Hypogastric Mass
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.
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 , 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 lymphoma, 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 or 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.
After 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:
If the test is positive, ultrasonography may be done particularly if an
ectopic pregnancy is suspected or the patient denies that she could be
pregnant.
After 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
-
Stool for occult blood (rectal carcinoma)
-
CBC
-
Urinalysis (bladder neoplasm or stone)
-
Urine culture (cystitis, bladder diverticulum)
-
IVP (malformation neoplasm, pelvic kidney)
-
Barium enema (rectal or sigmoid carcinoma)
-
Colonoscopy (sigmoid or colon carcinoma)
-
Culdoscopy (ectopic pregnancy, ovarian cyst)
-
Laparoscopy (ovarian cyst, ectopic pregnancy, other pelvic mass)
-
Exploratory laparotomy
-
Aortogram (aortic aneurysm)
-
X-ray of the lumbosacral spine (deformities of the spine)
-
Lymphangiogram (retroperitoneal lymph nodes)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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