{"paper_id":"63aedba6-048e-4a09-b099-c77f0435504c","body_text":"Gynecol Surg (2006) 3: 43 –44\nDOI 10.1007/s10397-005-0157-x\nCASE REPORT\nAylur Gopalakrishnan Rajasri . Dominic Byrne\nAn unusual case of trapped ovary in a peritoneal pouch causing\nextrinsic ureteric compression associated with endometriosis\nPublished online: 13 December 2005\n# Springer-V erlag Berlin/Heidelberg 2005\nAbstract A 35-year-old woman presented with long-\nstanding right loin to groin pain and a right ovarian cyst.\nThe ovarian cyst was considered physiological at the initial\ngynaecological evaluation. A subsequent transvaginal scan\ndemonstrated a cystic immobile ovary adherent to the pel-\nvic side wall. Laparoscopy revealed endometriosis and a\nperitoneal defect holding the cystic ovary against the ureter\nand causing compression with secondary loin pain. The\ntrapped ovary was removed and the patient was cured of the\nlong-standing ureteric colic. This is the first reported case of\nextrinsic ureteric compression caused by trapped ovary in a\nperitoneal pouch associated with endometriosis. The diag-\nnosis was suspected preoperatively from the transvaginal\nscan findings demonstrating a cystic immobile ovary\nadherent to the pelvic side wall. This case demonstrates\nthat in women with unresolved ureteric compression where\nadnexal cyst is found, the investigator should look for\nfeatures that suggest entrapment to the pelvic side wall.\nKeywords Endometriosis . Ureteric obstruction .\nOvarian cysts . Peritoneal pocket . Laparoscopy\nIntroduction\nEndometriosois affects 2.5–15% of women of reproductive\nage. Ureteric involvement associated with endometriosis is\nrare and most often endometriosis is identified as the cause\nof obstruction only during surgery. We report an interesting\ncase of a trapped ovary causing extrinsic ureteric compres-\nsion associated with endometriosis. The patient had long-\nstanding ureteric colic, which was completely cured on\nremoval of the right ovary found to be trapped in a\nperitoneal pouch.\nCase report\nA 33-year-old parous woman presented with right loin to\ngroin pain, which had lasted for 18 months following the\nnormal delivery of her fifth child. The pain was colicky,\nalmost always present and associated with urgency of\nmicturition. She had a regular 28-day menstrual cycle with\nheavy bleeding for 4–5 days. Clinically she was well except\nfor mild right renal angle tenderness and right iliac fossa\ntenderness. She was referred as an emergency with\nexacerbation of the right loin pain and investigated under\nthe urologists. No cause was found and cholecystitis and\nrenal calculi were excluded. However, an intravenous uro-\ngraphy (IVP) demonstrated mild obstruction of the right\nureter with mild renal pelvicalyceal dilatation. The urolo-\ngist arranged a CT scan to look for any lesions causing\nureteric compression. The CT scan demonstrated mild\nureteric dilatation within physiological limits, but, in\naddition, revealed a 3-cm right adnexal mass. After referral\nto the gynaecologists an ultrasound scan was carried out\nand a 3-cm physiological cyst of the right ovary was con-\nfirmed. The gynaecologist reassured the woman that this\nwas not a cause for concern. However, the pain persisted\nand the urologist advised a second gynaecological opinion.\nAt this subsequent gynaecological examination bimanual\npalpation demonstrated an adnexal mass and pressure on\nthis mass reproduced the loin pain. A transvaginal scan\nrevealed an immobile tender right ovary with a simple cyst\nmeasuring 3.8×3.3 cm, adherent to the pelvic side wall. The\nuterus and the left ovary were normal. The provisional\ndiagnosis was adnexal pathology, causing secondary ure-\nteric compression. The patient underwent a diagnostic\nlaparoscopy, which revealed a normal uterus and left ad-\nA. G. Rajasri\nObstetrics and Gynaecology, Derriford Hospital,\nDevon, PL6 8DH, UK\nA. G. Rajasri ( *)\n8 Chartley, 22 The Avenue, Sneyd Park,\nBristol, BS9 1PE, UK\ne-mail: rajasri_iyer@yahoo.com\nTel.: +44-117-9681846\nFax: +44-1452-395713\nD. Byrne\nObstetrics and Gynaecology, Royal Cornwall Hospital,\nTruro, UK\n\nnexa. The right ovary was trapped in a peritoneal defect in\nthe broad ligament forming a pouch within the pelvic\nsidewall (Fig. 1). This trapped ovary was compressing the\nright ureter explaining the symptoms and the hydronephro-\nsis. The ovary was delivered through the defect and the cyst\nwas drained. Attempts to ensure the ovary remained outside\nthe pouch failed and hence a right salpingo-oophorectomy\nwas performed. The patient was immediately aware the\npain had gone from the first postoperative day, confirming\nthe adnexal cyst was the cause of her loin pain. At the time\nof surgery a single spot of endometriosis was seen at the\nbase of the peritoneal pouch, it was presumed that the pouch\nmight have been present due to endometriosis. The com-\nbined contraceptive pill was prescribed as a continuous\nmedication for further treatment of the endometriosis.\nSurgical follow up at 6 weeks confirmed that the pain had\nnot recurred.\nDiscussion\nThis case is the first report of a trapped ovary in a peritoneal\npocket associated with endometriosis causing extrinsic\nureteric compression. In most of the previous reports of\nureteric involvement in endometriosis, the patient was\nknown to suffer from endometriosis [ 1–3] and the ureteric\ninvolvement was due to periureteric fibrosis or direct\nmechanical compression by the cysts [ 1, 2, 4, 5]. Often,\nendometriosis is not identified to be the cause of the\nobstruction before surgery [ 1–4]. In this case the diagnosis\nwas suspected preoperatively from the clinical and trans-\nvaginal scan findings demonstrating a cystic immobile\novary adherent to the pelvic side wall. Laparoscopy re-\nvealed that the peritoneal defect was holding the ovary\nagainst the ureter and causing compression with secondary\nloin pain. The puckered pigmented lesion at the base of the\ndefect confirmed the presence of endometriosis and may be\nthe cause of the defect itself [ 6]. There was no evidence of\nextensive pelvic endometriosis. Ureteric involvement in\nendometriosis is very rare (1.2%) [ 7] and most often ex-\ntrinsic. Successful medical management of extrinsic ure-\nteric involvement has been reported [ 1, 2]. Once fibrosis\nhas occurred medical management is not effective at\naltering the course of obstruction [ 2]. In our case an\noophorectomy was performed because the compression on\nthe ureter was thought to be mechanical and the ovary\ncould not be repositioned away from the defect.\nPost-operatively the patient was totally symptom-free,\nwhich confirms the diagnosis, and she is on medical\ntreatment to prevent recurrence or growth of endometriosis.\nConclusion\nThis case demonstrates that in any women with unresolved\nureteric compression where an adnexal cyst is found, the\ninvestigator should look for features to suggest entrapment\non the pelvic side wall. This patient endured 18 months of\npain without a diagnosis being reached. The ovarian cyst\nwas physiological as the first gynaecologist explained, but\nits immobility was missed. The consequence of this finding\nwas eloquently shown at laparoscopy.\nReferences\n1. Deprest J, Marchal G, Brosens I (1997) Obstructive uropathy\nsecondary to endometriosis. N Engl J Med 337:1174 –1175\n2. Brough RJ, O ’Flynn K (1996) Recurrent pelvic endometriosis\nand bilateral ureteric obstruction associated with hormone\nreplacement therapy. BMJ 312:1221 –1222\n3. Ryan JF, Booth CM (1992) Endometriosis of the ureter. Br J Urol\n69:430–431\n4. Sanyal D, Argent VP (2003) Silent pelvic endometriosis\npresenting as pyelonephritis and ureteric obstruction. J Obstet\nGynaecol 23:328 –329\n5. Esen T, Akinci M, Ander H, Tunc M, Tellaloglu S, Narter I\n(1990) Bilateral ureteric compression secondary to endometri-\nosis. Br J Urol 66:98 –99\n6. Walter JA, Hentz GJ, Magtibay MP , Cornella LJL, Magrina FJ\n(2001) Endometriosis: correlation between histologic and visual\nfindings at laparoscopy. Am J Obstet Gynecol 184:1407 –1413\n7. Ball TL, Platt MA (1963) Urological complications of endome-\ntriosis. Am J Obstet Gynecol 84:1516 –1521\nFig. 1 The peritoneal defect in the broad ligament\n44","source_license":"CC0","license_restricted":false}