WEEK 6 PBL: PELVIC MASSES

OUTLINE THE CAUSES OF ACUTE AND CHRONIC PELVIC PAIN

Pelvic inflammatory disease

Is caused by a bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract,
including the uterus, fallopian tubes, ovaries and surrounding tissues. The most common pathogens are
Chlamydia trachomatis and Neisseria gonorrhoea. The less common pathogens are Ecoli, Ureaplasma,
Mycoplasma and other anaerobes.

Risk factors

- Multiple sex partners

- Unprotected sex
- History of prior STI’s and adnexitis
- Risk is lower during pregnancy; PID development during pregnancy increases the risk of maternal
morbidity and preterm births.
- Vaginal dysbiosis.

Clinical features

- Lower abdominal pain (generally bilateral) which may progress to acute abdomen.
- Nausea and vomiting
- Fever
- Dysuria, urinary urgency, dyspareunia
- Menorrhagia, metrorrhagia
- Abnormal vaginal discharge (yellow/green in colour).

Diagnostics

Diagnosis is primarily based on clinical findings. Further diagnostic tests confirm the diagnosis.

1. Important diagnostic criteria

- History: most often a sexually active young woman
- Lower abdominal pain
- Vaginal examination; cervical motion tenderness, uterine and adnexal tenderness, purulent bloody
cervical discharge
2. Blood tests: elevated CRP, ESR and leucocytosis
3. Pregnancy test: to rule out ectopic pregnancy
4. Cervical and urethral swab: gonococcal and chlamydial DNA cultures.
5. Imaging
- USS: free fluid, abscesses, hydrosalpinx
- Exploratory laparoscopy: Indicated in ambiguous cases and if patient does not respond to treatment,
characteristic findings include tubal edema, erythema and purulent exudate.
- Endometrial biopsy: to confirm the presence of endometritis
- Culdocentesis: aspiration of intraperitoneal fluid from the pouch of Douglas. Largely replaced by USS.

Ectopic pregnancy:

See in notebook

Appendicitis

The acute inflammation of the vermiform appendix typically due to obstruction of the appendiceal lumen.
Uncomplicated is appendicitis with no evidence of an appendiceal fecalith, an appendiceal tumour or
complications such as perforation, gangrene, abscess or mass. Complicated is appendicitis associated with
perforation, gangrene, abscess, an inflammatory mass, an appendiceal fecalith (concretion of feces that
develops in the appendix that can obstruct the appendiceal lumen) or an appendiceal tumor.

Causes

- Lymphoid tissue hyperplasia: most common cause in children and young adults.
- Appendiceal fecalith and fecal stasis: most common cause in adults
- Neoplasm: uncommon but more likely in patients > 50 years
- Parasitic infestation: uncommon but Enterobius vermicularis, ascaris lumbricoides and species of the
Taenia and Schistosoma.

Pathophysiology

Obstructed proximal appendiceal lumen resulting in

- stasis of mucosal secretions > bacterial multiplication and local inflammation > transmural spread of
infection > clinical features of appendicitis.
- Increased intraluminal pressure > obstruction of veins > edema of the appendiceal walls > obstruction
of capillaries > ischemia > gangrenous appendicitis with/without perforation.
- Inflammation can spread to the serosa and result in peritonitis

Clinical features

1. Migrating abdominal pain: most common and specific symptom. Typically, constant and rapidly worsens.
Most patients present within 48 hours of symptom onset. Initiate diffuse periumbilical pain caused by the
irritation of the visceral peritoneum (pain is referred to T8 – T10 dermatomes). Localizes to the RLQ within
12 – 24 hours.
2. Associated nonspecific symptoms
- Nausea
- Anorexia, Hamburger sign (if there is no loss of appetite, appendicitis is unlikely).
- Vomiting
- Low grade fever
- Diarrhea
- Constipation
3. Clinical signs of appendicitis
- McBurney’s point: RLQ tenderness.
- Blumberg sign: rebound tenderness in the RLQ
- Rovsing: RLQ pain elicited on deep palpation of the LLQ
- Psoas sign: RLQ pain elicited on passive extension of the right hip when the patient is position on their
left side.
- Pain in the Pouch of Douglas: pain elicited by palpated the rectouterine pouch on rectal examination
- Baldwin sign: pain in the flank when flexing the right hip (suggests an inflamed rectrocecal appendix).

Management

1. Initial management
- Perform rapid clinical evaluate using ABCDE approach
- Screen for peritoneal signs
- Establish IV access and obtain blood samples for laboratory studies
- Provide immediate hemodynamic support if necessary
- Keep patients NPO and initiate supportive care; IV fluids, analgesia, antiemetics
- Determine likelihood of appendicitis using risk scores
- Proceed with subsequent management based on the likelihood of diagnosis
2. Low likelihood of appendicitis
- Alvarado score < 2 – 4, AIR score < 4
- Additional testing may not be required.
 - Consider D/C home with follow up within 24 hours in select patients; patients < 40 years and no red
flags for abdominal pain.
- Consider observation, reassessment (q6-8hrs) and diagnostic imaging for suspected early appendicitis,
unclear underlying cause of symptoms and older adults > 60 years.
3. Moderate likelihood of appendicitis
- Alvarado score < 5 -6, AIR score < 5 – 8
- Confirmatory imaging is required
- If the imaging is inconclusive or negative for appendicitis, consult surgery, consider admission, serial
abdominal examination, consider empiric antibiotic therapy and diagnostic laparoscopy.
4. High risk likelihood of appendicitis
- AIR score > 9, Alvarado score > 7 – 9
- Urgent surgical consult, begin empiric antibiotics and arrange preoperative CT abdomen.
- Laparoscopic appendectomy within 24 hours for uncomplicated appendicitis
- Emergency appendectomy for complicated appendicitis with systemic manifestations (generalized
peritonitis or sepsis)
- Nonoperative management of appendicitis is recommended for complicated appendicitis with an
appendiceal phlegmon or appendiceal abscess.

Risk stratification tools

AIR SCORE

Laboratory studies

1. Routine studies
- CBC: mild leucocytosis with left shift
- CRP: elevated
- BMP: Increased creatinine, electrolyte abnormalities may be present in patients with severe vomiting
and diarrhea.
- Urinalysis: typically, normal in appendicitis with possible findings of mild pyuria and hematuria
2. Tests to evaluate differentials
- B-Hcg: In all women of reproductive age to rule out pregnancy

Imaging

1. First line imaging in non-pregnant adults: CT abdomen

2. First line imaging for pregnant adults and children: USS abdomen
- Distended appendix
- Non compressible and aperistaltic appendix
- Target sign: concentric rings of hypo and hyper echogenicity in the axial and transverse section of the
appendix
- Possible appendiceal fecalith: focal hyper echogenicity with posterior acoustic shadowing.
3. CT abdomen with IV contrast
4. MRI abdomen and pelvis
5. Diagnostic laparotomy’

Treatment
1. Supportive care
- Bowel rest (NPO)
- IV fluids
- Electrolyte repletion
- IV analgesics and antiemetics
- Antipyretic therapy
2. Empiric antibiotic therapy for acute appendicitis
- All patients with acute appendicitis
- Against gram negative and anaerobic organism
- Administer one of the following agents against surgical site infection; cephalosporin with anaerobic
coverage, in patients allergic to penicillin / cephalosporin administer clindamycin or metronidazole
PLUS a high dose gentamicin or ciprofloxacin.
3. Appendectomy
- Within 24 hours of diagnosis is the current standard of care for acute uncomplicated appendicitis.
- Contraindications: appendiceal mass / appendicular abscess
- Can be done via laparoscopic appendectomy or open appendectomy
4. Interval appendectomy
- Appendectomy performed 6 – 8 weeks following the resolution of an acute episode of appendiceal
mass or appendiceal abscess to minimize surgical complications.
- Consider for persistent or recurrent symptoms of appendicitis in a patient with an appendiceal mass
or appendiceal abscess treated conservatively
- Consider in patients > 40 years of age if there is concern for an underlying appendiceal tumor.
5. Nonoperative management: typically preferred for patients at high risk of surgical morbidity if operated
on immediately.
- Indications: inflammatory appendiceal mass, appendiceal abscess, patient refusal or surgery, high
surgical risk due to comorbidities, history of previous surgical/ anesthesia complications, consider in
select patients with early uncomplicated appendicitis.
- Contraindications: septic shock, generalized peritonitis, inability to percutaneously drain an
appendiceal abscess, appendiceal fecalith
- Empiric antibiotic therapy for 3 days, supportive care, image guided drainage for peri appendiceal
abscess > 4 cm, monitor vitals and serial abdominal exams every 6 – 12 hours, schedule interval
colonoscopy in patients > 40 years of age.

Uterine fibroids

A benign hormone sensitive smooth muscle tumor of the uterus. Can be submucosal, intramural or subserosal.
It arises from a single myometrial cell (monoclonal growth) and causes upregulation of hormone receptors like
estrogen and progesterone and excessive production of extracellular matrix (hence fibroids). This results in an
overgrowth of smooth muscle cells and connective tissue (often multiple tumors). The myometrium then
develops vascular changes.

Risk factors

- Nulliparity
- Early menarche < 10 y/o
- Age 25 – 45 years
- African descent
- Obesity
- Positive family history

Clinical features

Depend on the number, size and location.

- Abnormal menstruation
 - Features of mass effect: back/pelvic pain, urinary and bowel symptoms
- Infertility
- Dyspareunia

Classification

Diagnostics

1. USS (transvaginal / transabdominal)

- Well circumscribed hypoechoic solid mass
- Calcifications and/or cystic areas due to degeneration
- Mass effect: hydronephrosis can be seen in patients with large fibroids.
2. Sonohysterography
- Used to further evaluate endometrial abnormalities detected on USS
- Can distinguish between endometrial polyps and submucosal fibroids
3. Laboratory studies
- CBC: to assess anemia
- BMP: to assess renal function
- Urine pregnancy test: if the patient is of childbearing age
- PT, PTT, fibrinogen
- Diagnostic studies for Von Willebrand disease
- Consider TSH and liver enzymes if clinically stable

Treatment

1. Expectant management
- For asymptomatic or minimally symptomatic patients
- Also for perimenopausal patients
- Monitor reported symptoms for any worsening at annual well – women exams
- Typically, no active treatment is required
- Hematinics
2. Pharmacotherapy
- GnRH agonist like Zoladex
- GnRH antagonist like Elagolix
- Levonorgestrel intrauterine device
- OCP for combined or progesterone only
- Tranexamic acid
3. Non-surgical intervention
- Uterine artery embolization: a minimally invasive percutaneous radiologic procedure in which an
embolic agent is injected into the uterine arteries that supply the fibroid causing it to shrink. It
significantly reduces fibroid size and bleeding. It can cause post-embolization syndrome,
thromboembolic events, bleeding and endometritis. It has unknown effects on fertility.
 - Radiofrequency ablation: ultrasound guided targeted coagulative necrosis of fibroid. It causes a
significant decrease in fibroid size and symptoms. Has unknown effects on fertility.
4. Surgery
- Myomectomy: a uterus preserving surgical option for the removal of fibroids. Indicated in patients
with symptoms who wish to preserve fertility, consider in patients with fibroids and a history of
infertility hoping to conceive. Hysteroscopic myomectomy is preferred for submucosal fibroids and
laparoscopic myomectomy may be preferred for subserosal and most intramural fibroids.
- Hysterectomy: indicated in patients seeking definitive treatment who do not desire fertility or have
had an insufficient response to alternative treatments.

Adenomyosis

A benign disease characterized by the occurrence of endometrial tissue within the myometrium due to
hyperplasia of the endometrial basal layer. Peak incidence is at 35 – 50 years. The exact Etiology is unknown
but risk factors include; endometriosis, uterine fibroids and parity.

Clinical features

- May be asymptomatic
- Dysmenorrhea
- AUB
- Chronic pelvic pain aggravated during menses
- Globular uniformly enlarged uterus that is soft but tender on palpation

Diagnostics

- Is clinical but may be supported by transvaginal ultrasound and MRI findings; asymmetric myometrial
wall thickening and myometrial cysts. Histology can be used to confirm the results.

Treatment

1. Conservative
- Combined OCP
- Progestin only contraception
- NSAIDS for pain relief
- GnRH agonists
2. Surgical
- Hysterectomy is definitive
- Excision of single organized adenomyomas

Endometriosis

A common benign and chronic disease characterized by the occurrence of endometrial tissue outside the
uterus. The age of onset is 20 – 40 years and is more common in white and Asian women than Black and
Hispanic women.

Cause

The Etiology is not yet fully understood however retrograde menstruation seems to play a major role. Other
contributing factors include; coelemic metaplasia, iatrogenic implantation. Hematogenic and lymphogenic
dissemination of endometrial cells and a hereditary component.

Risk factors include; nulliparity, prolonged exposure to endogenous estrogen (early menarche and late
menopause), short menstrual cycle < 27 days, menorrhagia > 1 week, family history.

Pathogenesis

In endometriosis, the endometrial tissue occurs outside of the uterus. Common locations include ovaries
(bilaterally affected), rectouterine pouch, fallopian tubes, bladder, cervix and peritoneum. Regardless of where
the endometrial tissue is located, it reacts the same way to the hormone cycle and proliferates under
estrogen. This will result in increased production of inflammatory and pain mediators, anatomic changes like
pelvic adhesions and nerve dysfunction.

Clinical features

Depends on involved structures but generally;

- Chronic pelvic pain that worsens before onset of menses

- Infertility
- Dysmenorrhea
- Pre or post menstrual bleeding
- Dyspareunia

Diagnostics

1. Patient history
2. Physical examination
- Rectovaginal tenderness
- Adnexal masses
- Lateral displacement of the cervix
3. TVUSS (best initial test).
- Uterus generally not enlarged
- Evidence of ovarian cysts (chocolate cysts)
- Nodules in bladder or rectovaginal septum
4. Laparoscopy (confirmatory test)
- May show endometriotic implants and adhesions.

Treatment

Asymptomatic: expectant management (a mgt involving serial monitoring).

Symptomatic

1. Pharmacological therapy
- For mild – moderate symptoms: empiric treatment with NSAIDs and continuous hormonal
contraceptives or NSAIDs alone if pregnancy is desired, synthetic androgens like danazol.
- For severe symptoms: GnRH agonists and estrogen – progestin OCP
2. Surgical therapy
- First line: laparoscopic excision and ablation of endometrial implants. It is done to treat patients who
don’t respond to pharmacologic and to treat expanding endometriomas and complications including
fertility, bowel obstruction and rupture of endometrioma.
- Second line: open surgery with hysterectomy with or without bilateral salpingo – oophorectomy.
Done in patients with treatment resistant symptoms and those who have no desire to bear children.

Complications

- Anemia
- Endometriosis in the uterotubal junction inhibits implantation of the zygote increasing risk of ectopic
pregnancy
- Endometriosis results in fibrous adhesions that results in strictures and entrapment of organs.
- It is also associated with a slightly elevated risk of ovarian cancer.

APPROACH TO A PATIENT PRESENTING WITH CHRONIC PELVIC PAIN (HX TAKING, PHYSICAL EXAM AND
INVESTIGATIONS)
A proposed definition of chronic pelvic pain (CPP) is nonmenstrual pain of 3 months’ duration or longer that
localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or
surgical treatment.

History

- Location: Ask the patient to describe the pain location and type on a pain diagram (anteroposterior
and lateral view of human picture).
- Precipitating factors: Ask questions about factors that provoke or intensify pain. This may provide
clues for possible etiologies or associated disorders. For example, in pelvic congestion syndrome, pain
is related to posture and is worse at the end of day. In endometriosis, pain is commonly reported
during or after intercourse.
- Alleviating factors: Alleviating factors may be present. For example, rest may decrease pain of
musculoskeletal or adnexal origin.
- Quality of pain: Various terms can be used to describe the quality of pain. Such terms include
throbbing, pounding, shooting, pricking.
- Severity: Use some type of rating system to evaluate pain severity or intensity with a degree of
objectivity and reproducibility. Different types of pain scales may be used. Numerical scales are more
useful and reliable. The visual analog scale is one of the commonly used numerical scales.
- Gynecologic hx: For example, excessive bleeding with menses suggests uterine leiomyomas or
adenomyosis. History of previous surgery may suggest intra-abdominal or pelvic adhesions. Patients
with cervical stenosis usually have a history of chronic cervical infection or treatment with
cryosurgery/laser surgery/loop excision or endometrial resection. Having multiple sexual partners is a
risk factor for pelvic inflammatory disease. Women with adenomyosis have higher levels of
dysmenorrhea, pelvic pain, depression, and endometriosis than women with fibroids. Women
undergoing hysterectomy with a histologic diagnosis of adenomyosis have a distinct symptomatology
and medical history compared with women with leiomyomas.
- Urologic: A detailed history to evaluate the urological system is important. For example, as compared
to patients with pelvic pain, patients with interstitial cystitis report urgency and increased frequency
of urination as the most distressing features.
- Continue with the ROS

Physical exam

Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with
chronic pain. A thorough systematic examination usually suggests an appropriate diagnosis and therapy.
Lithotomy examination includes the following;

- Visual inspection of the external genitalia

- Basic sensory testing and evaluation for trigger points: A cotton-tipped swab can be used for precise
sensory and tender-point evaluation of the vestibule, vaginal cuff, cervical os, paracervical region, and
cervical region; single-digit examinations of the vulva, pubic arch, levator ani coccyx, introitus,
urethral, trigonal, cervix, paracervical areas, vaginal fornices, uterus, and adnexa are indicated.
- Colposcopic evaluation of the vulva and vestibule
- Sims retractor or single-blade speculum examination of the vagina and pelvic muscles
- Bimanual pelvic examination
- Rectovaginal examination

Perform detailed examinations for other systems (eg, GI, urologic, neurologic, musculoskeletal) as required.

- Betty maneuver (for piriformis syndrome): When abduction of the thigh against resistance is
requested, the patient will report pain.
- Obturator sign (dysfunction of the obturator muscles or fascia)
- Straight-leg raising test (possible herniated disc, radiculopathy)
 - Psoas sign: If pain is elicited during flexion of hip against resistance, this may suggest dysfunction of
the psoas muscles or fascia.
- Patrick or faber (flexion in abduction and external rotation) test for hip evaluation

IDENTIFY THE DIFFERENTIAL DIAGNOSIS TO ABDOMINOPELVIC MASS

OVARIAN CYSTS

Are fluid filled sacs within the ovary. The most common types are functional follicular cysts, corpus luteum
cysts and theca lutein cysts which all develop as part of the menstrual cycle and are usually harmless and
resolve on their own. Non – functional cysts include chocolate cysts, dermoid cysts, cystadenomas and
malignant cysts.

Functional cysts

Functional cysts result from a disruption in the development of follicles or the corpus luteum and often resolve
on their own.

1. Follicular cyst of the ovary (most common ovarian mass in young women)
- Develops when a Graafian follicle does not rupture and release the egg (ovulation) but continues to
grow.
- Eventually develops into a large cyst (almost 7cm) lined with granulosa cells
- Associated with hyperestrogenism and endometrial hyperplasia.
2. Corpus luteum cysts
- Enlargement and build-up of fluid in the corpus luteum after failed regression following release of an
ovum.
- Produces progesterone which may delay menses
- Associated with progesterone only contraceptive pills and ovulation inducing medication.
- Common during pregnancy.
3. Theca lutein cysts
- Often multiple cysts that typically develop bilaterally
- Result from exaggerated stimulation of the theca interna cells of the ovarian follicles due to excessive
amounts of circulating gonadotropins such as BhCG
- Strongly associated with gestational trophoblastic disease and multiple gestations
- Usually resolve once BhCG levels have normalized.
Non – functional cysts

A group of ovarian cysts that do not produce hormones

1. Chocolate cysts: a cyst like ovarian structure that contains blood, fluid and menstrual debris. Caused
by proliferation of ectopic endometrial tissue (endometriosis).
2. Dermoid cysts: a mature cystic teratoma that can occur on the head, neck, spine, cranium and in the
abdomen (most common ovarian tumour in females). Cysts typically become symptomatic as they
grow in size. They are treated with complete surgical excision.
3. Cystadenoma: a benign ovarian tumor of epithelial origin. Can be serous or mucinous, is frequently
bilateral and often shows psammoma bodies on histopathologic examination. Usually symptomatic
and found incidentally and or ovarian torsion can occur.
4. Malignant cysts: form of ovarian cancer and is of higher risk in postmenopausal women.

Clinical features

- Usually asymptomatic (incidental finding)

- Can cause lower abdominal pain and lead to complications
- Adnexal mass that is sometimes palpable
- Possibly signs of the underlying cause such as menorrhagia in endometriosis and hirsutism in PCOS.

Approach

- First line imaging pelvic USS

- For acutely symptomatic patients;
 Rule out pregnancy with serum or urine BhCG test
 Consider CT to rule out non – gynaecological causes and complications
 Perform additional diagnostics as clinically indicated.
- Laboratory studies
 Urine or serum BhCG: to rule out ectopic pregnancy
 CBC: to evaluate for hemorrhage

Imaging

1. Pelvic ultrasound with Doppler: transvaginal or transabdominal is the first-line imaging modality for
symptomatic and asymptomatic patients with a suspected adnexal mass.
- Simple cysts
 Smooth lining on all sides
 Single: follicular cyst of the ovary, corpus luteum cyst
 Multiple: PCOS, multilocular theca lutein cysts
 Anechoic
 No internal flow on Doppler
- Corpus luteum cysts
 Unilocular cyst with thick walls
 Increased peripheral vascularity (ring of fire sign)
 Small central lucency
 Intracystic echogenic debris may be present
- Theca lutein cysts
 Bilateral multilocular cysts with thin walls
 Fluid filled
 Solid components may be present
- Potentially malignant cysts
 Multilocular cysts with solid components
 Solid irregular masses
 Ascites and peritoneal nodules
Management

Usually determined by cysts appearance and size as well as menopausal status.

1. All patients
- Pain management with NSAIDS and opioids (only for severe cases).
- Treatment of underlying conditions such as PCOS or endometriosis.
- Refer for outpatient follow up with gynaecologist.
2. Functional cysts
- Watchful waiting with repeat ultrasound
- Oral contraceptives are not routinely recommended
3. Complications, large cysts, persistent painful cysts: consider surgery

Ruptured ovarian cyst

Rupture is caused by an increase in Intracystic pressure. The most common type of ruptured cyst is the corpus
luteum cyst. Risk factors are: vigorous physical activity, vaginal intercourse, large cysts, reproductive age.

Clinical features

- May be asymptomatic
- Sudden onset of unilateral lower abdominal pain
- Possible sign of peritonitis
- Possible nausea and vomiting
- Minimal vaginal bleeding (spotting may occur)
- In case of significant hemorrhage; hypovolemic shock

Laboratory studies

- Urine / serum BhCG: obtain in all patients to rule out intrauterine or ectopic pregnancy
- CBC: may show anemia
- Coagulation panel, type and screen Rh

Imaging

1. POCUS/FAST: consider in unstable patients to rapidly assess for the presence and extent of free fluid.
2. Transabdominal / transvaginal ultrasound: imaging modality of choice
- Free fluid mostly in the pouch of Douglas
- An adnexal mass may be visualized if the cyst is large
- The disadvantage is that it’s difficult to distinguish between ruptured ectopic and ruptured ovarian
cyst.
3. CT pelvis with IV contrast: consider in non-pregnant patients if ultrasound findings are inconclusive. Pelvic
hemoperitoneum will be found.

Treatment

- Assess hemodynamic stability

- Transfuse and stabilize

OVARIAN TUMORS

Ovarian tumors are a gynaecological neoplasm occurring the in the ovaries. They are the most common
ovarian mass in women > 55 years. It is the second most common cancer (after endometrial cancer) but causes
the most deaths.

Risk factors

1. General
- Incidence increases with age
 - Asbestos
2. Genetic predisposition
- BRCA 1/ BRCA 2 mutations: positive family history and/or the occurrence of breast cancer < 30 years
increases the likelihood of carrying a mutation in these genes.
- HNPCC syndrome: family history and Puetz – Jeghers
3. Hormonal factors
- Early menarche and late menopause
- Endometriosis

Protective factors

1. Surgical intervention
- BTL
- Hysterectomy
- Tubal ligation
2. Hormonal factors
- OCP
- Breastfeeding
- Parity