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GYNECOLOGY

• Parametrial mass – benign or malignant


P.07 DIFFERENTIAL DIAGNOSIS OF PELVIC MASSES • Adnexal mass – benign or malignant; fallopian tubes and
Dr. Jandoc | August 18, 2018 ovaries; cornual

III. HISTORY
TOPIC OUTLINE • A thorough history is very important
I. Pelvic Mass • Last menstrual period
II. Potential Sources of pelvic mass • Menstrual irregularities
III. History o Normal menstrual cycle: 21-35 days
IV. Pelvic Exam • Pain
V. Diagnostic Test o Character
VI. Gynecological Cause of pelvic mass o Frequency
A. Ovarian o Location
1. Benign Ovarian Masses • Gastrointestinal symptoms
a. Functional Cyst • Urinary bowel changes
b. Benign Ovarian Tumors • Fever
2. Malignant Ovarian Tumors - Important in determining if mass is infectious
3. Pelvic Inflammatory Disease • Weight loss
4. Endometriosis - Possibility of malignancy
B. Uterine • OB/ GYNE History
1. Myoma/Leiomyoma • Gravidity/ parity
2. Adenomyosis • Details of obstetric history
3. Endometrial Polyp - Number of pregnancies, abortions
4. Uterine Cancer • Pelvic surgery
5. Hematometra • Pelvic infection
• Menstrual history
I. PELVIC MASS • Previous Pap smear history
- Mass in the pelvis diagnosed by physical examination or found • Urinary history
incidentally during diagnostic imaging studies • Frequency
- Pelvic masses might not be only gynecologic in nature so when a • Hematuria
female patient comes to ER complaining with a pelvic mass, we • Incontinence
don’t know if she is a patient of gyne or surgery. • Voiding pattern
• Gastrointestinal
II. POTENTIAL SOURCES OF PELVIC MASS • Increased girth as the size of the mass increases
- Any structure in or abutting the pelvis may be the source of • Nausea/ Vomiting
enlargement, distention or neoplasia, resulting in the • Bowel dysfunction
formation of a mass • Tarry stools/ blood in stools
1. Central nervous system • Diarrhea/Constipation
• Meningocele • Vascular
2. Urinary tract • Known aneurysm or hemangioma
• Pelvic kidney • Developmental
• Neurogenic bladder • Congenital anomalies
• Bladder malignancy • Neurologic motor problems
• Interview patient first in ER to make thorough history if • Past history
this is a gynecologic pathology before referring the • Stroke, diabetes, medication, malignancy
patient. • Family history
3. Vascular / lymphatic • Diabetes, malignancy
• Hemangioma IV. PHYSICAL EXAM
• Aneurysm A. Abdomen
• Lymph node enlargement • Inspection - scar, abdominal enlargement
4. Gastrointestinal • Auscultation - bowel sounds
• Appendiceal abscess • Percussion
▪ Patient with high tolerance to pain might not go • Palpation – Mass (Characterize), tenderness, guarding, fluid
or seek medical attention wave, assess size of abdominal organs
• Diverticular abscess B. Pelvis
• Gastrointestinal tumors or malignancy • Inspection
5. Retroperitoneal/ Peritoneal Masses • Speculum examination
• Peritoneal inclusion cyst • Internal examination/bimanual examination
• Retroperitoneal mass – fibrosarcoma - Internal examination: 2 examining fingers are
• Endometriosis implants inserted to the introitus
6. Reproductive Organs - Bimanual examination: one examining finger is inside
• Pregnancy - In or out of uterus the introitus while the other hand is placed on the
▪ If patient is in the reproductive age group, we abdomen
cannot discount the possibility of pregnancy • Rectovaginal examination
even if the patient claims she has no history of - Once done with the
sexual contact. internal examination,
• Cervical mass – benign or malignant insert the middle
• Uterine mass – benign or malignant

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GYNECOLOGY
finger in the rectum with the index finger still in the • Most common in young women
introitus -> feel for any masses because what might • It may have sebum and hair, fat, tooth
you be feeling is a mass in the rectum and not in the c) Sex cord
vagina. • Diagnostic test
• Rectal examination - Ultrasound
- For patients with no history of sexual contact; ex: - CT scan, MRI
pediatric patients ▪ Useful in differentiating if it is functional cyst
- There is a very thin septum separating the rectum and or benign ovarian mass/tumor
the rest of the pelvic organs so what is being • Management
measured reflects what you would have measured had - Normal ovary size is 2.5-5 cm
you done an internal exam 1. Prepubertal and reproductive – aged women
o For every procedure you are going to do, you have - Most ovarian cysts are functional and
to inform the patient. spontaneously regress within 6 months
o If you are a male doctor examining the female - Usually, the menstrual period of patient is able
patient, it will be prudent for you be accompanied to correct the hormonal imbalance ->
by a female before you do internal or rectovaginal SPONTANEOUS REGRESSION. If the mass still
exam. persists, hormonal therapy is done
2. Post-menopausal women
- Expectant management (no need to operate) may be
done if the following criteria are met:
✓ Thin-walled, unilocular cyst on ultrasound
✓ Cyst diameter less than 5 cm
• 5 cm size persistently in a 65 year old
women and all the features tell us
benign. What should we do? Expectant
management may done. Meaning you
! not need to operate in this patient it
Speculum examination Bimanual Examination will create more morbidity in a benign
lesion. And with normal CA125 do not
V. DIAGNOSTIC TEST operate but continue monitoring.
A. Blood work ✓ No cyst enlargement during surveillance
• Complete blood count (CBC) - Malignant tumors usually grow very fast
• Pregnancy test ✓ Normal serum cancer antigen 125 (CA125)
• Urinalysis (UA) level
• Occult blood 2. Malignant Ovarian Tumors
• Blood culture a. Epithelial ovarian carcinoma – most common 90-95%; older
B. Radiographic studies women
• Abdominal and vaginal sonogram b. Germ cell- younger women
• Computed tomography (CT) • Signs and Symptoms
• Magnetic resonance imaging (MRI) - Increased abdominal girth
• Barium enema - Bladder/ bowel changes
• Bone scan - Abdominal pain/distention
• Renal sonogram/Intravenous pyelogram (IVP) • Metastasis
C. Colonoscopy and/or Cystoscopy • Diagnosis
• Should be performed if all above are inconclusive - Ultrasound
o High degree of accuracy and very cost
VI. GYNECOLOGICAL CAUSES OF PELVIC MASSES effective.
A. OVARIAN - CT scan
- Establish first if it is benign, malignant, what the cause of - MRI
the inflammatory process is, or if it is endometriosis - Tumor Markers
1. Benign Ovarian Masses 3. Pelvic inflammatory Disease
a) Functional cyst - Ascending in nature
- Hand in hand with the menstrual cycle of the patient - Usually results from infection (usually STI) that is left
- Functional: hormone-producing cyst; assess for menstrual untreated which then ascends to the uterus from the vagina
irregularities and progresses to fallopian tube; you will see a stretching of
- Small <1.5 cm in diameter the fallopian tube -> hydrosalphinx or pyosalphinx
- Usually resolve spontaneously - Common cause of ectopic pregnancy: FT stretched because
- Types: of pus/fluid (hydrosalphinx or pyosalphinx) -> cilia still
a. Follicular cyst – from graafian follicles present but is unable to move the fertilized ovum until it
b. Corpus luteum Cyst becomes a blastocyst that will implant outside the uterus.
b) Benign Ovarian tumors - Inflammation in tissue
- Slow growing, rarely become malignant • Capillary oozing/small blood vessel erosion
- 3 major types:
a) Epithelial - Vulvitis, vaginitis, cervicitis, endometritis
• serous mucinous cystadenoma • Vaginal bleeding / spotting
• most common in older age group • Foul-smelling discharge
b) Germ Cell
• Mature cystic teratoma - Acute salpingitis or tuboovarian abscess

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GYNECOLOGY
• Pain
• Tenderness
• Generalized signs and symptoms of infection
4. Endometriosis
- Presence of endometrial glands and stroma outside the
uterus
- Most frequent sites:
a. Ovaries
o Most frequently affected site by virtue of
contiguity
o Retrograde menstruation:
- Menstrual blood containing endometrial cells
back flows towards the fallopian tube to the
ovaries where endometrial cells eventually
attach themselves. Every menstrual period,
these endometrial cells become activated just
like the endometrial cells found in the uterus
-> products of menstruation released in the
ovary -> PAIN
b. Pelvic viscera 2. Adenomyosis
c. Peritoneum - Growth of endometrial glands and stroma into uterine
• Clinical presentation:
myometrium to a depth of at least 2.5 mm from the basalis
a. Chronic pelvic pain layer of the endometrium
b. Infertility (long term complication) - Ectopic sites may bleed; same principle with endometriosis -
- Blood produced by the endometrial cells outside the > PAIN every menstrual period
endometrium are considered foreign body causing - Reaction of myometrium to ectopic endometrium is
inflammatory reaction. During the process of healing, hyperplasia and hypertrophy of individual muscle fibers ->
there is scarring leading to the structural destruction of Globular enlargement of uterus
normal anatomy of reproductive system. • Ultrasound findings:
c. Dysmenorrhea o Thickened walls
d. Dyspareunia if endometrial cells implant in the vagina o “Sunburst or sun rays appearance”
Figure 4b: linear striations "sun rays appearance"
- Aberrant endometrial tissues are hormonally dependent on
high estrogen levels
- Disease of reproductive age group
- Ovaries enlarged, tender, fixed to the broad ligament or
lateral pelvic sidewall

3. Endometrial polyp
Figure 2: Enlarged ovary to show a cystic cavity filled with old blood - Localized overgrowths of endometrial glands and stroma
typical of endometriosis that project beyond the surface of endometrium
- Wide range of bleeding pattern
B. UTERINE o Menorrhagia
1. Myoma/ Leiomyoma o Premenstrual and postmenstrual spotting
- Sharply circumscribed, discrete, round, firm gray-white • Polyp not responsive to hormonal treatment so management is
tumors varying in size from small nodules to massive tumors polypectomy.
that fill the pelvis
- Submucous, intramural, subserous
Figure 3: Submucosal, intramural and subserosal leiomyomata
Figure 5: Uterus:
Opened anteriorly
through the cervix and
into the endometrial
cavity

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GYNECOLOGY
4. Uterine Cancer Management
• Clinical presentation (Referral to appropriate specialty)
- Abnormal vaginal bleeding
- Pelvic pain Checkpoint
- Pelvic mass T or F
- Weight loss 1. Cystoscopy should only be performed if other diagnostic test are
• Diagnosed with inconclusive
- Pelvic exam 2. A functional cyst is slow growing and rarely becomes malignant
- Ultrasound 3. The germ cell type of a functional cyst is common among young
- Biopsy women.
• Management depends on 4. Adenomyosismay progress to the enlargement of the uterus
o Age characterized as globular
- If patient is very young and management is very aggressive 5. Endometriosis presents as an acute pelvic pain
then you will be curtailing the reproductive function of the 6. Frequent sites of endometriosis to occurare in the ovaries, pelvic
patient viscera and peritoneum
o General health
o Desire for future childbearing Matching type
- Hysterectomy cannot always be considered especially if 1. Collection of blood in the uterus
patient has not completed her family or has not gotten 2. Presents with abnormal vaginal bleeding, pelvic pain and mass, and
pregnant yet weight loss
o Patient preference 3. Grey white tumors varying in size that fills the pelvis
4. Growth of endometrial gland and stromainto uterine myometrium to
5. Hematometra a depth of atleast 2.5 mm
- Collection or retention of blood in the uterus 5. Types ovarian tumor that is most common in older age group
- With cyclic menstruation 6. Types ovarian tumor that is most common in young women
o Vaginal canal distends - cervix dilates – formation of 7. Presence of endometrial glands and stroma outside the uterus
hematometra
• Etiology a. Malignant ovarian tumor (epithelial)
a. Imperforated hymen B. Malignant ovarian tumor (germ cell)
- Bluish bulge at the introitus C. Endometriosis
- Patient has not menstruated yet but complains of D. Myoma
cyclical pain E. Adenomyosis
- Menstrual blood that has accumulated cannot go F. Uterine cancer
out so patients will complain of pelvic pain/mass G. Hematometra
H.benign ovarian mass (epithelial)

T|F|F|T|F|T.
G.F.D.E.H.B.C

!
b.Transverse vaginal septum
- Hymen is open but there’s something blocking
the vaginal canal
c. Previous gynecologic procedures – Scarring
• Clinical presentation
- Cyclic pain
- Amenorrhea
- Abdominal pain mimicking acute abdomen
- Difficulty with urination or defecation
SUMMARY

Complete history

Physical exam

Diagnostic tests

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