Differential Diagnosis of Pelvic Mass PQ1 Dr. Roma Anna F.

Garcia-Dumaup
Differential Diagnosis of Pelvic Masses PELVIC MASS D/Dx are vastly different throughout different age groups Origin can be: Gynaecologic (uterine or adnexal [fallopian tubes and ovaries]) Urinary tract (urinary bladder and portions of the ureter) Bowel AGE GROUPS Prepubertal Adolescent (Postpubertal) Reproductive Post-menopausal PREPUBERTAL AGE GROUP From birth until onset of menarche Most frequent initial symptom: abdominal or pelvic pain The pelvic size is small in prepubertal age group. Because pelvic masses quickly enlarge and the pelvic cavity capacity is small they become abdominal (hence abdominal pain) Ovarian ligament becomes stretched masses can be prone to torsion causing pain (from ischemia due to impedance of blood supply) Can manifest with many nonspecific symptoms: Nausea and vomiting Fever Irritability Constipation or diarrhea due to compression DIAGNOSIS History o Pain OPQRST o Mass express size into two-dimensional measurements (in centimeters) Physical examination (complete with emphasis on) o Abdominal palpation o Bimanual rectoabdominal exam Dont do vaginal exam! One hand with finger on the rectum, one hand palpating the abdomen. Midline: uterus Lateral: adnexae Ultrasound for all age groups o Solid, liquid, cystic? o Contents of cyst? CT, MRI, Doppler flow studies DIFFERENTIAL DIAGNOSIS <5% of ovarian malignancies occur in children and adolescents Approximately 1% of all tumors in these age groups are ovarian. Germ cell tumors: 50-66% of ovarian tumors in these age groups. 80% of ovarian neoplasms in girls <9 y/o are malignant. 60% of masses are non-neoplastic. 2/3 of neoplastic masses are benign. Most of benign neoplastic tumors are functional (secrete hormones) follicular cysts seen in fetuses, newborns and prepubertal girls. o These individuals can manifest with sexual precocity (e.g., blood in the diaper). o Early development of secondary sexual characteristics. WILMS TUMOR NEUROBLASTOMA o These two can be differentiated by UTZ. Must rule-out because they are common in this age group.

ADOLESCENT AGE GROUP From the onset of menarche until 19-21 y/o. Differential Diagnoses: Ovarian masses Uterine masses Inflammatory masses Pregnancy OVARIAN MASSES Risk of carcinoma is lower than among young children Most frequent neoplastic tumor: mature cystic teratoma (benign) a.k.a. Dermoid Cyst Functional ovarian cysts may be seen incidentally (on UTZ or laparotomy). o Functional ovarian cysts disappear spontaneously within 4-6 weeks (at most: 3 menstrual cycles); not an alarm: surgery is unnecessary Others functional ovarian cyst: corpus luteum cyst which may oversecrete Progesterone theca lutein cyst Endometriosis is less common than in adults (but there is an increasing frequency of incidence). o Etiology: may be due to exposure to environmental factors (pollution, food preservatives). o Most frequent site: ovary UTERINE MASSES Very rare in this age group Leiomyoma: most common uterine mass What are frequently seen as uterine enlargement in this age group are obstructive uterovaginal anomalies: o Imperforate hymen Endometrial lining accumulates in the vagina hematocolpos If in the uterus hematometra (pelvic mass) o Transverse vaginal septum o Vaginal agenesis with normal uterus and functional endometrium

1 Saint Louis University School of Medicine Batch 2015

Differential Diagnosis of Pelvic Mass PQ1 Dr. Roma Anna F. Garcia-Dumaup

Causes hematometra right away If in the fallopian tube hematosalpinx o Vaginal duplication with obstructing vaginal septum o Obstructed uterine horn Signs and symptoms o Cyclic pain (but no bleeding) o Primary amenorrhea never had menses o Vaginal discharge o Hematocolpos o Hematometra INFLAMMATORY MASSES Highest rate of PID of all age groups: o More sexual partners o Less safe sexual practices o Ectropion columnar epithelium of the cervix is still exposed: thus, more prone to infection and injury o Higher risk of developing cervical cancer. Tuboovarian complex (matted bowel, tube and ovary due to infection) o Combination of salpingitis and oophoritis plus matted bowel Tuboovarian abscess Pyosalpinx pus in the fallopian tube Hydrosalpinx if PID is chronic o Fluid in the tube not necessarily pus Consequences: o Infertility o Ectopic pregnancies Most common causative agent: Chlamydia PREGNANCY Always consider this in adolescents! Intrauterine or ectopic DIAGNOSIS History PE presumptive, probable and positive signs of pregnancy Laboratory tests: o Pregnancy test always! o CBC especially if considering inflammatory disease o Tumor markers (AFP and hCG) o Ultrasonography, CT, MRI o Epithelial cell tumors Serous cystadenoma and cystadenoma CA125 is a good marker mucinous

POSTMENOPAUSAL AGE GROUP Ovarian size: Premenopause 3.5 x 2 x 1.5 cm (almond shaped) Early menopause 2 x 1.5 x 0.5 cm Late menopause 1.5 x 0.75 x 0.5 cm A normal sized ovary in the postmenopausal age group should always be considered abnormal high risk for ovarian cancer. POSTMENOPAUSAL PALPABLE OVARY (PMPO) Normally not palpable, even in the reproductive age group. Any ovary palpable beyond menopause is abnormal and deserves evaluation. Not a reliable predictor of malignancy Postmenopausal ovary as large as a premenopausal ovary is considered abnormally large Consider ovarian Ca DIAGNOSIS History: personal and family history of cancer (breast, colonic, ovarian) Pelvic exam o It is assumed that we can do a vaginal exam in this age group o If they refuse (NSSB, or no sex since birth) do rectoabdominal exam instead Ultrasound/color flow Doppler o Malignant neoplasms show hypervascularity Serum CA 125 important marker for epithelial tumors o Nonspecific o Calcifications can be seen in benign cystic teratoma and myomas. Mucinous ovarian cysts can grow very large, yet still remain benign. Myoma: pedunculated, subserous, intramural, submucosal, cervical, etc.

REPRODUCTIVE AGE GROUP Differential diagnoses: Full urinary bladder (jokingly called urinoma) o Always ask patient to urinate first. Urachal cyst Sharply anteflexed or retroflexed uterus o Anteflexed body and fundus positioned anteriorly, cervix pointing anteriorly o Anteverted body pointing anteriorly, cervix pointing posteriorly Pregnancy Ovarian or adnexal masses Paraovarian or paratubal cysts Myomas most frequent in this age group Others tumors that may arise from other abdominal organs

SUMMARY Infancy and prepubertal Functional cysts Germ cell tumor Adolescence Functional cyst Pregnancy Dermoid cyst/other germ cell tumor Sobstructing vaginall or uterine anomalies Epithelial ovarian tumor PID Reproductive Functional cyst Pregnancy Uterine fibroids leiomyomas

2 Saint Louis University School of Medicine Batch 2015

Differential Diagnosis of Pelvic Mass PQ1 Dr. Roma Anna F. Garcia-Dumaup

Epithelial ovarian tumors Perimenopausal Fibroids Epithelial ovarian tumor Functional cyst o Follicular cyst o Corpus luteum cyst corpus luteum with hemorrhage (cyst contains blood) o Theca lutein cyst Postmenopausal Ovarian tumor (malignant > benign) Functional cyst Bowel tumors (malignant), or inflammatory disease Metastases

3 Saint Louis University School of Medicine Batch 2015