Diagnostic Considerations
During an ED workup, it is imperative that life-threatening or causes of abdominal and/or pelvic pain associated with high morbidity be excluded before ovarian cyst is diagnosed. This includes ruling out emergent female gynecologic and urologic symptoms such as ectopic pregnancy, ovarian torsion, tubo-ovarian abscess, or other conditions such as appendicitis or diverticulitis.
After etiologies of acute abdominal pain are ruled out, the physician's primary concern is to determine whether the pain or pelvic mass reflects a possible neoplastic etiology, which must be assessed further by a gynecologist in the ED or in an outpatient setting in an appropriate time frame.
Conditions to consider in the differential diagnosis of ovarian cyst include the following:
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Hydronephrosis
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Hydrosalpinx
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Paraovarian cyst
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Pedunculated leiomyoma
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Pelvic kidney
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Pelvic lymphocele
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Peritoneal cyst
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Psoas abscess
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Tubo-ovarian abscess
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Tubal disease
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Abdominal abscess
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Ectopic pregnancy
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Ovarian torsion
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Polycystic ovarian syndrome
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Renal calculi
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Salpingitis
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Urethral diverticulum
Differential Diagnoses
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Abortion, Threatened
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Appendicitis, Acute
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Diverticular Disease
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Meckel Diverticulum
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Obstruction, Large Bowel
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Obstruction, Small Bowel
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Pelvic Inflammatory Disease
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A multilocular right ovarian cyst that is 24 cm in diameter. It is seen with the adjacent fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Image courtesy of C. William Helm, MBBChir.
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Transabdominal sonogram of a multilocular right ovarian cyst that is 24 cm in diameter, with the adjacent fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided. This sonogram demonstrates a large, complex cystic mass with vascularity within the septations. Red and blue colors show blood flow towards and away from the transducer. The resistive index was low. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Courtesy Patrick O'Kane, MD.
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A multilocular right ovarian cyst that is 24 cm in diameter has been removed and cut open. It has a smooth surface and a multicystic internal structure. Image courtesy of C. William Helm, MBBChir.
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An ovarian cyst that underwent torsion (twisting of the vascular pedicle). The patient presented with a short history of severe lower abdominal pain. The twisted pedicle can be seen attached to the cyst, which has turned dusky due to ischemia. No viable epithelial lining was available for histologic diagnosis. Image courtesy of C. William Helm, MBBChir.
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Endovaginal sonogram shows a striking echogenic mass lateral to the uterus, with posterior acoustic shadowing giving a "tip-of-the-iceberg" appearance. This is pathognomonic for a dermoid cyst. Occasionally, this appearance may be mistaken for a gas-filled bowel. Courtesy of Patrick O'Kane, MD.
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A dermoid cyst (mature cystic teratoma) after opening the abdomen. Note the yellowish color of the contents seen through the wall. Image courtesy of C. William Helm, MBBChir.
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A dermoid cyst has been opened in the operating room to reveal copious sebaceous fluid. This cyst also contained hair. Image courtesy of C. William Helm, MBBChir.
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A dermoid cyst has been opened and contains teeth. Image courtesy of C. William Helm, MBBChir.
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Theca-lutein cysts replacing an ovary in a patient with a molar pregnancy. Despite their size these cysts are benign and usually resolve after treatment of the underlying disease. Image courtesy of C. William Helm, MBBChir.
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Cross-section of a clear cell carcinoma of the ovary. Note the cystic spaces intermingled with solid areas. Image courtesy of C. William Helm, MBBChir.
