Pelvic Masses

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Pelvic Masses

• Anna Mae Smith, MPAS, PA-C
• Lock Haven University
• Physician Assistant Program

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• Patient may present with or without symptoms

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Central Pelvic Masses

• Pregnancy
• Leiomyomata - uterine fibroids
• Endometrial malignancy or uterine sarcoma
• Ovarian or other laterally located masses may
  present centrally
• Bladder

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Leiomyomas

• benign smooth muscle tumors of the uterus
• commonly called fibroids
• estrogen dependent
• rarely occur before menarche or after menopause
• grow larger during pregnancy
• rarely malignant
• most common indication for pelvic surgery in women

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Leiomyomas in Pregnancy

• interfere with fetal growth and nutrition
• increase the risk of
• spontaneous abortion during the first and second
  trimesters
• preterm labor

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Epidemiology of Leiomyomas

• develop from smooth muscle cells by means of
  metaplasia
• cause for growth is unknown
• occurs in 20 of women of reproductive age
• most often occurs among African American women
• nulliparous women
• women older than 35
• nonsmokers
• oral contraceptive or IUD users

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Classification of Leiomyomas

• submucous - protrude into the uterine cavity
• intramural - within the myometrial wall
• subserous - growing toward the serous surface of
  the uterus
• intraligamentous - located in the cervix or in
  between the folds of the broad ligament

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Leiomyomas Symptoms

• usually asymptomatic
• symptoms increase as tumors grow
• common symptoms
• pelvic pressure
• bloating
• pelvic congestion
• feeling of heaviness
• urinary frequency
• dysmenorrhea
• dyspareunia
• menorrhagia
• pain - less common
• may report infertility
• pregnant women complain more of pain

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Leiomyomas Physical Exam

• absence of ascites
• normal bowel sounds
• enlarged uterus that is firm and irregular but
  not tender
• may be mistaken for adnexal mass if situated
  laterally
• if mass moves with the uterus, likely to be a
  leiomyoma

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Leiomyomas Diagnostic Tests

• CBC to determine if anemic
• UA to r/o urinary tract infection
• Pregnancy test
• Hemoccult
• Ultrasound
• Barium enema
• IVP
• Endometrial biopsy

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Leiomyomas Differential Diagnoses

• ovarian neoplasm
• tubo-ovarian inflammatory mass
• diverticular inflammatory mass
• pregnancy
• ectopic pregnancy
• adenomyosis
• pelvic kidney
• malignancy

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Leiomyomas Treatment

• Medroxyprogesterone 20-30 mg po qd for several
  weeks
• GnRH-a
• Lupron injection monthly x 6 months
• Synarel nasal spray bid x 6 months
• oral iron preparation
• re-evaluate every 3-6 months to check change in
  uterine size
• pelvic ultrasound as needed
• monitor Hgb and Hct frequently
• Uterine artery embolization

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Leiomyomas Conservative Surgery

• myomectomy
• uterus is 12 weeks size
• solitary pedunculated myoma
• nature or location of the myoma appears to be
  interfering with fertility
• myoma is causing pregnancy loss
• rapid growth carries the possibility of malignant
  sarcoma transformation

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• Leiomyomas Hysterectomy
• rapid enlargement of the uterus may mean possible
  malignancy
• abnormal uterine bleeding not responding to other
  methods of treatment and that may lead to anemia
• pelvic pain
• secondary dysmenorrhea
• urinary symptoms
• uterine growth after menopause
• patient has completed childbearing
• health care provider is unable to evaluate the
  adnexa because uterus is an abdominal organ
• uterus is possible

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Central Masses contd

• GI Tract
• Stool
• Inflammatory abscesses
• Broad ligament tumors
• Thrombosis

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Lateral Pelvic Masses

• Ovary
• Normal premenopausal ovary - 3x2x1.5cms
• Early Menopausal ovary - 2x1.5x0.5cms
• Postmenopausal ovary - 1.5x0.75x0.5cms
• GI causes
• Crohns Disease
• Diverticuli
• GI neoplasm

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Lateral Pelvic Masses

• Pelvic kidney
• PID with tubo-ovarian abscess
• Ectopic pregnancy

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Ectopic Pregnancy

• Potentially life-threatening condition in which
  the embryo implants outside the uterine
  endometrial cavity.
• Leading cause of pregnancy-related death during
  the first trimester
• Must be considered in all sexually active women
  of reproductive age who have abdominal pain or
  abnormal vaginal bleeding

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Risk Factors for Ectopic

• current IUD use
• previous tubal surgery
• history of pelvic inflammatory disease
• history of infertility
• In-utero DES exposure
• H/o STDs
• Smoking
• Progesterone only contraception
• Use of fertility drugs

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Classic Triad of Symptoms

• Amenorrhea
• Irregular vaginal bleeding
• Pelvic pain

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Physical Findings of Ectopic Pregnancy

• Prior to rupture may feel nothingusually some
  form of abnormal bleeding present
• Ruptured
• Hypovolemic/orthostatic hypotension
• Peritoneal signs
• Positive CMT adnexal tenderness
• Bulging cul-de-sac of Douglas

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Ectopic Testing

• hCG
• Transvaginal U/S
• Treatment
• Surgery
• methotrexate

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Fallopian Tube

• Differential diagnosis includes pyosalpinx,
  hydrosalpinx, cystic teratomas, adenomatoid
  tumor, paratubal cysts, and adenocarcinoma.

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Dermoid Cyst/Teratoma
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Ovary

• With ovulation the size of the follicle about to
  rupture can be as large as 2.5cms
• Total ovary may be 6cms at mid-cycle!
• Any cyst larger than 3cms hanging off the ovary
  needs further investigation

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Laparoscopy