> Table of Contents > Ovarian Cyst, Ruptured
Ovarian Cyst, Ruptured
Heather O'Connor Greer, MD
Patricia Beauzile, MD
image BASICS
  • Ovarian cysts are frequent in reproductive-aged women.
  • Most ovarian cysts are benign physiologic follicles created by the ovary at the time of ovulation.
  • Ovarian cysts can cause symptoms when they become enlarged and exert a mass effect on surrounding structures, or when they rupture and the cyst contents cause irritation of the peritoneum or nearby pelvic organs.
  • Patients with a symptomatic ruptured cyst will usually complain of acute onset unilateral lower abdominal pain.
  • Evaluation of the patient should include exclusion of ectopic pregnancy, ovarian torsion, and nongynecologic sources of acute unilateral lower abdominal pain.
  • Once the diagnosis of a ruptured cyst is confirmed, most patients can be managed conservatively as outpatients with adequate pain control. Surgical intervention is rarely indicated.
DESCRIPTION
A suspected ruptured ovarian cyst should be treated as an unknown adnexal mass (mass of the ovary, fallopian tube, and surrounding tissue) until proven otherwise.
EPIDEMIOLOGY
  • The actual incidence of ovarian cysts is difficult to calculate as many ruptured cysts are asymptomatic or found incidentally.
  • Ovarian cysts can be seen on transvaginal ultrasounds in nearly all premenopausal women and in up to 18% of postmenopausal women. The vast majority of these cysts are benign or functional.
  • Most ruptured ovarian cysts are self-limiting, and expectant management with pain control is usually sufficient.
  • About 13% of ovarian masses in reproductiveaged women are malignant, as opposed to 45% in postmenopausal women.
RISK FACTORS
As benign physiologic cysts are a result of ovulation; medications or conditions associated with increased ovulation increase risk of cyst rupture. Examples include:
  • Ovulation induction agents (i.e., Clomid, aromatase inhibitors, GnRH agonists)
  • Tamoxifen increases the risk of ovarian cysts in reproductive-aged women.
  • Rare risk factors for increased ovarian cyst formation include fibrous dysplasia/McCune-Albright syndrome.
GENERAL PREVENTION
Ovulation suppression with combined oral contraceptives is the mainstay therapy for prevention of recurrent ovarian cysts.
image DIAGNOSIS
  • When a ruptured ovarian cyst is suspected, a pregnancy test should be performed to rule out an ectopic pregnancy.
  • Ultrasound imaging is standard for determining whether or not a patient with a ruptured cyst can be managed conservatively, or immediate intervention is indicated. Hemoperitoneum or hemodynamic instability is an indication for emergent intervention (1)[B].
  • Sonographic imaging can also determine the characteristics of the cysts and can aid in separating malignant versus benign etiologies.
  • Additionally, ultrasound is useful in confirming normal Doppler flow to affected ovary.
PHYSICAL EXAM
  • Vital signs are usually normal unless significant blood loss has occurred.
  • Rupture characterized by significant blood loss may be present in the form of pallor, pale mucosal membranes, and tachycardia.
  • Patient will have significant tenderness to palpation or an acute abdomen if the peritoneum is irritated or inflamed.
  • On some occasions, a palpable adnexal mass can be felt on bimanual exam. Care should be taken not to cause further injury with a forceful exam.
DIFFERENTIAL DIAGNOSIS
Should include all causes of acute abdominal pain, both gynecologic and nongynecologic
DIAGNOSTIC TESTS & INTERPRETATION
  • Urinalysis, STD testing, and a complete blood count should be obtained to evaluate for infectious causes, PID, or symptomatic renal stones. There are no laboratory tests that can definitively diagnose ovarian cyst rupture (2)[C].
  • A type and screen is indicated if surgical intervention is planned or blood products are being considered.
  • Transvaginal ultrasound is helpful in determining the presence of an ovarian mass, its characteristics, and the presence of intraperitoneal fluid (1)[A].
  • CT, MRI, or PET imaging are not indicated for initial evaluation; however, these modalities are useful if malignancy is suspected (1)[A].
image TREATMENT
GENERAL MEASURES
  • Cyst rupture in a stable healthy patient can be managed conservatively with analgesia, bleeding and symptoms precautions, and outpatient follow-up (1)[A].
  • P.749

  • For many patients, pain associated with a ruptured cyst will be transient and self-limiting.
  • Scheduled NSAIDs or oral narcotics can be prescribed depending on pain severity.
  • Unstable patients with hemodynamic compromise or patients with significant intraperitoneal fluid should be resuscitated, and laparoscopy or a laparotomy should be considered. Surgical exploration should also be considered if there is a concern for malignancy.
ISSUES FOR REFERRAL
  • OB-GYN
    • Consider referral to an obstetrician if an adnexal mass is diagnosed during pregnancy. Such masses have a low risk of malignancy or acute complication for the pregnancy.
  • GYNECOLOGIC ONCOLOGY
    • Referral to a gynecologic oncologist should be considered for complex adnexal masses with an elevated CA125 and associated symptoms concerning for malignancy such as ascites, early satiety, pleural effusion, enlarging abdominal mass, or bowel obstruction.
  • GENERAL SURGERY
    • Acute lower abdominal pain that is nongynecologic and suspicious for bowel involvement should be referred to general surgery or a gastroenterologist.
SURGERY/OTHER PROCEDURES
  • Although the need for surgical intervention is rare, it is usually of an emergent nature.
  • In most cases, laparoscopy will be sufficient to evaluate intra-abdominal bleeding. The decision to proceed with cystectomy or oophorectomy should be made intraoperatively after a thorough evaluation of the intra-abdominal environment has been completed.
  • The advantages of a laparoscopic approach include a shorter length of stay, and most patients can be discharged home the same day. Postoperative recovery time as well as patient satisfaction is significantly improved with a minimally invasive approach.
  • Laparotomy should be performed in cases of critical hemodynamic instability or lack of laparoscopically trained surgeons. If there is concern for malignancy or metastases, laparotomy may be the preferred method of surgery.
INPATIENT CONSIDERATIONS
Patients who require inpatient management should be managed with serial abdominal exams, analgesia, and intravenous resuscitation as indicated by their initial presentation.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Follow up for patients managed conservatively should be scheduled 1 to 2 weeks from the initial onset of symptoms. Patients should present sooner for new or worsening symptoms.
  • Patients with complete resolution of symptoms within a few days can follow-up as needed. However, these patients should be counseled on ovarian cysts and options for prevention.
  • Patient in whom surgical intervention was indicated, postop follow-up should be scheduled 2 weeks from the date of surgery.
  • Patients in whom an ovarian cyst was diagnosed incidentally should follow-up based on the size of their cyst.
  • Simple cysts up to 10 cm in diameter on ultrasound findings are almost always benign and may safely be followed without intervention in pre- and postmenopausal patients. These patients should also be referred to a gynecologist (3)[B].
Pregnancy Considerations
Adnexal masses in pregnancy have a low risk of malignancy or acute complications to the pregnancy, so in most cases, they can be managed expectantly (1)[C].
PATIENT EDUCATION
Reassurance of the benign nature of most ovarian cysts is an important cornerstone of patient education.
REFERENCES
1. Prakash A, Li T, Ledger WL. The management of ovarian cysts in premenopausal women. The Obstetrician and Gynecologist. 2004;6:12-15.
2. McDonald JM, Modesitt SC. The incidental postmenopausal adnexal mass. Clin Obstet Gynecol. 2006;49(3):506-516.
3. Pavlik EJ, Ueland FR, Miller RW, et al. Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography. Obstet Gynecol. 2013;122(2 Pt 1):210-217.
Additional Reading
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  • American College of Obstetricians and Gynecologists. ACOG practice bulletin. Management of adnexal masses. Obstet Gynecol. 2007;110(1): 201-214.
  • Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009;23(5):711-724.
  • Collins MT, Singer FR, Eugster E. McCune-Albright syndrome and the extraskeletal manifestations of fibrous dysplasia. Orphanet J Rare Dis. 2012;7 (Suppl 1):S4.
  • Hoo WL, Yazbek J, Holland T, et al. Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome? Ultrasound Obstet Gynecol. 2010;36(2):235-240.
  • Kaunitz AM. Oral contraceptive health benefits: perception versus reality. Contraception. 1999;59 (1 Suppl):29S-33S.
  • Mimoun C, Fritel X, Fauconnier A, et al. Epidemiology of presumed benign ovarian tumors. J Gynecol Obstet Biol Reprod (Paris). 2013;42(8):722-729.
  • Møller LM. Complications of gynaecological operations. A one-year analysis of a hospital database. Ugeskr Laeger. 2005;167(49):4654-4659.
  • Raziel A, Ron-El R, Pansky M, et al. Current management of ruptured corpus luteum. Eur J Obstet Gynecol Reprod Biol. 1993;50(1):77-81.
  • Roch O, Chavan N, Aquilina J, et al. Radiological appearances of gynaecologic emergencies. Insights Imaging. 2012;3(3):265-275.
  • Saunders BA, Podzielinski I, Ware RA, et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol. 2010;118(3):278-282.
  • Stany MP, Hamilton CA. Benign disorders of the ovary. Obstet Gynecol Clin North Am. 2008;35(2): 271-284.
  • Suzuki S, Yasumoto M, Matsumoto R, et al. MR findings of ruptured endometrial cyst: comparison with tubo-ovarian abscess. Eur J Radiol. 2012;81(11):3631-3637.
Codes
&NA;
ICD10
  • N83.20 Unspecified ovarian cysts
  • N83.0 Follicular cyst of ovary
  • N83.1 Corpus luteum cyst
Clinical Pearls
&NA;
  • Functional ovarian cysts are very common in reproductive-age women and are usually self-limiting.
  • Always exclude ectopic pregnancy.
  • Management of symptomatic ruptured cysts is usually accomplished with outpatient pain control with follow-up.
  • In cases where the patient with a ruptured cyst is unstable or presents with signs of an acute abdomen, surgical intervention is indicated.