Pelvic Masses Flashcards
Differential for benign ovarian mass
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)
What’s the deal with Sertoli-Leydig tumours?
Can turn malignant
Produces testosterone
What’s the deal with granulosa cell tumours?
Produces estrogen (can cause precocious puberty if before puberty and post-menopausal bleeding if it occurs after menopause) Locally malignant and can recur
What is Meige syndrome
Right hydrothorax
Ascites
Fibroma
Resolves after resection of the tumour
What is the most common benign tumour of the ovary
Endometriosis
10% of women
What are characteristics of benign tumours?
Unilateral Mobile (can flip upwards) Soft 100% cystic No adhesions No vascularization No modularity, no adhesions, no scarring, no ascites of the surrounding peritoneum
Hydrosalpinx
Blocked tube from previous PID (usually bilateral) or surgery
Differential for benign para-ovarian cysts
Tubal - hydrosalpinx, tubo-ovarian cyst, pyosalpinx, pelvic abscess
Para-tubal (remnants of the Wolfiaan duct)
What are characteristics of a para-tubal cyst
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
Pyosalpinx etiology
Usually hydrosalpinx that becomes infected from appendix or diverticulitis
What’s the deal with Mullerian and Wolfiaan ducts
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
Clinical presentation of benign adnexal mass
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)
Surgical abdomen
Tenderness
Rebound tenderness
Rigidity
Guarding
Differentiation of tachycardia in hemorrhage vs infection
Hemorrhage - thready pulse
Infection - bounding pulse
What is a hectic fever?
Fever at night that normalizes in the morning
Indicative of pus under pressure (abscess)
Management of Adenexal mass
- Observation
Asymptomatic, simple cyst, no signs of malignancy, <5cm in postmenopausal and 8 cm in premenopausal females - Suppression with OCP with high estrogen (Brevicon 35/0.5) or GnRH analogue (Lupron)
This is for functional cyst (overactive ovaries) - Excision
Mature teratomas - origin, prevalence, presentation, potential complications, treatment
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
Corpus luteal cyst origin, presentation, complications and treatment
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)
With what beta HCg level can you see pregnancy on u/s in utero
5000
Beta hCG level trends and what they mean
Good pregnancy - double every 48 hours
Poor pregnancy - decreases
Ectopic - stable
Consequence of surgical management of CL cyst
Difficult to control bleeding and can result in needing to remove the ovary
If pregnant, will also kill baby because you are removing CL
Adenomyosis epidemiology, associations, pathophysiology, presentation and treatment
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
Fibroid epidemiology, presentation and treatment
> 75% of females
Increased prevalence in African American females
Positive family history
<25% symptomatic
Presentation:
- Menorrhagia
- Intermenstrual bleeding (IMB)
- Mass effect, pressure, backache
- 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
Differential diagnosis of pelvi-abdominal mass
Pregnancy Ovarian mass (mutinous cyst) Fibroid hematocolpus (imperforate hymen) As it is Full bladder Mesenteric cyst Colon cancer, Crohn’s disease etc
Pelvic floor dysfunction etiology and presentation
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
Vestibulitis vulvodynia syndrome Provoked Vestibulodynia (PVD)
- Chronic vulvar discomfort or pain >6 month, can be cyclical
- Acute onset, possibly with trigger
- Superficial and later deep dyspareunia
- Perineal burning or rawness
- Q tip test positive
- Erythema, Bartholine gland openings visible, swollen hymen
- Vaginismus and elevator anii spasm (chronic pelvic pain)
- Urgency, frequency, dysuria
Pelvic Congestion Syndrome
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
