Sexual pleasure with ruptured corpus luteum cyst that ends in emergency room: A case report

ABSTRACT

Rupture of corpus luteum cyst from sexual pleasure is an uncommon event that has not been reported in our environment (Africa). The patient is a 30-year-old primiparous woman who developed severe lower abdominal pain thirty minutes after sex; the pain was unrelenting despite the use of over-the-counter analgesic drugs and local herbs. Twelve hours after sex, when the problem persisted and she complained of dizziness and weakness, she was rushed to the emergency room of our facility for medical treatment. An initial diagnosis of ruptured ectopic gestation was made. She had an emergency laparotomy with repair of the ruptured cyst and blood transfusion. Incisional biopsy was taken from the cyst and pathological examination revealed a ruptured corpus luteum cyst. She did well post-surgery and was discharged to follow up in the clinic on the third day after surgery. Ruptured corpus luteum cyst from sexual pleasure is a rare event. Thus, a high index of suspicion is necessary to elicit a history of sex, which patients are often unwilling to disclose.

Introduction

Corpus luteum cyst rupture resulting in Hemoperitoneum is a rare clinical entity with an increased likelihood of rupture during pregnancy likely due to the increase in size of the corpus luteum cyst in pregnancy. Ruptured corpus luteum can pose a serious dilemma as the presentation could mimic ruptured ectopic gestation, ovarian torsion, and acute appendicitis.[1]

We know that sexual activities bring pleasure to partners, but sometimes this may translate to life-threatening situations. Thereby, bringing problems not only to the patients but also to medical practitioners and emergency physicians. It has been reported that postcoital hemoperitoneum usually occurs with evidence of vaginal injury.[2] However, postcoital hemoperitoneum without evident vaginal injury is rarely reported.[1,2] Ruptured hemorrhagic corpus luteum is one of the most common gynecologic causes of hemoperitoneum second to ruptured ectopic gestation.[3]

The diagnosis is based on a high index of suspicion from the history with patients usually being in the luteal phase of the ovarian cycle and may present after recent sexual intercourse.[1] The majority of such cases do not admit the preceding act of coitus during the initial presentation and examination. The attending emergency room physician needs to elicit sexual history in female patients who are of reproductive age and who complain of acute lower abdominal pain.[1]

We here report the case of a 30-year-old female who presented with post-coital hemoperitoneum without vaginal injury due to a rupture of a corpus luteal cyst that was identified only after surgical biopsy and histopathological examination [Figure 1].

Figure 1.

Ruptured corpus luteum cyst at surgery

Case Report

A 30-year-old primiparous woman was referred to the gynecological emergency unit of our facility 12 hours after the onset of lower abdominal following sexual intercourse.

She was well until 12 hours before the presentation when she started experiencing abdominal pain. The pain was sharp and sudden in onset, located initially at the lower abdominal region more to the right iliac region but later became generalized; the pain started thirty minutes after non-vigorous coitus with the patient mostly on top (in cowgirl sex position), the information she volunteered reluctantly. The pain was persistent and worsened by touch and movement. The pain was also not relieved by the use of over-the-counter analgesic drugs or local herbs. There was no history of fever, vomiting, or anorexia. No history of bleeding per vagina. She does not have a medical condition for which she is being managed. Her last menstrual period was 12/11/2022. She menstruates for 4–5 days in a 26–28 days cycle. She did not have any known gynecologic problems such as dysmenorrhea, menorrhagia, or dyspareunia.

She does not smoke cigarettes or drink alcohol.

On examination, She is a young woman in painful distress, afebrile, moderately pale (++), anicteric, not dehydrated, not cyanosed, no pedal edema.

There was generalized abdominal tenderness with positive rebound tenderness. No intra-abdominal organ was palpably enlarged. No obvious genital injury and cervical excitation tenderness was negative. A tentative diagnosis of Acute Abdomen secondary to suspected ruptured ectopic gestation was made.

The blood pressure (BP) was 96/60 mmHg, pulse rate (PR) – 108bpm, saturated oxygen pressure (SPO2) – 97% in room air [Table 1].

Table 1.

A summary of the results of the test

Vital signs	BP-96/60 mmHg	PR-108 bpm	RR-28 cpm	Temp 36.5°C	SPO2-97% in room air
Full blood count	PCV-20%	WBC-5.8×109/L	PLT 118×109/L	NEUT 62%	LYM 32%	MONO 6%
Serum pregnancy test	Negative
Urinalysis	Normal

The result of the emergency Abdominopelvic ultrasound showed.

Significant free fluid was noted within the abdominal cavity and pouch of Douglas (POD) with internal echoes within it. Generalized probe tenderness was marked at the right iliac region. Normal-sized non-gravid anteverted uterus with regular outline measuring 7.99 cm by 4.66 cm in longitudinal section (LS) and anterior-posterior (AP) dimensions. The endometrial stripe was 4.2 mm thick. A right adnexal mass of 4.56 cm by 4.77 cm was noted. The left adnexa was free.

Subsequently, the patient had exploratory laparotomy and 850 ml of hemoperitoneum was evacuated. Active bleeding on the right ovary was repaired and a biopsy was taken for histopathological examination [Figure 2]. No other anatomical abnormality was seen. Postoperatively, the patient was clinically stable, she received blood products for a low packed cell volume of 20%. The remaining postoperative period was uneventful and she was discharged on postoperative day three. She has been on follow-up clinic visits in the past three months of which she is doing well.

Figure 2.

X 40 Wall of ruptured hemorrhagic corpus luteum cyst (H&E)

At the histopathology lab, we received two pieces of grey, flat, hemorrhagic tissue that aggregated to 2 × 1 × 0.5 cm that were all embedded. The result was a hemorrhagic corpus luteal cyst.

Discussion

Corpus luteum rupture is a common cause of hemoperitoneum and recent sexual intercourse is usually a preceding factor. There may be no evidence of vaginal injury or trauma. Patients may present with a wide range of clinical signs and are often misdiagnosed as ruptured ectopic pregnancy, ovarian torsion, endometriosis, and acute appendicitis.[1,3]

The diagnosis of a ruptured corpus luteum cyst is based on a high index of suspicion from clinical history, with patients usually in the menstrual cycle’s luteal phase.[4] In addition, due to sociocultural factors in our environment, patients are unwilling to disclose the history of recent sexual intercourse as seen in the case of this patient.

Rupture of corpus luteum cyst with hemoperitoneum may appear sonographically similar to a ruptured ectopic pregnancy. Hence, estimation of serum β human chorionic gonadotropin (hCG)-levels becomes mandatory to rule out pregnancy.[5] The precise mechanism of postcoital hemoperitoneum due to corpus luteum cyst rupture remains unknown; it is hypothesized that forces occurring during intercourse may result in acceleration-deceleration injuries.[3] In addition, a change in intraluminal pressure created during coitus might have precipitated the episode.[5] Recent studies suggest that women on anticoagulant therapy and those with a bleeding diathesis are at greater risk of rupture with significant hemorrhage. Such women are also at a much higher risk of recurrent rupture.[3,6]

Postcoital hemoperitoneum without evident vaginal injury has infrequently been reported in the literature.[2] The features of corpus luteum hemorrhage have been similar in previous studies[3] and include (i) patient age range within reproductive years, (ii) sharp and sudden-onset pain more often on the right than the left side, which is what we experienced in this index patient, (iii) history of recent sexual intercourse or strenuous physical activity, (iv) a tendency of onset during the secretory phase of the menstrual cycle, and (v) an increased incidence in pregnant females. Postcoital pain can vary in localization, radiation, time of onset since injury, and progression.[2,3] Hemoglobin level is usually normal, and blood transfusion is rarely required.[3] However, reports of postcoital hemoperitoneum with a volume range from 150 to >2000 ml requiring blood transfusion have been reported.[1] This is similar to our case as about 850 ml of blood was evacuated from the peritoneum intraoperative and she was subsequently transfused with two units of packed cells.

Multiple sources of bleeding may be identified during laparotomy which include: A lacerated round ligament, lacerated ovary, and ruptured serous cystadenoma when present.[3] None of this was witnessed during the operation of this patient, which made the surgery faster and less complicated.

Ho et al. described 91 women diagnosed with ruptured corpus luteum cysts and hemoperitoneum following recent sexual intercourse or pelvic trauma, before the onset of pain.[5] Patients may present with no apparent clinical signs or severe peritoneal irritation. Other features include anemia, elevated c-reactive protein (CRP), and mild leukocytosis.[4]

Ultrasound can effectively diagnose patients with mild corpus luteum hemorrhage, allowing physicians to conservatively manage hemodynamically stable patients and thus avoid surgery. Previous studies considered ultrasound to be a useful diagnostic modality and focused mostly on the interpretation of images to maximize the benefit of earlier diagnosis, or on variations in image acquisition and processing techniques that could increase the specificity or sensitivity of diagnosis.[7,8,9] We know from a study that computerized tomography (CT) scanning is more sensitive than ultrasonography, it is less specific in detecting ovarian cysts. It is considered the best option for imaging hemorrhagic ovarian cysts or hemoperitoneum due to cyst rupture and can be used to differentiate other intra-abdominal causes of acute hemorrhage.[9] Availability and affordability are an issue in our environment. Thus, we had to deplore the use of ultrasound due to the patient’s worsening condition.

Although there is no consensus on treatment, a growing number of physicians prefer laparoscopy as the surgical diagnostic choice for many hemodynamically unstable patients.[10] In the past, management of hemoperitoneum due to corpus luteal rupture was exclusively surgical but recently, conservative management is possible and considered the first treatment of choice in patients with clear-cut ultrasound diagnosis, hemodynamic stability (systolic BP >90) and stable hemoglobin values over 4–6 h of monitoring.[4,5] In addition to the use of intravenous fluids and blood transfusion, administration of tranexamic acid (500 mg intravenous loading dose and 250 mg intravenous maintenance dose every 6 h) has also been suggested.[5]

The clinical presentation of a ruptured corpus luteum cyst is variable, ranging from a benign asymptomatic state to clinical shock. While mild cases of ruptured corpus luteum cysts require only clinical observation and support, surgical intervention is necessary for severe cases of ruptured corpus luteum cysts with hemodynamic instability. Management of ruptured corpus luteum cyst is not defined in relatively stable cases.[11] A ruptured corpus luteum cyst can be defined as either uncomplicated or complicated. A ruptured corpus luteum cyst is uncomplicated in the absence of hypotension, tachycardia, fever, signs of an acute abdomen, leukocytosis, or sonographic evidence of an enlarging hemoperitoneum. Prior studies have indicated that uncomplicated cases can be managed conservatively with oral analgesia given as needed or with observation.[12]

However, a ruptured corpus luteum cyst is complicated when vital signs become abnormal and significant hemoperitoneum is suspected either by clinical, laboratory, or radiological findings as seen in this case. Complicated ruptured corpus luteum cyst patients should be hospitalized with fluid replacement, frequent vital signs, serial hematocrit levels, and repeated imaging to monitor bleeding. If the patient’s clinical condition is unstable or deteriorating, surgery should be performed to control hemorrhage.[13]

We preferred laparotomy because the patient was hemodynamically unstable with a presenting hemoglobin of <7 g/dl. However, the current literature search shows that laparoscopy seems to be the preferred surgical diagnostic modality for those with hemodynamic instability, with conversion to laparotomy in case of failure, or a decrease in hemoglobin of ∼2 g/dl over 4–6 hours with increasing hemoperitoneum on follow-up imaging studies.[5] Laparoscopic management of gynecologic hemoperitoneum is the preferred choice of surgical treatment over laparotomy because of shorter hospital stays, shorter operative times, improved wound care, and less postoperative pain.[5,10]

Conclusion

Postcoital hemoperitoneum resulting from rupture of corpus luteum cyst without evidence of genital trauma is uncommon. None has been reported in the literature in Nigeria and Africa. This case required a high index of suspicion by the researchers to elicit a history of recent sexual activity by the patient. We advocate for emergency surgery where the patient is hemodynamically unstable for a good outcome. A histopathological examination serves as the definitive modality to identify the underlying etiology of the hemorrhage.

Declaration of patient consent

The authors certify that they obtained all necessary patient consent forms. In the form, the patient gave her consent for images and other clinical information to be reported in the journal. She understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflicts of interest.