Diagnosis of Hysterectomy

Hysterectomy Diagnosis: Book Excerpts

• Ask the Following Questions - PELVIC MASS
• Ask the Following Questions - PELVIC PAIN
• Differential Diagnosis - Pelvic Masses - Female
• Differential Diagnosis - Pelvic Pain - Female
• Approach to the Diagnosis - PELVIC MASS
• Approach to the Diagnosis - PELVIC PAIN
• Diagnosis - Pelvic inflammatory disease
• History - Chronic Pelvic Pain
• Differential Overview - Abdominal/Pelvic Mass
• Diagnosis - Pelvic inflammatory disease
• Approach to the Diagnosis - PELVIC MASS
• Approach to the Diagnosis - PELVIC PAIN

Diagnosis of Hysterectomy: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Hysterectomy:

• Simple treatments exist for menorrhagia
• Treatment options are available for excessive menstrual bleeding
• More news »

Diagnostic Tests for Hysterectomy: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Hysterectomy.

PELVIC MASS: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there abdominal pain? The presence of abdominal pain suggests PID, ectopic pregnancy, and endometriosis, among other things. It should also suggest pelvic appendix.
2. Is there fever or vaginal discharge? The presence of fever or vaginal discharge would be most suggestive of PID.
3. Is there a history of menorrhagia or metrorrhagia? The history of menorrhagia or metrorrhagia should suggest ectopic pregnancy, endometriosis, and threatened abortion, as well as retained secundinae.
4. Is the pregnancy test positive? A positive pregnancy test is the key to a diagnosis of ectopic pregnancy when there is abdominal pain along with the abdominal mass. If there is no pain, the pregnancy test will help diagnose a normal pregnancy.

DIAGNOSTIC WORKUP

Routine diagnostic studies include a CBC, sedimentation rate, pregnancy test, urinalysis, urine culture, chemistry panel, VDRL test, and Pap smear. If there is vaginal discharge, a smear and culture of the material should be made. If a distended bladder is suspected, catheterization for residual urine must be done. Pelvic ultrasound or a CT scan will often be useful, but why not consult a gynecologist before ordering these more expensive tests? The gynecologist may do a laparoscopy, a culdocentesis, and, ultimately, an exploratory laparotomy.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PELVIC PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a pelvic mass? The presence of a pelvic mass would suggest salpingo-oophoritis, ectopic pregnancy, endometriosis, uterine fibroid, or an ovarian tumor that is twisting on its pedicle.
2. Is there fever or purulent vaginal discharge? The presence of fever or purulent vaginal discharge would suggest PID, diverticulitis, and appendicitis.
3. Is there a history of metrorrhagia or menorrhagia? The history of metrorrhagia or menorrhagia would suggest ectopic pregnancy, threatened abortion, retained secundinae, uterine fibroids, and endometriosis.
4. Is there a positive pregnancy test? The presence of a positive pregnancy test would suggest an ectopic pregnancy or threatened abortion.
5. Is the pain related to the menstrual cycle? If the pain is related to the menstrual cycle, mittelschmerz should be considered.

DIAGNOSTIC WORKUP

Routine studies include a CBC, sedimentation rate, pregnancy test, urinalysis, urine culture, chemistry panel, VDRL test, and Pap smear. A vaginal smear and culture should also be done routinely.

The next step would logically be a pelvic ultrasound, but it is wise to consult a gynecologist before ordering expensive tests. The gynecologist may proceed with laparoscopy, culdocentesis, and, ultimately, an exploratory laparotomy. A CT scan of the abdomen and pelvis may also be necessary.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Pelvic Masses - Female: Differential Diagnosis
(In a Page: Signs and Symptoms)

• 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

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Pelvic Pain - Female: Differential Diagnosis
(In a Page: Signs and Symptoms)

Acute pain (<6 months)

• Pregnancy-related
  –Ectopic pregnancy
  –Threatened abortion
  –Incomplete abortion
  –Septic abortion
  –Ruptured corpus luteal cyst
• Gynecologic (noncyclic)
  –Ovarian cyst
  –Pelvic inflammatory disease
  –Tubo-ovarian abscess
  –Vaginitis/cervicitis
  –Ovarian torsion
  –Uterine fibroids
  –Pelvic (ovarian, uterine, urinary) neoplasm
  –Pelvic floor prolapse (cystocele/rectocele)
• Gynecologic (cyclic pain)
  –Primary dysmenorrhea
  –Endometriosis
  –IUD
  –Mittelschmerz (midcycle ovulation)
• Nongynecologic
  –Irritable bowel syndrome
  –UTI/pyelonephritis
  –Nephrolithiasis
  –Appendicitis
  –Diverticulitis
  –Sexual abuse/trauma
  –Abdominal aortic aneurysm
  –Mesenteric ischemia/infarction
• 
  Chronic pain (>6 months)
• Very difficult to diagnose; differential includes gynecologic and nongynecologic etiologies (above), as well as the following
  –Pelvic adhesions
  –Interstitial cystitis
  –Inflammatory bowel disease
  –Adenomyosis
  –Leiomyoma (fibroids)
  –Hernia (femoral or inguinal)
  –Depression
  –Irritable bowel syndrome
  –Diverticulosis or diverticular abscess
  –Lymphoma
• Less common etiologies (“zebras”) include pelvic congestion syndrome, mesenteric adenitis, surgical adhesions, Asherman's syndrome, foreign body (e.g., tampon), abdominal wall nerve entrapment, and porphyria

Workup and Diagnosis

• History and physical examination
  –Note the nature, severity, onset, radiation, duration of pain; relation to menstrual cycle, intercourse, or other activities; chronic versus acute; chance of pregnancy
  –Note associated symptoms: Fever, nausea, vomiting, dysuria, frequency, vaginal bleeding/discharge, abdominal or back pain
  –Screen for domestic violence and sexual abuse
  –Full abdominal and pelvic exams, including speculum, bimanual, and rectal exam
• Laboratory studies may include urine pregnancy test, urinalysis, urine Gram stain and culture, cervical cultures for Chlamydia and gonorrhea, and wet mount of vaginal smear
• Consider ultrasound if ovarian cyst, torsion, or mass is suspected, or to evaluate for intrauterine versus ectopic pregnancy
• Diagnostic laparoscopy for acute abdomen or endometriosis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

PELVIC MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association with other symptoms is the key to the clinical diagnosis. A painless mass is likely to be a neoplasm, whereas a tender mass with fever suggests PID or a diverticular abscess. Obviously, an ectopic pregnancy should be associated with tender breasts, frequency of urination, and morning sickness. The next logical step is ultrasonography and a gynecology consult.

Laboratory tests include urinalysis and culture, pregnancy test, stool for blood and parasites, and vaginal cultures. A proctoscopy and barium enema may be useful. Colonoscopy, culdoscopy, peritoneoscopy, and cystoscopy may all need to be done before an exploratory laparotomy is performed.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

PELVIC PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A good pelvic and rectal examination is essential. These will often disclose a mass or other pathology to explain the pain. If there is a vaginal discharge, a smear and culture for gonococcus and Chlamydia need to be done. A pregnancy test will help rule out an ectopic pregnancy, but ultrasonography is most useful.

A gynecology consult should be obtained when there is any doubt. In acute cases, the gynecologist may proceed with an exploratory laparotomy immediately.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Pelvic inflammatory disease: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnostic tests generally include:

❑ Gram stain of secretions from the endocervix or cul-de-sac. Culture and sensitivity testing aids selection of the appropriate antibiotic. Urethral and rectal secretions may also be cultured.

❑ Ultrasonography to identify an adnexal or uterine mass.

In addition, patient history is significant. In general, PID is associated with recent sexual intercourse, insertion of an intrauterine device, childbirth, abortion, or a sexually transmitted disease.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Chronic Pelvic Pain: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 As with any pain, the onset, duration, and pattern of the pain must be assessed. The location, intensity, character, and radiation are important historical elements. Aggravating or relieving factors are important, especially as they relate to the urinary, musculoskeletal, or gastrointestinal systems as well as the relationship of pain to sexual activity or menstruation. Systemic symptoms such as fatigue and anorexia are often present. A medication history (e.g., use of birth control pills or over-the-counter medications) should be obtained. The past obstetric, gynecologic, and general surgical histories are extremely important.

It should be noted that women with a history of pelvic inflammatory disease are four times more likely to develop chronic pelvic pain. The list of possibilities for the condition is substantial. A person with intestinal, sexual, urinary, musculoskeletal, and systemic symptoms may be suffering from a psychiatric disorder (e.g., depression) and an acknowledged or remote history of sexual abuse. Often this information is possible to obtain only when the provider creates an atmosphere of mutual respect and trust.

Dyspareunia is often present. Cyclic pain that is related to menstruation usually points to a gynecologic problem. Pain referred to the anterior thigh, pain associated with irregular uterine bleeding, or new onset dysmenorrhea may have a uterine or ovarian cause. Urethral tenderness, dysuria, or bladder pain suggests interstial cystitis or a urethral problem (Chapter 10.1). Pain on defecation, melana, bloody stools, or abdominal pain with alternating diarrhea and constipation can point toward pelvic floor problems, irritable bowel syndrome, or inflammatory bowel diseases.

Physical examination

 A. The general condition of the patient should be noted. Does the patient look chronically ill, which may suggest a pelvic lesion or an inflammatory bowel disorder? Does the patient appear anxious, stressed, or inappropriate?

 1. Can the patient point to the pain with one finger? If so, this can indicate that the pain may have a discrete source.

2. An examination of the lower back, sacral area, and coccyx, including a neuologic examination of the lower extremities, is necessary. Herniated disc, exaggerated lumbar lordosis, and spondylolisthesis can all cause pelvic pain.

 3. Examine the abdomen, looking for surgical scars, distension, and palpable tenderness, particularly in the epigastrium, flank, back, or bladder.

 B. A thorough pelvic examination is the most important part of the evaluation.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

Diagnostic Approach

Consider the structures in the region of the mass for clues to its origin and the presence of tenderness as an indicator of inflammation/infection. It is possible to miss initially even a relatively large mass unless a systematic four-quadrant examination is performed.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Pelvic inflammatory disease: Diagnosis
(Handbook of Diseases)

Tests commonly used to diagnosis PID include:

❑ Gram stain of secretions from the endocervix or cul-de-sac; culture and sensitivity testing aids selection of the appropriate antibiotic. Urethral and rectal secretions may also be cultured.

❑ ultrasonography or computed tomography scanning to identify an adnexal or uterine mass. (X-rays seldom identify pelvic masses.)

❑ culdocentesis to obtain peritoneal fluid or pus for culture and sensitivity testing.

The patient’s history is also significant because PID is commonly associated with recent sexual intercourse, IUD insertion, childbirth, or abortion.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

PELVIC MASS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association with other symptoms is the key to the clinical diagnosis. A painless mass is likely to be a neoplasm, whereas a tender mass with fever suggests pelvic inflammatory disease (PID) or a diverticular abscess. Obviously, an ectopic pregnancy should be associated with tender breasts, frequency of urination, and morning sickness. The next logical step is ultrasonography and a gynecologic consult. Laboratory tests include urinalysis and culture, pregnancy test, stool for blood and parasites, and vaginal cultures. A proctoscopy and barium enema may be useful. Colonoscopy, culdoscopy, peritoneoscopy, and cystoscopy may all need to be done before an exploratory laparotomy is performed.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

PELVIC PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

A good pelvic and rectal examination is essential. These will often disclose a mass or other pathology to explain the pain. If there is a vaginal discharge, a smear and culture for gonococcus and Chlamydia need to be done. A pregnancy test will help rule out an ectopic pregnancy, but ultrasonography is most useful. A gynecology consult should be obtained when there is any doubt. In acute cases, the gynecologist may proceed with an exploratory laparotomy immediately.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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