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3rd year - Obstetrics and Gynecology > Pelvic Masses > Flashcards

Pelvic Masses Flashcards

1
Q

Differential for benign ovarian mass

A

Functional cyst
Neoplasm — Epithelial (cystadenoma), germ cell (mature teratoma), sex cord tumour (Sertoli-Leydig or Granulosa cell), connective tissue tumour (fibrous, thecoma)
Other — Endometriosis (chocolate cyst)

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2
Q

What’s the deal with Sertoli-Leydig tumours?

A

Can turn malignant

Produces testosterone

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3
Q

What’s the deal with granulosa cell tumours?

A 
Produces estrogen (can cause precocious puberty if before puberty and post-menopausal bleeding if it occurs after menopause) 
Locally malignant and can recur
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4
Q

What is Meige syndrome

A

Right hydrothorax
Ascites
Fibroma

Resolves after resection of the tumour

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5
Q

What is the most common benign tumour of the ovary

A

Endometriosis

10% of women

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6
Q

What are characteristics of benign tumours?

A 
Unilateral 
Mobile (can flip upwards) 
Soft
100% cystic 
No adhesions 
No vascularization 
No modularity, no adhesions, no scarring, no ascites of the surrounding peritoneum
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7
Q

Hydrosalpinx

A

Blocked tube from previous PID (usually bilateral) or surgery

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8
Q

Differential for benign para-ovarian cysts

A

Tubal - hydrosalpinx, tubo-ovarian cyst, pyosalpinx, pelvic abscess

Para-tubal (remnants of the Wolfiaan duct)

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9
Q

What are characteristics of a para-tubal cyst

A 
10% of para-ovarian cysts 
Always unilateral 
Never attached to the ovary or tube 
In the broad ligament; parallel the upper third of the vagina, uterus and Fallopian tubes 
Can be huge
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10
Q

Pyosalpinx etiology

A

Usually hydrosalpinx that becomes infected from appendix or diverticulitis

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11
Q

What’s the deal with Mullerian and Wolfiaan ducts

A

Mullerian - regress in males usually due to anti-Mullerian signalling
Females often have Wolfiaan duct remnants because there is no ‘anti’

Mullerian runs lateral to Wolfiaan and then crosses over medial to it as you run inferiorly

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12
Q

Clinical presentation of benign adnexal mass

A

Asymptomatic
Mild symptoms - increased girth, distension, frequency
Symptoms of complications (Acute pain)
Torsion - N/V, tachycardia, peritonitic signs
Rupture - as above but generalized + fainting, shoulder pain, hypotension
Hemorrhage -
Intra-cystic - tachycardia, hypotension, localized (pelvic) signs
Intra-peritoneal - tachycardia, hypotension, generalized (abdominal) signs
Infection (abscess)- fever (hectic), tachycardia, local peritoneal signs and generalized peritonitis if rupture of abscess

Chronic pain-
Deep dysparunia, Congestive dysmenorrhea (these are indicative of pelvic pathology such as endometriosis, adenomyosis or chronic PID)

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13
Q

Surgical abdomen

A

Tenderness
Rebound tenderness
Rigidity
Guarding

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14
Q

Differentiation of tachycardia in hemorrhage vs infection

A

Hemorrhage - thready pulse

Infection - bounding pulse

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15
Q

What is a hectic fever?

A

Fever at night that normalizes in the morning

Indicative of pus under pressure (abscess)

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16
Q

Management of Adenexal mass

A
  1. Observation
    Asymptomatic, simple cyst, no signs of malignancy, <5cm in postmenopausal and 8 cm in premenopausal females
  2. Suppression with OCP with high estrogen (Brevicon 35/0.5) or GnRH analogue (Lupron)
    This is for functional cyst (overactive ovaries)
  3. Excision
17
Q

Mature teratomas - origin, prevalence, presentation, potential complications, treatment

A

AKA Dermoid cyst

Germ cell tumour, ectodermal predominance
20% of ovarian tumours and 90% in young females
20% bilateral

Long pedicle (higher risk of torsion) 
Thick wall (decreased risk of rupture) 
Aseptic peritonitis and severe adhesions risk with rupture (filled with thick sebaceous) 
Solid ridge (Macmillan) with cartilage, bone, muscle, thyroid tissue, GI tract tissue etc

Treatment - ovarian cystectomy if >8cm

18
Q

Corpus luteal cyst origin, presentation, complications and treatment

A

Retention cyst resulted from premature sealing of the corpus luteum after the egg is released, causing the CL to enlarge (can be up to 10cm)

Presentation:
Usually disappear after a few weeks
Common in pregnancy (especially twins and molar pregnancy)

Complications:
Intra-cystic bleeding is very common
Rupture is common (thin wall)

Treatment
Observe, suppress, do not touch (make sure to follow beta hCG trend before confusing this with ectopic pregnancy)

19
Q

With what beta HCg level can you see pregnancy on u/s in utero

A

5000

20
Q

Beta hCG level trends and what they mean

A

Good pregnancy - double every 48 hours
Poor pregnancy - decreases
Ectopic - stable

21
Q

Consequence of surgical management of CL cyst

A

Difficult to control bleeding and can result in needing to remove the ovary
If pregnant, will also kill baby because you are removing CL

22
Q

Adenomyosis epidemiology, associations, pathophysiology, presentation and treatment

A

More common in multiple because the uterus repeatedly has stretched and contracted, and previous uterine surgery

Associated with fibroid, endometriosis (always if in multip?), depression

Endometrium —> myometrium —> hypertrophic and hyperplasia —> globular enlargement or localized swelling (adenomyosis)

Present with menorrhagia (less contraction of the uterine muscle decreasing bleeding), congestive dysmenorrhea and dyspareunia

Treatment - hysterectomy

23
Q

Fibroid epidemiology, presentation and treatment

A

> 75% of females
Increased prevalence in African American females
Positive family history
<25% symptomatic

Presentation:

  1. Menorrhagia
  2. Intermenstrual bleeding (IMB)
  3. Mass effect, pressure, backache
  4. Pain if degeneration

Treatment
1. Iron
2. Antifibrinolytics (TXA)
3. NSAID (Anti prostaglandin to decrease menstrual sloughing)
4. Progestins
5. OCP
6. Levonorgestrel IUD (Mireya or Jayden’s)
7. Androgens (Danazol)
8. GnRH agonists (Luprolide acetate) cause immediate and reversible menopause, give with estrogen, progesterone for symptom control
9. Ulipristal acetate (FIBRISTAL) - progesterone receptor modulator (reduces size of fibroid and stops bleeding), monitor liver
10. Surgical (myomectomy, hysterectomy)
11. Embolization - significant decrease in size and bleeding, but not appropriate for >20 cm fibroids (pain) and submucosa fibroids (risk of infection)
The purpose of most of these is to thin down the endometrium

24
Q

Differential diagnosis of pelvi-abdominal mass

A 
Pregnancy 
Ovarian mass (mutinous cyst) 
Fibroid 
hematocolpus (imperforate hymen) 
As it is 
Full bladder 
Mesenteric cyst 
Colon cancer, Crohn’s disease etc
25
Q

Pelvic floor dysfunction etiology and presentation

A

Pelvic floor muscle (elevator anii) —> chronic spasm for unknown reason or following painful experience —> shorten, tight and tender
Can be primary (fibromyalgia) or secondary

Presentation - pelvic pain, dysparunia, dysurea, dyschezia

26
Q

Vestibulitis vulvodynia syndrome Provoked Vestibulodynia (PVD)

A
  1. Chronic vulvar discomfort or pain >6 month, can be cyclical
  2. Acute onset, possibly with trigger
  3. Superficial and later deep dyspareunia
  4. Perineal burning or rawness
  5. Q tip test positive
  6. Erythema, Bartholine gland openings visible, swollen hymen
  7. Vaginismus and elevator anii spasm (chronic pelvic pain)
  8. Urgency, frequency, dysuria
27
Q

Pelvic Congestion Syndrome

A

Varicose veins of the pelvis

Dull aching pain in pelvis and lower abdomen

Caused by multiparous, sedentary lifestyle, constipation, sexual dissatisfaction (orgasm is the only way to drain the vein)

Poor correlation between symptoms and doppler findings

3rd year - Obstetrics and Gynecology (7 decks)

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