Bilateral Ovarian Dermoid Cyst withBladder Involvement and Hematuria: A Case Report and Literature Review

Mohammad Mehdi Hosseini, Shahrokh Jahanbini, Sara Pakbaz, Shahryar Zeighami♦

Nephrology-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Case ReportMiddle East Journal of Cancer; October 2014; 5(4): 225-228

♦Corresponding Author: Shahryar Zeighami, MDUrology Office, FaghihiHospital, Zand Blvd., Shiraz,IranTel: +98 711 2331006Fax: +98 711 2330724

Email: zeyghamishahryar@yahoo.com

IntroductionMature ovarian dermoid cysts are

the most common benign ovarianneoplasms which compriseapproximately 10% to 25% of allovarian neoplasms. Of these, about1% to 3% may become malignant andoccur most often in women older than40 years of age. Squamous cellcarcinoma, the most common, isobserved in approximately 80% ofcases. In 10% of cases dermoid cystsare bilateral.1 They are usuallyasymptomatic unless torsion, infectionor rupture develop.

In rare conditions the cyst mayinvolve surrounding organs such asthe colon, rectum or urinary bladder.

Case Report A 63-year-old multiparous,

postmenopausal woman presented

with dysuria and intermittent grosshematuria for six months. On physicalexamination she had only mildsuprapubic tenderness. Routinehematological investigations werenormal, however urine analysisrevealed microscopic hematuria andpyuria. Ultrasound examinationrevealed a right ovarian cyst and sessilemass in the left posterior wall of theurinary bladder. A cystoscopy wasperformed and it was determined thatthe mass protruded into the bladderlumen on the posterior wall withcongested mucosa and a smoothsurface. The patient underwent atransurethral resection of the leftbladder wall mass but after resectionof superficial layer, hair and creamydischarge drained from the tumor bed.The procedure was stopped and aurethral catheter inserted for additional

AbstractBilateral ovarian dermoid tumor with invasion to surrounding organ is a rare entity.

We report the case of a 63-year-old woman with prolonged dysuria and hematuria whohad bilateral ovarian dermoid cysts with urinary bladder involvement.

Keywords: Ovarian tumor, Dermoid, Hematuria

Received: February 23, 2014; Accepted: June 6, 2014

evaluation.Abdominal and pelvic CT scans revealed a 5×6

cm cystic mass in the right ovary. The left ovaryshowed a remnant of the partially resected cyst,which was located between the bladder dome anduterus (Figures 1 and 2).

The patient underwent a laparotomy whichshowed that the right ovary was cystic, about 5×7cm, with no adhesion to the surrounding organs.However the left side was 2×3 cm with a single twistover the infundibulopelvic ligament and locatedbetween the bladder and uterus. The cyst infiltratedinto the bladder wall with loose adhesion to theuterus. Both ovaries were resected with 1 cm of the

bladder wall at the adhesion site of the left ovary.The patient had an uneventful hospital course,improved urinary symptoms, and was subsequentlydischarged in good condition. Histopathologicexamination revealed a bilateral benign cysticovarian teratoma with a mature component (Figures3-5).

Discussion Ovarian teratoma is a germ cell ovarian neoplasm

that may contain all three germ layers, the ectoderm,mesoderm and endoderm.2 It usually is filled withsebaceous secretion, hair and occasional nodulartissue that may transform into teeth, bone, cartilage,

Figure 1. Pelvic CT scan showing the right ovarian cyst marked onthe left side and remnant of the resected left ovarian cyst (right side).

Figure 2. Pelvic CT scan showing more prominent view of theremnant of the left cyst.

Figure 3. Mature teratoma. Cystic space filled with keratin materialand lined by stratified squamous epithelium with some sebaceous tissuein the wall (H&E; 40×).

Figure 4. Mature teratoma. Respiratory epithelium with underlyingsebaceous tissue and a number of different types of glands (H&E;200×).

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bronchial and gastrointestinal epithelium.3 Theteratoma is a spectrum of tumors from immature tomature teratoma with different behavior frommalignant to benign. Ultrasonography andcomputerized tomography scan are two valuablemodality for diagnosis of teratoma.4 Torsion is themost reported complication of the dermoid cyst,where approximately 1% to 3% develop malignancy.Risk factors include age over 45 years and tumor sizelarger than 9.9 cm, which has 86% sensitivity formalignancy.5

Tekwavi Deepa et al. have reported the case ofa 40-year-old woman with a solid cystic ovarianteratoma that had squamous cell carcinoma arisingfrom the teratoma which involved the urinarybladder, uterus, and other adjacent organs.6

According to Chong et al., an 80-year-old womanhad a large abdominal gas-filled squamous cellcarcinoma mass which arose from a mature cysticteratoma of the ovary that communicated to thesigmoid colon.7 Presentation of benign cystic ovarianteratoma with fistula to adjacent organs is a rarecondition; the most common presentation is into theurinary bladder. Landmann has also reported abenign ovarian teratoma that fistulated to the rectumwhich presented with rectal bleeding and a polypoidmass in the rectum.8 Khanna et al. reported thecase of an18-year-old woman who had a leftteratoma that ruptured into the sigmoid colon9 anda 39-year-old woman with lower abdominal pain andhematochezia which, upon evaluation, had a massin the anterior rectal wall from a benign cysticteratoma in her left ovary.10 Invasion into the urinarybladder is a rare entity. Rantomalala et al. discusseda case that had a right ovarian dermoid cyst whichfistulated to the bladder who presented with recurrenturinary infection11 and Tandon et al. presented thecase of a 30-year-old woman with urethral dischargeafter laparotomy. Invasion of ovarian tumor tobladder was detected. Pathologic evaluationconfirmed the presence of a benign cystic teratoma.12

The current case had a bilateral ovarian cysticteratoma with invasion of the left side into thebladder. She presented with dysuria and episodes ofgross hematuria for six months duration.

ConclusionOvarian dermoid cysts are common ovarian

tumors that have an indolent course which maybecome symptomatic due to complications suchas torsion, hemorrhage, infection, and malignantchange. Rare fistula to adjacent organs may bepresent. Spontaneous rupture of a teratoma due towall thickness is a rare event and usually presentswith an acute abdomen. Rupture into a hollowviscous such as the bladder is extremely rare,however in a female patient with chronic urinarysymptoms the physician must be aware of thiscondition.

Conflict of InterestNo conflict of interest is declared.

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Figure 5. Mature teratoma. Cystic space lined by ciliated pseudos-tratified columnar epithelium characteristic of the respiratory system(H&E; 400×).

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