Pelvic mass

differentials on the basis of organs

1. Pelvic Mass Semester VI Group D 06/04/2016

2. INFANCY PREPUBERTAL ADOLESCENT REPRODUCTIVE PERI-MENOPAUSAL POST-MENOPAUSAL Functional Cyst Functional Cyst Functional Cyst Functional Cyst Fibriods Ovarian Tumor (malignant or benign) Germ Cell Tumor Germ Cell Tumor Pregnancy, Sequelae of PID Pregnancy, Ectopic Pregnancy Epithelial ovarian tumor Functional Cyst Benign cystic teratoma / Other germ cell tumors Uterine fibriods , Functional Cyst Bowel, malignant tumor or inflammatory Obstructing vaginal or uterine anomalies Epithelial ovarian tumor, Mature cystic teratoma Metastases Epithelial ovarian tumor Tubo -ovarian masses (acute/chronic) CAUSES: According to the age groups

3. CAUSES: According to the site involved UTERUS ADNEXA INTESTINE AND OTHERS Fibroid Adenomyosis Hematocolpos Pyometra Ectopic pregnancy Ovarian tumour Chocolate cyst Tubo ovarian mass Pelvic Abscess Appendicular lump Impaction of worms Iliopsoas abscess Pelvic kidney

4. Differential diagnosis for pelvic/abdominal mass Gynaecological Pregnancy-related Normal intrauterine pregnancy Old ruptured extrauterine pregnancy (abdominal, tubal pregnancy) Molar pregnancy Uterine origin Uterine fibroids Advanced uterine carcinoma or sarcoma Hematometra / pyometra Tubal origin Hydro-/ pyosalpinx Tubo -ovarian abscess Advanced cancer of the tube Ovarian origin Ovarian torsion Benign cyst Endometrioma Benign tumor ( dermoid , fibroma, cyst-adenoma) Borderline tumor Malignant tumor (carcinoma, granulosa cell or germ cell tumor

5. Differential diagnosis for pelvic/abdominal mass Surgical Appendicular abscess Obstructed hernia Intussusception Colorectal carcinoma Subacute intestinal obstruction Diverticular abscess Large bowel tumor/mesenteric tumor Abdominal aortic aneurism Renal tumor: pelvic kidney, bladder carcinoma, urinary retention

6. Differential diagnosis for pelvic/abdominal mass Neuroblastoma Hodgkin’s and non-Hodgkin’s lymphoma, pelvic spleen Pregnancy and Full Bladder are the physiological causes. In case of full bladder it is tense and cystic, may reach upto umbilicus. Neurological Hematological Disappears on catheterization.

7. Pregnancy – Intrauterine Reproductive (Child bearing) Age group Cessation of menstruation Mass lower abdomen On ultrasonography, gestational sac is present intrauterine.

8. Uterine Fibroids ( Leiomyomas ) Uterine leiomyomas are estrogen- and progesterone-sensitive tumors Leiomyomas themselves create a hyperestrogenic environment, which appears requisite for their growth and maintenance. Classification of Uterine Leiomyomas Classified based on their location and direction of growth Subserosal leiomyomas Intramural leiomyomas Submucous leiomyomas

9. Subserosal leiomyomas originate from myocytes adjacent to the uterine serosa, and their growth is directed outward When these are attached only by a stalk to their progenitor myometrium, they are called pedunculated leiomyomas Intramural leiomyomas are those with growth centered within the uterine walls Submucous leiomyomas are proximate to the endometrium and grow toward and bulge into the endometrial cavity. (Only about 0.4 percent of leiomyomas develop in the cervix) ( Leiomyomas have also been found less commonly in the ovary, fallopian tube, broad ligament, vagina, and vulva)

10. Grows slowly M enorrhagia Feel- firm C ystic in cystic degeneration Nodular Surface No features of pregnancy On internal examination : Origin of swelling is uterine Cervix feels firm Fig: Cystic degeneration (arrow) seen within this “ submucous fibroid”

11. Benign Ovarian tumour Benign tumors predominantly occurs in late child bearing age Grows slowly Symptoms i nclude heaviness and dull aching pain in lower abdomen. However the menstrual pattern remain unaffected. Abdominal examination- bulging of lower abdomen Mass is unilateral, mobile, cystic, smooth Lower pole may not be reached Ascites may be present

12. ` On pelvic examination- Swelling is separated from uterus Movement of mass per abdomen fails to move the cervix Absence of pulsation of uterine vessels through fornices

13. Malignant ovarian tumours Occur mostly in post menopausal women Symptoms -abdominal distension and pain, loss of appetite , dyspepsia,respiratory distress, but no menstrual abnormalities Signs - cachexia , pallor, jaundice, left supra clavicular lymph gland enlargement and edema of legs and vulva.

14. Abdominal examination- Usually the mass is bilateral, fixed, solid, irregular, tender Enlarged liver Pelvic examination- uterus is separated from the mass Nodules may be felt through posterior fornix.

15. Adenomyosis Adenomyosis is a condition where there is ingrowth of the endometrium , both glandular and stromal components, directly into myometrium A ssociated with parous females above 40 Symptoms – Menorrhagia D ysmenorrhea

16. Abdominal examination reveals hypogastric mass – size is rarely more than 14-16 weeks pregnant uterus Pelvic examination –Uniform , enlarge with well defined margins of the uterus Internal examination: Uterine swelling Cervix-firm, uterus- tender

17. Endometriosis M ost commonly occurs in white, nulliparous women between the ages of 35-45 P resent with cyclic pelvic pain or pressure , dyspareunia , dysmenorrhoea , dyschaezia and infertility M ay occur on the ovaries and occasionally can form large cysts filled with chocolate colored, called “chocolate cysts” or endometriomas Laparoscopy is the gold standard for the treatment.

18. Tubo ovarian abscess Present with fever and pelvic pain H istory of salpingitis in which the fallopian tube becomes distended with pus forming a pyosalpinx , if left untreated ovary may become involved forming tubo -ovarian abscess. Examination – lump can be palpated on the lower abdomen Internal examination – adnexal tenderness and forniceal fullness felt Diagnosed by ultrasound and confirmed by lapa ra scopy

19. Diagnosis History Examination Investigation

20. History Systematic and symptomatic assessment to find out the cause and origin for the mass Presenting complaints: -Pain -Fever -Bloating -Frequency -Weight Loss -Loss Of Appetite

21. History Menstrual History: Secondary amenorrhea suggests pregnancy or ectopic pregnancy Pelvic pain in 2 nd half of menstrual cycle could be due to hemorrhagic corpus luteum cyst Menorrhagia: submucosal fibriods Dysmenorrhea: Endometriosis/ fibriods / PID Obstetric History Past History: medical and surgical

22. History Contraceptive History: OC’s reduce the likelihood of functional cysts but more likely to have PID Ectopic pregnancy are more common among Intrauterine contraceptive devices

23. History Character of the Pain Sudden onset of severe pain suggests ovarian torsion, hemorrhage into a cyst, rupture of a cyst, abscess or ectopic pregnancy. Cyclic menstrual pain associated with menorrhagia and passing clots suggests fibroids C yclic menstrual pain associated with back pain or dyspareunia suggests endometriosis.

24. History Progressively worsening pain associated with constitutional symptoms suggests tumour Often ovarian cancer patients present only with vague gastrointestinal complaints.

25. Examination General Physical Examination Head to toe examination Cachetic – carcinoma Pallor – Ectopic pregnacy Rise in temperature - Tubo ovarian abscess Abdomen: ascites in case of ovarian tumour

26. Pelvic Examination C haracteristics of all masses including size, shape, mobility, consistency. Cervical discharge with mucus (PID) Adnexal masses or tenderness Cervical motion tenderness Uterine enlargement

27. Rectovaginal area: Assess: P osterior uterine surface U terosacral ligaments T he rectum • Lymph nodes: - Supraclavicular , and groin nodes

28. Abdominal Examination Distension,scars Features of ascites:shifting dullness,fluid thrill Palpation of mass if present

29. Speculum Examination For discharge,tumors or growths,warts Inspection of vulva,vagina,cervix

30. Bimanual Examination Recto-vaginal Examination

31. Investigations Urine Pregnancy Test(ruling out pregnancy in reproductive age group) Urinary beta hCG or serial quantitative beta hCGs for ectopic pregnancies; serum beta hCG may be found in nonpregnant patients with embryonal cell CA or chorioCA Full Blood Count Urea and electrolytes Blood grouping and cross-match Ultrasound scans of the abdomen and pelvis

32. Investigations CA 125 (cancer antigen 125) – E xpressed by epithelial cells on ovarian tumors but also on normal as well as abnormal tissues of mullerian origin. More useful in menopausal patients than in adolescent patients. May be elevated in: Endometriosis , Adenomyosis , Fibroids, PID

33. CA-125 contd … - It is rarely elevated beyond 100 to 200 U/ml in patients with the above conditions (normal is < 35 U/ml). It is also elevated in cancers of: Ovary, Lung, Pancreas, Breast, Colon/rectum - Elevated in 80% of serous cystadenocarcinomas of the ovary but in only 50% of patients with stage I disease.

34. Ultrasound CT SCAN MRI

35. Management Depends on the cause Large adnexal masses (> 8 cm) in the premenopausal woman or masses with characteristics of malignancy (solid or mixed solid and cystic on USG) should be followed closely, STAGING LAPAROTOMY is the choice of treatment If features of torsion – E mergency laparotomy

36. Functional cysts in the premenopausal woman which are < 8 cm, freely movable, smooth, mildly tender, and have the appearance of a simple cyst on USG can be followed into the next menstrual cycle and reassessed on day 10 or so (70% resolve spontaneously) or alternatively, the patient can be started on oral contraceptive Pills

37. Asymptomatic or minimally symptomatic fibroids may be followed; symptomatic fibroids may require hormonal suppression, myomectomy or occasionally hysterectomy Tubo-ovarian abscess and hydrosalpinx in cases of PID are best managed through hospitalization, IV antibiotics and sometime require drainage of the pus and laparotomy

38. Ruptured Ectopic pregnancy requires immediate laparotomy Endometriosis require longterm hormonal therapy, cystectomy or oophorectomy

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