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Perineural Cysts Presenting as Complex Adnexal Cystic Masses on Transvaginal Sonography

Mark J. McClure1,2, Mostafa Atri1, Masoom A. Haider3 and John Murphy1

1 Department of Medical Imaging, Sunnybrook & Women's Health Science Centre, 2075 Bayview Ave., Ontario, M4N 3M5 Canada.
2 Present address: Department of Radiology, Craigavon Area Hospital, 68 Lurgan Rd., Portadown Craigavon, BT63 5QQ Northern Ireland.
3 Department of Medical Imaging, Mount Sinai Hospital and University Health Network, 600 University Ave., Toronto, Ontario, M5G 1X5 Canada.



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  		Fig. 1A. —42-year-old woman with perineal pain and bowel disturbance. Sagittal transvaginal sonogram of right adnexa shows complex cystic mass (white arrows) containing heterogenous internal debris. Mass is clearly separate from right ovary (RO) and posteriorly located anterior to sacrum (black arrow). Multiocular cystic lesion was also identified in left adnexa (not shown).

 


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  		Fig. 1B. —42-year-old woman with perineal pain and bowel disturbance. Transverse transvaginal sonogram of right adnexa shows absence of detectable blood flow on color Doppler sonography. Some internal debris is seen layered dependently with change in patient's position.

 


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  		Fig. 1C. —42-year-old woman with perineal pain and bowel disturbance. Axial T2-weighted MR image shows bilateral hyperintense multilocular cysts (arrows). Note uniformly thin walls and absence of septa. Heterogenous signal intensity of right-sided lesions correlates with heterogenous debris seen on transvaginal sonography.

 


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  		Fig. 2A. —43-year-old woman with left lower quadrant pain and dysmenorrhea. Sagittal transvaginal sonogram of left adnexa shows complex cystic mass containing thin (<2 mm) septation (curved arrow) and fine internal floating debris with dependent layering (white straight arrow). Lesion is posteriorly located on sacrum (black arrow).

 


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  		Fig. 2B. —43-year-old woman with left lower quadrant pain and dysmenorrhea. Axial T2-weighted MR image shows hyperintense fluid in unilocular cyst that contains layering internal debris (arrow).

 


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  		Fig. 3A. —28-year-old woman with persistent pelvic pain, dysmenorrhea, and dyspareunia. Transverse transvaginal sonogram of left adnexa shows complex cyst containing several thin (<2 mm) septa (curved arrow), with some floating and layered internal debris (straight solid arrow) located posteriorly adjacent to sacrum (open arrow).

 


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  		Fig. 3B. —28-year-old woman with persistent pelvic pain, dysmenorrhea, and dyspareunia. Axial T2-weighted MR image shows multilocular left-sided cysts. Location of these cysts abutting left piriformis muscle (P) may help explain initial consideration of piriformis muscle hematoma in differential diagnosis based on transvaginal sonographic appearance.

 


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  		Fig. 4A. —41-year-woman with 2-month history of pelvic pain. Sagittal transvaginal sonogram of right adnexa shows complex multilocular cystic mass containing few thin (<2 mm) septations (curved arrow) and floating and layered internal debris (white arrow). Lesions are located posteriorly on sacrum (black arrow). Note presence of free fluid (FF).

 


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  		Fig. 4B. —41-year-woman with 2-month history of pelvic pain. Contrast-enhanced CT image reveals bilateral hypodense (<10 H) lesions (arrows).

 


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  		Fig. 4C. —41-year-woman with 2-month history of pelvic pain. Coronal T2-weighted MR image shows origin of cysts from sacral foramina bilaterally (arrows).

 


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  		Fig. 5A. —44-year-old woman with lower abdominal pain. Transverse transvaginal sonogram of left adnexa shows complex tubular-shaped cystic lesion (small white dots) containing internal floating (white arrow) and layered (asterisk) echogenic debris. Dorsal location is evident by sacrum (black arrow).

 


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  		Fig. 5B. —44-year-old woman with lower abdominal pain. Contrast-enhanced CT image shows bilateral hypodense (<10 H) lesions (arrows).

 


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  		Fig. 5C. —44-year-old woman with lower abdominal pain. Sagittal T2-weighted MR image shows connection of cystic masses with sacral foramina (asterisk).

 

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