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When does fluid in the cul de sac become concerning to a diagnostician?

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Practicing since : 1983
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I'm a 40 yo , with no health hx, no medication, avid exerciser, 5'11"; 150 lbs. 1 pregnancy, no birth control
I have been experiencing a chronic, though intermittent, dull left flank ache for a little over a year. Last summer I had a transvaginal/abdominal u/s done which showed bilateral ovarian cysts. Approx 2 months ago I noted a vague sob that has persisited. Recently, the flank ache has been more pronounced. An abd/pelvic/transvag u/s was ordered recently. I just received the results of the abd/pelvic/transvag u/s and all was negative except for the pelvis. The finding showed: " A hypoechoic, slightly heterogeneous area (2.1 x 1.1 x 1.5 cm) in the left ovary of uncertain significance. It is possible this could relect an evolving corpus luteum Also there was a small amount of fluid found in the cul de sac". I was referred to my gyn for followup. My concern is the vague sob combined with this abnormal report. Could the intermittent flank ache be related to the findings of the ultrasound? Does ovarian cancer present with intermittent flank pain for over a year? When does fluid in the cul de sac become concerning to a diagnostician? I have requested a chest xray and a CEA 125 to be done tomorrow. Any thoughts re: how concerned I should be and how imperative it is to see my GYN?
Posted Tue, 8 May 2012 in Women's Health
Answered by Dr. Minoo Bhagia 12 hours later
Hello ,

Thanks for the query

1. Your ultrasound is showing hypoechoic and heterogenous area. Such changes can occur due to ovarian cyst / follicular cyst / haemorrhagic cyst / can be an endometrioma.

2. Free fluid in pouch of XXXXXXX means pelivic inflammatory disease. The flank pains which you have been experiencing may be likely due to pelvic inflammatory disease. Perhaps a detailed pelvic examination, genital swab test, culposcopy and microscopy can help us in diagnosing infection.

3. Another condition which can cause similar pain is diverticulosis.

5. Tumours are unlikely, but test are necessary to rule them out. CA 125 should be done to exclude any other tumour.
If required diagnostic laparoscopy , CT , MRI are also to be done.

Meanwhile you can take a course of metronidazole or tinidazole for intestinal problem and an antispasmodic and anti inflammatory drug.

The most likely cause seems to be pelvic inflammatory disease with follicular cyst left ovary.

I hope may answers are adequate. Should you have more concerns, I will be available to answer them.

Best wishes
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