Presentation
Pelvic pain and mild tenderness on examination. Tachycardia with mild leukocytosis. History of multiple pelvic surgeries. Pelvic MRI is requested to rule out pelvic abscess.
Patient Data
A simple left ovarian cyst is noted measures about 3.2x2.6 cm with adjacent insinuating irregular shape cystic structure with fine smooth septations lacking a discrete limiting wall, no mural nodularity or debris. Signal characteristics appear as homogenous T1 hypointense and T2 hyperintense without evidence of blood component. No restricted diffusion pattern or fluid levels. Minimal peripheral enhancement is noted. The cyst measures about 6.5x5 cm.
Features are highly suggestive of peritoneal inclusion cyst (peritoneal pseudocyst).
The uterus is normal in size and zonal anatomy. Cesarean section scar is noted. Small endocervical cysts are noted. Normal right ovary.
The adequately distended urinary bladder appears normal and has a normal wall thickening.
Case Discussion
In this case, the gynecologist suspected a pelvic abscess because of mild leukocytosis, pelvic tenderness, and a history of pelvic surgeries. So that MRI is requested which shows features consistent with inclusion cyst. After that, the patient undergoes laparoscopy which confirms the inclusion cyst, and no abscess was found. The patient's symptoms are not significantly improved, the surgical and urologic consultations were free and they said nothing to do.
Inclusion cysts are non-neoplastic reactive mesothelial proliferation, seen exclusively in child-bearing age women with a history of previous surgeries (abdomen or pelvis) or endometriosis.
Normally, the peritoneum can absorb the ovarian fluid easily, however when the presence of previous peritoneal insult (inflammation, surgery, trauma, endometriosis, and adhesions) the absorptive capacity is decreased and the fluid accumulates and contained within the adhesions forming a pseudocyst which can be very large occupying the abdomen and pelvic cavity.