A 26-year-old White woman presents to the gynecology clinic complaining of a 6-month history of progressively worsening right lower quadrant (RLQ) pain and painful defecation. She reports constant, dull, and throbbing pain, with occasional sharp, stabbing pains that radiate to her lower back and right hip. She also describes a “pulling sensation” in her abdomen during defecation.

Her symptoms include fatigue, constipation, bloating, decreased stool caliber, pressure on urination, and deep dyspareunia. The patient notes that symptoms are notably worse the week before menses. She denies weight loss, hematochezia, fever, nausea, vomiting, hematuria, vaginal discharge, dysmenorrhea, and menorrhagia and reports that ibuprofen and polyethylene glycol laxatives have not relieved her pain.

Medical History

Medical history is significant for a hemorrhagic right ovarian cyst that resulted in an emergency department visit 4 months before the onset of the current symptoms. She is an otherwise healthy woman, with no history of pregnancy, abdominal surgery, or sexually transmitted disease. The patient’s menarche occurred at 13 years of age, and her menstrual cycles occur every 28 to 32 days and last 5 to 7 days. Her family history is positive for uterine fibroids and breast and colon cancers. She takes no medications other than those previously mentioned for pain and constipation.

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On further questioning, the patient admits the dyspareunia began when she was 22 years old. She reports that 3 different gynecologists examined her and failed to identify a cause for her dyspareunia. She was referred to physical therapy for pelvic floor strengthening but was dismissed after her first treatment due to normal pelvic tone. No other treatments or diagnostic tests were offered.

Around this time, she also had 2 visits to her primary care provider (PCP) for evaluation of her abdominal pain and gastrointestinal complaints. Her examinations were unremarkable and a hemoccult test was negative. The PCP recommended an over-the-counter laxative and told her to eat a higher fiber diet for her constipation. The PCP also advised her to try a gluten and lactose elimination diet to rule out food allergies. The patient’s symptoms persisted despite these therapies. Her PCP ultimately recommended that she follow up with a gynecology provider due to her recent history of an ovarian cyst.

Gynecologic Examination and Imaging

On examination, the patient’s abdomen is soft and nondistended, with bowel sounds active in all 4 quadrants. She has moderate tenderness and guarding during palpation of the right lower quadrant. No abdominal mass is noted and costovertebral angle tenderness is negative. Her vitals are shown in Table 1.

During pelvic examination, the patient experiences mild pain on insertion of the vaginal speculum. Her external genitalia, vaginal mucosa, and cervix appear normal. The adnexa of the uterus are moderately tender on bimanual examination. She does not have cervical motion tenderness. Palpation of the uterosacral ligaments and posterior cul-de-sac during rectovaginal examination causes severe pain, and there is palpable fullness in the posterior cul-de-sac. A hemoccult test is negative.

On transvaginal ultrasound (TVUS), the uterus is anteverted and measures 8.50 × 4.27 × 4.15 cm, with an endometrial thickness of 0.73 cm. The myometrium appears normal. A small amount of fluid is present in the cul-de-sac. The bladder is compressed by the uterus. The left ovary is located laterally and measures 5.43 × 3.71 × 4.07 cm. It contains multiple simple follicles. No abnormal blood flow is noted. The right ovary is enlarged by an 8.08 × 8.19 × 7.03 cm cyst with a wall thickness of 0.55 cm. The cyst appears homogeneous and hypoechoic, surrounded by poor vascular flow.