abdominal cavity, achieving hemostasis, and removing the cyst wall if possible.