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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.

Virilization
  • CASE: A 63-year-old woman presented with a pelvic mass, abdominal pain and virilization. CA 125 and testosterone were elevated (74 U/mL and 384 ng/dL, respectively). Preoperative clinical diagnosis was suggestive of Sertoli-Leydig tumor.[ncbi.nlm.nih.gov]
  • Findings may suggest a cause: In young girls, precocious puberty: A masculinizing or feminizing ovarian tumor In women, virilization: A masculinizing ovarian tumor Menometrorrhagia or postmenopausal bleeding: A feminizing ovarian tumor Examination During[msdmanuals.com]
  • Retroperitoneal pelvic location is very rare and only few case histories have been reported. 1 Although retroperitoneal ganglioneuromas are usually asymptomatic, some patients may get compression symptoms, diarrhea, hypertension, virilization and myasthenia[bjmp.org]
Splenectomy
  • BACKGROUND: Splenosis is a rare complication after splenectomy and generally does not cause clinical symptoms. CASE: A 34-year-old woman who had splenectomy in childhood after trauma presented with a pelvic mass.[ncbi.nlm.nih.gov]
Left Lower Quadrant Pain
  • lower quadrant pain, nausea, vomiting, and constipation.[gut.bmj.com]
Urinary Retention
  • [email protected] Abstract We report on the case of a 55-year-old male with acute urinary retention, caused by a large pelvic mass. Contrast enhanced computed tomography showed a vascularized prostatic mass with calcifications.[ncbi.nlm.nih.gov]
  • Abstract We report two cases of acute urinary retention in women with an impacted pelvic mass. In both cases, all urinary symptoms resolved completely after the surgical removal of the mass.[ncbi.nlm.nih.gov]
  • Two women had overt urinary retention that resolved completely postoperatively. All women completed pre- and postoperative UDI-6 and IIQ-7.[ncbi.nlm.nih.gov]
  • Hsu KP, Chen CP, Chien SC, Hsu CY (2008) Hematocolpometra associated with an imperforate hymen and acute urinary retention mimicking a pelvic mass. Taiwan J Obstet Gynecol 47:222–223 PubMed CrossRef Google Scholar 2.[link.springer.com]
Imperforate Hymen
  • An imperforate hymen was also documented on vaginal inspection. Further inquiry revealed a positive history of parental consanguinity.[ncbi.nlm.nih.gov]
  • Hsu KP, Chen CP, Chien SC, Hsu CY (2008) Hematocolpometra associated with an imperforate hymen and acute urinary retention mimicking a pelvic mass. Taiwan J Obstet Gynecol 47:222–223 PubMed CrossRef Google Scholar 2.[link.springer.com]
  • The cause is usually an imperforate hymen; other causes include congenital malformations of the uterus, cervix, or vagina. In women of reproductive age, the most common cause of symmetric uterine enlargement is pregnancy, which may be unsuspected.[msdmanuals.com]
Foot Drop

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]
  • TREATMENT: Laparoscopy with radical exeresis was performed. RESULTS: Microscopic exam revealed florid cystic endosalpingiosis of the uterus.[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]

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. Copyright 2011 Elsevier Inc. All rights reserved.[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]
  • In contrast, the remaining 252 tumours had unfavourable prognosis and were called ganglioneuroblastoma nodular unfavourable subset (GNB-N-US).[bjmp.org]
  • Though benign in nature, occasionally raised carcinoma antigen 125 (CA-125) and Meig’s syndrome may be associated and result in poor prognosis. Surgical excision is the treatment of choice and histology remains the gold standard for diagnosis.[jpgo.org]

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]
  • Abstract Intrapelvic granulomatous masses from polyethylene wear debris can easily be misdiagnosed if orthopaedic etiology is not considered.[ncbi.nlm.nih.gov]
  • Etiology Pelvic masses may originate from gynecologic organs (cervix, uterus, uterine adnexa) or from other pelvic organs (intestine, bladder, ureters, skeletal muscle, bone). Type of mass tends to vary by age group.[msdmanuals.com]
  • Gastrointestinal duplications: clinical, pathologic, etiologic, and radiologic considerations. Radiographics 1993;13:1063-1080. Gumus M, Kapan M, Gumus H, et al. Unusual noncommunicating isolated enteric duplication cyst in adults.[jaocr.org]

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]
  • Goodman MT, Howe HL: Descriptive epidemiology of ovarian cancer in the United States, 1992-1997. Cancer 97:: 2615 , 2003 -2630, (suppl) Crossref , Medline , Google Scholar 11.[jco.ascopubs.org]
  • […] 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]
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

  • This allows for easy removal and prevents fluid from the mass from spilling into the pelvic cavity. Any masses suspected for malignancy are sent for frozen section analysis.[innovativegyn.com]
  • Getting prompt medical attention could prevent a benign mass from becoming malignant.[wisegeek.org]
  • Moving around as soon as possible after your operation can help to prevent this. We will give you surgical compression stockings to wear whilst you are in hospital, and injections to thin the blood.[hey.nhs.uk]
  • 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]

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: 2017-08-09 17:38