Patient Presentation
A 15-year-old female came to clinic for her health maintenance examination. She was overall well but had been diagnosed in the emergency room 4 weeks previously with an enlarged left ovarian cyst of 11 ml in volume. The ovarian cyst was noted incidentally during an evaluation for abdominal pain. The abdominal pain had been consistent with gastroenteritis and had resolved in the interim, and she was well during the visit. The past medical history showed she had menarche at age 12 with regular menstrual cycles.

The pertinent physical exam revealed a healthy female with normal vital signs and growth parameters of 25-75%. Her examination was normal.

The diagnosis of a healthy female with an enlarged left ovarian cyst was made. As the ultrasound characteristics were of a benign functional cyst, the patient was to be monitored and have repeat ultrasound after 3 menstrual cycles. Two months later she had a normal pelvic ultrasound and the cyst was now only 3 ml in volume in size, well below the normal volume.

Discussion
Ovarian masses are classified as non-neoplastic vs neoplastic.
Non-neoplastic masses are the most common and are follicular (simple), hemorrhagic, corpus luteum or paratubal cysts. These are 25-69% of all adnexal masses.
Neoplastic ovarian masses in children and adolescents are usually benign (about 90% of all neoplastic causes) and occur in 2.6 per 100,000 girls. Examples are mature teratomas and cystadenomas.
Neoplastic ovarian masses in children occur in about 10% of all neoplastic masses. They include immature teratomas, dysgerminomas, yolk sac tumors, granulosa cell tumors and borderline tumors.

Ovarian masses are usually found because of evaluation for abdominal pain, abnormal growth or puberty, or being incidentally noted on radiographic imaging. Treatment depends on clinical symptoms. As most masses are non-neoplastic and those that are neoplastic commonly are benign, conservative monitoring, and/or conservative surgical procedures are the most common and preferred treatment. Functional cysts often resolve within 2-3 menstrual cycles like the patient above, and therefore close monitoring and repeated imaging is often the treatment plan for presumed functional ovarian cysts.

Large masses can have an increased risk of ovarian torsion and therefore any patient with an enlarged ovarian mass should be counseled regarding symptoms to return to the emergency room for. A review of ovarian torsion can be found here.

Polycystic ovarian syndrome is also a cause of ovarian cysts. A review can be found here.

Learning Point
Ovarian volume is measured on 3 axes (length, width, height) and then volume is calculated by multiplying the 3 measurements and a constant of 0.52.

Normal ovarian volume for a neonate is 1 ml, in prepubertal females is up to 3 ml and in post-pubertal adolescent females is 6 ml. Normal, non-pregnant adult women ovarian volume is also 6 ml. The volume can be different between each ovary. There can also be a range of normal volumes and deciding what is normal vs. abnormal therefore can be more difficult.

In adult women, values that are 2 standard deviations above the mean for ovarian volume are:

“14-15 mL at <30 years of age
13 mL in the 30s
11 mL in the 40s
5-6 mL in the 50s
4-5 mL above 60 years of age”

Questions for Further Discussion
1. What causes abdominal pain? A review can be found here.
2. What is the normal range for menarche in normal girls?
3. What are the clinical signs and symptoms for McCune-Albright syndrome?

Related Cases

Disease: Ovarian Cysts

Symptom/Presentation: Abdominal Pain | Health Maintenance and Disease Prevention

Specialty: Obstetrics / Gynecology | Radiology / Nuclear Medicine / Radiation Oncology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Ovarian Cysts and Ovarian Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Papanikolaou A, Michala L. Autonomous Ovarian Cysts in Prepubertal Girls. How Aggressive Should We Be? A Review of the Literature. Journal of Pediatric and Adolescent Gynecology. 2015;28(5):292-296. doi:10.1016/j.jpag.2015.05.004

Management of benign ovarian lesions in girls: a trend toward fewer oophorectomies – PubMed. Accessed September 9, 2025. https://pubmed-ncbi-nlm-nih-gov.proxy.lib.uiowa.edu/28759460/

Stankovic Z. Ovarian Cysts and Tumors in Adolescents. Obstetrics and Gynecology Clinics of North America. 2024;51(4):695-710. doi:10.1016/j.ogc.2024.08.006

Ovary size and volume | Radiology Reference Article | Radiopaedia.org. Accessed September 9, 2025. https://radiopaedia.org/articles/ovary-size-and-volume?lang=us

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A pediatrician was reviewing some radiographs and overheard the radiology fellow talking with some learners about a patient with stercoral colitis. “This patient doesn’t have it, but see how there is bowel inflammation here? So that should be on your general differential diagnosis of bowel inflammation. We don’t see it much in kids but it has a high morbidity and mortality in adults. All you budding internists, emergency room docs and surgeons need to know about stercoral colitis,” he remarked.

Figure 148. Axial CT with contrast of the abdomen (above) shows marked diffuse wall thickening and mucosal enhancement of the transverse colon. Wall thickening and mucosal enhancement is also present but less pronounced in the descending colon on the coronal CT (below left) and rectum (below right). The colon is filled with a marked amount of stool from the cecum to the rectum.

Discussion
The gastrointestinal system provides lots of feedback to the brain that is usually unconsciously occurring as it breaks down food, absorbs the nutrients and eliminates waste. Sensations from the GI tract do come to our awareness though at important times. The sensation of stomach fullness causes us to stop eating and drinking. The sensation of rectal fullness causes us to toilet. Nausea occurs when something is causing irritation (e.g. food poisoning) and the body may induce emesis to try to remove the irritation. Similarly increased peristalsis may hasten the transit of the irritation (e.g. infectious diarrhea) though the body and evacuate it. Emesis causes a variety of unpleasant sensations, and increased peristalsis is often perceived as abdominal pain. Stretching of the bowel does cause abdominal pain and is commonly seen in constipation and encopresis. The pain/unpleasant sensation is trying to signal that the bowel needs evacuation, but for many reasons (e.g. stubborn toddler), this is being overridden by the brain and not occurring. This causes more stool to build up and therefore more stretching, peristalsis and potential for the perception of pain that happens with impaction. If this occurs long enough, the body may not appear to pay attention to those signals and the peristalsis/evacuation may not occur in normal ways. This causes constipation/encopresis and all of their potential problems.

Older school age and junior high aged patients often become more aware of normal body sensations, especially around the time of puberty, and normal body, especially GI sensations may be perceived by some as abnormal. Most parents will monitor the child and point out the normality of what is occurring, but some patients may end up in the office seeking help for “abdominal pain”.

A review of constipation causes can be found here.

Learning Point
Stercoral colitis is “…caused by increased intraluminal and colonic wall pressure from a fecaloma (a large mass of dry, hard stool).” It is thought that the increased pressure causes bowel ischemia which can cause ulceration and/or perforation. It is more common in the sigmoid colon as “…it is the narrowest portion of the colon, has the lowest blood supply, and is the area of maximal dehydration of feces.” It is estimated that up to 3.2% of colonic perforations are due to stercoral colitis. It is most common in the geriatric population and has a mortality rate of 35-60%%. Risk factors include geriatric age group, sedentary life-style including problems that increase it such as cerebral palsy or paresis, mental health issues around toileting, opiate use, diabetic enteropathy, and hypothyroidism.

Stercoral colitis with or without perforation is uncommon in pediatrics. Presentation due to perforation in all age groups is more common probably as it presents with peritoneal signs. Patients are treated with bowel decompression if not perforated, and need surgical treatment if perforated and antibiotics for peritonitis.

Patients overall but those without perforation potentially may be underdiagnosed. “Stercoral colitis is an uncommon pediatric disease and one that may be unknown among physicians who have not also had an adult practice.” It should be considered in the differential diagnosis of patients with a history of constipation and persistent abdominal pain.

Questions for Further Discussion
1. What causes recurrent abdominal pain? A review can be found here
2. What causes acute abdominal pain? A review can be found here
3. What causes abdominal distension? A review can be found here
4. What causes rectal prolapse? A review can be found here

Related Cases

Disease: Stercoral Colitis | Constipation

Symptom/Presentation: Abdominal Pain | Constipation and Encopresis

Specialty: Gastroenterology | Radiology / Nuclear Medicine / Radiation Oncology

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Abdominal Pain and Constipation.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Canders CP, Shing R, Rouhani A. Stercoral Colitis in Two Young Psychiatric Patients Presenting with Abdominal Pain. The Journal of Emergency Medicine. 2015;49(4):e99-e103. doi:10.1016/j.jemermed.2015.04.026

Caillet A, Steiner M, Sawaya D, Nowicki M. Stercoral Colitis With Silent Perforation in a Child. J Clin Gastroenterol. 2016;50(9):799-800. doi:10.1097/MCG.0000000000000610

Unal E, Onur MR, Balci S, Gormez A, Akpinar E, Boge M. Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017;23(1):5-9. doi:10.5152/dir.2016.16002

Proulx E, Glass C. Constipation-Associated Stercoral Colitis. Pediatr Emerg Care. 2018;34(9):e159-e160. doi:10.1097/PEC.0000000000001600

Derrick DK, Azeez L, Barragan M. Pediatric Stercoral Colitis and Acute Kidney Injury From Chronic Constipation. Clin Pediatr (Phila). 2024;63(11):1592-1596. doi:10.1177/00099228241226501

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 3.5-year-old male came to clinic with his mother because of large reactions to bug bites for the past 2 days. The mother was concerned because he kept scratching and had no relief from an over the counter steroid cream. There was some increased redness around a couple of them with one looking like it was particularly irritated. There were no systemic symptoms.

The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters. The skin examination revealed several reddened lesions on his extremities, neck and face. His lower legs had 2 lesions that appeared more erythematous than the others with a central area that had drainage and a small scab. This was more tender also than the central parts of other lesions.

The diagnosis of bug bites with two lesions with localized mild cellulitis was made. He was started on mupirocin for the cellulitis and oral cetirizine for pruritis. “I also wanted to followup on his language since we last talked. His repeating of words doesn’t seem to be getting better. His teacher at daycare says the same thing. He’s a happy kid, but some people think he’s a little quirky. He still plays by himself mostly, and still does more playing next to the other kids rather than with them. His teacher says he does get frustrated with toys, or changing some routines but not that is a lot different from the other kids. At home I see him repeating things, but I keep talking to him. I talked with my husband and we’re ready now to see someone about this,” she stated. The pediatrician replied, “I noticed today that he seems to be a happy child, but he was repeating a lot of what we said like “bug bites” and “get up on the table.” “Yes, he does that and at home sometimes he gets frustrated with me not really understanding what he is trying to say. If I ask, “Can you tell me?” he’ll just repeat that and it’s hard to help him,” she said. The pediatrician responded, “We talked before about having him seen by the developmental specialist and I’m also going to send you to a speech-therapist to see how they can help him be less frustrated with his language. We already tested his hearing before so we know that is not the problem with his speech.”

Discussion
Echolalia is the repetition of a part of whole of what was said, whether or not it was understood by the person. It is “echoed” or borrowed speech from someone else. “Echolalia has many forms heard in everyday speech, such as quoting or mimicking one another, doing comedic impressions, acting out dialogue in plays or counselors reflecting utterances of clients….It is also common to use literal and partial repetitions as turn-taking strategies to maintain conversational discourse….Echolalic speech, although most common before 36 months in typical language development, can have appropriate communicative functions across the lifespan in all speakers.” Immediate imitation of speech may be helpful for learning vocabulary, while recombining phrases may be helpful for learning syntax. Echolalic speech is very common up to 3 years and then disappears gradually as the child reaches linguistic proficiency. Echolalic speech can be normal or atypical behavior depending on the situation.

Learning Point
Echolalia may be the only term for repetitive speech patterns that a non-specialist provider may know when a more specific- or other diagnosis is more accurate or actually the case. Referral to a speech-language pathologist for further evaluation of repetitive speech past the normal developmental age, or that is causing communication problems is important. Little is lost and much is potentially gained with referral if there is any suspicion of a speech-language problem.

Immediate echolalia is when the utterance is produced within 2 conversational turns, while delayed occurs after more than two conversational turns or is of a higher linguistic complexity than the individual would speak themselves or is a learned routine. Echolalic utterances need to be differentiated from those that are self-generated and produced independently and creatively. “Nonlingistic vocalizations (e.g. humming, laughing, crying, whistling, vegetative sounds such as burping, ticlike squeals, grunts, hoots) are not echolalia.” Vocal stereotypies may include echolalia and nonlinguistic vocalizations and are unrelated to the current situational context. For example, when interacting in the office setting, the patient says “Let’s swing” when not at the playground. The patient is using the verbal stereotypy to express being happy or excited to be playing with the examiner. Palilalia is the repetition of an entire word (“I’m Marie, Marie, Marie,…”). Logoclonia is the last syllable of the word being repeated (“I’m Marie, re, re, re, …”). Echologia is the echoing of a question but using different words/wording. Verbigeration is when one or more sentences or sentence fragments are repeated.

Echolalic speech is often thought of as a compensatory communication strategy for people whose linguistic proficiency is too weak to respond spontaneously. While echolalic speech is very common in all young patients, after age 3 the frequency of echolalic speech increases for patients with autism and decreases for those that are neurotypical. Echolalia is one of the main characteristics in patients with autism. It can be used by autistic patients to “…affirm, call, request, label, protest, relate information, perform verbal routines and offer instructions….[it can also be used] as a turn-taking device in maintaining social interactions, to serve a declarative (labeling) function, as a form of cognitive rehearsal, and as a means of self-regulation.” While echolalia may not be a socially appropriate response in all situations, and its meaning may not be understood by all listeners, it often is an important part of communication and should be respected. Treatment is usually centered not on extinction but on improvement of functional use and overall communication. Behavioral therapy, often today as ABA or applied behavioral analysis therapy, is used to assist patients to increase functional skills and interactions. There are speech-therapy techniques which can be used within this framework to assist patients with their functional communication needs. ABA is not the only treatment, one other example is Gestalt Language Processing.

Patients with other neurodivergent diagnoses than autism may have echolalia. Patients who may be neurotypical, but exposed to many hours of language through computers and not through human interaction, may also have atypical speech development which may include echolalia.

Questions for Further Discussion
1. What are indications for referral to a speech-pathologist? A review can be found here
2. What are stereotypies? A review can be found here
3. At what age are articulation problems not considered normal? A review can be found here

Related Cases

Disease: Echolalia | Speech and Communication Disorders

Symptom/Presentation: Infections | Developmental Delay

Specialty: Developmental Disabilities | Speech and Hearing

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Speech and Language Problems in Children and Autism Spectrum Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Stiegler LN. Examining the Echolalia Literature: Where Do Speech-Language Pathologists Stand? Am J Speech Lang Pathol. 2015;24(4):750-762. doi:10.1044/2015_AJSLP-14-0166

Kaufmann C, Agalawatta N, Malhi GS. Catatonia: Stereotypies, mannerisms and perseverations. Aust N Z J Psychiatry. 2018;52(4):391-393. doi:10.1177/0004867418765669

Gladfelter A, VanZuiden C. The Influence of Language Context on Repetitive Speech Use in Children With Autism Spectrum Disorder. Am J Speech Lang Pathol. 2020;29(1):327-334. doi:10.1044/2019_AJSLP-19-00003

Dinello A, Gladfelter A. Intervention Techniques Targeting Echolalia: A Scoping Review. Am J Speech Lang Pathol. 2025;34(3):1528-1543. doi:10.1044/2025_AJSLP-24-00211

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 16-year-old male came to clinic for his health supervision visit. He had noticed two small masses on the left scrotal skin. He had noticed them in the shower about a month previously. They were not changing in size or texture, were not painful, red nor swollen. He denied any obvious trauma, and hadn’t changed any soaps/detergents or hygiene products. He hadn’t been exposed to any plants. He also denied any specific restrictive clothing, except he wore cotton boxer brief-style underwear.

The past medical history was positive for mild acne vulgaris on his face and upper chest that was treated with benzoyl peroxide. He also had some folliculitis on his right upper thigh in the past year that was treated with mupirocin.

The pertinent physical exam showed a healthy teenager with normal vital signs and growth. His genitourinary examination showed 2 yellow-flesh colored nodules on his left scrotum near the thigh, that were approximately 5-8 mm in size without a punctum or erythema, or pain, and they were mobile. There were no other obvious lesions on dermatological examination. The surrounding skin appeared healthy. There were no masses on the testicles or phallus.

The diagnosis was unclear to the pediatrician. Although the nodules appeared benign, she was not sure what they were. “They look like some type of keratin inclusion cyst to me, but they are a little bigger and this is a different location than I usually see these,” she explained to the teenager and parents. A dermatologist, through an asynchronous electronic consultation thought that it was likely a syringoma or steatocytoma multiplex, and later made the diagnosis of steatocytoma multiplex during a subsequent office visit. The patient was treated by monitoring.

Discussion
Skin disorders or variations are one of the most common reasons for visiting a health care provider. Even from birth there are multiple different variations of differences in skin. As the skin is the largest organ and readily visible, patients have concerns that skin changes may be the presenting symptom of a systemic illness. The skin is also one of the major protective factors for the body and therefore the normal wear and tear and exposure of the skin can cause a range of different skin problems that may need treatment.

The differential diagnosis of small skin nodules similar to steatocytoma multiplex includes:

• Acne vulgaris
• Acne conglobata
• Adenoma, sebaceous
• Dermoid or epidermoid cysts
• Follicular infundibular tumors
• Hidradenitis suppurativa
• Lipoma
• Milia
• Sebaceous hyperplasia

Learning Point
For Images – see To Learn More below

• Steatocytoma multiplex (SM)
  • Pilosebaceous gland disorder
  • Presents with asymptomatic, multiple, sebum containing, dermal cysts that are yellow or flesh colored, and has freely moving papules/nodules. There is a variation where there is some inflammation called SM suppurativa which has risk of infection and scarring. Steatocytoma simplex is a solidary lesion.
  • No malignant potential
  • Occurs in mainly 2nd and 3rd decade but can occur in any age group
  • Most cases are sporadic but there is an autosomal dominant form
  • Locations where pilosebaceous glands are prominent – arms, axilla, face, scalp, thighs, trunk, and less commonly breasts and genitals
  • Numerous lesions can occur over time and currently there is no preventative treatment
  • Treatment includes education and monitoring, laser, needle aspiration, cryotherapy, tretinoin cream
• Syringoma
  • Adnexal tumor of the (presumably) eccrine sweat gland (presumably)
  • Asymptomatic, multiple, yellow or flesh-colored papules that can be hyperpigmented, often 1-3 mm in size but can be larger, and can occur in groupings or have solitary lesions.
  • No malignant potential
  • Occurs in mainly 2nd and 3rd decade but can occur in any age group
  • Most cases are sporadic but there is an autosomal dominant form
  • Locations face (especially upper cheeks and lower eyelids), axilla, neck, chest, umbilicus and genitals
  • Treatment includes education and monitoring, atropine sulfate, tretinoin cream, cryotherapy, excision

Questions for Further Discussion
1. What are the worrisome ABCs of skin lesions? A review can be found here
2. What are epidermal cysts? A review can be found here
3. How is hidradenitis suppurativa treated? A review can be found here

Related Cases

Disease: Steatocytoma multiplex | Benign Tumors | Skin Diseases

Symptom/Presentation: Mass or Swelling

Specialty: Dermatology

Age: Teenager

To Learn More

To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Benign Tumors and Skin Conditions.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images – Syringoma.

To view images related to this topic check Google Images – Steatocytoma multiplex.

To view videos related to this topic check YouTube Videos.

Petersson F, Mjornberg PA, Kazakov DV, Bisceglia M. Eruptive Syringoma of the Penis. A Report of 2 Cases and a Review of the Literature. The American Journal of Dermatopathology. 2009;31(5):436. doi:10.1097/DAD.0b013e3181930d93

Varshney A, Aziz M, Maheshwari V, et.al. Steatocystoma multiplex – PMC. Accessed July 28, 2025. https://pmc-ncbi-nlm-nih-gov.proxy.lib.uiowa.edu/articles/PMC3185371/

Georgakopoulos JR, Ighani A, Yeung J. Numerous asymptomatic dermal cysts: Diagnosis and treatment of steatocystoma multiplex. Can Fam Physician. 2018;64(12):892-899.

Singh A, Oakley A. Syringoma. DermNet®. October 26, 2023. Accessed August 5, 2025. https://dermnetnz.org/topics/syringoma

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa