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Pelvic Mass

A pelvic mass can arise in numerous disorders of the female reproductive system, whereas certain urinary, gastrointestinal and skeletal diseases can also present with a pelvic mass as well. The diagnosis mandates a thorough imaging workup, preceded by a meticulous clinical examination.


Presentation

Symptoms that are seen in the case of a pelvic mass may significantly vary depending on the etiology. Because of its very high mortality rate, ovarian cancer is among the first conditions that has to be considered as a possible diagnosis. The majority of women report abdominal pain, bloating, weight loss and urinary tract-related symptoms such as increased urinary frequency, dysuria, and incontinence, in addition to a pelvic mass [1]. Other symptoms are fatigue, early satiety, and loss of appetite. If the abdominal or pelvic pain is coupled with vaginal bleeding and hypotension, ectopic pregnancy should be suspected, whereas intermittent, unilateral pain accompanied by nausea and vomiting could point to ovarian torsion, especially if the onset is abrupt [1]. The cyclic appearance of similar symptoms, in addition to dysmenorrhea, are highly suggestive of endometriosis [2]. If signs of an infection are present (fever, leukocytosis, vaginal discharge), pelvic inflammatory disease (PID), tubo-ovarian abscess, hydrosalpinx or pyosalpinx can be included in the differential diagnosis, as they may also present as a pelvic mass [2]. Acute diverticulitis can manifest as altered bowel habits, pain in the left lower quadrant of the abdomen, fever, and mild leukocytosis. However, gastrointestinal symptoms appearing with a pelvic mass necessitate a detailed workup to exclude neoplastic disorders of the colon [3]. Apart from accompanying symptoms, the size, shape, consistency and exact location of the mass can significantly aid in making a presumptive diagnosis.

Recurrent Urinary Tract Infection
  • A 3-year-old female child presented with a history of recurrent urinary tract infections. On general examination, polydactyly and a pelvic mass were present. An imperforate hymen was also documented on vaginal inspection.[ncbi.nlm.nih.gov]
Skin Lesion
  • The patient underwent conservative treatment and recovered well, although the skin lesion only healed after 12 weeks of oral antibiotic treatment.[ncbi.nlm.nih.gov]
Breast Mass
  • A woman in her ninth decade was discovered to have both a breast mass and a pelvic mass at examination. After diagnostic breast biopsy results that confirmed invasive breast carcinoma, pelvic examination and ultrasonography were performed.[ncbi.nlm.nih.gov]
Foot Drop
Prostatic Mass
  • Contrast enhanced computed tomography showed a vascularized prostatic mass with calcifications.[ncbi.nlm.nih.gov]

Workup

A detailed patient history and a thorough physical examination (including a gynecologic exam) are key initial steps in the diagnostic workup, and information regarding the onset and duration of symptoms, family history for similar symptoms and conditions that can present in a similar fashion, as well as features of the pelvic mass (size, shape, consistency, location) can provide vital clues for a presumptive diagnosis [1]. The obtained findings should be supported by various imaging studies, such as ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI), each having its beneficial roles when evaluating a pelvic mass [2] [4]. Although ultrasonography (both abdominal and vaginal) is considered as a first-line procedure, its depth of penetration is a limiting effect, while the lack of soft tissue contrast is the main limitation of CT [2]. For this reason, MRI is used for all masses with an undisclosed etiology despite performing an ultrasound or CT and is considered as the gold standard of diagnosis [2] [4]. Laboratory workup is also a vital component of pelvic mass assessment, with complete blood count (CBC), serum beta-human chorionic gonadotropin (β-hCG), CA-125 levels (an ovarian tumor marker that has shown good predictive results across several reports) and inflammatory marker tests (erythrocyte sedimentation rate, C-reactive protein, and fibrinogen) being most important tests [1] [2] [5]. As a last resort, explorative surgery may be considered, but having in mind the fact that it detects a malignant disease in 13-21% of cases, it should be performed promptly in the absence of a definite diagnosis [6].

Actinomyces Israelii
  • We report the second case in the literature, of a patient presenting with abdominal wall abscess, psoas abscess and hydronephrosis as a long-term complication of Actinomyces israelii infection of the ipsilateral ovary with a favourable outcome having[ncbi.nlm.nih.gov]
  • Abbreviations A. israelii : Actinomyces israelii CT: computed tomography IUD: intra-uterine device, MRI: magnetic resonance imaging.[jmedicalcasereports.com]

Treatment

  • The patient underwent conservative treatment and recovered well, although the skin lesion only healed after 12 weeks of oral antibiotic treatment.[ncbi.nlm.nih.gov]
  • We advise a planned multidisciplinary treatment approach at the first hint of the diagnosis of desmoid tumor.[ncbi.nlm.nih.gov]
  • Surgical resection is the treatment of choice for most LMs. We here describe a case of a 46-year-old woman who presented with a 3-month history of abdominal pain associated with worsening constipation and abdominal distension.[ncbi.nlm.nih.gov]
  • Once ovarian dysgerminoma was diagnosed, the possibility that this patient's renal findings may represent paraneoplastic syndrome also becomes important for her treatment.[ncbi.nlm.nih.gov]
  • After unsuccessful treatment with LH-RH analogues, the patient underwent ureteral resection and ureteroneocystostomy. At six months' follow-up, she is asymptomatic with no evidence of hydronephrosis.[ncbi.nlm.nih.gov]

Prognosis

  • Uterine hemangiopericytomas are usually low grade malignancies with better prognosis. The primary treatment is usually total hysterectomy and bilateral salpingo-oophorectomy.[ncbi.nlm.nih.gov]
  • Once excised completely, the prognosis of the disease is good.[ncbi.nlm.nih.gov]
  • Ovarian (germ cell) CA19-9 Monitoring disease status Pancreatic CEA Aid in management and prognosis Not specified (commonly for colorectal) Our ovarian cancer risk quiz was designed based on studies of robust ovarian cancer risk factors.[vermillion.com]
  • Its clinical behavior is similar to the serous borderline tumors, whose prognosis is significantly better compared to invasive forms, with a 5-year survival in stage I greater than 95%.[ncbi.nlm.nih.gov]
  • For example, dysgerminomas have an excellent cure rate, whereas endodermal sinus (yolk sac) tumours have a very poor prognosis.[geekymedics.com]

Etiology

  • For this reason, MRI is used for all masses with an undisclosed etiology despite performing an ultrasound or CT and is considered as the gold standard of diagnosis.[symptoma.com]
  • Intrapelvic granulomatous masses from polyethylene wear debris can easily be misdiagnosed if orthopaedic etiology is not considered.[ncbi.nlm.nih.gov]
  • Valour F, et al. (2014) Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infect Drug Resist 7:183–197 PubMed PubMedCentral Google Scholar 24.[link.springer.com]
  • In nonpregnant patients, the most common etiologies are functional cysts and leiomyomata. 10 Adnexal masses are characterized on ultrasonography as cystic, solid, or complex.[aafp.org]
  • Tubo-ovarian or other pelvic abscesses occur from a number of etiologies in the female patient. Usually there is an appropriate history of fever, elevated white blood cell count, and adnexal tenderness, which will indicate such a process.[appliedradiology.com]

Epidemiology

  • We review the literature on the epidemiology and the treatment options for desmoid tumors and suggest a strong index of suspicion when a new pelvic mass arises in an adult with previous pelvic surgery.[ncbi.nlm.nih.gov]
  • Hayat MJ, et al. (2007) Cancer statistics, trends, and multiple primary cancer analyses from the Surveillance, Epidemiology, and End Results (SEER) Program. Oncologist 12(1):20–37 CrossRef PubMed Google Scholar 2.[link.springer.com]
  • […] implantation. for more detail on the menstrual cycle, see here for the Geeky Medics guide TERMINOLOGY ovarian cancer is a malignant neoplasm arising from the tissues of the ovary – it is the leading cause of death from gynaecological cancer in the UK Epidemiology[geekymedics.com]
  • In menstruating women, those who persist beyond the length of a normal menstrual cycle without typical characteristics of a benign process such as a hemorrhagic cyst Epidemiology Frequency Determining the true frequency of adnexal masses is impossible[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • Pregnancy-related adnexal masses, including ectopic pregnancy, theca lutein cysts, corpus luteum cysts, and luteomas, must be considered in all premenopausal women. [21, 22] Pathophysiology The pathophysiology is not well understood for most adnexal masses[emedicine.medscape.com]

Prevention

  • Getting prompt medical attention could prevent a benign mass from becoming malignant.[wisegeek.org]
  • A rectosigmoidoscopy revealed narrowing of the lumen at 12 cm due to a mass lesion either in the wall or due to an extrinsic lesion that prevented the passage of the endoscope.[jmedicalcasereports.com]
  • Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: systematic evidence review for the U.S.[aafp.org]
  • Most of the cyst fluid is drained first to prevent unnecessary spillage and seeding of cancer cells into the abdominal cavity, then the ovary and tumour are removed...[geekymedics.com]

References

Article

  1. Givens V, Mitchell GE, Harraway-Smith C, Reddy A, Maness DL. Diagnosis and management of adnexal masses. Am Fam Physician. 2009;80(8):815-820.
  2. Allen BC, Hosseinzadeh K, Qasem SA, Varner A, Leyendecker JR. Practical approach to MRI of female pelvic masses. AJR Am J Roentgenol. 2014;202(6):1366-1375.
  3. Murji A, Sobel ML. Bowel obstruction and pelvic mass. CMAJ : Canadian Medical Association Journal. 2011;183(6):686-692.
  4. Szklaruk J, Tamm EP, Choi H, Varavithya V. MR imaging of common and uncommon large pelvic masses. Radiographics. 2003;23(2):403-424.
  5. Moore RG, Bast RC Jr. How do you distinguish a malignant pelvic mass from a benign pelvic mass? Imaging, biomarkers, or none of the above. J Clin Oncol. 2007;25:4159–4161.
  6. Bast RC, Skates S, Lokshin A, Moore RG. Differential diagnosis of a pelvic mass: improved algorithms and novel biomarkers. Int J Gynecol Cancer. 2012;22(1):S5-S8.

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Last updated: 2019-07-11 22:27