7,8,9 adnexal mass, pelvic anatomy, incontinence

Question 1

Complex adnexal mass in a repro-aged female, seen on U/S:

Differential dx: (6) and their classic presentations

Answer 1

1. Adnexal torsion–sudden onset abd pain, no inciting event
2. Teratoma–massive cyst growing slowly
3. TOA–repeated bouts of PID
4. Ectopic pregnancy–pregnant, no IUP
5. Endometrioma–dyspareunia, dysmenorrhea, assoc with periods
6. Cancer

Question 2

Woman presents with sudden onset of excruciating abdominal pain with no inciting event.

Transvag U/S shows a complex cyst. Most likely dx?

How to tx?

Answer 2

Adnexal torsion, classic presentation.

Tx: surgery to untwist ovary. If necrotic, remove ovary.

Question 3

Pt presents with sudden, excruciating abdominal pain.

How to differentiate between ovarian cyst rupture and adnexal torsion?

Answer 3

Do U/S: Adnexal torsion could show cyst (not always)

Do U/S Doppler: If there is blood flow to ovaries, it is rupture. If no blood flow, it’s torsion.

Question 4

Simple cyst, discovered on transvag U/S:

Tx/management

Answer 4

• first do OCPs x2 months. By turning off hormonal stimulation, cysts should resolve on own.
• If no resolution after 2 months, or cyst occured on OCPs, or it’s large (>7cm), it’s automatically a complex cyst. Do CT scan.

Question 5

Adnexal mass: Think what for each age group:

1. premenstrual
2. repro aged
3. postmenopausal

Answer 5

1. CA until proven otherwise
2. wider differential (simple vs complex cysts, etc)
3. CA until proven otherwise

Question 6

Teratoma:

-what don’t you bx it

Answer 6

Biopsy could promote peritoneal seeding

Question 7

Ectopic pregnancy:

• steps of dx
• tx options

Answer 7

Do B-HCG and transvag U/S:

If B-HCG is >1500, you should see IUP on transvag U/S for normal pregnancy.

If B-HCG <1500 and you don’t see ectopic on U/S, wait 2 days to see if B-HCG doubles (for regular pregnancy)

Tx: MTX, salpingostomy, salpingectomy (if rupture)

Question 8

Ectopic pregnancy, unruptured:

-what criteria allows tx of with MTX? (4)

Answer 8

1. no FHT
2. no folate
3. B-HCG <8000
4. mass <3 cm

Question 9

Endometriosis

1. sx (3)
2. Dx

3.

Answer 9

1. dysmenorrhea, dyspareunia, infertility!
2. 1) U/S shows complex cyst
   2) OCP trial (both tx and diagnostic)
   3) scope with laser ablation (diagnostically superior, and curative)
3. Tx: OCP, leuprolide continuous, scope with ablation.

Question 10

TOA

• mech
• sx/presentation
• Dx
• Tx

Answer 10

mech: repeated trauma/inflamm of cervical barrier by PID allows entrance of vaginal flora into sterile uterus/tubes
presentation: fever, leukocytosis, adnexal mass

Dx: U/S shows complex mass

Tx: Amp/Gent + Flagyl (or Cipro/Flagyl). If 72 hours later no improvement, it must be drained. (TOA is one of the few abscess conditions that doesn’t require emergent drainage)

Question 11

Ovarian torsion: what is being twisted?

Answer 11

Twist around suspensory ligament, which has the ovarian a and v

Question 12

PPH: What arteries to ligate, in what order?

Answer 12

Uterine arteries are branches of internal iliacs.

1. uterine a
2. internal iliacs (which supply other pelvic parts too)
3. TAH

Question 13

Pelvic anatomy: what ligaments to know? (3)

Clinical significance of each?

Answer 13

1. suspensory ‘ligament’ (infundibulo-pelvic ligament)
   - ovarian torsion around this.
2. uterosacral lig: looks like ureters, located close by, and must be cut in TAH. So, don’t mistakenly cut the ureters.
3. cardinal lig: get stretched in pregnancies and delivery. Can cause:
   - uterine prolapse
   - cystocele/stress incontinence
   - rectocele/constipation

Question 14

What problems can cardinal ligament loosening cause? (3)

Answer 14

1. uterine prolapse
2. cystocele, stress incontinence
3. rectocele, constipation

Question 15

Urinary incontinence:

List 3 main types, and 2 others

Answer 15

1. Stress.
2. Urge (hypertonic/overactive)
3. Overflow (hypotonic/neurogenic)
4. irritative bladder
5. fistula

Question 16

Stress incontinence

1. path/mech
2. sx
3. dx
4. tx

Answer 16

1. females only. Stretching of cardinal lig (pelvic floor) leads to cystocele, so bladder sphincter falls into vagina, where increased abdominal pressure cannot close it.
2. Urination with cough, sneeze, etc
3. clinical dx. can also do Q-tip test (rotation of urethra >30 degrees)
4. Tx: Pessaries, surgery to rebuild pelvic floor

Question 17

Urge incontinence

1. path/mech
2. sx
3. dx
4. tx

Answer 17

1. spastic contractions of bladder at any time
2. irrepressible urges, nocturnal urination
3. clinical dx, but cystometry will show contractions
4. Antimuscarinics: Solifenacin, oxybutynin

Question 18

Overflow incontinence

1. path/mech
2. sx
3. dx
4. tx (2 drugs)

Answer 18

1. absent detrusor contractions, from nerve injury (DM, MS, trauma)
2. Pt cannot sense urge to void. Overflowing bladder leaks urine all day, including nocturnal. Beware of hydro!
3. cystometry shows absent detrusor contractions
4. Bethanecol (cholinomimetic) and Doxazosin (A-blocker), and scheduled catheterizations

Question 19

Incontinence from Irritative Bladder

1. path/mech
2. sx
3. dx
4. tx

Answer 19

1. Irritation from inflammation/infection (stones/UTI/cancer) causes bladder CTX
2. Similar to urge: pt feels contractions, but they are suppressible. F/U/D
3. If UTI, U/A (shows WBCs) and Urine Cx
4. Abx to treat infection

Question 20

Incontience from fistula

1. path/mech
2. sx
3. dx
4. tx

Answer 20

1. fistula from bladder to other organ. Caused by radiation or inflamm disease (eg Crohn’s)
2. Constant leak
3. Dye tampon test: inject dye into bladder. If there is fistula, tampon in vagina/rectum will show dye.
4. fistulotomy