Introduction

Endometriosis of ovary is a well known and documented entity in gynaecological practice. But rarity does appear when atypical manifestation of endometriosis presents in clinical practice. Endometriosis affects 4 out of every 1000 women of 15 – 64 yrs. being hospitalized annually with intermenstrual bleeding, dysmenorrhoea, pelvic pain or infertility.¹

Rarely, they present as cystic masses. Current literature describes three different mechanisms by which endometriotic cysts originate. Cortical invagination cyst arises when surface ovarian endometriotic deposits adhere to another structure (such as broad ligament, uterus, etc.) blocking the egress of menstrual fluid produced cyclically which then collects and causes the ovarian cortex to be invaginated. Surface inclusion cysts in relation to endometriotic cysts develop when endometriotic tissue colonizes pre-existing inclusion cysts. Physiological cyst related to endometriotic cysts occur when endometriosis gains access to a follicle at the time of ovulation.²

Case Report

A 30 yr old unmarried female presented to casualty with complaints of abdominal pain for past 3 days. Pain was sudden in onset and spread all over the abdomen, more so in the lower abdomen. It was associated with high grade fever with chills. She gave h/o burning micturition and obstipation since 2 days. There were 3 episodes of vomiting since morning.

• She had irregular cycles at intervals of 15-25 days which lasted for 3-4 days and were associated with dysmenorrhoea. She had her last menstrual period 7 days back. No h/o sexual contact. Her urine pregnancy test was negative.
  
• Past medical and surgical history were insignificant.
  
• On examination, Pulse : 110/min, BP : 120/70 mmHg, respiratory rate : 24/min and temperature : 38.2°C. On abdominal examination – slight guarding of lower abdomen with vague tenderness in bilateral iliac fossae. Auscultation revealed very sluggish intestinal peristaltic sounds. Local examination showed hymen to be intact. Per rectal examination revealed bilateral adenexal masses.
  
• Routine investigations including complete haemogram, blood sugar, renal function test, liver function test and electrolytes were within normal limits. CA -125 levels were within normal limits

With clinical diagnosis of acute abdomen, an ultrasound examination was sought which revealed bulky uterus with small anterior wall fibroid (Fig. 1). Both ovaries were well visualized and enlarged in size with complex cystic areas in both ovaries forming ovarian masses, with significant free fluid in the abdomen.

Fig. 1 : USG showing bulky uterus with small ant. wall fibroid.

Patient was taken up for diagnostic laparoscopy, that revealed bilateral tubo-ovarian abscesses and sigmoid adhesions on left side. Decision to proceed with an exploratory laparotomy was taken. Bilateral abscesses formed in endometriomas were drained and cyst wall excised.

The histopathological examination revealed strips of ovarian tissue covered on external aspect by fibrinous necrotic material containing neutrophils. The ovarian parenchyma showed a cyst cavity lined by columnar endometrial type lining cells with underlying endometrial stroma and partly by clusters of siderophages.

Post-operatively patient was put on monthly dose of Inj. Leuprolide acetate with remarkable improvements in pain symptoms.

Discussion

ruptured tubo-ovarian abscess remains controversial and generally is decided on the basis of the patient’s age, parity and clinical circumstances.

Although in the past, tubo-ovarian abscess occurred primarily in an older age group; over the past several decades, a progressively younger patient group has been encountered. The young patient with a tubo-ovarian abscess who desires to maintain reproductive function presents a significant dilemma to the gynaecologist today.

In a retrospective study of laparoscopic treatment of ovarian endometriomas conducted by Saleh, et al at McGill University, out of 231 patients having endometrioma only 4 presented with acute pelvic pain but none was secondarily infected (Table 1).³

In a retrospective study of ovarian histology in pelvic inflammatory disease by Stuart Weiner et al, out of 40 patients, only 4 showed evidence of endometriosis, but none of them presented as an acute abdomen.⁴

References

1. Sangi-Haghpeyker H, Poindexter AN III. Epidemiology of endometriosis among parous women. Obstet Gynaecol 1995; 85 : 983-92.
   
2. Scurry J, Whitehead J, Healy M. Classification of ovarian endometriotic cysts. Int J Gynaecol Pathol 2001; 20 : 147-54.
   
3. Ahmed Saleh, Togas Tulandi. Reoperation after laparoscopic treatment of ovarian endometriomas by excision and fenestration. Fertil Steril, vol. 72, no. 2, 32-324.
   
4. Stuart Weiner, E. Wallach, et al. Ovarian histology in pelvic inflammatory disease. Obstet Gynaecol vol. 43, no. 3, 431-38.