A 29-year-old woman comes to the emergency department due to pelvic pain that started immediately after sexual intercourse 3 hours earlier. The pain is sharp and stabbing in nature and has intensified significantly. She has no fever but is slightly nauseous. The patient has no chronic medical conditions and has had no surgeries. Her last menstrual period was 3 weeks ago. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, and pulse is 98/min. The abdomen is soft and tender to palpation in the right lower quadrant. Laboratory results are as follows: Urine pregnancy test is negative. Pelvic ultrasound shows an enlarged uterus with multiple fibroids and a 4×5 cm right cystic ovarian mass with a moderate amount of free fluid in the pelvis. Doppler shows normal blood flow to the adnexa. Which of the following is the most likely cause of this patient's acute symptoms?

Question

A 29-year-old woman comes to the emergency department due to pelvic pain that started immediately after sexual intercourse 3 hours earlier.  The pain is sharp and stabbing in nature and has intensified significantly.  She has no fever but is slightly nauseous.  The patient has no chronic medical conditions and has had no surgeries.  Her last menstrual period was 3 weeks ago.  Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, and pulse is 98/min.  The abdomen is soft and tender to palpation in the right lower quadrant.  Laboratory results are as follows:  Urine pregnancy test is negative.  Pelvic ultrasound shows an enlarged uterus with multiple fibroids and a 4×5 cm right cystic ovarian mass with a moderate amount of free fluid in the pelvis.  Doppler shows normal blood flow to the adnexa.  Which of the following is the most likely cause of this patient's acute symptoms?

Quizplus · Accepted Answer

11ec25c8_d19b_5ebf_bc81_0702d0bccb7a_MD0003_00 This patient with an acute onset of pelvic pain and a cystic ovarian mass with a moderate amount of free fluid in the pelvis likely has a ruptured ovarian cyst. Ovarian cysts are common in reproductive-aged women due to physiologic cyst formation from ovulation and, therefore, typically occur 2-3 weeks after the last menstrual period (as in this patient). Physiologic ovarian cysts are usually small (eg, <3 cm) and asymptomatic, but they can become larger and rupture with vigorous activity (eg, intercourse). Patients typically have acute-onset, unilateral pain due to cyst rupture and spilling of fluid into the peritoneal cavity; some patients may also have associated bleeding, causing additional peritoneal irritation. Diagnosis is confirmed by ultrasound, which typically reveals an ovarian cyst with free fluid in the pelvis. Management of a ruptured ovarian cyst is based on hemodynamic stability. Hemodynamically stable patients with no signs of infection (eg, fever) are managed with observation and reassurance. In contrast, those who are hemodynamically unstable may have continued bleeding from the ruptured cyst and require surgery. (Choice A) Adnexal torsion also presents with sudden onset of unilateral lower abdominal pain. Although an ovarian mass is often present, pelvic ultrasound with Doppler velocimetry shows enlarged, edematous ovaries with decreased or absent blood flow. (Choice B) A degenerating leiomyoma causes chronic pain when a large fibroid outgrows its blood supply, resulting in necrosis. The release of prostaglandins from the necrotic fibroid can cause fever and abdominal pain. This patient's ovarian cyst and acute pain following strenuous activity make this a less likely cause of her symptoms. (Choice C) Endometriosis typically causes chronic (not acute) pelvic pain. Pelvic ultrasound shows an adnexal mass (eg, ovarian endometrioma), but free fluid is typically not present. (Choice E) Salpingitis, an infection of the Fallopian tubes, is associated with pelvic inflammatory disease. Patients can present with unilateral pelvic pain but usually have an associated fever. Imaging may show a dilated tubular structure (ie, pyosalpinx). Educational objective: A ruptured ovarian cyst presents with acute onset of unilateral pelvic pain, often precipitated by strenuous activity or sexual intercourse. Pelvic ultrasound can confirm the diagnosis by showing free fluid in the pelvis from leaking cyst contents. References: Diagnosis and management of ovarian cyst accidents. (http://www.ncbi.nlm.nih.gov/pubmed/19299205)

A 29-Year-Old Woman Comes to the Emergency Department Due to Pelvic