Medical question #2. Ovarian cysts. Part1 by Aleksandr Kavokin MD, PhD

Medical question #2. Ovarian cysts

Ms. L wrote me:

Hello Dr. Kavokin,

I was reading some of your literature and found it to be quite informative. I have a question that perhaps you may be able to answer: If a woman's ovarian cyst ruptures, (especially multiple cysts from PCOS) can these ruptured cysts become an infection?

...

Hi, MS. L

Short answer: anything can become infected. Though I do no think ruptured ovarian cyst becomes infected very often, did not hear about that. I will look more literature and probably place the answer on my website.

Sincerely,

Alex

…

OK. I looked the literature.

I didn't do very extensive literature search. Should admit.

Anyway, some available books mention that ovarian cyst may become infected. However the infection is not described as the main complication in ovarian cyst rupture.

Also, I don't remember that anybody told me otherwise. Maybe there is some specialized article that says: the condition happens in one point three percent of cases with Standard Deviation of half percent. I don't know exact percentage. Need to look more. PubMed service did not give many abstracts on PCOS + infection.

Anyway.

So how would it look alike?

A young woman comes to ER. She is premenopausal. She complains on mild (or maybe severe) pain in her belly. ER Doctor takes history. The woman also mentions changes in her menstrual interval. Let's say regular is 28 days. Last one was delayed.

Physician puts gloves, puts jelly on gloves. Then he puts his two fingers into the female vagina.

The other hand is on belly. Then he starts to palpate.

It is named pelvic exam. Modest name. Though in Russia it is named vaginal exam, which it is.

Is it a common type of exam? Depends. They usually send you to CT (computer tomography) scan if there is severe abdominal pain. Charge 1000. Boom.

Done.

Exclude the price. Exclude delay in reading (somebody should look and interpret what is going on). Exclude radiation. CT scan gives better picture than just poking your belly.

CT scan helps to diagnose abdominal pain of uncertain origin. You can really image what is going on. Though, there are cases when physical exam gives more clues. Physical exam must be performed always. Pelvic exam is somewhat a special one.

I remember how I performed a pelvic exam in medical school. It is actually difficult even just to insert two fingers into vagina first time.

Female Gynecologist asks me: "So, what do you feel?"

Patient goes the same, encourages me:

"What do you feel, what do you feel, do you feel it?"

I guess she felt a sort of museum artifact.

Heck, I did not feel anything.

Well. Actually I felt something - aside from uterus - something round. I would say 5 cm in diameter (would it be less I probably would not feel it at all) and semi-solid on touch. Also I saw that the patient grimaces. It is tender when I push hard.

It's it. How to say that it was tuboovarian abscess (that it was) for sure, I don’t know.

You really need experience to perform this type of exam. Experienced gynecologist can tell almost precisely what is going on.

Let's discuss that woman in ER. She will have tenderness on one side. Physician should be able to feel a mobile cystic mass.

(Cyst or rather cystis is Latin for bubble. Palpate is Latin for touch. It means you touch something and feel what it is).

What if the pain is severe? It often means that the cyst ruptured.

My impression is that modern ER orders CT scan right away. If you are not very sure what is going on, you will go from less expensive methods to more expensive and end up with CT anyway. Ruptured cyst causes significant pain. Here CT is indicated.

Alternatively they may order Ultrasound Exam. Transvaginal ultrasound uses the probe inserted into vagina. Ultrasound is cheaper than CT. Ultrasound visualizes cysts clearly. Though, ultrasound gives less information for excluding other pathology. Ultrasound is also safe from the radiation point of view.

In PCOS ultrasound shows increased number of small cysts in both ovaries. Usually more than five confirms the diagnosis.

Culdocentesis may give some useful information too. The name came from cul-de-sac. It's French I guess. Cul-de-sac is one of the pouches in the pelvis. Centesis means: stick a needle and draw. These days it is considered an outdated method. But if you do not have other machines, it is very useful.

If the content is blood, the ruptured cyst was probably Corpus luteum cyst. If the content is purulent the ruptured thing was probably a tubo-ovarian abscess or other pelvic inflammatory disease (PID).

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BIO:

Aleksandr Kavokin MD/PhD,

http://www.kavokin.com

http://www.kavokin.uni.cc
Aleksandr Kavokin, MD1994 Russia,PhD1997 Russia - Immunology and Allergy, postdoc at Cancer Center at Med U of South Carolina, postdoc at Yale - Cardiology, Molecular Medicine. http://www.geocities.com/aging_rejuvenation/ http://www.appendicitis.uni.cc/ http://www.geocities.com/appendicitis_disease/

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