differentials on the basis of organs

1. Pelvic Mass
06/04/2016

2. INFANCY PREPUBERTAL ADOLESCENT REPRODUCTIVE PERI-
MENOPAUSAL
POST-
MENOPAUSAL
Functional
Cyst
Functional Cyst Functional Cyst Functional Cyst Fibriods Ovarian Tumor
(malignant or
benign)
Germ Cell
Tumor
Germ Cell Tumor Pregnancy,
Sequelae of PID
Pregnancy,
Ectopic
Pregnancy
Epithelial
ovarian tumor
Functional Cyst
Benign cystic
teratoma /
Other germ cell
tumors
Uterine
fibriods,
Functional Cyst Bowel,
malignant
tumor or
inflammatory
Obstructing
vaginal or uterine
anomalies
Epithelial
ovarian tumor,
Mature cystic
teratoma
Metastases
Epithelial ovarian
tumor
Tubo-ovarian
masses
(acute/chronic)
CAUSES: According to the age groups

3. CAUSES: According to the site involved
UTERUS ADNEXA INTESTINE AND
OTHERS
• Fibroid
• Adenomyosis
• Hematocolpos
• Pyometra
• Ectopic pregnancy
• Ovarian tumour
• Chocolate cyst
• Tubo ovarian mass
• Pelvic Abscess
• Appendicular lump
• Impaction of worms
• Iliopsoas abscess
• Pelvic kidney

4. Differential diagnosis for pelvic/abdominal mass
Gynaecological
• Pregnancy-related • Normal intrauterine pregnancy
• Old ruptured extrauterine pregnancy (abdominal, tubal
pregnancy)
• Molar pregnancy
• Uterine origin • Uterine fibroids
• Advanced uterine carcinoma or sarcoma
• Hematometra/pyometra
• Tubal origin • Hydro-/pyosalpinx
• Tubo-ovarian abscess
• Advanced cancer of the tube
• Ovarian origin • Ovarian torsion
• Benign cyst
• Endometrioma
• Benign tumor (dermoid, fibroma, cyst-adenoma)
• Borderline tumor
• Malignant tumor (carcinoma, granulosa cell or germ cell
tumor

5. Differential diagnosis for pelvic/abdominal
mass
Surgical
• Appendicular abscess
• Obstructed hernia
• Intussusception
• Colorectal carcinoma
• Subacute intestinal obstruction
• Diverticular abscess
• Large bowel tumor/mesenteric tumor
• Abdominal aortic aneurism
• Renal tumor: pelvic kidney, bladder
carcinoma, urinary retention

6. Differential diagnosis for pelvic/abdominal
mass
• Neuroblastoma
• Hodgkin’s and non-Hodgkin’s lymphoma,
pelvic spleen
• Pregnancy and Full Bladder are the physiological causes.
• In case of full bladder it is tense and cystic, may reach upto
umbilicus.
Neurological
Hematological
• Disappears on catheterization.

7. Pregnancy – Intrauterine
- Reproductive (Child bearing) Age group
- Cessation of menstruation
- Mass lower abdomen
- On ultrasonography, gestational sac is
present intrauterine.

8. Uterine Fibroids (Leiomyomas)
• Uterine leiomyomas are estrogen- and progesterone-
sensitive tumors
• Leiomyomas themselves create a hyperestrogenic
environment, which appears requisite for their growth
and maintenance.
• Classification of Uterine Leiomyomas
• Classified based on their location and direction of
growth
 Subserosal leiomyomas
 Intramural leiomyomas
 Submucous leiomyomas

9. • Subserosal leiomyomas originate from myocytes
adjacent to the uterine serosa, and their growth is
directed outward
When these are attached only by a stalk to their
progenitor myometrium, they are called pedunculated

11. • Grows slowly
• Menorrhagia
• Feel- firm
• Cystic in cystic degeneration
• Nodular Surface
• No features of pregnancy
• On internal examination:
– Origin of swelling is uterine
– Cervix feels firm
Fig: Cystic degeneration (arrow) seen
within this “submucous fibroid”

12. Benign Ovarian tumour
Benign tumors predominantly occurs in late child
bearing age
Grows slowly
Symptoms include heaviness and dull aching pain in
lower abdomen. However the menstrual pattern
remain unaffected.
Abdominal examination-
• bulging of lower abdomen
• Mass is unilateral, mobile, cystic, smooth
• Lower pole may not be reached
• Ascites may be present

13. `
On pelvic examination-
• Swelling is separated from uterus
• Movement of mass per abdomen fails to move
the cervix
• Absence of pulsation of uterine vessels
through fornices

14. Malignant ovarian tumours
• Occur mostly in post menopausal women
• Symptoms-abdominal distension and pain,
loss of appetite, dyspepsia,respiratory
distress, but no menstrual abnormalities
• Signs- cachexia, pallor, jaundice, left supra
clavicular lymph gland enlargement and
edema of legs and vulva.

15. Abdominal examination-
• Usually the mass is bilateral, fixed, solid,
irregular, tender
• Enlarged liver
Pelvic examination-
• uterus is separated from the mass
• Nodules may be felt through posterior fornix.

16. Adenomyosis
Adenomyosis is a condition where there is ingrowth
of the endometrium, both glandular and stromal
components, directly into myometrium
• Associated with parous females above 40
Symptoms –
• Menorrhagia
• Dysmenorrhea

17. • Abdominal examination reveals hypogastric mass –
size is rarely more than 14-16 weeks pregnant uterus
• Pelvic examination –Uniform, enlarge with well
defined margins of the uterus
• Internal examination:
– Uterine swelling
– Cervix-firm, uterus- tender

18. Endometriosis
• Most commonly occurs in white, nulliparous
women between the ages of 35-45
• Present with cyclic pelvic pain or pressure ,
dyspareunia , dysmenorrhoea, dyschaezia and
infertility
• May occur on the ovaries and occasionally can
form large cysts filled with chocolate colored,
called “chocolate cysts” or endometriomas
• Laparoscopy is the gold standard for the treatment.

19. Tubo ovarian abscess
- Present with fever and pelvic pain
- History of salpingitis in which the fallopian tube
becomes distended with pus forming a
pyosalpinx , if left untreated ovary may become
involved forming tubo-ovarian abscess.
- Examination – lump can be palpated on the lower
abdomen
- Internal examination – adnexal tenderness and
forniceal fullness felt
- Diagnosed by ultrasound and confirmed by
laparascopy

20. Diagnosis
• History
• Examination
• Investigation

21. History
• Systematic and symptomatic assessment to
find out the cause and origin for the mass
• Presenting complaints:
-Pain
-Fever
-Bloating
-Frequency
-Weight Loss
-Loss Of Appetite

22. History
• Menstrual History:
Secondary amenorrhea suggests pregnancy or
ectopic pregnancy
Pelvic pain in 2nd half of menstrual cycle could
be due to hemorrhagic corpus luteum cyst
Menorrhagia: submucosal fibriods
Dysmenorrhea: Endometriosis/ fibriods/ PID
• Obstetric History
• Past History: medical and surgical

23. History
• Contraceptive History:
- OC’s reduce the likelihood of functional cysts
but more likely to have PID
- Ectopic pregnancy are more common among
Intrauterine contraceptive devices

24. History
• Character of the Pain
- Sudden onset of severe pain suggests ovarian
torsion, hemorrhage into a cyst, rupture of a
cyst, abscess or ectopic pregnancy.
- Cyclic menstrual pain associated with
menorrhagia and passing clots suggests
fibroids
- Cyclic menstrual pain associated with back
pain or dyspareunia suggests endometriosis.

25. History
• Progressively worsening pain associated with
constitutional symptoms suggests tumour
• Often ovarian cancer patients present only
with vague gastrointestinal complaints.

26. Examination
• General Physical Examination
Head to toe examination
- Cachetic – carcinoma
- Pallor – Ectopic pregnacy
- Rise in temperature - Tubo ovarian abscess
- Abdomen: ascites in case of ovarian tumour

27. Pelvic Examination
- Characteristics of all masses including size,
shape, mobility, consistency.
- Cervical discharge with mucus (PID)
- Adnexal masses or tenderness
- Cervical motion tenderness
- Uterine enlargement

28. • Rectovaginal area:
- Assess:
- Posterior uterine surface
- Uterosacral ligaments
- The rectum
• Lymph nodes:
- Supraclavicular, and groin nodes

29. Abdominal Examination
• Distension,scars
• Features of ascites:shifting dullness,fluid thrill
• Palpation of mass if present

30. Speculum Examination
• For discharge,tumors or growths,warts
• Inspection of vulva,vagina,cervix

31. • Bimanual Examination
• Recto-vaginal Examination

32. Investigations
• Urine Pregnancy Test(ruling out pregnancy in
reproductive age group)
• Urinary beta hCG or serial quantitative beta
hCGs for ectopic pregnancies; serum beta hCG
may be found in nonpregnant patients with
embryonal cell CA or chorioCA
• Full Blood Count
• Urea and electrolytes
• Blood grouping and cross-match
• Ultrasound scans of the abdomen and pelvis

33. Investigations
• CA 125 (cancer antigen 125) –
- Expressed by epithelial cells on ovarian
tumors but also on normal as well as
abnormal tissues of mullerian origin.
- More useful in menopausal patients than in
adolescent patients.
- May be elevated in:
Endometriosis, Adenomyosis, Fibroids, PID

34. CA-125 contd…
- It is rarely elevated beyond 100 to 200 U/ml in
patients with the above conditions (normal is <
35 U/ml).
- It is also elevated in cancers of: Ovary, Lung,
Pancreas, Breast, Colon/rectum
- Elevated in 80% of serous
cystadenocarcinomas of the ovary but in only
50% of patients with stage I disease.

35. • Ultrasound
• CT SCAN
• MRI

36. Management
• Depends on the cause
• Large adnexal masses (> 8 cm) in the
premenopausal woman or masses with
characteristics of malignancy (solid or mixed
solid and cystic on USG) should be followed
closely, STAGING LAPAROTOMY is the choice
of treatment
• If features of torsion – Emergency laparotomy

37. • Functional cysts in the premenopausal woman
which are < 8 cm, freely movable, smooth,
mildly tender, and have the appearance of a
simple cyst on USG can be followed into the
next menstrual cycle and reassessed on day 10
or so (70% resolve spontaneously) or
alternatively, the patient can be started on
oral contraceptive Pills

38. • Asymptomatic or minimally symptomatic
fibroids may be followed; symptomatic
fibroids may require hormonal suppression,
myomectomy or occasionally hysterectomy
• Tubo-ovarian abscess and hydrosalpinx in
cases of PID are best managed through
hospitalization, IV antibiotics and sometime
require drainage of the pus and laparotomy

39. • Ruptured Ectopic pregnancy requires
immediate laparotomy
• Endometriosis require longterm hormonal
therapy, cystectomy or oophorectomy

40. THANK YOU