Pelvic masses

Question 1

Go over this pic of the main structures of the pelvis

Question 2

What are some of the non-gynaecological causes of pelvic masses ?

Answer 2

Bowel:

• Constipation!
• Caecal carcinoma - colon cancer at the caecum area
• Appendix abscess
• Diverticular abscess

Bladder/Urological.

• Urinary retention
• (pelvic kidney)

Other:

e.g. retroperitoneal tumour.

Question 3

What are some of the gynaecological origins of pelvic masses ?

Answer 3

• Uterine - body, cervix
• Uterine Tubes
• Ovarian

Question 4

What are the uterine causes of pelvic masses ?

Answer 4

1. Pregnancy!
2. Uterine fibroids.
3. Endometrial cancer
4. Cervical cancer

Question 5

What is the commonest cause of uterine pelvic masses ?

Answer 5

Uterine fibroids (remember that uterine fibroids are very common)

Question 6

Endometrial and cervical cancers are common causes of pelvic masses - T or F?

Answer 6

False

• Endometrial cancer usually presents with postmenopausal bleeding and therefore is picked up then so unusual to be at the stage where it is large enough to produce a mass
• Cervical cancer - this would also be a late presentation of cervical cancer so unlikely as usually picked up in screening or vaginal bleeding etc would have resulted in it being picked up

Question 7

What are uterine fibroids ?

Answer 7

They are benign smooth muscle tumours of the uterus also known as leiomyomas

Question 8

Who do uterine fibroids typically occur in ?

Answer 8

Women >40

Question 9

How big can uterine fibroids become ?

Answer 9

Usually few cm, but may be much bigger & multiple - A very large uterine fibroid can cause the uterus to expand to the size of a 6 or 7 month pregnancy

Pic shows large uterine fibroids

Question 10

What are the typical presenting features of uterine fibroids ?

Answer 10

Many are asymptomatic

Others may have the following symptoms:

• Menorrhagia - they often produce heavy and prolonged periods (dont generally cause intermenstrual or postmenopausal bleeding)
• Pelvic mass
• Pain/tenderness
• Pelvic Pressure
• Urinary and bowel symptoms - freq urination, difficulty emptying bladder, constipation
• May cause fertility problems

Question 11

What is red degeneration of fibroid ?

Answer 11

It is a rare complication where thrombosis of fibroid vessels occurs followed by venous engorgement an inflammation, causing severe abdo pain +/- vomiting and low grade fever, and localised peritoneal tenderness usually occuring in the last half of pregnancy or 6 months following childbirth (puerperium)

Question 12

What is the typical presentation of a uterine fibroid felt on pelvic exammination?

Answer 12

• A firm, enlarged, and irregularly shaped non-tender uterus is characteristic of uterine fibroids.
• The mass can be moved slightly from side-to-side.

Question 13

How are uterine fibroids diagnosed ?

Answer 13

• 1st line = Transvaginal ultrasound - showing a smooth echogenic (lighter colour) mass which is often multiple
• 2nd line = hysteroscopy

Firboid in pic is indicated

Question 14

What is the pharmacological treatment symptoms of uterine fibroids in terms of:

• Red degeneration
• Menorrhagia + fibroid < 3cm

Answer 14

Red degernation requires painkiller and usually settles down

Menorrhagia:

• 1st line = mierena IUS
• 2nd line = tranexamic acid (not mefenamic acid as shown to be ineffective) think good for pain
• 3rd line = Combined pill or other homronals (progestogens also shown to be ineffective)

Need to try at least 2 medical ones before surgery

Question 15

What is the treatment required for most people with uterine fibroids ?

Answer 15

None - usually asymptomatic

Question 16

What is the surgical options for uterine fibroids that could be considered if pharmacological management doesnt work or for those with menhorragia + fibroids > 3cm?

Answer 16

• Hysterectomy — complete removal of the uterus. This is the most successful treatment - if completed family
• 1st Myomectomy,2nd uterine artery embolization — these are both uterine sparing surgeries. - if not completed family

Question 17

What are the causes of tubual swellings resulting in a pelvic mass ?

Answer 17

Ectopic pregnancy: (covered in another lecture)

• Emergeny +IPT/empty uterus/pain/bleeding
• May detect adnexal mass on USS - need to do the 2 pregnancy tests 48hrs apart to diagnose

Hydrosalpinx:

• Often longstanding/incidental

Pyosalpinx:

• Acute/inflammatory

Paratubal Cysts:

• Usually small & incidental (embryological remnants)

Question 18

What are some of the causes of ovarian masses resulting in pelvic masses ?

Answer 18

Tumours/Neoplastic:

• Benign
• Malignant

or

Not tumours:

• ‘Functional’ cysts
• Endometriotic cysts.

Question 19

What is the treatment of benign ovarian cysts/masses ?

Answer 19

Removal or drainage if likely benign

Malignant treatment covered in ovarian cancer lecture

Question 20

What is pyosalpnix and what is it caused by?

Answer 20

A condition in which the fallopian tube fills up and swells with pus.

Due to untreated PID which in turn is caused commonly by chlamydia and gonorrhoea

Question 21

What are the symptoms potentially caused by pyosalpinx ?

Answer 21

• pain in the lower belly that is constant, or that comes and goes
• painful lump in the lower belly
• pain before your periods
• fever
• pain during sex