PROLAPSED OVARY AS CAUSE OF CHRONIC PAIN, DYSPAREUNIA, LACK OF ORGASM, CONSTIPATION AND DEFECATION CHALLENGES
A research study by. Adams O.Sani, MD, RVS, RCS, RDMS(Abd,Ob/Gyn.), RPVI
Abstract:
This observatory study aims to evaluate the significance of recognizing prolapsed ovary as the cause of painful intercourse (Dyspaurenia) in childbearing-age women who previously did not experience such episodes before childbearing. Prolapsed ovaries as a cause of dyspareunia and ovarian trauma are much more common than perceived, and are, unfortunately, often overlooked.
Until now, there is little published literature about ovarian prolapse, a debilitating condition that often renders coitus difficult and defection an agony; exposes the ovary to injury from pelvic exanimation and makes coitus a miserable adventure. Thus, emphasizing the need to explore more about the subject. Most textbooks of Gynecology have only trivially mentioned this condition as part of a complex pelvic organ prolapse or uterine prolapse. This common but hallenging clinical scenario, is hereby extensively addressed in this manuscript.
Keywords:
Ovarian prolapse, pain during sexual intercourse, pain in lower abdomen after sexual intercourse, ultrasound, Okene triad, stages of simple ovarian prolapse.
Introduction:
Ovarian prolapse is a common and rarely diagnosed pathology because it presents a diagnostic challenge. The clinical features in patients with prolapsed ovary are usually nonspecific and mimic most other pelvic pathologies such as cervicitis, pelvic inflammatory disease (PID), ectopic gestation, pelvic congestion, endometriosis, ovarian cysts, constipated sigmoid, diverticulitis, a disease involving the posterior cul-de-sac, uterosacral ligaments, rectovaginal septum, or upper vagina. Also, patients are always hesitant in revealing the crucial information necessary for healthcare providers to address the issue. The sexual symptoms for which most women hesitate to seek help from healthcare providers are dyspareunia and the inability to achieve orgasm. Ovarian prolapse is a frequent cause of deep vaginal pain. It is made worse with coitus, menses, and gynecologic examination. Dyspareunia (painful intercourse) and the associated postcoital acute onset of diffuse lower abdominal pain from the traumatized ovary are frequently the reasons for Emergency room visits in childbearing multi-para women.
Ultrasound forms the backbone of the diagnostic workup. Ultrasonography is the diagnostic modality of choice in evaluating lower abdominal pain in females. Transvaginal ultrasound is extremely efficient in diagnosing many disorders since it allows detailed evaluation of disorders due to closer proximity to the area and organ of interest. Its smaller field of view is augmented with trans-abdominal ultrasound that allows a broader field of view.
In addition, Ultrasound examination is the gold standard diagnostic modality in establishing the location and structural appearance of the ovary. Transvaginal sonography allows accurate characterization and location of the ovary. But a report for Sonographic findings does not usually mention the location of the ovary, instead, it is stated as, not seen at its usual anatomical location, and/or located in the posterior cul-de-sac. This omitted crucial information about the location of the ovary is part of the origin of prolapsed ovarian diagnostic dilemma. In addition, patients reveal only lower abdominal pain to their healthcare providers and withhold crucial information about the factor that exacerbates the pain episode, (dyspareunia and associated post-coital pain). The lack of adequate information from patients steers healthcare providers away from making the appropriate diagnosis of a prolapsed ovary. As such, patients always initially failed to reveal that they have dyspareunia and that their persistent pain was aggravated following sexual intercourse. In this regard, Ovarian prolapse should therefore be included in the differential diagnosis of a young multi-para female who presents with acute lower abdominal pain. Moreso, sexual history should be an integral part of every medical history because pertinent sexual and psychosocial data are essential to evaluate the patient wholly.
For this prospective observational study, I observed 56 patients seeking help in the Emergency Room at Fort Washington Medical Center (Nexus Health), Fort Washington, Maryland, U.S.A between December 2015, and September 2018. The records of all these patients in their reproductive ages indicated that they had prolapsed ovaries that caused their painful intercourse and the subsequent lingering lower abdominal pain. The scope of this observatory research was retrospective, randomized, single institution and compiled from patients with Gynecological complaints at the Fort Washington Medical Center’s Emergency Room, Fort Washington, Maryland, USA, from the year 2015 to 2018. The mean patient age is 28 (19-38 years). Also, the author was on-call assignments at this centre, hence, exposure to more patients with this condition was limited. Given the above limitation, the prevalence of this medical condition cannot be specifically presented in this observatory study.
The following are some of the classic cases of patients that were presented at Fort Washington Medical Center Emergency Room between December 2015 and September 2018.
Case Reports
Case 1
A woman in her late 20s, gravid 2, Para 2, was referred for sonographic examination to evaluate diffuse lower abdominal pain for the proceeding 6 hours. The patient‘s past medical history was unremarkable, but further questioning revealed that she often has dyspareunia, and the pain was aggravated following sexual intercourse. The patient reported no other symptoms, such as nausea, vomiting, diaphoresis, or shortness of breath. The patient delivered a healthy baby boy 6 months ago, and before the delivery of her last child, she was not having dyspareunia. Her Gynecologist concluded that her pain emanated from vaginal dryness because she was breastfeeding and prescribed a vaginal cream that did not help. Vaginal dryness has been reported in breastfeeding mothers due to low estrogen which is thought to alter the endocrine milieu of the vaginal lumen. During the examination, the patient had tenderness, and vaginismus– an involuntary reflex spasm of the pubococcygeal muscles that occurs in anticipation of vaginal penetration. The pregnancy test was negative. Her serum quantitative Beta Human Chorionic Gonadotropine (BHCG) was 1mlU/mL (normal, less than 3mlU/mL). Laboratory findings showed the white blood cell count to be normal but had mild hypochromic-microcytic anaemia (Hgb=10.0).
Transabdominal and transvaginal sonograms were performed on GE logiq 9 ultrasound machine using a 5 MHz curvilinear transducer and an 8 MHz endovaginal transducer. The examination revealed a retroverted normal-size uterus, 7.2 x 3.2 x 4.8cm, with a well-delineated endometrial stripe. The left ovary was heterogeneous and enlarged by a cyst, measuring 4.2 x 3.0 x 2.8 cm. It was seen lying behind the uterus in the pouch of Douglas. The transvaginal scan showed a mild amount of hypoechoic fluid collection around the left ovary in the posterior cul-de-sac secondary to the ruptured cyst, in this case, due to ovarian trauma. Color Doppler examination showed increased vascularity secondary to a traumatized ovary. Spectral Doppler revealed high velocity and low resistance arterial flow. The right ovary was normal in size and appearance and seen at the usual anatomical location. Traumatized prolapse of the left ovary in the posterior cul-de-sac was swiftly established with ultrasound.
Case 2
A 28-year-old patient, G4 P3 A1 presented in the emergency room with severe lower abdominal pain for 4 hours. The pain started suddenly and was accompanied by nausea, vomiting, and diaphoresis. On examination, the patient had rebound tenderness and guarding. The patient initially failed to reveal that the pain was aggravated following sexual intercourse. A ruptured and bleeding ovarian cyst of a prolapsed ovary can produce symptoms like a ruptured ectopic gestation. A sonogram was ordered to evaluate for pelvic inflammatory disease (PID), Tuba-ovarian abscess (TOA), or ruptured ovarian cyst. Pending laboratory blood workups, a quick urine pregnancy test was done and was negative.
Transvaginal and transabdominal examinations were done with a GE logiq9. Sonographic findings reveal a normal size and contour anteverted uterus with a well-delineated endometrial stripe. The right ovary contains several follicular cysts and is mildly enlarged by a cyst, but unremarkable echotexture and Doppler blood flow. The left ovary was not located at the usual anatomical location. A well-circumscribed hypoechoic structure was consistent with the ovary surrounded by free fluid of mixed echogenic pattern is seen within the cavum of Douglas. Also, free fluid with echoes was seen in the hepato-renal recess (Morrison pouch) in the trans-abdominal sonogram. Color Doppler examination of this ovary located in the posterior cul-de-sac showed increased vascularity and low resistant flow pattern consistent with a traumatized ovary. Subsequent laboratory findings are WBC, 9.8, RBC, 3.4 Hg, 35, and hematocrit 45. Ultrasound is the sole cost-effective and swift diagnostic tool needed to establish ovarian location and determine the origin of the emergent and dramatic medical condition as was conveyed in this patient.
Case 3
A Woman in her thirties came to ER because of sharp pain in her lower abdomen for 5 hours. She also complained of nausea, vomiting, and shoulder pain. She was diaphoretic. She had fallen earlier dressing up to come to ER. Signs of peritoneal irritation because of guarding and rebound tenderness were present. Laboratory findings and clinical assessment revealed a quantitative Beta human chorionic gonadotropin BHCG of 0mIU/mL. She was not pregnant but had hypochromic microcystic anaemia. Hemoglobin=10.1g/dL (normal range 12.0-16.0g/dL), WBC 8.6 and normal (normal range 4.8-10.8K/uL) Low RBC 2.8m/uL (normal range 4.2-504M/uL, low Heamatocite 24% (normal value 34-43%). normal White blood cell 9.2K/uL. She was hypotensive, BP 95/60, and sinus tachycardia, 101. This woman was heading to a hypovolemic shock due to intraperitoneal haemorrhage caused by a traumatized ovary.
A trans-vaginal and trans-abdominal sonogram was executed with GE logiq 9 revealed a normal size uterus measuring 7.5cm in length, which was unremarkable. The left ovary with follicular cysts is seen at the usual anatomical location. However, the Right ovary with some follicular cysts is placed in the cavum of Douglas surrounded by a heterogeneous structure with mixed components of solid and free fluid representing clots and lytic clots, that extended laterally which on transabdominal sonogram was noted in the hepato-renal recess (Morrison pouch). This suggests traumatized ovary and rupture with hemoperitoneum. Ovarian trauma and forceful ovarian cyst rupture are often associated with abdominal and pelvic pain due to hemoperitoneum, especially in patients with coagulation disorders, or receiving anticoagulants. Rarely will functional ovarian cyst rupture or intracystic haemorrhage will produce intra-peritoneal haemorrhage of such magnitude as found in the ones with ovarian trauma.
Acute pelvic pain in young childbearing women like this patient can be due to a variety of pathologies, and ultrasound is the swiftest, most cost-effective, and most accurate diagnostic modality to evaluate gynaecological disorders. In this patient presenting with a dramatic emergency condition, ultrasound especially transvaginal ultrasound provided better visualization of the ovary details and location. Duplex ultrasound remains the gold standard approach for the definite diagnosis of acute pelvic pain. Duplex ultrasound is a rapid, low-cost, non-invasive, and efficient diagnostic tool in the management of an array of disorders of the female reproductive system, eliminating a multi-disciplinary approach.
Discussion
There are two ovaries, one on each side of the lower abdomen along the side wall of the pelvis; beside the uterus, in a fold of the broad ligament. They are ellipsoid in shape; resembles unshelled almond in size and shape, measuring approximately 3-0cm in length by 2cm in breadth, and 2cm in thickness in a menarche female. They lie vertically and are suspended near the cornua of the uterus by a series of ligaments. Usually, they are lateral or posterior-lateral to a midline of the anteverted uterus. In a retroverted uterus, the ovaries are seen either lateral to the uterus body or superiorly near the fundus. The ovaries lie anterior to the internal iliac vessels and the long axis of the ovaries is parallel to these vessels.
The ligaments holding the ovaries in position are the mesovarium, the ovarian ligament, and the suspensory ligament. Mesovarium is a component of the broad ligament; a-double–layered fold of peritoneum attaches to and stabilizes the ovaries from the back of the broad ligament. Ovarian ligament originates laterally from the cornua of the uterus with the fallopian tube and anchors the ovaries to the uterus from its lower pole, and from its upper pole, the suspensory ligament, also known as infundibular-pelvic ligament, attaches the ovaries laterally to the pelvic wall and carries the ovarian vessels, nerves, and lymphatics.
The ovarian artery, one of the branches of the Abdominal aorta arising just below the renal arteries, is a slender artery that enters the pelvis at the level of the sacroiliac joint and runs below the fallopian tube in the layers of the broad ligament and supplies blood to the ovary, tube and broad ligament. Blood is drained by the ovarian vein, one of a pair of veins that emerge from convoluted plexuses in the broad ligament near the ovaries and the fallopian tubes. The right ovarian vein end in the inferior vena cave and the left ovarian vein joins the renal vein.
Though the ovarian location is variable when the ovary is found in the recto-uterine recess, which is also called posterior cul-de-sac, recto-uterine pouch, posterior-cul-de-sac, and cavum of Douglas, causing individual discomfort, then it is pathologic and the condition is regarded to as prolapse of the ovary. The posterior-cul-de-sac is most dependent on the peritoneal cavity, and a free-falling ovary will end up within the cavity. Also, very frequently, a mild free fluid is seen within the cavity and could be normal from the ruptured follicle, but if the fluid contains pus, blood, or is in large quantity then, pathology might be present that could be associated with ruptured ovarian cysts, ascitic fluid, ruptured ectopic pregnancy, traumatized and bleeding ovary, or pelvic inflammatory disease. This prospective observational study is focused on the ovary noted in this dependent peritoneal cavity region, and the associated dilemmas it poses.
Prolapse is the falling, sinking, or sliding of an organ from its normal position or location in the body, and ovarian prolapse occurs when the group of ligaments that hold the ovary weakens, allowing the ovary to descend into the posterior cul-de-sac. Prolapse of the ovary could occur due to previous injuries to the pelvic muscles, and ligaments, in pregnancy, during prolonged labor, or through having a large baby.
Certainly, not all prolapsed ovaries will have symptoms of discomfort, it depends on the magnitude of the prolapse, how low it has descended into the posterior cul-de-sac, and other factors. Usually, prolapsed ovary will cause severe backache, constipation, pain during intercourse, and hardships in defection. Blood in the peritoneal cavity may irritate the bladder, diaphragm, and rectum causing dysuria, shoulder-tip pain, and rectal tenesmus. Fainting could occur caused by reflex vasomotor disturbance following peritoneal irritation. Blood examination will indicate a substantial reduction in the Red blood cell (RBC) count and, or haemoglobin, without explanation by external blood loss, which is very suggestive of a leaking traumatized ovary. In patients with coagulopathy, blood clotting disorder, patients may be hemodynamically unstable, with tachycardia, and irregular sinus rhythm. Ovarian prolapse is seen frequently in ultrasound and not being mentioned. We should be aware of this type of finding and mention it alerting the physician to look into other associated problems with it. Clinical awareness is the key point here. Mention ovarian prolapse in comments, or report when seen, and make sure the physicians are getting this report. Physicians hope to get every information they could get from the exam.
Ovarian prolapse is classified as Simple and Compound Prolapse.
Simple Ovarian Prolapse: Simple ovarian prolapse is paramount in my investigation, as it commonly occurs in middle-aged childbearing females. It could also be called independent ovarian prolapse because only the ovary is prolapsed independent of other pelvic organs. The major predisposing factors to this type of prolapse are pregnancy and childbirth. The condition commonly follows pregnancy due to Stretching of the ovarian ligament, and other ligaments that support the ovary. Increased weight during pregnancy is also one of the predisposing causes. Injuries to pelvic organs, ligaments and the pelvic floor may occur in any labor, but are more likely with large babies, prolonged second-stage labor, and malpresentation of the fetus. These are all underlying causes of ovarian prolapse. In puerperium, the involuted uterus could be retroverted, the ovary relocated from its original location (prolapsed}, and in most cases placed in the pouch of Douglas. The tender ovary lying behind the uterus, in the pouch of Douglas. starts the unprecedented agony as the ovary is now vulnerable to injuries during pelvic exanimation or coitus, causing deep dyspareunia, lower backache, defecation problems, and abdominal pain. Any trauma including sexual intercourse and pelvic examination, could rupture the fragile ovary and produce haemorrhage, and the mechanism of pain involves peritoneal irritation by extruding blood or cyst fluid, ischemia, or acute enlargement of the ovary. Associated symptoms may include nausea and vomiting, shoulder pain, syncope, and shock. Signs of peritoneal irritation with guarding and rebound tenderness may be present. Anaemia or hypovolemic shock due to intraperitoneal haemorrhage and increased free fluid in the cul-de-sac are often encountered. Sonography is the sole diagnostic modality for a definitive diagnosis of a prolapsed ovary. Sonographers and other healthcare providers need to use ultrasound for diagnosis to recognize malposition of the ovary. When malposition of the ovary is encountered, its exact location should be documented. Not all simple ovarian prolapse will come with symptoms depending on how low the ovary has dropped into the Cavum of the Douglas, which is also referred to as, posterior cul-de-sac, and Recto-uterine recess.
The Three Stages of Simple Ovarian Prolapse
STAGE 1
This is a mild prolapse, and there is no significant clinical manifestation as the ovary has descended slightly lower from its original anatomical location, and at the entrance of Cavum of the Douglas.
STAGE 2
This is a moderate prolapse with clinical manifestations involving post-coital pain, and defecation dilemma. The ovary has descended into the Cavum of the Douglas, but not completely into the floor of the cavum of the Douglas.
STAGE 3
This is a complete prolapse with clinical manifestations such as defecation ordeals, back pain, post-coital pain due to ovarian trauma, and vaginismus. The ovary has descended completely into the extreme end of the cavum of Douglas as illustrated below.
Compound Ovarian Prolapse
Compound ovarian prolapse is worth discussing even though it is not the focus of this observatory study. In compound ovarian prolapse, the ovary is prolapsed along with other pelvic organs; better referred to as genital prolapse, it is the herniation of the uterus pulling ovaries along the bladder or rectum or all into the vaginal canal. In severe cases, the protrusion may bulge through the vaginal introitus. As earlier mentioned, childbirth is the common predisposing factor. The pressures of the gravid uterus on the cervix cause stretching or even tearing of the cardinal and uterosacral ligaments which are connected to it. Also, stretching occurs in the pelvic floor, especially to the lavatorial muscles; increased intra-abdominal pressure resulting from weight gain, heavy physical labor, a chronic cough, constipation or less frequently, the weight of an abdominal tumour are all contributing factors to genital prolapse.
Genital prolapse could manifest as uterine prolapse is classified as first, second and third degrees, and depends on the magnitude of the fall of the uterus into the vagina. When the uterine body can be seen outside the vaginal introitus is a third-degree prolapsed. Uterine prolapse that just pushed the cervix slightly into the vagina is classified as first-degree prolapse and when the cervix is inside the vagina, but not visible outside the vaginal introitus is a second-degree prolapse, and third-degree, of course as earlier mentioned, is when the uterus had protruded out the vaginal introitus.
Cystocele is the bulging of the front of the vaginal wall due to damage to uterine supports and pelvic floor that allows herniation of the bladder or urethra to occur through the anterior vaginal wall when the patient strains, and very commonly urine trickles from the urethral orifice at the same time. Typically the patient complains of stress incontinence which means the inability to control the passage of urine when she laughs, coughs, sneezes, and in the worse cases when she is simply up and about. Bladder prolapse may occur alone, it is commonly combined with more or less uterine prolapse.
Rectocele is the bulging of the back of the vaginal wall due to pelvic organ prolapse affecting the rectum. This condition only occurs if inflammation in the recto-vaginal septum has caused adhesions to form between the rectal and vaginal walls. In this case, the feeling of incomplete emptying of the rectum and possibly some degree of constipation is common.
Compound prolapse is most common during menopause when atrophy of the genitalia naturally occurs. Also, with advanced age, muscles, and ligaments weaken probably due to injuries sustained years earlier, in pregnancy, during a long labor, and during the delivery of large babies. Although this condition may occur at any age, it is very unlikely to occur in a woman under menopause age.
Rarely is prolapse encountered in women who have never been pregnant. The predisposing factor for non-pregnant women prolapsed is a congenital weakness of the cardinal ligaments and other supporting structures. Poor health, emaciation, heavy physical work and increased intra-abdominal pressure are additional factors which may cause genital prolapse in women that have never been pregnant.
Diagnosis:
Any condition that obstructs the entrance of the vagina or narrows the vagina tube may cause dyspareunia and interfere with intercourse. This obstruction may be congenital, the result of scarring from a birth injury or an operation, or the result of atrophy in menopausal women. Vagina and valvular infections will render the tissue so sensitive that coitus becomes either painful or impossible. Less often, pelvic lesions such as Salpingo-oophoritis, endometriosis, prolapsed ovaries, and retroversion of the uterus may be responsible causes of dyspareunia. Also, atrophic vaginitis caused by estrogen lack may cause dyspareunia in breastfeeding and post-menopausal women.
The elusive simple ovarian prolapse in women before menopause deserves better attention. Ultrasound is the sole diagnostic equipment needed for the diagnosis, and its treatment could be as simple as shortening the ovarian ligament and pulling it out from Douglas’s pouch. Appropriately focused evaluations should be initiated in women who complain of painful intercourse or the ones who during pelvic exanimation react by tensing the muscles that surround the introitus of the vagina; tightening of the thigh muscles and spasm of the levator ani muscles. The spasmodic reaction could almost close the entrance of the vagina. This condition is known as vaginismus-involuntary reflex spasm of the pubococcygeal muscles that occurs in anticipation of vaginal penetration. It could be a reaction to pain experienced in early intercourse due to prolapsed ovary. During vaginal examinations, patients who exihibits vaginismus should have prolapse of the ovary included in the differential diagnosis.
It is a difficult disease to diagnose because most clinical signs do not give clear evidence of ovarian prolapse. Most health care providers will attribute pelvic and other gynaecological problems to various other gynecologic pathologies, but not prolapse of the ovary. The rule has to change to best address young women with chronic pain, dyspareunia, lack of orgasm, constipation and defection problems. Prolapsed ovary should always be included in the differential diagnosis in all childbearing women with dyspareunia and other pelvic discomforts. The notion that a young woman who delivered a healthy baby six months ago, breastfeeding with a new onset of dyspareunia is emanating from atrophic vaginitis because she is breastfeeding, and the application of estrogen based suppositories, or creams to rectify the problem has to change. The notion that tenderness of the ovaries is due to neurasthenia and that after rest and proper diet, the tenderness will disappear has to change. The perception that most chronic pelvic discomfort is due to pelvic congestion, has to change. Endometriosis, PID and ovarian cyst which are often offending factors for persistent pelvic discomfort, and dyspareunia should be properly investigated to exclude ovarian prolapse.
To swiftly recognize and diagnose simple ovarian prolapse in young childbearing women, the Okene triad (concurrent three symptoms associated with simple ovarian prolapse) should be noted. When the symptoms are present in the patient history, ovarian prolapse should be included in the differential diagnosis, and ultrasound is used to evaluate the ovaries for a definite diagnosis.
The Okene triad: Three classical concurrent clinical symptoms associated with simple ovarian prolapse are:
- -Patient is of reproductive age and had delivered at least one child.
- -New onset of dyspareunia that was not experienced before childbearing, and after previous births.
- -Postcoital diffuse lower abdominal pain lasting for three hours.
Conclusion:
I have been in the field of Ob/Gyn ultrasound since 1987 when I was a resident physician in Ob/Gyn at the University Medical Center of the University of Sarajevo. Subsequently as a staff Gynecologist and Obstetrician; Medical student and Residents clinical mentor, diagnostic ultrasound was my area of interest. Since then, I have watched this simple, rapid, safe, and non-invasive fascinating diagnostic modality used in Ob/Gyn improve dramatically and evolve into a sophisticated diagnostic tool in the management of female reproductive, fetal and maternal problems. The 3D and 4D ultrasound have elevated this diagnostic tool to its Gold standard status in evaluating various conditions in Obstetrics/Gynaecology. Ultrasound has achieved significant advancement. Classical Okene triad symptoms and ultrasound will swiftly and accurately diagnose simple prolapses of the ovary.
Findings
This study finds that a careful history and physical examinations are essential to include sexual symptoms such as dyspareunia, vaginsmus, inability to achieve orgasm, and whether the lower abdominal pain is aggravated following sexual intercourse. Established Okene triad symptoms through medical history and physical examinations are augmented with ultrasound examination to establish a definite diagnosis of an ovarian prolapse. The agonizing patient will now be en route to recovery with a simple surgical correction of the prolapsed ovary by restoring the ovary to its proper position. Correction of the ovarian prolapse is by surgery, under general anaesthesia, elective, non-elective, or urgent depending on the patient’s condition. The ovary is fixed by a suture in its proper position; and or shortening of the ovarian ligament. Laparotomy and shortening of the ovarian ligament with a silk-plicating suture will correct the ovary malposition and relieve the symptoms. Where the prolapsed ovary is bound down by salpingo-oophoritis or endometriosis, the ovary must be freed, first, from adhesion to restore full mobility.
Future Recommendations
I am suggesting that patients who seek help for acute onset of pain in the lower Abdomen should be included in the differential diagnosis of ovarian prolapse and ovarian trauma, especially in multiparous childbearing age women. Prolapse of the ovary should be included in the differential diagnosis for a young multiparous female who presents with acute lower abdominal pain lasting several hours, and dyspareunia. The classical triad –okene triad, supported by sonographic findings of the location of the ovary in the cul-de-sac swiftly diagnoses simple ovarian prolapse and allows treatment workup.
It is important for healthcare providers utilizing ultrasound as a diagnostic imaging modality to accurately demonstrate the location of the ovary, especially if it is not seen at the usual anatomical location and document the location in all associated reports. Also, the characteristics, size of the ovary and absence and presence of colour flow, and associated findings, such as heterogeneous fluid collection around the ovary in the posterior cul-de-sac are very important in the diagnosis, management and treatment of ovarian prolapse. When all this information is conveyed in the report, even if factors that exacerbated lower abdominal pain are omitted in the patient history, a report depicting the ovary in the Cavum of Douglas will prompt the patient’s healthcare provider to ask the patient for further symptoms associated with her pain and ovarian prolapse. This approach further allows diagnosis and swift management and resolution of the patient’s medical ordeal.
Declaration of conflicting interests:
The author declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.
Funding:
The Author received no financial support for the research, authorship, and or publication of this article.
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Douglas G. Wilson Clyne: A Textbook of Gynecology and Obstetrics. Longmans 1963
Elsie Reid Carrington: Obstetrics and Gynecology, The C.V. Mosby Company, St. Louis 1983
JAMA. 1907; XLIX{18):1507-1512
Author: Sanidr333@gmail.com;
