Presentation
Patient presents for investigation of chronic pelvic pain. Known prior history of hysterectomy.
Patient Data
The uterus is known to be absent.
The right ovary contains a 14mm avascular unilocular cyst with ground glass echogenicity. This is likely to represent an endometrioma.
The left ovary appears normal.
In the midline posterior to the bladder, there is a 56x41x50mm unilocular cyst which appears to have a solid component. The cyst is thin-walled and contains low level echoes. The presumed solid component measures 15x15x13mm and demonstrates acoustic shadowing. It is avascular. The cyst appears separate to both ovaries and while it appears separate to the bladder it does appear to be closely associated with the posterior bladder wall.
The nature of the cyst was intedeterminate and further evaluation with MRI recommended.
Mass overlying the bladder dome in the midline is of high T1 signal, without fat saturation. It is predominantly high signal on T2, with a peripheral low T2 signal, non-enhancing nodule which has a height of 10.5 mm, measuring 17 x 14 mm in cross-section. This corresponds to the midline cystic mass seen on ultrasound and the MR features are typical for an endometrioma with retracted clot. It is in contact with, and likely arises from, the right ovary.
Multiple smaller endometriomas are seen in both ovaries.
Spiculated nodule measuring 9 x 8 x 13 mm centered in the pouch of Douglas and adherent to the cervical stump anteriorly, rectal wall posteriorly, confirming the background diagnosis of deep infiltrating endometriosis.
Case Discussion
This case demonstrates the typical appearance of an endometriotic cyst with a T2 dark spot. It also highlights the setting where MRI is an appropriate adjunct to ultrasound for characterizing an indeterminate appearance of a lesion and adding further detail to the assessment of endometriosis.
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