Small Group Discussion #4

A case of a 22-yr old Nullipara who

consulted for
Left Lower Quadrant Pain

Dr. Judith T. Morales

Consultant Preceptor

Group II-B
Objectives
Specific:
 To gather appropriate History for the case and identify salient features related
 To identify important physical examination findings pertaining to the case
General:
 To narrow down important differential diagnosis related to the case
To
 To discuss
identify properthe caseimpression
working of a 22y/o who
as basis forsought consult
management for
left
of the case
 To lower quadrant
discuss the pain
diagnosis for andaswas
the case, to: later discovered to have a
mass at the
 Etiology andleft
Risklower
factors quadrant upon PE.
 Pathophysiologic Considerations
 Management Options
 To identify management options appropriate for the case

2
Case Protocol
Date of consult: February 17, 2021

Patient CM, 22y/o nulligravid

C/c: Left Lower Quadrant Pain
HPI
 Asymptomatic until 5 mos prior noted LLQ
pain

 Dull, waxing and waning, exacerbated by

certain movements

 Recently, pain experienced more frequently

prompting consult

3
Past Medical History Family History

👪
 Unremarkable

👩
 Noncontributory
 No Surgeries  No Cancers

Menstrual History Obstetric History

M – 11 years
 She has had 3 sexual partners in the
I – regular, monthly
past
D – 4-5 days
Review of Systems
A – soaks 3-4 pads per day
 Uses Oral Contraceptive Pills

S – no dysmenorrhea
 Foul-smelling (fishy odor) vaginal
 
discharge
 LMP – February 3-7, 2021

4
Physical Exam
 Conscious, Coherent, Not in
Abdominal Exam Distress, Ambulatory

 Vital Signs:
Flat Abdomen
BP: 110/70 mmHg
Normoactive Bowel
PR: 74 bpm
Sounds
(+) 18
RR: 6x5cm
cpm mass at the
LLQ, cystic, movable,
T: 36.8°C
nontender
 Anthropometrics
Ht: 5’ 2” Wt: 60kg
BMI:
5
 Physical Exam
 Internal
Speculum Exam:
Exam:
Normal
VaginalExternal Genetalia
walls pink and smooth
Nulliparous
(+) greenish,Vagina
foul smelling (fishy
Cervix
odor) 3x2x2cm smooth
homogenous closed
frothy
Corpus smallat posterior fornix
discharge
(+) 6x5cm
cervix mass pink
midline at leftwith
adnexa
no lesions

 Rectovaginal Exam:
Good Sphincter Tone; Intact Rectal Vault
Inferior Pole of the mass not palpable at cul de sac

6
Guide

What Initial Impression can we

arrive to, considering the Hx
and PE? The Basis for this?

#1 7
Guide
What could be the possible
Differentials for this case, and
the basis for each?

#2 8
 (+) 6 x 5 cm

SALIENT left lower q

cystic, mov

FEATURES
ncer in family
medical history nontender
rtners Mass is at
(+) greenis
vaginal discharge smelling di
speculum e

9
INITIAL
IMPRESSION
G0, Adnexal Mass, Left, Benign VS
Malignant VS Tubo-ovarian Abscess
from PID; T/C Vaginitis prob
Trichomoniasis

10
 APPROACH TO
ABDOMINAL PAIN
1. Obtain general information about onset, duration, severity, and
quality of pain and about exacerbating and remitting factors.

2. Determine delineation of the pain’s location, radiation, and movement

3. Confirm findings from the history with physical examination.

11
 Causes of Left Lower Quadrant Pain
A. Gastrointestional
(+) Adnexal Sigmoidal Diverticulitis
Inflammatory Bowel Disease
Mass, 6 x 5 cm, B. Genitourinary
LLQ, Urinary Tract Infection
Nephrolithiasis
nontender, and
C. Gynecologic
movable Adnexal New Growth
Tuboovarian Abscess

12
DIFFERENTIAL
DIAGNOSES
RULE IN RULE OUT
RULE IN RULE OUT
(+) Chronic abdominal Increased risk with advancing age
pain
Chronic LLQ painIN Patient (-)
is not obese
Fever
RULE RULE OUT
Benign Adnexal Mass
(+) Adnexal
(+) Adnexal
mass, left
Mass, Left
OCPs has a protective effect to ovarian CA
History
(+) Chronic (-) Cannot
Family beofoftotally
history previous
breast andsurgeries
ovarian CA
ruled
abdominal pain Relatively slow growing mass
(+) greenish, foul-smelling, out
are not noted
(+) Adnexal mass, No obstructive symptoms such as
constipation, and difficulty in urination
frothyleft
vaginal discharge PE showedHistory of IUD
a mobile ismass,
cystic not noted
malignant
Malignant Adnexal Mass
Increased incidence in masses Patient
are usually solid in consistency and
is not
immobile
nulliparous woman   immunocompromised
Cannot be totally ruled out. A biopsy
Multiple sexual partners may beNo cervical
needed motionthetenderness
to confirm diagnosis.
Tuboovarian Abscess noted on PE 
DIFFERENTIAL
DIAGNOSES

Vaginitis from
Trichomoniasis
Guide

What Risk Factors are present in

the patient and what Pathologic
Considerations should the

#3 practitioners know about the case?

15
 Risk Factors
 Women with rare genetic transmitted basal cell
 Age Ovarian Lesions During
before and
Reproductive
during childhood:
Years:
nevus syndrome – Fibroma
Ovarian Lesions During Reproductive Years:  Fibroma
Maternal ovarian cyst during prenancy
 Fibroma
 cyst
 Fetal Pregnancy
Tubo-ovarian – Ovarian Torsion
abcess
 Tubo-ovarian abcess
 Polycystic ovarian syndrome  Polycystic
Benign cystic
ovarian
teratoma
syndrome
 Endometriomas
 History
 Follicular
Endometriomas of Endometriosis –Endometriomas
cysts
 Dermoid
 History of Laparoscopic Oopherectomy - Ovarian
Remnant Syndrome

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ADNEXAL MASS CLINICAL APPROACH

Premenopausal
 Common gynecologic problems  Majority occurs in reproductive age
 Mostly benign
 Anatomic Location  Associated with menstrual cycle reproductive
 May be symptomatic or discovered incidentally thru
hormones
 Age pelvic examination or imaging.
Pregnant women
 Reproductive Status of the  Ectopic pregnancy
 Corpus luteum cysts
Patient  Theca lutein cysts

Postmenopausal
 Excluding malignancy is the main priority

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ADNEXAL MASS M E D I C A L H I S T O RY

 Pelvic pain or pressure is the most common symptom.

 Genital tract bleeding
 Ovarian physiologic cysts: dull, achy pain that is
usually localized to the side of the mass
 Endometrioma: Dysmenorrhea or dyspareunia
 History of infertility: Endometrioma or Hydrosalpinx
 History of fever or vaginal discharge
 Questions about risk factors and symptoms associated
with ovarian or fallopian tube cancer
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ADNEXAL MASS I N I T I A L E VA L U AT I O N

 Family History of ovarian, breast, uterine or colon

cancer
 Family History suggestive of a hereditary ovarian
cancer syndrome (BRCA gene mutation or Lynch
Syndrome), should be counseled about genetic testing
 Should undergo surgical evaluation if any suspicious
adnexal mass

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ADNEXAL MASS PHYSICAL
E X A M I N AT I O N
 Size, consistency and mobility of a mass
 Solid mass that is irregular or fixed or is associated with posterior cul-de-
sac nodularity
 Abdominal distention and ascites and/or an abdominal mass
 Rectal mass or rectal bleeding
 Symptoms of pelvic/abdominal pain or pressure, bloating or
gastrointestinal/urinary tract symptoms
 Infrequently, a malignant mass may rupture or torse and present with
acute pain
 Symptoms related to estrogen excess (abnormal uterine bleeding) or
androgen excess (virilization or hirsutism)
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ADNEXAL MASS

FUNCTIONAL PAT H O L O G I C A L
 Most common type  Occur due to abnormal cell
 growth
Develops as part of the menstrual
cycle
 Usually harmless & short-lived

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Guide
What are the necessary
Laboratory and Diagnostic
Procedures to be requested and
the rationale of each?

#4 22
 Diagnostics - Laboratory
Cancer Antigen 125 (CA-125) test
 about one half of early-stage ovarian  has a high false-negative rate if it is used
cancers, the CA-125 level is normal to detect early-stage ovarian cancer

 levels higher than 200 U/mL in a

premenopausal woman indicate referral
to oncologist

23
 Diagnostics - Laboratory
Alpha-fetoprotein (AFP) Lactate Dehydrogenase
 Tumor marker elevated in endodermal sinus  Elevated in dysgerminomas
tumors, mixed germ cell tumors, immature
 FSH and may be a driving force in the field-effect theoryChorionic
for the
teratomas, embryonal carcinomas Human Gonadotropin
development of both ovarian neoplasms and their associated
 Elevated in choriocarcinomas, germ cell
peritoneal implants
tumors, or embryonal cell tumors

Estradiol
Testosterone and Estradiol
 Elevated in Thecomas or Dysgerminomas
Fibromas and Sertoli-Leydig
Tumors

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Diagnostics - Imaging
Transvaginal Ultrasound
Ultrasonography
 The
 standard
Limited for identifying
with regard to its role inovarian pathology
 CT
assessing masses and MRIchildren,
in neonates, are unnecessary in the evaluation of an
adnexal mass
and virginal adolescents

Color-flow Doppler
 useful for distinguishing between benign
and potentially malignant lesions

25
Diagnostics - Imaging
Ultrasonography
Suggestive of Malignancy:
 Ovarian Mass with solid or complex components
 Septations
 Surface Nodularity
 Increased Vascular Flow
 Heterogeneous echotexture

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Diagnostics – Case Protocol
Transvaginal Ultrasound
╺ Normal Anteverted Uterus
╺ Proliferative Phase endometrium
╺ Left Adnexal mass, consider Ovarian
New Growth, probably benign (Sassone
= 6, Lerner = 1)

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Guide
Given the History, Physical
Examination, and Ancillary
procedure done, what could be
our working impression?

#5 28
WORKING
IMPRESSION
G0, Adnexal Mass, Left, T/C Ovarian
New Growth, Benign

29
Guide
What would be our management for
patients with benign ONG?
Are there Medical and Surgical
options? How would we counsel this
patient?

#6 30
Management

SURGERY
CONTINUED MANAGEMENT
EXPECTANT SURVEILLANCE

 Suspicion
Etiology
Malignancyis ofismalignancy
suspected is low, but,
benign
 has
Other
No not been
risks
other completely
associated
indications ruled
with out
mass

 Includes:
Mass
No pelvic
followultrasound
is symptomatic
further up neededand/or
serum tumor markers

31
 Management
PREMENOPAUSAL WOMEN
HIGH RISK
 Surgery is required for women
with a mass with malignant
features
 Mass in combination with
ascites and/or evidence of
metastatic disease consistent
with ovarian cancer
LOW RISK
 Masses related to reproductive
function
 Surveillance is recommended,
with exception to those with very
elevated serum CA 125 or those
suspected with germ cell/ sex
cord stromal tumor
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Course
Laparoscopic Surgery
╺ The left ovary was converted to a 6 x 6 x
╺ There was no ascites. The omentum,
5 cm unilocular cystic mass with smooth
liver, subdiaphragmatic surface,
and intact capsule
gallbladder, stomach, intestines, and
╺ The right were
appendix ovarysmooth
appeared
andgrossly
grosslynormal.
╺ normal
Both fallopian tubes and the rest of the
abdominopelvic organs were grossly
normal.
╺ Estimated blood loss: 100 cc

For visual demonstration only, not the actual patient

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Course
Laparoscopic Surgery
╺ Cut section of the mass revealed sebum,
hair, scalp, and teeth
╺ The capsule measured 0.1 cm thick with
smooth inner surface and no solid areas
or papillary excrescences.

34
Final
Diagnosis

G0, Dermoid Cyst, Left Ovary

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Thank You!