Understanding benign ovarian cysts

Different kinds of ovarian cysts can develop at any age. These fluid-filled sacs are mostly benign, relatively common, and will often resolve on their own with time.

However, for some women, complications can arise, and they may experience ovarian torsion, a cyst rupture or a cyst haemorrhage. In these cases, the person will experience sudden or grumbling pain and require a diagnostic ultrasound scan to identify the problem and help rule out other conditions with similar symptoms, like pelvic inflammatory disease, ectopic pregnancy and appendicitis. For some women, ovarian cysts are picked up during scans for other reasons, such as during pregnancy, and they may not experience any symptoms at all.

Oxford Women’s Health gynaecologist Dr John Short recently gave a presentation to South Island General Practitioners about sudden or acute ovarian cyst changes and shared his key insights.

Ovarian torsion
An ovarian torsion occurs when the ovary twists on its surrounding ligaments, compressing the vein and blocking the artery, limiting essential blood supply to the organ. Symptoms include severe abdominal pain or a grumbling pain that builds up over time, nausea, vomiting and abdominal and/or pelvic tenderness.

Ovarian torsion is a serious condition that is common in women with cystic or enlarged ovaries. Pregnant women and younger women are more likely than others to experience an ovarian torsion because their tissue is stretchier. An ultrasound will determine the diagnosis and if the person is in significant pain, urgent surgery may be required. This involves a relatively simple laparoscopic procedure.

If cysts are found, they can be removed to help prevent the ovary twisting again. The surgeon may even stitch the ovary to another structure in the pelvis to stabilise it further. In serious cases, the ovary may need to be removed but this is avoided if at all possible. Sometimes the severe pain of an ovarian torsion may subside, or patients may experience chronic torsion, which is less painful, but grumbles over time as the ovary intermittently loses blood supply. In the long run, a chronic torsion will still require treatment, so don’t put off speaking to your GP if you are experiencing discomfort.

Cyst rupture
A cyst rupture is another common cause of abdominal pain, and can be sudden and severe. It may also involve vaginal bleeding and may become
 

Dr John Short

worse with movement as fluid is released into the pelvis. Generally, a ruptured cyst will resolve on its own without treatment, but if symptoms are difficult to control or there is significant bleeding, surgery may be required to remove the fluid from the pelvic area.

Cyst haemorrhage
Cysts that are filled with blood sometimes leak, resulting in a cyst haemorrhage. They may be associated with cyst ruptures and can cause sudden pain. As with a cyst rupture, an ultrasound will be needed and the issue will generally resolve without treatment, but in some cases, surgery may be required.

What next?
If you are diagnosed with an ovarian cyst, your specialist team will review the findings of the scan and let you know what happens next. This differs between pre-and post-menopausal women, but will often involve follow-up ultrasounds, and/or a referral to a gynaecologist for assessment. This may be urgent depending on symptoms, such as severe pain.

While some ovarian cysts will be cancerous, generally most are either simple cysts or classic benign lesions. The different types of classic benign lesions include:

·       Follicle cysts that occur when the ovary does not fully release an egg.

·       Corpus luteum cysts that form when the corpus luteum - a structure that has an important role during pregnancy - fails to break down and continues to grow, filling with fluid.

·       Dermoid cysts that form as sacs from reproductive cells, often containing hair, skin, and bony fragments.

·       Ovarian endometriomas that fill with menstrual blood and can be an indication of endometriosis.

·       Para-ovarian cysts that fill with fluid and are found near the ovaries or fallopian tubes.

Identifying surgical options to treat urinary incontinence

Continuing our series on urinary incontinence, Oxford Women’s Health Urogynaecologist Dr Fiona Bach shares an update from a surgical perspective.

These days there are many different options available when it comes to treating urinary incontinence. The ultimate decision on how to proceed, and whether surgery is required, will depend on the type of incontinence you have and the impact your symptoms are having on your lifestyle. Some people, for instance, want to avoid leakage at all costs and opt for surgery with the highest chance of success. Some people busy with family and work life may choose a less invasive option, and others find they can manage using various specialist incontinence treatments, such as pessaries.

There are two main types of urinary incontinence: Stress Urinary Incontinence (SUI) and Urgency Urinary Incontinence (UUI). SUI is leakage that is caused by increased intra-abdominal pressure and a relaxed or weakened pelvic floor, and can occur when a person coughs, laughs, jumps or sneezes. UUI symptoms happen when the detrusor muscle around the bladder squeezes involuntarily, often leading to more urgent, frequent trips to the bathroom.

Alongside these conditions, people often report other issues that may be causing or contributing to their discomfort, for instance, a history of recurrent urinary tract infections, an overactive bladder, constipation, leakage during sex, and side effects from other medications. For these reasons, it’s essential that we obtain a full picture of your symptoms and history, complete tests and a physical examination, and then discuss the best options to suit you and your lifestyle. They may include the following:

Non-surgical options

Lifestyle changes
In some cases, lifestyle changes may resolve the issue without any need for medical intervention. A good place to start is to avoid bladder stimulants, such as coffee and tea, and bladder irritants, including nicotine, alcohol, fizzy drinks, tomatoes, and onions. For SUI, pelvic floor muscle training is very important and most effective if you are supervised by a physiotherapist. Once you know the correct technique, the NHS squeezy app can be downloaded on to your phone to provide regular reminders and information. Pessaries may also be an option for some people.

Botox
If you have overactive bladder symptoms and conservative measures haven’t worked, Botox can be injected into the detrusor muscles surrounding the bladder to relax them. It takes about two weeks to work and the effects last for six months. This option can be beneficial for breaking the cycle of the brain ruling the bladder and often only requires one session.
 

Dr Fiona Bach

PTNS and TENS
There is increasing evidence that a Transcutaneous Electrical Nerve Stimulation (TENS) machine can help to improve bladder overactivity. Pretibial Nerve Stimulation (PTNS) can also be applied to the nerve that helps control the bladder, which goes down to the ankle. 

Surgical options for SUI
If lifestyle changes, along with pelvic floor exercises, and trialling pessaries have not helped, and the person wants to proceed with further treatment, there are four surgery options to consider.

Fascial sling
A fascial sling is prepared using your own connective tissue to create a sling that sits underneath the urethra. Tension is added to prevent urine leakage. While quite a major operation, the success rate for fascial slings is between 80 and 90 per cent.

Bulking agent
A lower risk operation to be considered is injecting the gel Bulkamid into the wall of the urethra. This is done using a cystoscopy. The Bulkamid narrows the urethra making it harder for urine to be released.

Colposuspension
Performed laparoscopically or through a lower abdominal incision, this involves stitches being placed in the vaginal tissue on the sides of the urethra and through a strong ligament in the pelvis. This pulls the urethra up slightly so that it’s harder for urine to escape.

Mid-urethral sling
Working in a similar way to a fascial sling, a cut is made along the mid portion of the urethra, and then a mesh tape is fed through on either side and is tightened enough to stop leakage. This option is currently not available in New Zealand until a number of conditions have been met.

There are risks associated with all surgical options including bleeding, pain, infection and occasionally damage to other organs inside the abdomen such as the bladder, urethra, and, occasionally, the bowel. There is also a risk of failure to improve the symptoms or for the tension to be too tight leading to difficulty passing urine. This sometimes leads to extended catheter use or a further procedure to release the tension. Discuss these with your specialist to find the best option that works for you.

Welcome to Anna and Hazel 

We are delighted to welcome two new members to the Oxford Women's Health team. General Practitioner Dr Anna Gilmour has recently joined us to work in our menopause clinic, as well as pelvic health and musculoskeletal physiotherapist, Hazel Cutler.

Dr Anna Gilmour has 20 years’ experience as a GP, with special clinical interests in menopause and allergic diseases. She completed her undergraduate degree, as well as her Postgraduate Diploma in Child Health and General Practice, through the University of Otago. She is also a medical educator and assessor for the Royal New Zealand College of General Practitioners (RNZCGP) and the Medical Council of New Zealand. 

Currently living between Christchurch and Dunedin, Dr Gilmour is married with two adult children and a much-loved French Bulldog. In her spare time, she enjoys walking, skiing, and sailing.

Hazel has a special interest in working with women during pregnancy and postpartum. She began her career in 2010 in a private musculoskeletal practice in Christchurch before heading to Melbourne where she trained in clinical pilates. During this time, she worked with a number of antenatal and postpartum clients, which piqued her interest in pelvic health physiotherapy.

She went on to formally train in this field, while working in musculoskeletal clinics offering women’s health physiotherapy in London. She returned to New Zealand in 2017 and has been working in private practice ever since. 
 

Dr Anna Gilmour

Hazel Cutler

Hazel says she enjoys seeing a mix of pelvic health and musculoskeletal clients, as well as new and expecting mums. “I especially like helping people get back to the activities they enjoy, such as returning to running after they have had their baby or getting back to exercise after having a hysterectomy.” Hazel is a mum to two young children.
She enjoys spending time at the beach, mountain biking, cooking, and skiing.
 

Joint team effort helps women in need

When the Oxford Women’s Health team heard about the life-changing work being done by Project Uplift, we quickly organised a collection of items to show our support. Project Uplift Regional Co-ordinator Shirley Sheppard (right), pictured with Oxford Women’s Health General Manager Catherine France, was delighted to forward our donations to women in need.