Clinical History

The patient is 23 years old.

Chief Complaint

Detection of pelvic mass for more than 2 months.

Present Illness

The patient has regular menstruation, menarche at 14 years old, menstrual cycle of 30 days and duration of 5 days, moderate menstrual volume, dysmenorrhea requiring oral analgesics. Last menstrual period (LMP): October 16, 2025, with normal menstrual volume and color. On August 14, 2025, she visited a local hospital due to abdominal pain; ultrasound indicated a right adnexal mass (suspected teratoma) measuring approximately 5.6cm×3.6cm, with pelvic effusion of 2.1cm×1.1cm. She received oral medication for pelvic effusion with unknown drug name. She came to our outpatient clinic today for further treatment. Repeat ultrasound showed the right ovary measured about 6.0cm×4.0cm, containing a slightly hyperechoic lesion of 5.8cm×3.3cm×2.6cm with regular shape and clear boundary. She was admitted for definitive diagnosis and treatment. At present, she has no fever, dizziness, headache, nausea, vomiting or chest tightness and shortness of breath; occasional dull pain in the right lower abdomen without abdominal distension. Her diet, sleep, defecation and urination are normal, with no obvious weight change recently. She takes oral vitamin D3 health supplements daily.

Past Medical History

No history of hypertension, diabetes or coronary heart disease; no blood transfusion history; no drug or food allergies; no previous pelvic or abdominal surgery or trauma.

Marital, Childbearing and Menstrual History

Unmarried, sexually active, gravida 0, para 0.

Special Physical Examination on Admission

Normal vulvar development, unobstructed vagina with a small amount of vaginal discharge, mild cervical ectropion. Uterus in midposition without tenderness. A cystic mass of approximately 6cm with good mobility is palpable in the right adnexa without tenderness. No abnormalities detected in the left adnexa.

Auxiliary Examinations

Gynecologic Pelvic Ultrasound

The uterus is retroverted, measuring about 4.5cm×3.9cm×3.1cm with regular shape and clear boundary. Endometrial thickness is about 1.1cm. No obvious space-occupying lesions in the uterine parenchyma. The right ovary measures about 6.0cm×4.0cm, containing a slightly hyperechoic lesion of 5.8cm×3.3cm×2.6cm with regular shape and clear boundary. The left ovary measures about 2.9cm×2.2cm. No obvious space-occupying lesions are visualized in the left adnexal area within the ultrasound scanning range. Free anechoic area is seen in the pelvic cavity with a depth of approximately 1.8cm.

Ultrasound Impression

Endometrial thickening; slightly hyperechoic lesion in the right ovary (teratoma suspected); pelvic effusion.

Diagnosis and Treatment

Admission Diagnosis

Pelvic mass (right ovarian teratoma).

Surgical Information

After admission, vaginal irrigation and topical vaginal medication were administered. Preoperative evaluation and preparation were completed with no surgical contraindications. Elective transvaginal natural orifice transluminal endoscopic surgery (VNOTES) for enucleation of right ovarian teratoma was performed under general anesthesia.

Surgeon Profile

Lei Yu

Chief Physician, Department of Gynecology, The Fourth People's Hospital of Shenyang; Master's Supervisor

Specialties

Minimally invasive surgery for gynecological benign and malignant tumors via laparoendoscopic single-site surgery (LESS) and transvaginal natural orifice transluminal endoscopic surgery (VNOTES), with leading domestic proficiency. Minimally invasive surgical treatment for pelvic organ prolapse (POP) including uterine prolapse, cystocele and rectocele, as well as stress urinary incontinence (SUI) and other pelvic floor dysfunction diseases (PFD).

Social Positions

Vice Chairman, Pelvic Floor Disorder Prevention and Treatment Committee, Liaoning Preventive Medicine Association Vice Chairman, Gynecologic Transnatural Orifice Single-port Laparoscopic Surgery Committee, Liaoning Maternal and Child Health Association Member, Cervical Cancer Prevention and Control Committee, China Maternal and Child Health Research Association Director, Female Genital Tract Reconstructive Surgery Branch, Chinese Association of Plastics and Aesthetics Member, Pelvic Tumor Integration Committee, Chinese Anti-Cancer Association Member, Gynecology, Urology and Pelvic Floor Professional Committee, Liaoning Life Science Society

Editor: Qinghuan

Reviewer: Ma Ye