Q: Which of the following diseases is associated with the feature of sudden onset severe unilateral (mostly right side) lower abdominal pain following sexual intercourse. On exam, there is no cervical or vaginal discharge?
A) Ectopic pregnancy B) Pelvic inflammatory disease C) Ovarian torsion D) Ruptured ovarian cyst E) Acute endometritis
The differential diagnosis of ruptured ovarian cyst is important, as it is mostly clinical but may subject patients to either undue procedures or wrong management. One of the biggest clues to the diagnosis is an association with physical activity. Another diagnostic clue is the side of the pain. Although ovary of either side can be affected, in most cases right side is affected, because the rectosigmoid colon protects the left ovary.
In case of hemodynamic instability and deteriorating clinical signs, a patient should be taken for emergent surgery, otherwise expectant treatment is the desired course.
Choice A - Ectopic pregnancy is mostly associated with vaginal bleeding typically after 6-8 weeks of last menstrual period (LMP).
Choice B - In pelvic inflammatory disease (PID), lateralization is uncommon and often associated with cervical discharge.
Choice C - Ovarian torsion is hard to distinguish but usually associated with an adnexal mass.
Choice E - Acute endometritis is often occurred in a patient with an established diagnosis of endometriosis and associated with dysmenorrhea, pelvic pain, dyspareunia, and/or infertility, as well as with bowel or bladder symptoms.
References: Kim JH, Lee SM, Lee JH, et al. Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. PLoS One 2014; 9:e91171. Abduljabbar HS, Bukhari YA, Al Hachim EG, et al. Review of 244 cases of ovarian cysts. Saudi Med J 2015; 36:834.