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PELVIC MASSES
Ellen C. Wells
DIFFEREI\JTIAL DIAGNOSES
UTERINE MASSES
514
Par! IV
Figure 41-1
Noncommunicating uterine horn (top left, long arrow) with
hematometra and (/ower midline, short arrow) hematocolpos.
OVARIAN NEOPLASM
A palpable but otherwise asymptomatic adnexal mass should
raise suspicion of an ovarian neoplasm. Benign cystic ter
atomas, or dermoid cysts, are among the most common ovar
ian neoplasms. Histologically, these slow-growing tumors
are found to contain elements from all three germ celllay
ers. They occur in all age groups, and are common in
teenagers and young adults. They are bilateral in 10 to 15
percent.
Benign teratomas frequentIy contain a thick sebaceous
fluid as well as hair, musc1e fibers, cartilage, bone, and teeth.
Although they are frequentIy discovered incidentally, they
may produce acute symptoms with rupture, which causes a
severe chemical granulomatous peritonitis, or with torsion,
which occurs secondary to their size and increased weight.
Approximately 1 to 2 percent of dermoid cysts undergo ma
lignant transformation, usually in women over age 40. The
malignant component is generally a squamous carcinoma.
Rarely, ovarian teratomas will contain functioning thyroid
tissue (struma ovarii) , causing hyperthyroidism. Other be
nign ovarian tumor s encountered in reproductive-age women
inc1ude serous cystadenomas, fibromas, and Brenner tumors.
Malignant ovarian neoplasms may al so occur in reproduc
tive-age women, but most occur in menopausal women. In
early stages, these adnexal masses may be mobile witb no
evidence of ascites, but at advanced stages they will
monly be fixed with accompanying ascites.
OVARIAN CYST
Ovaran cysts are a common cause of adnexal eIlliilgt;lIm
associated with pain. The term.functional cyst is often
in this setting, and although dysfunction might be a
description, the term is simply used to convey the
tion of this cystic enlargement with the components of
mal cyc1ic ovaran function. Normal ovarian follic1es
a size of about 2.0 to 2.5 cm prior to ovulation.
the termfollicular cyst should be used to refer to cystic
tures within the ovary that are greater than 2.5 to 3 cm
diameter. Follicular cysts may reach 8 to 10 cm in size
generally regress spontaneously in i to 3 months.
stretching of the ovarian capsule due to the sze of the
is the general source of discomfort. Cysts may rupture
ing examination or with intercourse. Rupture is generally
sociated with an immediate sharp pain that which may
solve rapidly or gradually improve over several
Peritoneal signs may be present due to irritation from
fluid or blood.
Corpus luteum cysts are less common than follicular
A normal corpus luteum may be up to 3 cm in
Therefore, corpus luteum cysts are described as
. greater than 3 cm in diameter originating from the
luteum. In the normal development of a corpus luteum,
illaries invade the granulosa cells and produce a spontaneo
Chapter 41
bu! limited bleeding that fills the central cavity. This blood
is subsequcntly absorbed, forming a small cystic space. If
hemorrhage is excessive, the cystic space enlarges, stretch
ing the ovarian capsule and causing pain. An unruptured fol
licular or hemorrhagic cyst may continue to produce symp
toms of pain throughout the remainder of the cycle. It will
commonly regress after the cycle s complete and hemor
rhagic contents will gradually be resorbed. If a hemorrhagic
cyst ruptures, a sharp. pain as well as peritoneal irritation
from the blood will be noted. Bleeding after rupture is usu
ally self-limited. Rarely, women with anemia, marked or per
sistent pain, hypovolemia, or marked cul-de-sac fluid will
require admission for observation, seral hematocrits, or op
erative intervention.
uvllllVl"'UU."U
PELVIC MASSES
515
TUBOOVARIAN ABSCESSES
Pelvic inflammatory dsease refers to nflammaton caused
by an infection in the upper genital tracts. This includes en
dometriosis, salpingitis, oophoritis, myometritis, parametri
tis, and peritonitis. A tuboovarian complex (see Chapo 44)
is defined as a collection of infected fluid within an anatomic
space created by adherence of adjacent organs, ncluding the
fallopian tubes, ovares, and sometmes the intestines. Acute
pelvic inflammatory discase is usually a polymicrobial in
fection caused by organisms ascending from the vagina and
cervix. Bacterial organisms include Neisseria gonorrhoeae,
Chlamydia trachomatis, endogenous aerobic and anaerobic
bacteria, and perhaps genital mycoplasmal species. Women
with pelvic inflammatory disease will cornmonly have fever,
an elevated erythrocyte sedimentation rate, cervical motion
tenderness, and bilateral adnexal tenderness with or without
masses. 3 Indications for hospitalization in patients with
pelvic inflammatory disease include presence of a tu
boovarian complex or abscess, pregnancy, uncertain diag
nosis, gastrointestinal symptoms, and peritonitis in the up
per quadrants. Positive human immunodeficiency virus
(HIV) status, recent operative or diagnostic procedures, and
inadequate response to outpatient therapy are also reasons
for hospital admission.
Women with a history of pelvic inflammatory disease may
have sequelae of pelvic adhesive dsease presenting as
chronic or recurrent pelvc pain with the involved adnexus
palpable as a pelvic mass. Approximately 20 percent of
women with acute pelvic infections subsequently develop
chronic pelvic pain. Recurrent acute pelvic inflammatory
disease is experienced by approximately 25 percent of
women.
516
Part IV
EVALUATION
HISTORY
The initial history in any reproductive-age woman with ab
dominal or pelvic complaints should inc1ude her age, gra
vidity, party, last menstrual period, status of sexual activ
ity, and type of contraception. Symptoms that correlate with
the size of the mas s may inc1ude pressure, fullness, early
satiety, or increasing abdominal girth. Conditions producing
uterine enlargement may be associated with urinary fre
quency, urgency, and even stress urinary incontinence.
Masses at the level of the cervix or the lower uterine seg
ment or masses exerting pressure at the pelvic brim may pre
sent with ureteral obstruction or hydronephrosis and flank
discomfort. Masses in the cul-de-sac from the uterus, ad
nexa, or lower gastrointestinal tract may present as rectal
pressure, deep dyspareunia, or fullness and constipation. It
is somewhat disturbing to realize that a number of etiolo
PHYSICAL EXAMINATION
The physical examination begins with an initial
of vital signs. Blood pressure and pulse with
changes may demonstrate evidence of hypovolemia
acute hemorrhage. An elevated temperature may
diagnosis of infection. An acute abdomen with fever
alert one to the possibility of a ruptured tuboovarian
or a ruptured appendix, which could progress rapidly to
SISo
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Chapter 41
PELVIC MASSES
517
518
Part IV
Figure 41-3
Transvaginal sonography reveals a circular pattern within the my
ometrium consistent with a myoma (arrow).
TREATMENT
In a woman who presents with acute, relentless
pain and a mass, immediate gynecologic or surgieal
sultation is imperative. It is particularly important to rule
ectopic pregnaney, as a del ay in this diagnosis may
significant morbidity or mortality. Hospitalzation is
ally required in tbis setting due to the potential of
ate surgical management or, in cases of an uncertain
nosis, close observation. Peritoneal lavage or
may give a rapid diagnosis of hemoperitoneum. ~.
laparoscopy can be help1'ul in evaluating the presenee
moperitoneum as well as inspecting the pelvis, the
dix, and the gallbladder.
Chapter 41
PELVIC MASSES
519
Figure 41-4
Transvaginal sonography reveals a follicular cyst (outlined by crosses)
(A), a hemorrhagic cyst (arrow) (B), and an endometrioma (outlined by
crosses) (e).
520
Part IV
UTERIt\IE LEIOMYOMAS
Treatment of uterine leiomyomas depends on both their size
and the severity of the symptoms they produce. Small my
omas in an intramural or subserosal location may produce
minimal or no symptoms and may be followed expectantly
for any evidence of growth. Myomas that create uterine en
largement consistent with or greater than a 12-week gesta
tion, particularly those associated with symptoms or exces
sive bleeding, should be considered for remova1. In addition,
their size limits the ability of an examiner to adequately eval
uate the ovares on routine examination. Depending on their
shape and location, they may also cause obstruction of the
ureters at the level of the pelvic brim or ccrvix. Uterine
leiomyomas may also produce severe dysmenorrhea as well
as irregular bleeding and menorrhagia. Nonsteroidal anti
inflarnmatory drugs decrease prostaglandin release, reduc
ing menstrual pain and decreasing menstrual blood 10ss.
Medroxyprogesterone acetate or depo-medroxyprogesterone
acetate may control symptoms by regulating menses or pro
ducing amenorrhea. Gonadotropin-releasing hormone ago
nist therapy decreases the size of uterine leiomyomas by as
much as 60 percent. 4 Women also experience amenorrhea
on this therapy, with a subsequent rise in their hematocrit.
Limitations of GnRH agonist therapy include hot flashe8 and
other menopausal symptoms. Its use is generally limited to
6 months, as use beyond this point is associated with bone
los8. The reduction in size of uterine leiomyomas does not
persist after discontinuation of therapy and virtualIy all
leiomyomas retum to their pretreatment size. Surgical op
tions include myomectomy, which involves removing the in
dividual leiomyomas without complete remo val of the
uterus, versus hysterectomy. The blood loss at the time of
surgery is generally higher with myomectomy than wth hys
terectomy. Among women followed after myomectomy, ap
proximately 25 to 30 percent subsequentIy undergo a sec
ond surgical procedure for recurrent myomas and symptoms.
Women who have not completed childbearing may choose
myomectomy over hysterectomy despite the increased in
traoperative blood 1088 and potential recurrent symptoms.
Women who are followed expectantly should have ultra
sound evaluation of the ovaries on a regular basis if the ad
UTERINE ANOMALlES
In adolescents who present with congenital uterine or lower
genital tract anomalies as a source of pelvic mass, surgical
intervention is warranted after appropriate evaluation. An
imperforate hymen or transverse vaginal septum may be sur
gically opened to create an outlet for menstrual bleeding
(Fig. 41-5). A symptomatic noncommunicating uterine horn
will require removal. These women face an increased risk
of endometriosis due to the retrograde menstruation that has
cornmonly occurred prior to their diagnosis.
ADNEXAL MASSES
Adnexal mas ses that, on evaluation, are fe1t to be consistent
with benign ovaran neoplasms will be treated
with removal via ovarian cystectomy or unilateral ooohorec
tomy. Frozen section is extremely useful in these
as a borderline tumor or carcinoma may then be
ately staged and lymph node sampling obtained.
Figure 41-5
Imperforate hymen with associated hematocolpps. (From
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Chapter 41
PELVIC MASSES
521
Table 41-1
INPATIENT TREATMENT FOR PELVIC
INFLAMMATORY DISEASE
DIVERTICULlTIS
Women with acute diverticulitis generally require hospital
izaton for bowel rest, intravenous fluids, and broad-spec
trurn antibiotics. "Triple therapy" (e.g., ampicillin, gen
tamycin, and metronidazole) remains the gold standard in
the unstable septic patient, although newer single-agent
antibiotics (ampicillin/sulbactam, Impipenumlcilastatin or
ticarcillin clavulanate) may be employed for more stable
patients with local peritoneal signs. Recurrent attacks may
prompt surgical resection. Severe attacks with peritoneal
signs, suspected abscess, or perforation require intravenous
antibiotics and surgical drainage or resection. A diverting
colostomy and resection may be performed acutely, with re
anastomosis accomplished at a second operation.
COLORECTAL CAI\JCER
In colorectal cancer, total resection of the tumor is the op
timal management. Tumor-related symptoms of gastroin
testinal bleeding or obstruction may require immediate man
522
Part IV
LYMPHOMA
Therapeutic options for the management of lymphomas are
based on histologic subtype and, less frequently, stage.
Therefore, tissue biopsy of sufficient quantity to determine
pathologic and immunologic subtype is of primary impor
tance. Other studies commonly employed to evaluate extent
of disease include a complete blood count, chemistries, Uver
function studies, semm protein electrophoresis, chest radi
ograph, CT of the abdomen and pelvis, and bone marrow
biopsy. Surgical staging is not routine in non-Hodgkin Iym
phoma and is controversial in Hodgkin lymphoma. Radio
therapy may cure over 80 percent of patients with 10calized
Hodgkin lymphoma and chemotherapy over 50 percent of
cases with disseminated disease. Non-Hodgkin Iymphoma
References
1. Leibsohn S, d'Ablaing G, Mishell DR Jr,
Leiomyosarcoma in a series of hysterectomies
for presumed uterine leiomyomas. Am J Obstet
162:968, 1990.
2. Hibbard LT: Adnexal torsion. Am J Obstet
152:456, 1985.
3. Hager WD, Eschenback DA, Spence MR, et al:
for diagnosis and grading of salpingitis. Obstet
61:113,1983.
4. Friedman AJ, Hoffman DI, Comite F, et al: Treatment
leiomyomata uteri with leuprolide acetate depot: A
ble-blind, placebo-controlled, multicenter study.
Gynecol77:720, 1991.
5. Steinkampf MP, Hammond KR, Blackwell RE:
monal treatment of functional ovaran cysts: A
ized prospective study. J?ertil Steril 54:775, l
for Disease Control and Prevention: 1993 Sexually
mitted diseases: Treatment guidelines. MMWR
1993.
6. Centers for Disease Control and Prevention: 1993
ally transmitted diseases: Treat ment guidelines. !
42:75, 1993.