11 Abdominal Masses in Gynecology Pubudu Pathiraja INTRODUCTION Some pelvic masses typically present only sono- graphically, for example: Abdominal or pelvic mass can present at any age of life. In a random sample of 335 asymptomatic • Endometrioma women aged 25–40 years, the point prevalence of • Hydro-/pyosalpinx an adnexal lesion on ultrasound examination was • Sero-/hematometra 1 7.8% (prevalence of ovarian cysts 6.6%) . Preva- If you diagnose a mass in a woman’s lower abdo- lence of pelvic masses in postmenopausal women men you must decide on: can vary widely from 2.5%2 to 10%3 in postmeno- • Which organ the tumor arises from (organ pausal women. specificity). Lower abdominal masses can be A woman presenting with an abdominal or divided according to their anatomical origin in pelvic mass might complain of various symptoms genital and extragenital masses (Table 2). but a significant majority will have no guiding/ • What kind of tumor you are dealing with ( entity, obvious symptoms at presentation although the i.e. malignant or benign). final diagnosis may be life-threatening. The abdo- men can be distended by either a solid or cystic Table 1 Common gynecological causes of free fluid in mass or by free fluid in the abdomen. To distin- the abdomen guish between masses and free fluid you must examine the patient and sometimes you will need Free See to perform an ultrasound as described in Chapter 1. fluid Cause Chapter: Blood Ectopic pregnancy 12 ABDOMINAL MASSES VERSUS A Pus Tubo-ovarian abscess/PID/peritonitis 5 DISTENDED ABDOMEN CAUSED BY FLUID Infected miscarriage 2, 13 Free fluid in the abdomen can either be ascites, Ascites Peritonitis, carcinomatosis (cancer) 26, blood, chylus or pus. Table 1 shows the most impor- Hyperstimulation of ovaries 28–30 tant gynecological causes of free fluid in the abdo- men. This chapter focuses on abdominal masses. CLASSIFICATION OF ABDOMINAL MASSES Table 2 Anatomical origin of abdominal masses A patient with an abdominal mass may present with Genital mass Extragenital mass symptoms, but the mass might only be detected Uterine Gastrointestinal and pancreatic during physical examination or even only through Tubo-ovarian Hepato-biliary ultrasound. This chapter deals with palpable and Renal and urological sonographically detectable masses as the difference Mesenteric and retroperitoneal between the two may only be in size but not neces- Abdominal wall herniation sarily in treatment. 100 Abdominal Masses in Gynecology This chapter will only describe in detail the diagno- Table 3 Differential diagnosis for pelvic/abdominal mass sis and treatment of genital masses. Please refer to Gynecological surgical textbooks for further investigations and Pregnancy-related treatment of other conditions. Normal intrauterine pregnancy Old ruptured extrauterine pregnancy (abdominal, tubal SIGNS AND SYMPTOMS pregnancy); see Chapter 12 As was said earlier, many women with a pelvic mass Molar pregnancy see Chapter 15 Uterine origin will have no symptoms at all. Most symptoms are Uterine fibroids, see Chapter 19 not specific for a specific organ or entity. Patients Advanced uterine carcinoma or sarcoma, see Chapter may present with: 29 Hematometra/pyometra • Feeling of heaviness or fullness in the lower Tubal origin abdomen. Hydro-/pyosalpinx (Chapter 17 on STI) • Acute or chronic pain. • Tubo-ovarian abscess (Chapter 17) Bowel symptoms such as constipation or Advanced cancer of the tube bloating. Ovarian origin • Urogenital symptoms: frequent micturition, Ovarian torsion, see Chapter 5 on acute pelvic pain urge, recurrent urinary tract infection (UTI), Benign cyst retention of urine. Endometrioma, see Chapter 6 on chronic pelvic pain • Increased abdominal circumference. Benign tumor (dermoid, fibroma, cyst-adenoma) Borderline tumor Genital symptoms such as abnormal vaginal bleed- Malignant tumor (carcinoma, granulosa cell or germ ing, amenorrhea, dysmenorrhea or increased vagi- cell tumor; see Chapter 28) nal discharge may point to the reproductive organs A pelvic mass associated with an upper abdominal mass as causative organs. The absence of those symptoms may indicate advanced ovarian cancer with omental however doesn’t exclude a genital origin of the cake especially when associated with ascites patient’s complaints. Surgical causes Menstrual, bladder and bowel symptoms with or Appendicular abscess without pressure symptoms associated with a pelvic Obstructed hernia mass may point to fibroid uterus in women of re- Intussusception productive age, but similar symptoms may manifest Colorectal carcinoma sinister disease in a postmenopausal patient. There- Subacute intestinal obstruction fore each symptom needs further evaluation, i.e. Diverticular abscess onset, duration of symptoms, character and inten- Large bowel tumor/mesenteric tumor sity of pain or discomfort, loss of weight and Abdominal aortic aneurism Renal tumor: pelvic kidney, bladder carcinoma, urinary appetite and limitations of daily activity etc., to retention achieve a differential diagnosis. Neurological causes DIFFERENTIAL DIAGNOSIS Neuroblastoma It is of utmost importance to identify those patients Hematological causes with a potentially life-threatening disease, as well Hodgkin’s and non-Hodgkin’s lymphoma, pelvic spleen those patients who are already in a critical condi- tion. Table 3 gives an overview of the differential diagnosis. It is important to have a systematic approach for ductive age coming with a pelvic mass. The most assessment in order not to miss a patient with a common benign gynecological mass is a leio myoma potentially dangerous condition. The commonest (fibroid). Note that pelvic masses are also causes of mass arising from the pelvis in a woman of repro- generalized abdominal swellings or acute abdomen ductive age is an intrauterine or old ruptured which may be dealt with initially by general sur- ectopic pregnancy. It is thus important to have a geons in many countries, so sensitization of surgical suspicion for pregnancy in every woman of repro- colleagues is important. 101 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS HISTORY TAKING • Sexual history: current relationship, number of previous partners, dyspareunia, condom use Symptomatic assessment in regard to general health ( patients may find it embarrassing so put her at and specific systems must be carried out in a ease and be comfortable yourself about these systematic fashion. It is useful to have a set pattern issues). Newly experienced dyspareunia can of obtaining a history. See general questions for point to endometrioma in the pouch of Douglas gynecological history taking in Chapter 1. Ques- or acute infection. A higher number of partners tions you may want to ask are: with inconsistent condom use makes an STI • Presenting complaints: onset, duration, charac- more likely. ter and intensity if pain; is it radiating to another part of the body, what makes the symptom GENERAL EXAMINATION better/worse, relationship to menstrual cycle, As indicated above you first want to know whether loss of weight, appetite, fever, bloating, fre- your patient needs immediate treatment which quency. Weight loss and increased abdominal cannot be delayed. So after taking her vital signs to circumference can indicate a malignancy. A pel- rule out shock you should assess her abdomen for vic mass with fever can point to an infectious signs of peritonism as described in Chapter 1: assess cause of the mass such as a tubo-ovarian abscess for rebound tenderness and guarding. Once you’ve or diverticulitis. ruled out peritonitis or peritonism you can con- • Menstrual history: last menstrual period, abnormal tinue to assess your patient to establish your diag- bleeding (spotting, flooding, intermenstrual nosis. Don’t forget to check for generalized lymph bleed ing, amenorrhea, if yes since when?), dys- node enlargement to include lymphoma and tuber- menorrhea (see Chapter 7). Irregular bleeding culosis, but also gynecological malignancy in your can point to either a pregnancy or a uterine cause differential diagnosis. Note: after routine general of the mass, e.g. fibroids, but also to carcinoma. examination it is worth stating the patient’s per- Secondary dysmenorrhea (i.e. not since the first formance status (performance status aims at assess- period) points to endometriosis, adenomyosis and ment of physical ability and evaluates the fitness for fibroids. Amenorrhea of more than 6 months to- surgery if required; see http://en.wikipedia.org/ gether with advanced age makes menopause more wiki/Performance_status). likely than a pregnancy. The differential diagnosis Systematic examination will be extremely of pre- and postmenopausal patients differ! important for identifying the origin and cause of • Obstetric history: number of pregnancies and abdominal mass and other undiagnosed factors that deliveries with outcome, number of present the patient may have. For example, a patient pre- children, desire for children, current contracep- senting with a 1-day history of nausea and vomit- tion. An ectopic pregnancy in the history makes ing may have an advanced stage ovarian or a recurrence more likely. A pregnancy is likely peritoneal cancer, and vomiting may be due to in a woman who wants more children and intestinal obstruction or this may be acute gastro- doesn’t use any contraception. enteritis. So evaluation of symptoms and indivi- • Past history: past sexually transmitted infection dualization will help you to diagnose each condition (STI) symptoms, abdominal and vaginal opera- accurately. tions,