Archive | January, 2017

ovarian cysts (quick review)

23 Jan

submitted by Christina Brown, M.D.

Follicular cysts:

  • Most common
  • Occur from fetal life to menopause
  • Unilocular; diameter 3–8 cm
  • Thin wall predisposes to rupture, which usually causes minimal or no bleeding.
  • Rupture during ovulation at midcycle is known as mittelschmerz.

Corpus luteal cysts:

  • Most significant
  • Diameter 3 cm, but usually <10 cm
  • Rapid bleeding from intracystic hemorrhage causes rupture.
  • Rupture is most common just before menses begins.
  • Can cause severe intraperitoneal bleeding
  • Gradual bleeding into cyst or ovary distends capsule and may cause pain without rupture.



  • Follicular cysts result from non-rupture of mature follicle or failure of atresia of immature follicle.
  • Corpus luteal cysts result from unrestrained growth in early pregnancy or from normal intracystic hemorrhage days after ovulation.
  • Other cysts:
    • Theca lutein
    • Cystic teratoma
    • Endometrioma (chocolate cyst)


  • Abdominal pain
    • Sharp, unilateral
    • Intermittent vs. constant
    • Migration
    • Previous episodes
    • May occur with exercise, intercourse, trauma, or pelvic exam
  • Fever is rare.
  • Irregular menses (may suggest polycystic ovary syndrome).


Physical Exam

  • Abdominal tenderness (mild to severe with peritonitis)
  • Adnexal tenderness
  • Pelvic mass
  • Hemorrhagic shock possible:
    • Usually from corpus luteal cyst rupture
    • Orthostasis, hypotension, tachycardia

Lab work:

  • Urine or serum human chorionic gonadotropin determination
  • CBC
  • Urinalysis
  • If significant hemorrhage, type and cross packed RBCs
  • Cervical cultures to rule out PID

Transvaginal US:

  • Adnexal cysts and masses:
    • Cystic masses <5 cm in premenopausal women generally benign
    • Should be reevaluated at end of menstruation
  • Pelvic free fluid


  • May demonstrate cysts or evidence of torsion or suggest alternative diagnosis
  • May provide enough information to proceed to laparoscopy if abnormal ovary and no other cause of pain identified
  • Uterus may be shifted to side of torsed adnexa.
  • Ascites may be present.

Disposition – If hemorrhagic conversion due to ruptured ovarian cyst, admit to Gynecology.
FOLLOW-UP RECOMMENDATIONS:  If pain is resolved and cyst is <4–5 cm, close follow-up is recommend with gynecology for further studies.


Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Ovarian Cyst/Torsion. Rosen’s 5-minute EM Consult.
Bottomley C and Bourne T.: Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009; 23:711–724.
McWilliams GDE, Hill M J, and Dietrich C S.: Gynecologic emergencies. Surg Clin North Am. 2008; 88:265–283.


modified valsalva maneuver (quick reference)

12 Jan

for a more in-depth look, check out last May’s ACEP Now article.

brief highlights:

  • 428 patient study
  • modified valsalva maneuver
    • forced strain (e.g. blow into 10 cc syringe)
    • lie patient flat
    • elevate legs to 45 degrees x 15 seconds
  • return to sinus rhythm at 1 minute:
    • 43% with modified valsalva
    • 17% standard valsalva (strain x 15 sec, no position change)
    • NNT = 4


quick visual aid (start at the 1:17 mark if short on time):


There you go.  Add it to the toolbox.

References: ACEP Now article; video