What to do when confronted by a mass arising from the pelvis

1. AN APPROACH TO
EVALUATION OF PELVIC
MASSES IN WOMEN
1

2. Learning objectives
! to formulate a list of
differentials for a patient with
a pelvic mass
! identify the risk factors for
malignancy
! to establish a system of
evaluation for such tumours
2

3. These are growths that are
associated with the reproductive
What are they?
tract
They include tumours arising from
the female reproductive organs
Although pertinent, breast
tumours will not be discussed
here
3

4. Why the fuss?
! We all worry about
cancer
! As such, all growths
should be suspected
cancerous
! It is our duty to confirm
non-malignancy
4

5. We all worry about cancer
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6. The objectives when a growth is
discovered
! Most importantly,
assess the
probability of
malignancy
! If malignancy is
less likely, then
assess the
association with
fertility
! Plan for
management, most
likely surgery
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7. Aetiology
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8. Concepts on aetiology
! most premenopausal tumours are benign in origin
! malignancy can occur at all ages
! this risk increases with age
! postmenopausal women require aggressive evaluation
! cancer until proven otherwise
8

9. General Causes
! Uterine fibroids ! Ovarian cysts
! Adenomyosis (older pt) • Epithelial (arising from ovarian
epithelium)
! Functional cysts -
- Serous & mucinous
occasionally grow large &
symptomatic - most common
! Pregnancy • Germ cell (from egg-producing
cells)
- In younger women
• Stromal ( from hormone
producing cells)
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10. In the reproductive age group
! functional cysts (follicular or luteal) are most common
! usually small but may become larger - 10 cm
! frequently asymptomatic but can have dull, non-
specific pain
! mostly due to intracystic haemorrhage
! tumours are rare - most common dermoid cysts &
benign teratomas
! never forget pregnancy!
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11. nongynae causes
Don t forget there s other stuff in the pelvis!
Brown G. A gynecologic approach to evaluation of pelvic masses in women JAAPA 2012
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12. Symptoms
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13. The asymptomatic patient
! during a routine medical
check up – physical
exam, U/S scan etc
! from Pap smear results
13

14. Abnormal Vaginal Bleeding
! usually occurs with tumours of lower tract
! endometrial, myometrial cervical etc..
! fibroids are prone to heavy cyclical bleeding
! irregular, non-menstrual bleeding is more sinister
! postcoital bleed suggests intravaginal location
! polyps and cancers can occur, but infection is the most
common cause
! ovarian tumours mostly bleed if cancerous, & only when advanced
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15. Abdominal pain
! ascertain if cyclical/dysmenorrhoea - more likely
endometriosis or PID
! how long has it been there?
! If it has been there for a long time, is it progressively
worsening?
! remember abdominal quadrants,
! usually, the pain will be overlying the offending
organ
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16. Nonspecific symptoms
! bowel or urinary, these usually are sinister
associations with the tumour
! endometriosis and/or adhesions may mimic these
! other symptoms that should be questioned include
appetite & weight loss
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17. Infertility
! women in the reproductive age group must be
questioned on this
! endometriosis & adenomyosis are among the most
common causes of the pelvic mass
! the association of this symptom with a mass in most
cases is due these conditions
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18. Ovarian cancer
! often manifests late
! abdominal or pelvic pain
! bloating
! abdominal distension
! other nonspecific symptoms
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19. Postmenopausal patient
! any tumour here warrants
extensive investigation
! postmenopausal bleeding
must be taken seriously
! commonest tumours at this
age are ovarian
! may present only with
nonspecific symptoms
! the pelvis should be
looked at carefully
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20. SUMMARY OF !
TUMOUR!
CLINICAL FEATURES!
heavy cyclical menstruation,
fibroids ! irregularly enlarged, mobile smooth
uterus, usually non-tender
nonspecific pelvic or abd pain,
bloating, constitutional symptoms,
ovarian cancer!
fixed mass, may be irregular, firm,
hard or soft, ascites may be present
cyclical pain, dyspareunia, infertility,
abnormal menstruation,soft-to-firm
endometrioma!
mass, usually fixed, lateral or
central
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21. Signs
21

22. Inspection
! overall, the patient
may look unwell
! she may be in
extreme pain
! the abdomen may be
distended, generally
or asymmetrically
! the umbilicus may be
deviated
! if acute, the abdomen
may not move with
respiration
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23. Palpation
! is the surface smooth or nodular?
! nodularity is not good
! is the mass fixed or mobile
! consistency - hard, firm or soft
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24. Can you go below the
mass?
! important to feel if you can go
below the mass
if not, then it is most likely arising
from the pelvis
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25. Ascites
! this is never
a good sign
! you must
know how to
evaluate for
shifting
dullness
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26. Cervicovaginal inspection
! do not forget to
assess below!
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27. An overview of cancers
https://www.dropbox.com/s/whhmrateafmqus7/gynaecancers.pdf
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28. some common conditions
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29. Ovarian Cysts
29

30. ! quite
common at
a later age,
about 40s
! may be
asymptomat
ic, but most
often cause
heavy
menstruatio
n
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Fibroids

31. Endometriosis
! May present as
either
adenomyosis
(uterine
enlargement),
! a cyst or
! both.
31

32. Adenomyosis
Can be a diffuse or globular
swelling
K
Endometrium-like tissue is found
embedded within myometrium
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33. Funny
things
are seen
This is a fibroid!
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34. The most
common
growth -
fat!
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35. Investigations
35

36. Role of ultrasound
! an essential tool for diagnosis - first Ix to be
considered
! any mass must initially be scanned
! abdominal or transvaginal
! features to look for include composition of tumour,
size, uni- or bilateral and presence of ascites
36

37. Ultrasound
TVS image produces greater
resolution
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38. Blood tests
! General - assess cell lines for health & mx issues
! Tumour markers - limited diagnostic capability
• May be used as surveillance when increased
! Other tests depend on type of tumour
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39. Other imaging
! MRI & CT
! Laparoscopy - can be diagnostic, but better to be
therapeutic
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40. summary
40

41. Key points
! pelvic masses may have a benign or malignant
aetiology
! the risk of malignancy is increased in
postmenopausal women
! premenopausal masses are usually benign
! evaluation of premenopausal masses must include
relationship with fertility
! U/S is an important evaluation tool for possibility of
malignancy
41

42. References
! Brown G. A gynecologic approach to evaluation of pelvic masses in women JAAPA
2012
! Johnson BA. Evaluation of pelvic masses 2001
http://www.eric.vcu.edu/home/resources/whh/
VIIIeEVALUATION_PELVIC_MASSES.pdf
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43. Let s have coffee!
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