Adenomyotic cyst of the uterus associated with pelvic pain: A case report

Adenomyotic cysts of the uterus are extremely rare and this case report is to document an adenomyotic cyst of the uterus associated with pelvic pain. A 27-year old nul - liparous patient admitted to the hospital with the com - plaint of dysmenorrhea, dyspareunia and pain in the right pelvic region for the last 3 months. Transvaginal ultraso - nographic examination revealed a 50 × 36 mm intramural cystic lesion on the right region of the corpus uteri. Hys - teroscopic examination showed that it did not deteriorate the endometrial cavity. During laparatomy dissection of the uterine wall revealed 5 cm cystic lesion that was ex - cised circumferentially protecting the surrounding myo - metrial tissue. The definitive pathology report came out as adenomyotic tissue. Imaging techniques are critical in differential diagnosis of adenomyotic cysts and to choose the appropriate intervention. Medical therapy or surgical intervention like excision of the cyst or hysterectomy may be the choices of treatment. J Clin Exp Invest 2014; 5 (1): 100-102 Key words: Adenomyotic cyst, pelvic pain, laparatomy

Adenomyosis is the presence of endometrial glands and stroma placed in the uterine myometrium. Dif - fuse adenomyosis is the most common form of ad - enomyosis; but focal adenomyosis in the form of adenomyoma, cystic adenomyosis, or adenomyotic cyst may also be seen [1]. Adenomyotic cysts of the uterus are extremely rare. The potential mecha- nisms of pathophysiology of adenomyosis can be explained by endomyometrial invagination or estro- gen stimulation of Mullerian remnants or iatrogenic implantation during uterine surgery [1]. Adenomyo - sis is usualy a diffuse disease but rarely may be a focal lesion [1]. We aimed to present this case re - port which was associated with pelvic pain. CASE A 27 year old nulligravid patient was admitted to our hospital with the complaint of dysmenorrhea, dyspareunia and pain in the right pelvic region for the last 3 months. Her menstrual cycle was regular and she had no menorrhagia. She had no history of any other disease or operation. The vital signs of the patient were normal. On gynecological ex - amination a tender uterus slightly larger than nor - mal was palpated. Complete blood count, basic biochemical tests were normal, serum β-HCG level was within no pregnant values. Urinalysis, cervical and urinary cultures were negative. Transvaginal ul- trasonographic examination revealed a 50 × 36 mm intramural cystic lesion with homogeneous internal Dilbaz et al. Adenomyotic cyst of the uterus 101 J Clin Exp Invest www.jceionline.org Vol 5, No 1, March 2014 echogenities on the right region of the corpus uteri (Figure 1). Magnetic resonance imaging of the pa - tient revealed 52 × 46 mm lesion with internal fluid located in the myometrium on the right side of the corpus uteri. Adenomyotic cyst, cystic degeneration of intrauterine leiomyoma were firstly thought in the differential diagnosis and hysteroscopy and lapara - tomy were planned. Informed consent covering per- mission for documentation of the case was taken from the patient before the operation. Figure 1. The ultrasonographic image of the adenomyotic cyst The patient was prepared for the operation and draped in litotomy position. At first hysteroscopy done to evaluate the relationship between the cyst and the endometrial cavity and it has been docu - mented that the cytic lesion did not deteriorate the endometrial cavity. Laparatomic exploration showed that the uterus was enlarged and there was a mass on the right side of the corpus uteri. Both ovaries and fallopian tubes were normal in appearance, no endometriotic lesion was detected. Dissection of the uterine wall above the mass revealed a 5 cm cystic lesion that was excised circumferentially pro- tecting the surrounding myometrial tissue. The well- circumscribed cyst ruptured during disection and dark brown fluid was expelled. Excision of the cystic wall was done without entering the endometrial cav- ity (Figure 2). Intraoperatively the frozen section of the cyst wall was reported as benign. The definitive pathology report came out as adenomyotic tissue. The patient was discharged from the hospital on the second day of the operation and the follow-up and recovery period was uneventful. Her symptoms of pain were dissolved one month after the operation. Figure 2. The adenomyotic cyst of the uterus

Cystic lesions of the uterus are rare lesions and are considered to be benign [2]. Adenomyotic cysts are usually observed in parous women, and usually seen in association with diffuse adenomyosis uteri [3]. But isolated adenomyotic cysts may also be de- tected [4,5]. Adenomyotic cysts are usually seen in older ages but they may be even detected in ado - lescents [5]. Small adenomyotic cysts that do not usually exceed 5 mm in diameter are found in 24% of hysterectomy specimens [6] but larger adeno - myotic cysts are extremely rare. Repeated surgical intervention may be a risk factor for adenomyotic cysts [7]. Pelvic pain, dysmenorrhea, menorrha - gia and larger sized uterus are the most common clinical features of adenomyosis. But even urinary retension may be the symptom of an adenomyoma- tous polyp [8]. Pain or severe dysmenorrhea may also be the main symptom in adenomyotic cysts [2,4,5]. This patient had also pelvic pain as the main symptom accompanied by dysmenorrhea and post- coital pain. The pain of the adenomyotic cyst may be attributed to the progressive increase in size of the mass, stretching of the endometrial cavity and intracystic bleeding [5]. Magnetic resonance imaging is important for the accurate diagnosis of cystic adenomyosis espe- cially when findings from other imaging modalities are nonspecific [9]. Magnetic resonance imaging can easily differentiate multiple cysts within the uter- ine myometrium, but hysterosalpingography may also be useful for the differential diagnosis when magnetic resonance imaging cannot differentiate isolated adenomyotic cyst from cavitated noncom - municating rudimentary uterine horn [4]. Dilbaz et al. Adenomyotic cyst of the uterus 102 J Clin Exp Invest www.jceionline.org Vol 5, No 1, March 2014 Imaging techniques are critical in differen - tial diagnosis of adenomyotic cysts and help us to choose the appropriate intervention by also taking into account the size and the localization of the cyst and age of the patient. In young patients hormonal ablative therapy is the first choice and can be ac - complished by combined oral contraceptives. In the presence of severe symptoms that do not diminish with medical therapy, a surgical intervention can be planned that aims total excision of the adenomytic cyst. An abdominal intervention has the advantages of precise restoration of the uterine cavity over lapa- roscopic aproach but various other techniques such as hysteroscopy can be recommended for excision depending on the localization of the cyst [10]. In older patients with no desire to preserve their fertil - ity and especially in cases when adenomyotic cysts are accompanied by diffuse adenomyosis, hyster - ectomy should be performed.

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