HYPOGASTRIC MASS

HYPOGASTRIC MASS: Excerpt from Differential Diagnosis in Primary Care

More physicians have been fooled by a hypogastric mass than by a mass in any other area. How many times can you recall the mass disappearing on the operating table after catheterization of the bladder? More often than not, the mass is more apparent than real because of a lumbar lordosis or a diastasis recti.

ABDOMINAL HYPOGASTRIC MASS

Anatomy is the key to the differential diagnosis. There are not many organs here normally. Under the skin, subcutaneous tissue, fascia, and rectus abdominus muscles, the bladder, terminal aorta, and lumbosacral spine may be palpated in a thin male. In the female, the uterus may be palpated on bimanual pelvic examination. When there is visceroptosis, the transverse colon will be palpated.

Under pathologic conditions, however, the lymph nodes, sigmoid colon, fallopian tube and ovary, and small intestines may be palpated as well as a pelvic kidney. Applying the mnemonic MINT to these organs results in the extensive differential diagnosis in Table 6. The discussion that follows mentions only the most significant causes of a hypogastric mass.

Lipomas of the skin, ventral hernias, and diastasis recti form the most frequently encountered disorders in the covering of the hypogastrium. The bladder may be obstructed by strictures and prostatism (see page 435) but bladder carcinoma and stones may also be palpable. Bladder rupture should be considered in trauma to the perineum. The uterus may be enlarged by pregnancy, endometritis, fibroid, choriocarcinoma, or endometrial carcinoma. An ovarian or tubal mass may be caused by a benign or malignant ovarian cyst, an ectopic pregnancy, or a tubo-ovarian abscess. The aorta may present as a mass in aneurysms or thrombosis and severe arteriosclerosis of the terminal aorta. Finally, the lumbosacral spine may present as a hypogastric mass in the severe lordosis of Pott disease, spondylolisthesis, metastatic carcinoma, and lumbar spondylosis. The preaortic lymph nodes may greatly enlarge in tuberculosis, Hodgkin disease, and metastatic carcinoma. If the transverse colon drops to the hypogastrium, a carcinoma or inflamed and abscessed diverticulum may be felt. Volvulus may present a mass here.

Ascites from cirrhosis of the liver, ruptured abdominal viscus, or bacterial or tuberculous peritonitis is often encountered and is difficult to differentiate from an ovarian cyst and a distended bladder. Careful percussion and ultrasonic evaluation will be extremely helpful, but a peritoneoscopy or a peritoneal tap in the lateral quadrants may be necessary.

Approach to the Diagnosis

Before the clinician can evaluate a hypogastric mass, it is important to have the patient empty his or her bladder. If the mass is still present, catheterization for residual urine or ultrasonography can determine if the mass is a distended bladder due to a neurogenic bladder or bladder neck obstruction. If there are objective neurologic findings, there may be a neurogenic bladder and the patient should be referred to a neurologist. If the clinician suspects bladder neck obstruction, a referral to a urologist is in order.

Once the possibility that the mass is a distended bladder has been excluded, one should consider ruling out pregnancy in women of childbearing age. A pregnancy test is done and if this is positive, ultrasonography may be done particularly if an ectopic pregnancy is suspected or the patient denies that she could be pregnant.

Once a distended bladder and pregnancy have been removed from consideration, the next step would be a CT scan of the abdomen and pelvis. It is probably wise to consult a gynecologist, general surgeon, or urologist before ordering this expensive test. Their wisdom may make the test unnecessary.

Other Useful Tests

1. Stool for occult blood (rectal carcinoma)
2. CBC
3. Urinalysis (bladder neoplasm or stone)
4. Urine culture (cystitis, bladder diverticulum)
5. IVP (malformation neoplasm, pelvic kidney)
6. Barium enema (rectal or sigmoid carcinoma)
7. Colonoscopy (sigmoid or colon carcinoma).
8. Culdoscopy (ectopic pregnancy, ovarian cyst)
9. Laparoscopy (ovarian cyst, ectopic pregnancy other pelvic mass)
10. Exploratory laparotomy
11. Aortogram (aortic aneurysm)
12. X-ray of the lumbosacral spine (deformities of the spine)
13. Lymphangiogram (retroperitoneal lymph nodes)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 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: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8