Ruptured ovarian cysts are one of the most common causes of acute pelvic pain in premenopausal women. The sonographic appearance depends on whether a simple or hemorrhagic ovarian cyst ruptures, and whether the cyst has completely collapsed. The most important differential consideration is a ruptured ectopic pregnancy.
Cysts may rupture during pregnancy (if a very early pregnancy, this may cause diagnostic confusion with ectopic pregnancy).
Rebound tenderness from the pain is possible and the hemorrhage from a cyst can rarely be severe enough to cause shock 2.
Although rupture of an ovarian follicle is a physiologic event (mittelschmerz, ‘middle pain’), rupture of an ovarian cyst (>3 cm) may cause more dramatic clinical symptoms.
The pain from a ruptured ovarian cyst may come from stretching the capsule of the ovary, torquing of the ovarian pedicle, or leakage of cyst contents (serous fluid/blood) which can cause peritoneal irritation 2.
Ruptured ovarian cysts can have a variety of appearances depending on when the rupture took place, and whether the cyst is hemorrhagic or not. If a candidate is found, it should fulfill the criteria for a cyst:
- thin wall
- if hemorrhagic, clot may adhere to cyst wall mimicking a nodule, but has no blood flow on Doppler imaging
- posterior acoustic enhancement
- may be less noticeable if harmonics or compounding is used
- there should not be any internal blood flow
- circumferential blood flow in the cyst wall is possible
Treatment and prognosis
Treated conservatively in a premenopausal woman unless evidence of haemorrhagic shock (tachycardia and postural drop in blood pressure).
A ruptured haemorrhagic cyst in a perimenopausal woman should be viewed more suspiciously and followed up appropriately. A haemorrhagic cyst or ruptured cyst in a postmenopausal woman deserves surgical evaluation.
Differential considerations on ultrasound include:
- ectopic pregnancy: differentiate with a positive beta-hCG level
- hemoperitoneum or echogenic intraperitoneal free fluid from another aetiology
- ruptured cystic ovarian tumour, with possible pseudomyxoma peritonei
- ruptured ovarian dermoid
Ultrasound - gynaecology
- ultrasound (introduction)
- acute pelvic pain
- chronic pelvic pain
- Mullerian duct anomalies
- ovarian follicle
- ovarian torsion
- pelvic inflammatory disease
- ovarian cysts and masses
- ovarian cyst
- corpus luteum
- haemorrhagic ovarian cyst
- ruptured ovarian cyst
- ovarian epithelial tumours
- granulosa cell tumours of the ovary
- paraovarian cyst
- polycystic ovaries
- ovarian hyperstimulation syndrome
- post-hysterectomy ovary
- fallopian tube
- 1. Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound evaluation of gynecologic causes of pelvic pain. Obstet. Gynecol. Clin. North Am. 2011;38 (1): 85-114, viii. doi:10.1016/j.ogc.2011.02.005 - Pubmed citation
- 2. Amirbekian S, Hooley RJ. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235. doi:10.1016/j.rcl.2014.07.008 - Pubmed citation
- 3. Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009;23 (5): 711-24. doi:10.1016/j.bpobgyn.2009.02.001 - Pubmed citation