An unusual case of trapped ovary in a peritoneal pouch causing extrinsic ureteric compression associated with endometriosis
© Springer-Verlag Berlin/Heidelberg 2005
Published: 13 December 2005
A 35-year-old woman presented with long-standing right loin to groin pain and a right ovarian cyst. The ovarian cyst was considered physiological at the initial gynaecological evaluation. A subsequent transvaginal scan demonstrated a cystic immobile ovary adherent to the pelvic side wall. Laparoscopy revealed endometriosis and a peritoneal defect holding the cystic ovary against the ureter and causing compression with secondary loin pain. The trapped ovary was removed and the patient was cured of the long-standing ureteric colic. This is the first reported case of extrinsic ureteric compression caused by trapped ovary in a peritoneal pouch associated with endometriosis. The diagnosis was suspected preoperatively from the transvaginal scan findings demonstrating a cystic immobile ovary adherent to the pelvic side wall. This case demonstrates that in women with unresolved ureteric compression where adnexal cyst is found, the investigator should look for features that suggest entrapment to the pelvic side wall.
KeywordsEndometriosis Ureteric obstruction Ovarian cysts Peritoneal pocket Laparoscopy
Endometriosois affects 2.5–15% of women of reproductive age. Ureteric involvement associated with endometriosis is rare and most often endometriosis is identified as the cause of obstruction only during surgery. We report an interesting case of a trapped ovary causing extrinsic ureteric compression associated with endometriosis. The patient had long-standing ureteric colic, which was completely cured on removal of the right ovary found to be trapped in a peritoneal pouch.
This case is the first report of a trapped ovary in a peritoneal pocket associated with endometriosis causing extrinsic ureteric compression. In most of the previous reports of ureteric involvement in endometriosis, the patient was known to suffer from endometriosis [1–3] and the ureteric involvement was due to periureteric fibrosis or direct mechanical compression by the cysts [1, 2, 4, 5]. Often, endometriosis is not identified to be the cause of the obstruction before surgery [1–4]. In this case the diagnosis was suspected preoperatively from the clinical and transvaginal scan findings demonstrating a cystic immobile ovary adherent to the pelvic side wall. Laparoscopy revealed that the peritoneal defect was holding the ovary against the ureter and causing compression with secondary loin pain. The puckered pigmented lesion at the base of the defect confirmed the presence of endometriosis and may be the cause of the defect itself . There was no evidence of extensive pelvic endometriosis. Ureteric involvement in endometriosis is very rare (1.2%)  and most often extrinsic. Successful medical management of extrinsic ureteric involvement has been reported [1, 2]. Once fibrosis has occurred medical management is not effective at altering the course of obstruction . In our case an oophorectomy was performed because the compression on the ureter was thought to be mechanical and the ovary could not be repositioned away from the defect.
Post-operatively the patient was totally symptom-free, which confirms the diagnosis, and she is on medical treatment to prevent recurrence or growth of endometriosis.
This case demonstrates that in any women with unresolved ureteric compression where an adnexal cyst is found, the investigator should look for features to suggest entrapment on the pelvic side wall. This patient endured 18 months of pain without a diagnosis being reached. The ovarian cyst was physiological as the first gynaecologist explained, but its immobility was missed. The consequence of this finding was eloquently shown at laparoscopy.
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