Pelvic Masses - Female

Pelvic Masses - Female: Excerpt from In a Page: Signs and Symptoms

Pelvic masses are most common in women, but they do occur in men. Obvious causes, such as bladder distension and pregnancy, must be ruled out prior to a full workup. Malignancy must be considered in all cases, particularly as the age of the patient increases or in patients with a past history of malignant disease.

Differential Diagnosis

• Postmenarche/premenopause
  –Ovarian: Follicular and corpus luteum cysts (most common), endometrioma, polycystic ovarian syndrome, neoplasms (benign or malignant)
  –Infectious: Tubo-ovarian abscess (secondary to PID), hydrosalpinx
  –Pregnancy: Uterine, ectopic, or molar
  –Leiomyomas (fibroids)
  –Retroperitoneal tumors
  –Constipation
• Postmenopause (increased risk of malignant neoplasms)
  –Ovarian fibromas
  –Ovarian cysts
  –Leiomyomas (fibroids)
  –Diverticular abscesses
  –Enlarged bladder
  –Hernia (femoral or inguinal)
  –Primary ovarian carcinoma
  –Metastatic disease from uterus, breast, or GI tract
  –Colorectal cancer
• Newborns/children
  –Functional ovarian cysts
  –Germ cell tumor: Dermoid (benign cystic teratoma), dysgerminomas
  –Wilms’ tumor
  –Lymphoma
• Sacral promontory can occasionally be confused with a pelvic mass by inexperienced clinicians
• Less common etiologies (“zebras”) include ovarian torsion, leiomyoma torsion, congenital obstructive genital lesion (e.g., imperforate hymen, blinded uterine horn), bicornuate uterus, pelvic kidney, and cervical cancer
• Males
  –Lymphoma
  –Colorectal cancer
  –Diverticular abscesses
  –Metastatic disease from colorectal cancer
  –Bladder distension (often secondary to BPH)
  –Hernia (femoral or inguinal)
  –Retroperitoneal tumors
  –Constipation

Workup and Diagnosis

• History and physical examination
  –Note whether mass is painful (constant or intermittent, cyclic or noncyclic, dyspareunia) or associated with menstrual disturbance (dysmenorrhea and menorrhagia are associated with endometriosis and leiomyomas) or other symptoms (e.g., fever, weight loss/gain, nausea, vomiting, dyspepsia, early satiety, abdominal bloating, constipation, diarrhea, change in stool caliber)
  –Full abdominal, breast, lymph node, and pelvic/genital exams, including bimanual and rectal
• Laboratory evaluation may include urine pregnancy test, urinalysis, BUN/creatinine, CBC with differential, Pap smear with culture for gonorrhea and Chlamydia, hemoccult testing, and liver function tests
• Pelvic ultrasound for adnexal/uterine masses to determine size, location, and composition of mass
• Pelvic/abdominal CT
• Colonoscopy to rule out colorectal cancer
• Consider bladder catheterization if bladder distension is considered
• Tumor markers are indicated if abnormal ultrasound
  –β-hCG (nongestational choriocarcinomas)
  –α-fetoprotein (endodermal sinus tumors)
  –LDH (dysgerminomas)
  –Serum CA-125

Treatment

• Treat the underlying etiology

• Ovarian masses
  –Premenarchal: Immediate gynecologic referral because of high malignancy potential
  –Premenopausal: If simple ovarian cyst <10 cm, observe 4–6 weeks, attempt to suppress with OCP; if persists, consider diagnostic laparoscopy; surgical evaluation is indicated if ovarian solid mass, complex cyst, or ascites is present
  –Postmenopausal: If <3 cm, asymptomatic, and normal exam, follow with serial ultrasounds; if persists, consider surgical evaluation; laparoscopy if cyst is >3 cm, symptomatic, or solid
• Leiomyoma
  –Hypoestrogenic medications (e.g., Depo-Provera, leuprolide)
  –Minimally invasive procedures: Hysteroscopic laser myomectomy, uterine artery embolization
  –Surgical: Myomectomy versus hysterectomy

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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