{"paper_id":"bd4dbac0-97d8-48f9-8ee7-72f599e5c124","body_text":"100\nEtlik Zübeyde Hanım Women’s Health Teaching and Research Hospital, Ankara, Turkey\nCorrespondence: Özlem Şengül, \nEtlik Zübeyde Hanım Kadın Sağlığı Eğitim ve Araştırma Hastanesi, Ankara, Türkiye     Email: ozlem.sengul@yahoo.com\nReceived: 03.09.2013, Accepted: 07.10.2013\nCopyright © JCEI / Journal of Clinical and Experimental Investigations 2014, All rights reserved\nJCEI /  2014; 5 (1): 100-102\nJournal of Clinical and Experimental Investigations  doi: 10.5799/ahinjs.01.2014.01.0368\nCASE REPORT / OLGU SUNUMU\nAdenomyotic cyst of the uterus associated with pelvic pain: A case report\nPelvik ağrı ile ilişkili uterusun adenomyotik kisti: Olgu sunumu\nBerna Dilbaz, Özlem Şengül, Tuba Zengin, Hatice Dilek Bülbül, Leyla Mollamahmutoğlu\nÖZET\nUterusun adenomyotik kistleri çok nadirdir ve bu vaka \nsunumunda pelvik ağrı ile ilişkili uterusun adenomyotik \nkisti sunulmuştur. 27 yaşındaki nulligravid hasta disme -\nnore, disparenü ve son 3 aydır devam eden sağ pelvik \nağrı şikayeti ile hastaneye başvurmuştur. Transvajinal ult-\nrasonografide uterus korpusunun sağında 50 × 36 mm \nintramural kistik lezyon saptandı. Histeroskopik incele -\nmede lezyonun endometrial kaviteyi etkilemediği izlendi. \nLaparatomi sırasında çevre myometrial doku korunarak 5 \ncm boyutundaki kist çepeçevre diseke edilerek çıkarıldı. \nPatoloji sonucu adenomyotik doku olarak geldi. Görüntü -\nleme yöntemleri adenomyotik kistlerin ayırıcı tanısında ve \nuygun tedavinin seçiminde önemlidir. Medikal tedavi veya \nkistin eksizyonu ya da histerektomi gibi cerrahi yaklaşım-\nlar tedavi seçenekleri olabilir.\nAnahtar kelimeler: Adenomyotik kist, pelvik ağrı, lapa -\nratomi\nABSTRACT\nAdenomyotic cysts of the uterus are extremely rare and \nthis case report is to document an adenomyotic cyst of \nthe uterus associated with pelvic pain. A 27-year old nul -\nliparous patient admitted to the hospital with the com -\nplaint of dysmenorrhea, dyspareunia and pain in the right \npelvic region for the last 3 months. Transvaginal ultraso -\nnographic examination revealed a 50 × 36 mm intramural \ncystic lesion on the right region of the corpus uteri. Hys -\nteroscopic examination showed that it did not deteriorate \nthe endometrial cavity. During laparatomy dissection of \nthe uterine wall revealed 5 cm cystic lesion that was ex -\ncised circumferentially protecting the surrounding myo -\nmetrial tissue. The definitive pathology report came out \nas adenomyotic tissue. Imaging techniques are critical in \ndifferential diagnosis of adenomyotic cysts and to choose \nthe appropriate intervention. Medical therapy or surgical \nintervention like excision of the cyst or hysterectomy may \nbe the choices of treatment. J Clin Exp Invest 2014; 5 (1): \n100-102\nKey words: Adenomyotic cyst, pelvic pain, laparatomy\nINTRODUCTION\nAdenomyosis is the presence of endometrial glands \nand stroma placed in the uterine myometrium. Dif -\nfuse adenomyosis is the most common form of ad -\nenomyosis; but focal adenomyosis in the form of \nadenomyoma, cystic adenomyosis, or adenomyotic \ncyst may also be seen [1]. Adenomyotic cysts of \nthe uterus are extremely rare. The potential mecha-\nnisms of pathophysiology of adenomyosis can be \nexplained by endomyometrial invagination or estro-\ngen stimulation of Mullerian remnants or iatrogenic \nimplantation during uterine surgery [1]. Adenomyo -\nsis is usualy a diffuse disease but rarely may be a \nfocal lesion [1]. We aimed to present this case re -\nport which was associated with pelvic pain.\nCASE\nA 27 year old nulligravid patient was admitted to \nour hospital with the complaint of dysmenorrhea, \ndyspareunia and pain in the right pelvic region for \nthe last 3 months. Her menstrual cycle was regular \nand she had no menorrhagia. She had no history \nof any other disease or operation. The vital signs \nof the patient were normal. On gynecological ex -\namination a tender uterus slightly larger than nor -\nmal was palpated. Complete blood count, basic \nbiochemical tests were normal, serum β-HCG level \nwas within no pregnant values. Urinalysis, cervical \nand urinary cultures were negative. Transvaginal ul-\ntrasonographic examination revealed a 50 × 36 mm \nintramural cystic lesion with homogeneous internal \n\nDilbaz et al. Adenomyotic cyst of the uterus\n101\nJ Clin Exp Invest  www.jceionline.org  Vol 5, No 1, March 2014\nechogenities on the right region of the corpus uteri \n(Figure 1). Magnetic resonance imaging of the pa -\ntient revealed 52 × 46 mm lesion with internal fluid \nlocated in the myometrium on the right side of the \ncorpus uteri. Adenomyotic cyst, cystic degeneration \nof intrauterine leiomyoma were firstly thought in the \ndifferential diagnosis and hysteroscopy and lapara -\ntomy were planned. Informed consent covering per-\nmission for documentation of the case was taken \nfrom the patient before the operation.\nFigure 1. The ultrasonographic image of the adenomyotic \ncyst\nThe patient was prepared for the operation and \ndraped in litotomy position. At first hysteroscopy \ndone to evaluate the relationship between the cyst \nand the endometrial cavity and it has been docu -\nmented that the cytic lesion did not deteriorate the \nendometrial cavity. Laparatomic exploration showed \nthat the uterus was enlarged and there was a mass \non the right side of the corpus uteri. Both ovaries \nand fallopian tubes were normal in appearance, no \nendometriotic lesion was detected. Dissection of \nthe uterine wall above the mass revealed a 5 cm \ncystic lesion that was excised circumferentially pro-\ntecting the surrounding myometrial tissue. The well-\ncircumscribed cyst ruptured during disection and \ndark brown fluid was expelled. Excision of the cystic \nwall was done without entering the endometrial cav-\nity (Figure 2). Intraoperatively the frozen section of \nthe cyst wall was reported as benign. The definitive \npathology report came out as adenomyotic tissue. \nThe patient was discharged from the hospital on the \nsecond day of the operation and the follow-up and \nrecovery period was uneventful. Her symptoms of \npain were dissolved one month after the operation.\nFigure 2. The adenomyotic cyst of the uterus\nDISCUSSION\nCystic lesions of the uterus are rare lesions and \nare considered to be benign [2]. Adenomyotic cysts \nare usually observed in parous women, and usually \nseen in association with diffuse adenomyosis uteri \n[3]. But isolated adenomyotic cysts may also be de-\ntected [4,5]. Adenomyotic cysts are usually seen in \nolder ages but they may be even detected in ado -\nlescents [5]. Small adenomyotic cysts that do not \nusually exceed 5 mm in diameter are found in 24% \nof hysterectomy specimens [6] but larger adeno -\nmyotic cysts are extremely rare. Repeated surgical \nintervention may be a risk factor for adenomyotic \ncysts [7]. Pelvic pain, dysmenorrhea, menorrha -\ngia and larger sized uterus are the most common \nclinical features of adenomyosis. But even urinary \nretension may be the symptom of an adenomyoma-\ntous polyp [8]. Pain or severe dysmenorrhea may \nalso be the main symptom in adenomyotic cysts \n[2,4,5]. This patient had also pelvic pain as the main \nsymptom accompanied by dysmenorrhea and post-\ncoital pain. The pain of the adenomyotic cyst may \nbe attributed to the progressive increase in size of \nthe mass, stretching of the endometrial cavity and \nintracystic bleeding [5]. \nMagnetic resonance imaging is important for \nthe accurate diagnosis of cystic adenomyosis espe-\ncially when findings from other imaging modalities \nare nonspecific [9]. Magnetic resonance imaging \ncan easily differentiate multiple cysts within the uter-\nine myometrium, but hysterosalpingography may \nalso be useful for the differential diagnosis when \nmagnetic resonance imaging cannot differentiate \nisolated adenomyotic cyst from cavitated noncom -\nmunicating rudimentary uterine horn [4].\n\nDilbaz et al. Adenomyotic cyst of the uterus\n102\nJ Clin Exp Invest  www.jceionline.org  Vol 5, No 1, March 2014\nImaging techniques are critical in differen -\ntial diagnosis of adenomyotic cysts and help us to \nchoose the appropriate intervention by also taking \ninto account the size and the localization of the cyst \nand age of the patient. In young patients hormonal \nablative therapy is the first choice and can be ac -\ncomplished by combined oral contraceptives. In the \npresence of severe symptoms that do not diminish \nwith medical therapy, a surgical intervention can be \nplanned that aims total excision of the adenomytic \ncyst. An abdominal intervention has the advantages \nof precise restoration of the uterine cavity over lapa-\nroscopic aproach but various other techniques such \nas hysteroscopy can be recommended for excision \ndepending on the localization of the cyst [10]. In \nolder patients with no desire to preserve their fertil -\nity and especially in cases when adenomyotic cysts \nare accompanied by diffuse adenomyosis, hyster -\nectomy should be performed.\nREFERENCES\n1. Ferenczy A. Pathophysiology of adenomyosis. Hum \nReprod Update 1998; 4:312.\n2. English DP, Verma U, Pearson JM. Uterine cyst as a \ncause of chronic pelvic pain: a case report. J Reprod \nMed. 2012;57:446-448.\n3. Ejeckam GC, Zeinab OA, Salman M, Bobeck HE. Giant \nadnomyotic cyst of the uterus. Br J Obstet Gynecol \n1993;100:596–598.\n4. Kamio M, Taguchi S, Oki T, et al. Isolated adenomyotic \ncyst associated with severe dysmenorrhea. J Obstet \nGynaecol Res 2007;33:388-391.\n5. Tamura M, Fukaya T, Takaya R, et al. Juvenile adeno-\nmyotic cyst of the corpus uteri with dysmenorrhea. To-\nhoku J Exp Med 1996;178:339-344.\n6. Slezak P, Tillinger KG. The incidence and clinical im -\nportance of hysterographic evidence of cavities in the \nuterine wall. Radiology 1976;118:581-586.\n7. Koga K, Osuga Y, Hiroi H , et al. A case of giant cystic \nadenomyosis. Fertil Steril 2006; 85: 748–749.\n8. Evsen MS, Sak ME, Soydinç HE, et al. Adenomyoma -\ntous polyp causing acute urinary retention in a post -\nmenopausal woman. J Clin Exp Invest 2011;2:312-\n314.\n9. Tamai K, Togashi K, Ito T, et al. MR imaging findings of \nadenomyosis: correlation with histopathologic features \nand diagnostic pitfalls. Radiographics 2005;25:21–40.\n10. Giana M, Montella F, Surico D, et al. Large intramyo -\nmetrial cystic adenomyosis: a hysteroscopic approach \nwith bipolar resectoscope: case report. Eur J Gynae -\ncol Oncol 2005;26:462-463.","source_license":"CC0","license_restricted":false}