Case Report

Ruptured Hemorrhagic Corpus Luteum Cyst in an Undescended

Ovary: A Rare Cause of Acute Abdomen
Dong Soo Suh MD, PhD 1, Si Eun Han MD 1, Ka Yeong Yun MD 1, Nam Kyung Lee MD, PhD 2,
Ki Hyung Kim MD, PhD 1,*, Man Soo Yoon MD, PhD 1
1
Department of Obstetrics and Gynecology, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan,
Republic of Korea
2
Department of Radiology, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea

a b s t r a c t
Background: Undescended ovaries are typically detected during infertility evaluations and are frequently associated with uterine mal-
formations. Ruptured hemorrhagic corpus luteum cyst of an undescended ovary is an unusual cause of acute abdomen in an adolescent.
Case: A 15-year-old girl presented with right lower quadrant pain, nausea, and vomiting, and transabdominal sonography and magnetic
resonance imaging of the pelvis showed a 10 cm  5 cm sized cystic mass at the level of the pelvic brim, anterior to the psoas muscle
suggestive of a retroperitoneal hemorrhagic cyst. At surgery, the uterus and left adnexa appeared normal, but the right ovary was not
visible within the pelvic cavity, and the right pelvic retroperitoneum was distended. After opening the retroperitoneum and aspirating
blood clots, the undescended ovary with a ruptured cyst was visualized within the retroperitoneum. Right ovarian wedge resection was
performed and the right ovary was repositioned in the pelvic cavity.
Summary and Conclusion: Rupture of a corpus luteum cyst in an undescended ovary should be included in the differential diagnosis of acute
abdomen in adolescents.
Key Words: Undescended ovary, Corpus luteum cyst, Acute abdomen

Introduction the RLQ area containing a hemorrhagic portion. Magnetic

Undescended ovaries and tubes are a relatively uncom-
mon congenital disorder. Ovaries and testes have similar
developmental descending pathways, but ovaries descend
from the posterior abdominal wall and end in the pelvic
cavity. Furthermore, abnormalities in the descent of ovaries
and tubes are less frequent.1 Common causes of acute
abdomen in adolescents, such as, acute appendicitis, torsion
of an ovarian cyst, rupture of a corpus luteum cyst, and
ectopic pregnancy should be included in the differential
diagnosis. Here, we report a rare cause of acute abdomen in
a patient who presented with a retroperitoneal unde-
scended ovary with corpus luteum hemorrhage.
Case
A 15-year-old girl presented with aggravating right lower
quadrant (RLQ) pain, nausea, and vomiting. Her last men-
strual period had occurred 3 weeks previously. She had a
history of surgery for a right inguinal hernia at 9 months of
age. Physical examination revealed tenderness in the RLQ
but no peritoneal signs. Her vital signs were stable, her urine
pregnancy test was negative, and laboratory examinations
were within normal limits. Transabdominal sonography
showed a 9.5  4.5 cm, well circumscribed, cystic mass in
The authors indicate no conflicts of interest.
* Address correspondence to: Ki Hyung Kim, MD, PhD, Department of Obstetrics
and Gynecology, Pusan National University School of Medicine, 179, Gudeok-Ro,
Seo-Gu, Busan 602-739, Korea; Phone 82-51-240-7287:
E-mail address: ghkim@pusan.ac.kr (K.H. Kim).
1083-3188/$ - see front matter Ó 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jpag.2015.09.004
resonance imaging (MRI) of the pelvis depicted a 10  5 cm
cystic lesion at the level of the pelvic brim, anterior to the
psoas muscle (Figure 1). On T2-weighted images, the lesion
presented as a 4  2.7 cm unilocular hypointense cyst that
was entrapped within the hyperintense fluid-filled cystic
lesion. The central unilocular cyst showed fluid-fluid level
on T2-weighted images, hyperintensity on T1-weighted
images, and thick wall with enhancement on contrast-
enhanced images, findings indicative of hemorrhagic
corpus luteum cyst. The peripheral cystic lesion was sus-
pected to be a peritoneal inclusion cyst. The uterus, vagina,
right ovary, and both kidneys were normal in appearance on
MRI. The RLQ pain, nausea and vomiting persisted after the
patient received painkillers and antiemetics. The patient
was taken to the operating room for diagnostic laparoscopy.
The uterus and left adnexa appeared normal but the right
ovary was not visible within the pelvic cavity, and the right
pelvic retroperitoneum was distended. The retro-
peritoneum was opened and hemorrhage and blood clots
were aspirated. The right ovary with a ruptured cyst was
visualized. The right tube was not in communication with
the uterus, and showed some swelling and a hydrosalpinx
pattern. Right ovarian wedge resection and salpingectomy
were performed. The retroperitoneum was repaired, and
then the right ovary was repositioned at the end of the
repaired peritoneum at the level of the contralateral ovary.
No other associated malformations were found.
Her postoperative recovery was uneventful, and she was
discharged 3 days after surgery. Postoperative pathological
findings revealed a corpus luteal cyst of the ovary.
e22 D.S. Suh et al. / J Pediatr Adolesc Gynecol 29 (2016) e21ee24

Figure 1. Magnetic resonance imaging findings of ruptured hemorrhagic corpus luteum cyst of an undescended ovary. (A) Coronal and (B) sagittal T2-weighted images of the pelvis
show a unilocular hemorrhagic cyst (arrows) in the right undescended ovary at the level of the pelvic brim, anterior to the psoas muscle. The hemorrhagic cyst of the right ovary is
entrapped within the fluid-filled peritoneal inclusion cyst (*). (C) On axial T1-weighted image, the right undescended ovary appears as a hyperintense hemorrhagic cyst (arrow). (D)
Axial contrast-enhanced fat-suppressed T1-weighted image shows a peripheral thick wall with enhancement (arrowhead) in the hemorrhagic cyst. (E) Axial T2-weighted image
shows a normal uterus and left-sided ovary. (F) Axial T1-weighted image of the upper abdomen shows normal kidneys.

Karyotype analysis showed a normal female chromosome.
During follow-up, the patient reported regular menstrua-
tion and no recurrence of abdominal pain, nausea, or
vomiting.
Summary and Conclusion
We report a rare cause of acute abdomen that presented
with a ruptured hemorrhagic corpus luteum cyst of an un-
descended ovary in an adolescent girl. The reported inci-
dence of undescended ovary is 0.3%-2%,2 and the condition
can occur when the gubernaculum fails to attach to the
lower pole of the gonad.3 Defects in the developments of
the Mu€ llerian structures can be accompanied by renal
anatomical defects, such as ectopic location, aberrant
anatomy, or complete agenesis.4 Undescended ovary can
occur unilaterally or bilaterally, and might occur in patients
with a normal uterus, but its incidence is significantly
greater in women with uterine anomalies.5 In cases of
unicornuate uterus, the incidence of ectopic or unde-
scended ovary has been reported to be as high as 42%.5 In
addition, unilateral undescended ovary has been reported
to be more common on the right side and more likely to be
located in the retroperitoneum.6 Although undescended
ovary is associated with infertility, spontaneous pregnancy
could be possible when a patient possesses at least 1 normal
tube and 1 normal ovary.6
Undescended ovary is uncommonly diagnosed in isola-
tion, and might be more frequent in infertile individuals or
in association with developmental anomalies of the uterus
or renal collecting system.2 In a previous report, 77% of
reported cases were asymptomatic and diagnosed
 D.S. Suh et al. / J Pediatr Adolesc Gynecol 29 (2016) e21ee24 e23

Table 1
Symptomatic Cases of Undescended Ovary

Source Cases Age, years Mu€ llerian Renal Anomalies Method of Preoperative Postoperative Affected
Anomalies Diagnosis Diagnosis Diagnosis Side

Kives et al8 1 13 Bicornuate uterus None CT, laparoscopy Congenital intestinal Ruptured hemorrhagic Both
duplication cyst of right ovary
Gabriel et al* 1 29 Left unicornuate Right renal agenesis IVP, laparoscopy, Ectopic pregnancy Right tubal pregnancy Right
uterus USG
Cohen et al* 1 18 None None CT, laparoscopy abdominal wall Functional cyst of left Left
hemangioma ovary
Pokoly et al* 1 26 Right unicornuate None HSG, laparoscopy Ectopic pregnancy Primary amenorrhea Left
uterus
Seoud et al* 1 28 Right unicornuate Left pelvic kidney Laparotomy Ectopic pregnancy Left tubal pregnancy Left
uterus
Brown et al* 1 24 Right unicornuate Left renal agenesis IVP, laparotomy, Ectopic pregnancy Left tubal pregnancy Left
uterus USG
Granat et al* 1 23 Right unicornuate Left renal agenesis HSG, IVP, laparotomy Ectopic pregnancy Left tubal pregnancy Left
uterus
Dabby et al* 1 34 None Right renal agenesis IVP, laparotomy None Right tubal pregnancy Right
Adnopoz et al* 1 22 None Not listed Laparotomy Torsion of left Torsion of left ovarian Left
ovarian cyst cyst
Nichols et al* 1 36 None Left renal agenesis Laparotomy Acute cholecystitis Hemorrhagic cyst of Left
right ovary
Present case 1 14 Left unicornuate None Laparoscopy, MRI, Pseudocyst Ruptured hemorrhagic Right
(2015) uterus USG cyst of right ovary

CT, computed tomography; HSG, hysterosalpingography; IVP, intravenous pyelography; MRI, magnetic resonance imaging; USG, ultrasonography
* Dietrich et al.7

incidentally during infertility evaluation.2 Furthermore, oocytes from an undescended ovary for in vitro fertilization
ectopic pregnancy rates are increased in these populations, were reported.2 In addition, some authors have concluded
with a prevalence of 4%,2 especially when an undescended that ovarian stimulation offers a useful approach to facili-
ovary has a rudimentary or ectopic tube or undescended tate the diagnosis of undescended ovary, especially in pa-
ovary is bilateral. If there are additional uterine anomalies, tients with uterine anomalies.5 Sometimes, an
such as unicornuate uterus, the risk of miscarriage in- undescended ovary becomes symptomatic and might cause
creases.2 More than 10 cases of successful retrieval of an acute surgical abdomen. In symptomatic cases, the

Table 2
Asymptomatic Cases of Undescended Ovary

Source Case Age, Mu€ llerian Renal Method of Diagnosis Diagnosis during Chief Problem Affected
years Anomalies Anomalies Infertility Workup Side
(yes or no)

Uyar et al1 1 26 Left unicornuate Right renal HSG, laparoscopy, MRI Yes Primary infertility Right
uterus agenesis
Halil et al* 1 27 None None Laparoscopy, USG Yes Secondary infertility Right
Trinidad et al2 1 20 None None HSG, MRI, USG No Menstrual irregularity Right
2 14 MRKH syndrome Left renal MRI, USG No Primary amenorrhea Left
agenesis
Ombelet et al3 1 Not listed Right unicornuate None HSG, laparoscopy, MRI Yes Primary infertility Left
uterus
2 26 Right unicornuate None HSG, hysteroscopy, Yes Primary infertility Left
uterus laparoscopy, MRI
3 Not listed Right unicornuate Left renal HSG, laparoscopy, MRI Yes Primary infertility Left
uterus agenesis
4 Not listed Left unicornuate Right renal HSG, laparoscopy, MRI Yes Primary infertility Right
uterus agenesis
4
Ombelet et al 1 28 Right unicornuate None HSG, hysteroscopy, IVP, Yes Secondary infertility Left
uterus laparoscopy, MRI
Ombelet et al* 1 Not listed Right unicornuate Left renal HSG, laparoscopy, MRI Yes Primary infertility Left
uterus agenesis
2 Not listed Left unicornuate None MRI, USG Yes Primary infertility Right
uterus
5
Gorgen et al 1 19 Bicornuate uterus None HSG, laparoscopy, USG Yes Primary infertility Both
Van Voorhis et al6 1 35 Bicornuate uterus None HSG, laparoscopy Yes Secondary infertility Both
Verkauf et al* 1 27 Bicornuate uterus None HSG, laparoscopy Yes Primary infertility Both
2 31 None None HSG, hysteroscopy, Yes Secondary infertility Left
laparoscopy
3 33 Left unicornuate None HSG, laparoscopy Yes Primary infertility Right
uterus
4 32 None None HSG, laparoscopy Yes Secondary infertility Right
5 35 None None HSG, laparoscopy Yes Secondary infertility Right
€ ster-Hauser; USG, ultrasonography.
HSG, hysterosalpingography; IVP, intravenous pyelography; MRI, magnetic resonance imaging; MRKH, Mayer-Rokitansky-Ku
* Dietrich et al.7
e24 D.S. Suh et al. / J Pediatr Adolesc Gynecol 29 (2016) e21ee24
Table 3
Comparison Between Asymptomatic Type and Symptomatic Type of Undescended
Ovary
Variable Asymptomatic Type
Number 18 cases
Mean age  SD, years 26.5  5.93
Method of diagnosis Infertility workup, ovarian
hyperstimulation
Mullerian anomaly 10 of 17 (55.6%)
Renal anomaly 5 of 17 (29.4%)
Affected site
Right 7 of 17 (41.2%)
Left 7 of 17 (41.2%)
Both 3 of 17 (17.6%)
History of Inguinal hernia 1 case
MRI, magnetic resonance imaging.
common symptom is abdominal pain secondary to a
ruptured ovarian cyst or ovarian torsion.6 Furthermore, the
condition might easily be mischaracterized because of
diverse preoperative impressions (Table 1).7 In all reported
cases, a definite diagnosis was made after surgery. Many
authors have reported that MRI is the best diagnostic im-
aging modality for undescended ovary, because it is
noninvasive, highly sensitive, and specific for the diagnoses
of genital tract and combined renal anomalies.2,5
Conservative management is preferentially considered
for undescended ovary. Morbid ovaries or tubes are not
always indicated for resection because no association has
been found between it and premature ovarian failure,
polycystic ovaries, endometriosis, or other gynecological
conditions.1,2 However, a noncommunicating fallopian tube
should be removed immediately to prevent ectopic preg-
nancy when recognized.6 Undescended ovary might be
associated with a previous history of ipsilateral inguinal
hernia,5,7 as was shown in our case.
Twenty-nine cases (including our case) of asymptomatic
or symptomatic undescended ovary have been reported. Of
these, 18 cases (62%) were asymptomatic and 11 (38%) were
symptomatic. Sixteen of the asymptomatic cases were
diagnosed at the time of infertility work-up (Table 2).1e6
However, all reported symptomatic cases were diagnosed
postoperatively (Table 1).7,8 Furthermore, a comparison of
these 18 asymptomatic and symptomatic cases (Table 3)
revealed mean age at diagnosis of 26.5  5.93 and
Symptomatic Type
24.3  7.07 years, respectively. The symptomatic type was
11 cases
usually diagnosed after MRI and surgery, and the asymp-
24.3  7.07
MRI, surgery tomatic type was diagnosed during infertility workup and
ovarian hyperstimulation. Mu € llerian anomaly and renal
7 of 11 (63.4%)
anomaly were more common for the symptomatic type.
5 of 10 (50%)
Affected sites were not different for the asymptomatic type.
2 of 11 (18.2%) However, the symptomatic type usually affected the left
7 of 11 (63.6%)
side, and a history of inguinal hernia was more common for
1 of 11 (9.1%)
3 cases the symptomatic type (three cases vs one case). However,
small case numbers obscure the relation between unde-
scended ovary and inguinal hernia.
We report herein on a case of retroperitoneal unde-
scended ovary with corpus luteum hemorrhage as a rare
cause of acute abdomen. In addition, we included a com-
parison of the features of asymptomatic and symptomatic
undescended ovary. Notably, the asymptomatic type is
usually diagnosed during infertility workup and the
symptomatic type is usually diagnosed after surgery
because of abdominal pain.
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